Current Issues in Nursing I
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CURRENT ISSUES IN NURSING I Editors Melike YAVAŞ ÇELİK Canan BİRİMOĞLU OKUYAN Lyon 2025
CURRENT ISSUES IN NURSING I Editors Melike YAVAŞ ÇELİK Canan BİRİMOĞLU OKUYAN Lyon 2025
Current Issues in Nursing I Editors ● Assoc. Prof. Dr. Melike YAVAŞ ÇELİK ● Orcid: 0000-0002-1155-1022 ● Assoc. Prof. Dr. Canan BİRİMOĞLU OKUYAN ● Orcid: 0000-0002-7339-6072 Cover Design ● Motion Graphics Book Layout ● Motion Graphics First Published ● October 2025, Lyon e-ISBN: 978-2-38236-934-0 DOI: 10.5281/zenodo.17398409 copyright © 2025 by Livre de Lyon All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the Publisher. The author or authors of the relevant section are responsible for any copyright infringement that may occur due to the images and graphics used in the book. The editor or publisher does not assume responsibility in this regard. Publisher ● Livre de Lyon Address ● 37 rue marietton, 69009, Lyon France website ● http://www.livredelyon.com e-mail ● [email protected]
I PREFACE Nursing is a continuously developing and adaptable profession that evolves in response to society’s changing demands, innovations in healthcare technology, and new global health challenges. Although its scope expands, nursing remains firmly anchored in the essential values of compassion, ethics, and evidence-based practice. “Current Issues in Nursing” aims to provide readers with an in-depth exploration of the contemporary challenges, innovations, and opportunities in nursing practice, education, and research. This book brings together a collection of evidence-based perspectives from experts in the field, aiming to stimulate critical thinking, support professional development, and inspire ongoing improvement in nursing care. Each chapter sheds light on the complex realities nurses encounters across diverse clinical and community settings ranging from ethical dilemmas and workforce sustainability to digital transformation and patient-centered care. Through these discussions, the book aims to connect theory with practical application, empowering nurses to provide compassionate, safe, and highquality care in an ever-evolving healthcare landscape. We extend our heartfelt gratitude to all contributors for their dedication and scholarly efforts, and to our readers whose passion for knowledge and excellence continues to drive the advancement of the nursing profession. It is our hope that this book will serve as both an inspiration and a resource for nurses striving to create a healthier future for all. Editors Assoc. Prof. Dr. Melike YAVAŞ ÇELİK Assoc. Prof. Dr. Canan BİRİMOĞLU OKUYAN
III CONTENTS PREFACE I CHAPTER I. POSTOPERATIVE NURSING CARE IN PATIENTS WITH INTESTINAL STOMA 1 Ali GÜZEL CHAPTER II. ARTIFICIAL INTELLIGENCE AND MENTAL HEALTH NURSING: BENEFITS AND CHALLENGES 15 Aynur BAHAR CHAPTER III. SILENT CHEMICALS ENDANGERING MATERNAL AND FETAL HEALTH: THE MANAGEMENT OF ENDOCRINEDISRUPTING CHEMICALS DURING PREGNANCY 31 Betül KAPLAN CHAPTER IV. THREATS AND IMPACTS OF THE CLIMATE CRISIS ON THE NEW GENERATION 43 Canan BIRIMOGLU OKUYAN & Melike YAVAS CELIK CHAPTER V. NEW TRENDS IN FAMILY HEALTH AND VOLUNTARY CHILDLESSNESS PREFERENCE 51 EsmaDEMİREZEN&MuazezKÜÇÜKKAYA CHAPTER VI. SPIRITUAL WELL-BEING IN NURSING 67 FerideKAPLAN&HüseyinYAŞAR CHAPTER VII. CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 81 SevalAKBEN&HüseyinYAŞAR CHAPTER VIII. BEHAVIORAL ADDICTIONS 105 Sibel POLAT OLCA CHAPTER IX. NURSING APPROACHES TO EMERGENCY AND DISASTER PREPAREDNESS FOR CHILDREN 121 Sinem ÖZTÜRKLER CHAPTER X. THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 131 Tuba ÖTÜN
IV CURRENT ISSUES IN NURSING I CHAPTER XI. THE CONTRIBUTION OF DIGITAL HEALTH LITERACY TO MATERNAL EDUCATION AND CHILDBIRTH DECISION-MAKING 153 TuğbaKONUKOĞLUYAVUZ CHAPTER XII. THE ROLE OF COMPLEMENTARY AND ALTERNATIVE METHODS IN NURSING CARE: A FOCUS ON THE PERIOPERATIVE PERIOD 169 ÜmmühanYİĞİT&ArzuÖZCANİLÇE CHAPTER XIII. CARBON FOOTPRINT IN OPERATING THEATRES AND SUSTAINABLE NURSING APPROACHES 189 ZekiyeBetülKARADEMİR CHAPTER XIV. NAVIGATION NURSING 201 ZeynepDOĞAN CHAPTER XV. FIRST AID FOR CHILDREN 213 Serap ÇELİK
POSTOPERATIVE NURSING CARE IN PATIENTS WITH INTESTINAL STOMA 7 · If a bottom-discharge pouch is being used, the faeces inside the pouch should first be emptied into the toilet. (20,21) · To ensure that the previously attached adapter can be easily removed from the skin, the adapter straps must be moistened using a gauze pad soaked in warm water, an alcohol-free wet wipe, etc. · When removing the pouch or adapter, stretch the skin around the stoma with one hand while slowly pulling the pouch or adapter downwards with the other hand to separate it from the skin. If any difficulties are encountered during this process, a sticky solvent spray may be used. (16,20,21) · If a two-piece system is used, the adapter is removed together with the pouch. · The colour, moisture level, diameter, height and shape of the stoma; the skin around the stoma, the healing process, etc. are assessed. · The skin around the stoma is wiped with a gauze pad moistened with warm water and dried. The drying process ensures that the adapter adheres better to the skin. · A small amount of bleeding may occur in or around the stoma while cleaning the stoma area, but applying light pressure will stop the bleeding. Harsh solvents, soap and disinfectants should not be used during skin cleansing. · The diameter of the stoma should be measured with a stoma measuring ruler. The stoma becomes edematous after the surgery and shrinks to its normal shape one to two months after the surgery. Therefore, diameter measurements should be made again at every bag change during the first two months. (20,21) · The diameter of the stoma adapter is cut using scissors so that it is approximately 2-3 mm larger than the diameter of the stoma. After the stoma adapter is cut, the adhesive paper on it is removed. · A thin layer of stoma paste is applied to the inside of the stoma adapter and the paste is waited for 1-2 minutes to dry. Stoma powder can be used to speed up the healing process of stitches around the stoma. · The stoma adapter is placed neatly over the stoma. · The patient is told to inflate his/her abdomen and the stoma pouch is attached to the adapter starting from the bottom and moving upwards (a clicking sound is heard). The stoma pouch is gently pulled back to check whether it is securely attached to the stoma adapter. Press lightly on the pouch or adapter with your hand for about one minute. If a bottom-discharge pouch is used, the pouch clamp is closed. · Gloves are removed and thrown into the waste bag with other dirty materials and hands are washed. (20,21)
8 CURRENT ISSUES IN NURSING I If there is redness, an open wound, discolouration, or raised tissue around the stoma; or if the stoma appears pale, purple/black, protruding outwards, or sunken inwards, the patient is advised to contact their WOC nurse or doctor. (16) Pouch systems can be used for three to seven days. However, disposable and closed-ended pouch systems require more frequent replacement. The pouch should be emptied when it is one-third full. In the event of a leak, the stoma pouch and adapter should be replaced immediately. (20,21) If only the pouch is to be changed and the adapter is to remain on the skin, one hand should hold the adapter in place while the other hand removes the pouch from the adapter. Any output such as feces or mucus that has contaminated the adapter is cleaned with a dry gauze. If skin is visible between the adapter and the stoma, the gaps are closed with stoma paste. The pouch is attached to the adapter and the bottom end is closed. (20,21) 7.2. Colostomy Irrigation Colostomy irrigation may be considered as one of the stoma management options in patients with sigmoid or descending colostomies. Colostomy irrigation is the process of emptying the contents of the intestine (gas, faeces, bacteria, etc.) by administering a certain amount of fluid into the large intestine through the stoma. Colostomy irrigation regulates intestinal movements, thereby preventing gas and stool discharge between irrigations and ensuring controlled stool discharge. (21) Colostomy irrigation is an alternative method that patients with permanent colostomies can use instead of constantly wearing a pouch. Colostomy irrigation can be performed in patients who do not have serious physical or mental limitations, who can learn the irrigation technique, who have good nutritional habits, and who had regular intestinal habits prior to surgery. (21) 8. Nutrition of the Patient with Stoma 8.1. Nutrition of the Patient with an Ileostomy Patients with ileostomies are initially given clear liquids after surgery, and their diet is gradually progressed according to the patient’s tolerance. As the patient’s appetite may decrease after surgery, they tolerate small, frequent meals better. Patients should not skip meals. Because this situation may cause liquid stools and increased gas. Chewing gum, smoking and drinking liquids through a straw can also increase gas formation. Cooked vegetables, fruit without skin
POSTOPERATIVE NURSING CARE IN PATIENTS WITH INTESTINAL STOMA 9 or seeds, seedless berries, dairy products, pasta, bread, and high-protein foods (cottage cheese, peanut butter, etc.) can be safely consumed after ileostomy surgery. Fibrous foods (popcorn, nuts and seeds, celery, dried fruit, apple peels, and coconut) are difficult to digest and can cause intestinal obstruction. Therefore, patients should avoid high-fiber foods for four to eight weeks after surgery. Because the terminal ileum is often removed during surgery, patients should be especially careful about vitamin B12 deficiency. It is important for the patient to be in communication with his/her doctor on this matter. (3) The majority of nutrient absorption and digestion occur in the first 100 cm of the small intestine. Therefore, unless a large portion of the ileum is removed, ileostomy patients can be protected from the risk of malnutrition as long as they follow a balanced diet and chew their food thoroughly. Patients should be advised to increase their water intake as long as it is medically appropriate. (16) Patients with high ileostomy output should be advised to avoid sugary drinks, reduce hypertonic and hypotonic fluids, and include high sodium and complex starches in their diet. Patients should regularly measure and record their weight and ileostomy output; they should seek medical help if they experience high output and signs of dehydration. Antidiarrheal medications such as loperamide may be used according to the doctor’s recommendation. (5) 8.2. Nutrition of the Patient with a Colostomy As nutrient absorption is generally unaffected, there is no need to make significant changes to the patient’s diet. Patients can return to their normal diet after a few weeks. To minimize gas immediately after surgery, patients should avoid carbonated drinks, drinking through a straw, smoking and skipping meals; avoid foods that can cause gas, such as onions, cabbage, eggs, broccoli, beans, milk, cheese and fish. Foods containing fibre that may cause gas can be added gradually, depending on the patient’s tolerance. Additionally, gas-filtered bags that can prevent the bag from becoming excessively filled with gas can also be used. (16) 9. Post-Discharge Nursing Approach Before discharge from the hospital, patients should be educated on topics such as common complications, evaluation of the stoma and peristomal skin, changing/emptying the pouching system, gas and odor management, medications, clothing, nutrition, the patient’s use of a medical alert bracelet, and how to obtain supplies. (5)
10 CURRENT ISSUES IN NURSING I Patients’ body structures are different from each other, and in the first three months after the stoma is created, the height and diameter of the stoma will decrease. Consequently, problems such as deep folds or wrinkles in the skin, inward or outward turning skin structure, and swelling may be observed. An irregular stoma shape and peristomal area may cause leakage by leading to incompatibility between the skin and stoma products. The WOC nurse should regularly monitor patients to ensure skin compatibility with stoma products or to offer more suitable alternatives. (22) Patients with stoma should be able to easily obtain the materials needed for stoma care and receive help from social support units to more easily adapt to living with a stoma. The WOC nurse should follow up with patients by telephone within ten days of their discharge from hospital to assess their adaptation to the stoma. The WOC nurse should visit patients at least every two, four and six weeks; the frequency of visits should be determined according to the needs of the patient and their family. During these visits, the patient’s ability to assess and protect their peristomal skin should be evaluated, and it should be ensured that the patient or their family can independently change the pouch system until the second week after surgery. Patients should be able to recognise possible complications and seek medical help if necessary in the following situations: · Abdominal pain, vomiting, tension, cramps, inability to pass stool or high-velocity watery stool are signs and symptoms of constipation. · Abnormal peristomal skin problems, · Symptoms and signs of parastomal hernia, such as swelling and pain in the abdominal area around the stoma. (14) Patients must always carry spare supplies with them when travelling. While the pouching system is intact, the patient can shower, but should dry gently with a towel after the shower. If the patient plans to change the pouching system after the shower, he or she can shower without the pouching system. When the patient wishes to swim, they must first empty the pouch and cover it with a waterproof material. (16) It is important to create support groups by introducing patients with stomas to other patients with stomas. Therefore, it would be beneficial to plan support meetings where stoma patients can share their problems in order to ensure their social integration, obtain information and benefit from each other’s experiences. (23)
POSTOPERATIVE NURSING CARE IN PATIENTS WITH INTESTINAL STOMA 11 10. Conclusion The creation of a stoma disrupts patients’ daily routines, forcing them to adapt to a new way of life. Nurses should support patients during this difficult process and guide them so that they can perform their self-care independently. To facilitate the stoma patient’s adaptation to their new life, coordination must be ensured between all disciplines involved in the care of stoma patients. In this context, WOC nurses should organize individualized trainings for patients and family about stoma care, teach stoma-specific skin care techniques, provide counseling on the selection and use of appropriate stoma products, provide psychosocial support, and plan and monitor home care processes after discharge. They should also actively participate in multidisciplinary team work and develop care plans to improve the quality of life of patients. References 1) Mulita F, Lotfollahzadeh S. Intestinal Stoma. 2023 Jun 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 33351447. 2) Martin ST, Vogel JD. Intestinal stomas: indications, management, and complications. Adv Surg. 2012;(46):19-49. 3) McCartney T, Markwell A, Rauch-Pucher M, Cox-Reber J. Caring for patients after ileostomy surgery. AJN. 2023;123(2):36-41. 4) Ayaz S. Role of the nurse in patients with stoma: Review. Turkish Clinics J Med Sci. 2007; 27:86-90. 5) Goldberg M, Colwell J, Burns S, et al. WOCN Society clinical guideline management of the adult patient with a fecal or urinary ostomyAn executive summary. JWOCN. 2018;45(1):50-58. 6) Ambe PC, Kurz NR, Nitschke C, Odeh SF, Möslein G, Zirngibl H. Intestinal ostomy. Classification, indications, ostomy care and complication management. Dtsch Arztebl Int. 2018;(115):182-187. 7) Ayık C, Özden D, Cenan D. Ostomy complications, risk factors, and applied nursing care: A retrospective, descriptive study. WOUNDS. 2020;66(9):20-30. 8) D’Ambrosio F, Pappalardo C, Scardigno A, Maida A, Ricciardi R, Calabrò GE. Peristomal skin complications in ileostomy and colostomy patients: What we need to know from a public health perspective. Int. J. Environ. Res. Public Health. 2023;20(79):1-19.
12 CURRENT ISSUES IN NURSING I 9) Beitz JM, Colwell JC. Management approaches to stomal and peristomal complications: A narrative descriptive study. JWOCN. 2016;43(3):263-268. 10) Ayık C, Özden D. Ostomy complications and nursing care: Current approaches. EHD. 2023;16(3):383-397. 11) Chan MS, Moore Z, Patton D, McNamara D, O’Connor T, Avşar P. A systematic review of patient risk factors for complications following stoma formation among adults undergoing colorectal surgery. Int. J. of Colorectal Disease. 2023;38(238):1-12. 12) Cihan E, Vural F. Intestinal ostomies and evidence-based nursing practices. Karayurt Ö, editor. Evidence-based practices in nursing for surgical diseases of the gastrointestinal system. 1st edition. Ankara: Türkiye Clinics. 2023:26-34. 13) Davis BR, Valente MA, Goldberg JE, Lightner AL, Feingold DL, Paquette IM. The American society of colon and rectal surgeons clinical practice guidelines for ostomy surgery. Dis Colon Rectum. 2022; 65(10):1173-1190. 14) Miller D, Pearsall E, Johnston D, Frecea M, McKenzie M. Executive summary: Eenhanced recovery after surgery best practice guideline for care of patients with a fecal diversion. JWOCN. 2017;44(1):74-77. 15) Yeo H, Park H. Benefits of a single-session, in-hospital preoperative education program for patients undergoing ostomy surgery a randomized controlled trial. JWOCN. 2023;50(4):313-318. 16) Cross HH. Nursing care for patients after ostomy surgery. What nurses need to know about colostomy and ileostomy management. AJN. 2023;123(8):34-41. 17) Steinhagen E, Colwell J, Cannon LM. Intestinal stomas-postoperative stoma care and peristomal skin complications. Clin Colon Rectal Surg. 2017;30:184-192. 18) Mayers PM, Mobara G, Nicola Fouché N. The lived experience of muslim patients with ostomies a phenomenological study. JWOCN. 2025;52(3):205–211. 19) Pittman J, Colwell J, Mulekar MS. Ostomy complications and quality of life of ostomy support belt/garment wearers a web-based survey. JWOCN. 2022;49(1):60-68. 20) Sezgünsay E, Türkmenoğlu G, Duluklu B. Wound Ostomy Incontinence Nurses’ Society (YOIHD). Living with an ileostomy. 2nd Edition. Ankara/ Türkiye. 2024. https://www.yoihd.org.tr/files/publication/leostomi-ile-yasam2024-duzelti%CC%87len-6839ad0bc5b7c.pdf
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15 CHAPTER II ARTIFICIAL INTELLIGENCE AND MENTAL HEALTH NURSING: BENEFITS AND CHALLENGES Aynur BAHAR Dr. Graduate Instructor, Gaziantep University, Faculty of Health Sciences. Department of Psychiatric Nursing, e mail: [email protected] ORCID:0000-0001-5356-0501 1.Introduction Artificial intelligence (AI) is the use of technologies that enable machines to perform tasks that require human intelligence, such as decisionmaking, learning and reasoning. In recent years, applications for integrating AI into healthcare have increased. The literature demonstrates that various aspects of AI (for example machine learning (ML) and natural language processing (NLP)) have highly effective and practical applications in improving patient care and supporting clinical decision-making. (1-4) Additionally, AI can contribute to improving healthcare services by reducing costs, improving administrative processes, and supporting decision-making processes in healthcare organizations. (5) One of the primary reasons driving the mental health field to utilize AI is the increasing prevalence of psychological problems. Millions of people worldwide experience mental health disorders. (6) It has been reported that rates of mental illnesses such as anxiety, depression, and suicide have increased during the Covid-19 pandemic. (7,8) Bickman (2020) identified the inadequacy of existing services as insufficient accessibility, inadequate evidence-based services, and insufficient diagnostic and treatment effectiveness. (9) Same study also stated that AI technologies will contribute to the mental health field in solving these problems.
16 CURRENT ISSUES IN NURSING I AI can provide many significant benefits to psychiatric nursing, including improving diagnostic accuracy, patient care, educational outcomes, and administrative efficiency. (10) AI-enabled patient monitoring enables continuous, remote monitoring of patients’ psychological states using measurements such as speech patterns, facial expressions, and physiological indicators. AI systems identify early signs of crisis, facilitating timely interventions and potentially reducing the incidence of hospitalizations and acute exacerbations. AI-enabled wearable sensors and real-time alert systems enable early detection of patient problems, reducing complications and improving outcomes. (11) AI-enabled systems automate routine tasks such as documentation, scheduling, and data management, which traditionally consumed a significant portion of nurses’ time. (10) AI applications have applications in analyzing cognitive and emotional processes and assessing psychopathologies. The use of AI in psychotherapy practices offers advantages in terms of increasing the effectiveness of therapeutic processes, increasing access to therapy, and efficient resource utilization. Virtual therapists can interact with clients in sessions, offer suggestions, and facilitate access to therapy. (12) The integration of AI into mental health services has also impacted psychiatric nursing, leading to some changes in nursing roles and responsibilities. (13) Psychiatric nursing is a discipline that aims to provide holistic care to individuals and places empathy, compassion, and trust at the center of the therapeutic relationship. (14) Services offered in this field extend from the therapeutic relationship to patient assessment, medication management, and psychosocial interventions. A holistic approach that simultaneously addresses the biological, psychological, and social aspects of an individual requires the ability to understand and support patients’ emotional states. However, it should be noted that algorithmic tools may have limited capacity to meet patients’ emotional needs within the therapeutic relationship. (15) AI technologies are expected to bring innovations to current medical practices and future healthcare systems. Current AI-based healthcare technologies have demonstrated significant effectiveness in accurately diagnosing and classifying patient conditions, as well as predicting disease progression using accumulated medical data. (16) 2. Benefits of Artificial Intelligence for Mental Health Nursing The increasing prevalence of mental disorders is placing increasing demands on healthcare systems, exposing the inadequacies of traditional
ARTIFICIAL INTELLIGENCE AND MENTAL HEALTH NURSING . . . 23 and implemented in areas such as virtual psychotherapies, telehealth, and patient monitoring. To understand the impact of AI on mental health services, comprehensive studies are needed. Furthermore, clarifying legal and ethical regulations regarding data privacy and algorithmic biases should be a priority. References 1-Battineni, G.; Sagaro, G.G.; Chinatalapudi, N.; Amenta, F. Applications of Machine Learning Predictive Models in the Chronic Disease Diagnosis. J. Pers. Med. 2020, 10, 21. 2-Lee EE, Torous J, De Choudhury M, et al. Artificial intelligence for mental health care: Clinical applications, barriers, facilitators, and artificial wisdom. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging.2021;6(9):856-864. https://doi.org/10.1016/j.bpsc.2021.02.001. 3-Soori M, Arezoo B, Dastres R. Artificial ıntelligence, machine learning and deep learning in advanced robotics, a review. Cogn. Robot. 2023;3: 54–70. 4-Dailah HG, Koriri M, Sabei A, Kriry T, Zakri M. (2024). Artificial ıntelligence in nursing: Technological benefits to nurse’s mental health and patient care quality. Healthcare. 2024;12(24): 2555. https://doi.org/10.3390/ healthcare12242555. 5-Dicuonzo G, Donofrio F, Fusco A, Shini M. Healthcare system: Moving forward with artificial intelligence. Technovation. 2023; 120: p.102510, Article 102510. 6-Allen S. Artificial intelligence and the future of psychiatry. IEEE Pulse. 2020;11(3): 2-6. https://doi.org/10.1109/MPULS.2020.2993657. 7-Khan KS, Mamun MA, Griffiths MD, Ullah I. The mental health impact of the Covid-19 pandemic across different cohorts. International journal of Mental Health and Addiction. 2020;20:380-386. https://doi.org/10.1007/ s11469-020-00367-0. 8-Ravens-Sieberer U, Kaman A, Erhart M, Devine J, Schlack R, Otto C. Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany. European Child & Adolescent Psychiatry. 2021;25:1-11. https://doi.org/10.1007/s00787-021-01726-5. 9-Bickman L. Improving mental health services: A 50-year journey from randomized experiments to artificial ıntelligence and precision mental health, Administration and Policy in Mental Health and Mental Health Services Research. 2020;47:795–843. https://doi.org/10.1007/s10488-020-01065-8.
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26 CURRENT ISSUES IN NURSING I 32-Conlon BN, Raeburn T, Wand T. Mental health risk assessments of patients, by nurses working in mental health settings: a qualitative study using cognitive continuum theory. Issues in Mental Health Nursing. 2024;45(5):488– 497. https://doi.org/10.1080/01612840.2024.2320731. 33-Rony MKK, Parvin MR, Ferdousi S. Advancing nursing practice with artificial ıntelligence: enhancing preparedness for the future. Nursing Open. 2024;11(1):1–9. https://doi.org/10.1002/nop2.2070. 34-Khan NS, Gahni SM, Anjum GG. ADAM-sense: Anxiety-displaying activities recognition by motion sensors. Pervasive and Mobile Computing. 2021;78. https://doi.org/10.1016/j.pmcj.2021.101485. 35-Amoroso N, Diacono D, Fanizzi A, et al. Deep learning reveals alzheimer’s disease onset in MCI subjects: Results from an international challenge. Journal of Neuroscience Methods. 2018;302:3-9. https://doi. org/10.1016/j.jneumeth.2017.12.011. 36-Kalmady SV, Greiner R, Agrawal R, et al. Towards artificial intelligence in mental health by improving schizophrenia prediction with multiple brain parcellation ensemble-learning. NPJ Schizophr. 2019;5(1):2. https://doi. org/10.1038/s41537-018-0070-8. 37-McGinnis EV, Anderau SP, Hruschak J, et al. Giving voice to vulnerable children: Machine learning analysis of speech detects anxiety and depression in early childhood. IEEE Journal of Biomedical and Health Informatics. 2019;23:2294-2301. 38-Fitzpatrick KK, Darcy A, Vierhile M. Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): A randomized controlled trial. JMIR Mental Health. 2017;4:2-19. 39Fernandes AC, Dutta R, Velupillai S, Sanyal J, Stewart R, Chandran D. Identifying suicide ıdeation and suicidal attempts in a psychiatric clinical research database using natural language processing. Sci Rep. 2018;;8(1):7426. https://doi.org/10.1038/s41598-018-25773-2. 40-Walsh CG, Riberio JD, Franklin JC. Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science. 2017;5(3):457-469. https://doi.org/10.1177/2167702617691560. 41-Halli‐Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. American Family Physician. 2019;100(1):32–38. 42-Brooks HL, Lovell K, Bee P, Sanders C, Rogers A. Is ıt time to abandon care planning in mental health services? a qualitative study exploring the views
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28 CURRENT ISSUES IN NURSING I 52-Avula R, Tummala S. Optimizing data quality in electronic medical records: addressing fragmentation, ınconsistencies, and data ıntegrity ıssues in healthcare. J. Big-Data Anal. Cloud Comput. 2019;4:1–25. 53-Aldoseri A, Al-Khalifa KN, Hamouda AM. Re-thinking data strategy and ıntegration for Artificial Intelligence: concepts, opportunities, and challenges. Appl. Sci. 2023;13:7082. 54-Olawade DB, Wada OJ, David-Olawade AC, Kunonga E, Abaire O, Ling J. Using artificial intelligence to improve public health: a narrative review. Front Public Health. 2023;26(11):1196397. https://doi.org/10.3389/ fpubh.2023.1196397. 55-Egbuna OP. Exploring the ethical ımplications of artificial ıntelligence in healthcare. J. Artif. Intell. Res. 2021;1: 46–70. 56-Lukkien DRM, Stolwijk NE, Ipakchian Askari S, et al. AI-assisted decision-making in long-term care: qualitative study on prerequisites for responsible ınnovation. JMIR Nurs. 2024;7:e55962. 57-Pailaha AD. The ımpact and ıssues of artificial ıntelligence in nursing science and healthcare settings. SAGE Open Nurs. 2023;9: 23779608231196847. 58-Norori N, Hu Q, Aellen FM, Faraci FD, Tzovara,A. Addressing bias in big data and aı for health care: a call for open science. Patterns. 2021; 2: 100347. 59-Manrai AK, Funke,BH, Rehm HL, et al. Genetic misdiagnoses and the potential for health disparities. N. Engl. J. Med. 2016;375: 655–665. 60-Agarwal R, Bjarnadottir M, Rhue L et al. Addressing algorithmic bias and the perpetuation of health inequities: an AI bias aware framework, Health Policy Technol. 2023;12(1):100702. https://doi.org/10.1016/j.hlpt.2022.100702. 61Nazer LH, Zatarah R, Waldrip S, et al. Bias in artificial intelligence algorithms and recommendations for mitigation. PLOS Digit Health. 2023;2(6):e0000278. https://doi.org/10.1371/journal.pdig.0000278. 62-Al Yahyaei, A. Reserving the human touch in nursing education while ıntegrating virtual reality and simulation. J. Prof. Nurs. 2024;54: 36–38. 63-Shaik T, Tao X, Higgins N, et al. Remote patient monitoring using artificial ıntelligence: current state, applications, and challenges. WIREs Data Min. Knowl. Discov. 2023;13:e1485. 64-Lammons W, Silkens M, Hunter J, Shah S, Stavropoulou C. Centering public perceptions on translating aı ınto clinical practice: patient and public ınvolvement and engagement consultation focus group study. J. Med. Internet Res. 2023;25:e49303.
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31 CHAPTER III SILENT CHEMICALS ENDANGERING MATERNAL AND FETAL HEALTH: THE MANAGEMENT OF ENDOCRINEDISRUPTING CHEMICALS DURING PREGNANCY Betül KAPLAN (Asst. Prof. Dr.) Department of Midwifery, Gaziantep Islamic Science and Technology University, Gaziantep, Turkey E-mail: [email protected] ORCID: 0000-0002-7361-6872 1. Introduction The risk of pediatric endocrine disorders is significantly influenced by maternal health, which contributes to embryonic development through direct physiological effects and indirect environmental factors (1). Hormonal disorders and exposure to endocrine disruptors during pregnancy are a pervasive and intricate health issue. The risk of fetal development and related endocrine disorders is linked to maternal health, as evidenced by an increasing body of experimental and clinical studies that demonstrate an interaction between endocrinopathies and endocrine disruptors (1,2). Pregnant women face an elevated risk of exposure to endocrinedisrupting compounds, as embryonic development is particularly vulnerable to environmental, chemical, and nutritional stressors (3). Exposure to endocrine-disrupting chemicals can result in a variety of health issues, such as reproductive disorders, neurodevelopmental issues, metabolic syndromes, and certain types of cancer, through skin contact, ingestion, or inhalation (4,5). Endocrine-disrupting compounds (EDCs) during pregnancy can influence the health of the mother and the development of the fetus. EDCs can cross the
32 CURRENT ISSUES IN NURSING I placental barrier through umbilical cord blood, build up in fetal tissue, and enter the fetal circulation. This can affect the development, growth, and function of the placenta. The placenta is essential for the production of hormones, including estrogen, hCG, and progesterone, that are essential for a healthy pregnancy. It is particularly susceptible to endocrine disruptors as a result of its high density of hormone receptors. The binding of endocrine disruptors to these receptors and hormone transport proteins or the modulation of endogenous hormone degradation and synthesis can disrupt hormonal balance. Moreover, the fetus is more vulnerable to changes that could disrupt the equilibrium of the fetoplacental environment, as neither the placenta nor the fetus has any protective mechanisms against endocrine disruptors. Adverse fetal outcomes, including preeclampsia, miscarriage, preterm birth, and low birth weight, may result from placental rupture (2,6,7). Nevertheless, the adverse effects of endocrine disruptors are not restricted to pregnancy; the developmental trajectory of new life can be substantially altered by the subtle changes associated with these chemicals, which can have a significant impact on developing tissues. Endocrine disruptors also affect epigenetic regulation, leading to heritable changes in gene expression without altering the underlying DNA sequence. DNA methylation, histone modifications, and noncoding RNA expression are among the critical epigenetic mechanisms that are influenced by endocrine disruptors. These mechanisms are essential for the proper formation of organs and the development of embryos (8-10). 2. Definition and Concept of Endocrine-Disrupting Chemicals Endocrine-disrupting compounds are exogenous factors that disrupt the production, release, circulation, and binding of the body’s endogenous hormones, which are essential for the maintenance of homeostasis, growth, and reproduction (11,12). Endocrine-disrupting chemicals are ambient chemicals that have the potential to disrupt the endocrine systems of either humans or wildlife (e.g., chemicals found in manufacturing and packaging materials) (13). The endocrine system is recognized as performing a critical and essential function in the following areas: metabolism, behavior, the nervous system, growth, reproduction, pregnancy, and fetal life. Consequently, it is of the utmost importance to investigate the presence of endocrine-disrupting chemicals, their detrimental effects, their pathways into foods, and, in particular, their levels during pregnancy (3).
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40 CURRENT ISSUES IN NURSING I 29. Santos ASE, Moreira JC, Rosa ACS, et al. Persistent organic pollutant levels in maternal and cord blood plasma and breast milk: results from the Rio Birth Cohort Pilot Study of Environmental Exposure and Childhood Development (PIPA Study). International Journal of Environmental Research and Public Health. 2022;20(1):778. 30. Tyagi V, Garg N, Mustafa M, Banerjee B, Guleria K. Organochlorine pesticide levels in maternal blood and placental tissue with reference to preterm birth: a recent trend in North Indian population. Environmental Monitoring and Assessment. 2015;187(7):471. 31. Toichuev RM, Zhilova LV, Paizildaev TR, et al. Organochlorine pesticides in placenta in Kyrgyzstan and the effect on pregnancy, childbirth, and newborn health. Environmental Science and Pollution Research. 2018;25(32):31885-31894. 32. Reed CE, Fenton SE. Exposure to diethylstilbestrol during sensitive life stages: a legacy of heritable health effects. Birth Defects Research Part C: Embryo Today: Reviews. 2013;99(2):134-146. 33. Maksimova L, Shafikova T. Endogenous phthalates as a prospective regulator of interspecific relations in a biocoenosis. Izvestiya Vuzov Prikladnaya Khimiya i Biotekhnologiya. 2022;12(3):424-437. 34. Yıldırım Y, Onmaz NE, Gönülalan Z, et al. Bisfenoller ve fitalatların halk sağlığı üzerine etkileri. Erciyes Üniversitesi Veteriner Fakültesi Dergisi. 2020;17(1):68-75. 35. Aldegunde-Louzao N, Lolo-Aira M, Herrero-Latorre C. Phthalate esters in different types of cosmetic products: a five-year quality control survey. Molecules. 2024;29(20):4823. 36. Jang EA, Kim KN, Bae SH. Associations of concentrations of eight urinary phthalate metabolites with the frequency of use of common adult consumer and personal-care products. Scientific Reports. 2024;14(1):5187. 37. Arıcan YE, Osmanoğlu EH. FOOD SAFETY. 2024; 38. Wowkonowicz P. Phthalates in the environment: Their toxicology and associated risk to humans. Environmental Protection and Natural Resources. 2023;34(1):1-12. 39. Inman ZC, Flaws JA. Impact of Real-life Environmental Exposures on Reproduction: Endocrine-disrupting chemicals, reproductive aging, and menopause. Reproduction. 01 Nov. 2024 2024;168(5):e240113. doi:10.1530/ rep-24-0113 40. Touhouche S, Guenifed A, Yaker ND, Khelfi A. Phtalates et fonctions reproductrices de la femme: effets réels ou mythes? Toxicologie Analytique et Clinique. 2024;36(2):109-130.
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43 CHAPTER IV THREATS AND IMPACTS OF THE CLIMATE CRISIS ON THE NEW GENERATION Canan BIRIMOGLU OKUYAN1 & Melike YAVAS CELIK2 1 Assoc. Prof. Dr., Sakarya University, Faculty of Health Sciences, Sakarya, Türkiye. e-mail: [email protected] ORCID: 0000-0002-7339-6072 2 Assoc. Prof. Dr., Gaziantep University, Faculty of Health Sciences, Gaziantep, Türkiye. e-mail: [email protected] ORCID: 0000-0002-1155-1022 1.Introduction The climate crisis threatens the lives of younger generations in multidimensional ways biophysical, psychosocial, and socioeconomic. Children and adolescents are particularly vulnerable due to their developmental characteristics and longer exposure to environmental changes. This situation necessitates prioritizing the risks related to physical health. Rising temperatures, extreme weather events, and deteriorating air quality increase heatrelated illnesses, respiratory problems, and the risk of infectious diseases (1-3). In addition to physical health effects, climate change negatively impacts young people’s mental well-being, creating eco-anxiety and stress, while at the same time motivating them to take climate action (4,5). Mental health consequences become more severe when intertwined with socioeconomic vulnerabilities. The impacts are felt more strongly in disadvantaged groups, which restricts children’s educational and future opportunities (1,3). Therefore, holistic interventions and the participation of young people in climate action are critically important for strengthening resilience and protecting
44 CURRENT ISSUES IN NURSING I future generations. Within this general framework, the first impacts of the climate crisis on younger generations manifest in the field of physical health. 2.Threats posed by the climate crisis 2.1. Socioeconomic threats Climate change disrupts children’s education, particularly in low and middle-income countries where environmental disasters are frequent; health problems increase school absenteeism, thereby reducing learning opportunities (6). At the same time, it exacerbates inequalities, as disadvantaged youth face health disparities and limited access to healthcare services (3,7). In addition, the decline in agricultural livelihoods reduces household income, leaving future generations under the threat of unemployment and economic insecurity. This situation perpetuates the cycle of poverty and intergenerational injustice (6,8,9). Among the most effective solutions to these problems are education and awareness-raising activities. 2.2. Health-related threats Climate change poses a major global challenge to human health, threatening clean air, safe water, nutrition, shelter, and mental well-being. Children, due to their rapid development, are the most vulnerable group, facing risks such as respiratory and vector-borne diseases, migration, stress, and drought. Pediatric nurses have an essential role in reducing these impacts through education and awareness-raising, which can help children adopt protective behaviors. Strengthening their own knowledge and supporting children’s awareness are key strategies for building resilience against the health effects of climate change (10). 3.Impacts of the climate crisis 3.1.Impacts on physical health 3.1.1. Heat waves and respiratory diseases: Climate-related heat waves contribute to a rise in asthma and various respiratory illnesses, with children being the most affected group (11). Extreme temperatures not only cause dehydration and heat-related illnesses but also exacerbate existing respiratory problems (12). Due to their developing respiratory systems, children are more vulnerable to these effects (13). In addition to this sensitivity in respiratory health, children’s nutritional conditions are also directly affected by the climate crisis.
THREATS AND IMPACTS OF THE CLIMATE CRISIS ON THE NEW GENERATION 45 3.1.2. Nutrition and food security: Climate change reduces agricultural productivity through rising temperatures and altered precipitation patterns, which in turn raises food prices and increases the risk of malnutrition among children (14,15,16). Children living in particularly vulnerable regions are more frequently affected by stunting, wasting, and anemia, with malnutrition rates projected to increase by 20% by 2050 (14,17). In addition to nutritional problems, climate change also accelerates the spread of infectious diseases. 3.1.3. Spread of infectious diseases: Rising temperatures and humidity associated with climate change improve the living conditions of vectors such as mosquitoes, leading to the geographic expansion of diseases like malaria, dengue fever, and Zika (18-20). Once confined only to tropical regions, these diseases are now observed in various parts of Africa, Asia, Europe, and the Americas (19,21). These developments have resulted in an increase in case numbers and an estimated additional 250,000 deaths annually (19). Consequently, the processes triggered by climate change place a significant burden on public health systems, making it essential to develop more effective monitoring and intervention strategies (18,22). Nevertheless, it should also be recognized that biological and sociological variables play a determining role in the dynamics of these diseases. 3.2.Psychosocialandmentalhealthımpacts 3.2.1. Climate anxiety (Eco-Anxiety): It is increasingly recognized as a mental health problem among younger generations. Awareness of environmental crises creates feelings of uncertainty and helplessness about the future, thereby increasing the risk of depression, anxiety, and sleep problems (23,24). Direct exposure to climate-related disasters exacerbates this anxiety, negatively affecting psychological adjustment (4,5). In addition, age, gender, and socioeconomic conditions are among the factors that intensify the severity of eco-anxiety (25). On the other hand, eco-anxiety can, in some cases, motivate young people to engage in environmental actions, thus acting as a trigger for positive activism (25). Moreover, direct exposure to disasters can also lead to other mental health problems in youth. 3.2.2. Trauma and mental health: Children directly exposed to disasters such as floods, fires, and storms frequently experience post-traumatic stress disorder (PTSD), depression, and sleep problems. For example, following Hurricane Katrina, 36.9% of children were found to have moderate-to-severe
46 CURRENT ISSUES IN NURSING I PTSD symptoms, while 23.6% exhibited mild symptoms (26). Research further indicates that PTSD and depression often co-occur, which complicates the recovery process (27). Sleep disturbances are also highly prevalent; after an earthquake, 57.9% of children were reported to have sleep problems, which showed a bidirectional relationship with PTSD (28,29). Early psychological interventions, particularly cognitive-behavioral therapy (CBT) along with strong family and community support, are critical in reducing long-term mental health consequences (28). In addition to these psychological problems, the climate crisis also leads young people to experience hopelessness regarding their educational and career goals. 3.2.3. Pessimism about the future: The climate crisis creates uncertainty in young people’s educational and career plans, thereby reducing their life satisfaction. Climate-related disasters and infrastructure damage disrupt learning processes and lower students’ motivation (30). The widespread prevalence of climate anxiety negatively affects self-esteem and mental well-being in 42% of students (31-33). Furthermore, uncertainty regarding career opportunities deepens this sense of pessimism (32). However, the impacts of climate change are not limited to the psychological domain; they also pose serious threats in socioeconomic spheres. 4. The Dimension of education and awareness: The intersection of education, awareness, and youth environmental sensitivity plays a critical role in combating the climate crisis, particularly for younger generations. School closures due to climate-related disasters disrupt learning processes and distance children from education. Nevertheless, climate change education (CCE) is of vital importance in equipping young people with the knowledge, skills, and ethical frameworks necessary for sustainable practices. Holistic climate justice education, by integrating intergenerational, sociocultural, and economic dimensions, addresses students’ emotional responses to climate threats and strengthens civic engagement (34,35). At the same time, this crisis has triggered youth activism: schools have become spaces of civil disobedience where young people defend their right to participate in climate discourse and demand action from policymakers (36). Global movements such as Fridays for Future demonstrate how education and activism reinforce each other, empowering youth to hold decision-makers accountable and encouraging them to take leadership in the fight against climate change (37).
THREATS AND IMPACTS OF THE CLIMATE CRISIS ON THE NEW GENERATION 47 However, unequal access to resources and institutional resistance can hinder the effectiveness of these initiatives. Therefore, the implementation of inclusive strategies that empower young people is of critical importance for building a sustainable future. 5.Conclusion The climate crisis constitutes a multidimensional threat that shapes not only the current living conditions of younger generations but also their future health, education, and social opportunities. The literature demonstrates that physical risks such as rising temperatures, nutritional problems, and the spread of infectious diseases combine with psychosocial impacts, including eco-anxiety, post-traumatic stress disorder, and depression, to significantly undermine young people’s well-being. In addition, disruptions in educational processes and socioeconomic inequalities increase the risk of intergenerational injustice. This highlights both risks and solutions; youth participation in tackling the climate crisis depends on climate literacy, justice-based education, and active engagement. In this context, educational institutions and civil society must both strengthen young people as resilient individuals and support their active involvement in decision-making processes. In doing so, it will be possible to build not only more resilient individuals but also a more just and sustainable society in the face of the climate crisis. References 1. Eichinger M, Andreas M, Hoeppe A, Nisius K, Rink K. Kinderund Jugendgesundheit in der Klimakrise. Monatsschr Kinderheilkd. 2023;171(2):114123. doi:10.1007/s00112-022-01685-4 2. Holzinger D. Auswirkungen der Klimakrise auf die Gesundheit und Entwicklung von Kindern und Jugendlichen. Kindh Entwickl. 2024;33(4):203213. doi:10.1026/0942-5403/a000464 3. Reichelt P, Schumacher A, Meyer N, Zenclussen AC. Climate change and child health: The growing burden of climate-related adverse health outcomes. Environ Res. 2025;122502. doi:10.1016/j.envres.2025.122502 4. Sanson A, Bellemo M. Children and youth in the climate crisis. BJPsych Bull. 2021;45(4):205-209. doi:10.1192/bjb.2021.16 5. Peter F, Dohm L, Krimmer M. Psychische Konsequenzen der Klimakrise. Monatsschr Kinderheilkd. 2022;171(2):130-137. doi:10.1007/s00112-02201670-x
48 CURRENT ISSUES IN NURSING I 6. Ghannam R, Bhatti S, Ameer A. Climate Change and Education in Lowand Middle-Income Countries (LMICs): A Systematic Review. 2025. doi:10.35542/osf.io/hvf4s_v1 7. Thiede BC. Children’s health and well-being in a changing climate. In: Climate Change and Health. 2024:164-175. doi:10.4324/9781003291206-13 8. Dias R. The complex interconnectedness of climate change and social inequality. Harmony Knowl Explor Interdiscip Synergie. 2024;1(1):119-130. doi:10.56238/sevened2023.006-119 9. Sanson A, Burke SEL. Climate change and children: An issue of intergenerational justice. In: Climate Change and Children. Cham: Springer; 2020:343-362. doi:10.1007/978-3-030-22176-8_21 10. Hacısalihoğlu A, Balcı S. İklim Değişikliğinin Çocuk Sağlığına Etkisi ve Çözüm Önerileri. Artuklu Int J Health Sci. 2023;3(1):93-97. doi:10.58252/ artukluder.1180448 11. Paoletti G, Costanzo G, Eigenmann P, Kalayci Ö. Environmental influences on childhood asthma: Climate change. Pediatr Allergy Immunol. 2023;34:e14011. doi:10.1111/pai.14011 12. Castillo C. Climate change impacts on children’s respiratory health. Curr Opin Pediatr. 2023;35(3):350-355. doi:10.1097/mop.0000000000001253 13. Iragamreddy VR. The impact of climate change on pediatric respiratory health: A global call to action. World J Biol Pharm Health Sci. 2025;21(1):3335. doi:10.30574/wjbphs.2025.21.1.1107 14. Nelson GC, Rosegrant MW, Koo J, et al. Climate Change: Impact on Agriculture and Costs of Adaptation. Washington, DC: International Food Policy Research Institute; 2009. 15. Kurashvili B, Siphrashvili T, Bochorishvili A, Machitadze M. Effect of climate change on children’s nutrition. J Exp Clin Med. 2023;4:41-48. doi:10.52340/jecm.2023.04.41 16. Otorkpa OJ, Yusuf AM, Aborode AT. Climate and conflict-induced child nutrition crisis in Sub-Saharan Africa. Confl Health. 2024;18(1):6. doi:10.1186/ s13031-024-00621-5 17. Mahapatra B, Walia M, Rao CAR, Raju BMK, Saggurti N. Vulnerability of agriculture to climate change increases the risk of child malnutrition: Evidence from a large-scale observational study in India. PLoS One. 2021;16(6):e0253637. doi:10.1371/journal.pone.0253637 18. Zhang Y. Impact of climate change on transmission patterns of infectious diseases and public health responses. Highlights Sci Eng Technol. 2024;123:71-76. doi:10.54097/p7328k87
NEW TRENDS IN FAMILY HEALTH AND VOLUNTARY CHILDLESSNESS . . . 55 increase in income (17). In another study, it is stated that longer education increases the opportunity cost of having children and, consequently, reduces fertility. Costs of raising children differ between rural and urban areas, with these costs being lower in rural areas, and therefore, fertility is higher in rural areas than in urban areas (18). Fertility is decreasing in many societies. People are living longer, large cohorts are advancing into older ages, and thus, the share of the elderly in the global population is increasing. Population/society aging has two fundamental dimensions, both positive and negative, whether at the global or national level. The positive aspect of population aging can be considered the fact that advancements in health, technology, economic, and social welfare have led to a decrease in mortality rates and, consequently, an increase in the proportion of the elderly population. The negative aspect of population aging is addressed in terms of its potential threat to the continuity and functioning of society and its potential for threats to the future of that society. The literature emphasizes that population aging, often seen as a result of a slowdown in mortality rates and a decrease in birth rates, is a global problem (19). Fertility rates in Türkiye have been declining significantly in recent years. According to data from the Turkish Statistical Institute, the total fertility rate, which was 2.38 in 2001, has fallen to 1.48 by 2024 (20). The decline in fertility rates is a complex phenomenon that can be explained not only by individual preferences but also by economic, sociocultural, and structural factors. Empirical studies in Turkey show that fertility decisions are associated with various variables, such as women’s education level, labor force participation, income level, age at marriage, level of urbanization, and access to care services (21). Especially among working women in Türkiye, fertility concerns are shaped by social, economic, and cultural factors. These concerns can have a significant impact on their commitment to work and overall job performance. However, in Türkiye, women not only take the responsibility of childbearing but also have primary responsibility for housework and child rearing (22,23). In Turkish society, where traditional values are strong, women’s social identities and status are largely defined through marriage and motherhood. Which is also one of the main causes of intense social pressures to have children, which in turn lead to fertility concerns (22). While the perception of childhood in Turkish society has changed from the ancient Turks to the Republican era, particularly under the influence of modernization, there are some unchanging elements in the cultural landscape
56 CURRENT ISSUES IN NURSING I related to childhood and parenting. The most prominent of these is the joyful and warm welcome given to the birth of a child and the identification of the child with the language of love since ancient Turkish history. Another constant in Turkish society’s perception of childhood and parenting is the expectation of obedience from children. This expectation of obedience seems to lead parents to raise their children with both love and authoritarianism. From this perspective, a child’s obedience is directly proportional to the authoritarian parenting style, which is thought to be related to the child’s economic value within the family like providing labor for the family and providing care for the family in old age (24, 25). In a study from 1975 by Kağıtçıbaşı with the title “The Value of the Child: Values and Fertility in Turkey,”(1975) determined that parents’ perceptions of children, particularly their expectation of a boy, were related to the child’s economic value. Another finding related to this perspective was that parents raised their children with an authoritarian attitude, expecting them to care for and obey them (25). The meaning attributed to children within the family institution in Turkey has clearly shown some shifting trends, particularly with rising education levels and changes in women’s social status. Furthermore, it has been observed that as parents’ socioeconomic and educational levels increase, the emphasis on the traditional meaning attributed to children decreases, and there are also diversifications in views (26). 4. Definition of Voluntary Childlessness / Childfreeness Childlessness is defined as the absence of children in an individual’s life. This situation is also defined as childfreeness. This can be considered involuntary when an individual is unable to have children due to known or unexplained medical reasons, infertility problems. However, this situation can also be the person’s free choice, which is nowadays becoming more prominent among young women and women. In summary, “childlessness” can be considered voluntary when a person deliberately chooses not to have children (27). Researchers define voluntary childlessness as women of childbearing age who are still fertile but have no intention of having children. Another group of women also chose to undergo sterilization. Women who past childbearing age, no longer fertile, and choose not to have children (28,29). The decision to have children is a complex, involving various social processes and identities of an individual (30). Having children appears to be an important element of social cohesion and social organization. Childlessness can be a stigma, causing
NEW TRENDS IN FAMILY HEALTH AND VOLUNTARY CHILDLESSNESS . . . 57 numerous problems not only for partners and marital relationships but also for their social image (27). Considering the developments in public on motherhood and childbirth, childbirth became accepted as a national duty due to the significant loss during the World War I. With the industrial revolution and World War II. Women’s entry into the labor market and the labor movement, women’s posed a threat to the working class. However, women’s duties were limited to childcare and housework, and regulations were being made regarding the roles of women and mothers (2). Although not as prevalent as discussions of motherhood, being a non-mother has been a topic of discussion in feminist literature in North America and Western Europe since the 1970s, and particularly since the 1990s (14). At that time, not having children was seen as a contradiction (30). In the 19th century, childless women began to be defined as problematic individuals experiencing psychological distress, while motherhood was portrayed as a path to happiness and personal fulfillment (2). Furthermore, with policies encouraging more children in the 2000s, women still prioritize fertility. Traditional thinking defines men by what they are, while women are defined by their “fertility.” In traditional Turkish families, Turkish women are blessed with motherhood and encouraged to give birth. In societies where traditional gender stereotypes prevail, a woman’s status in family life rises, particularly after giving birth to a son (2). 4.1. Reasons For Preferring Childlessness/Childfreeness The rise of childlessness among women is associated with macro-level changes shaping marriage, family, and work life, including higher education levels, older marriage age, increased participation in the paid workforce, greater access to contraceptives, and increased individualization (14, 29). Involuntary childlessness, the inability to become a mother despite being desired due to physiological reasons, is often viewed as a physical defect or even an illness. While involuntary childlessness, medicalized as infertility, is more socially acceptable because it is treatable, voluntary childlessness is associated with immaturity, selfishness, irresponsibility, and unfemininity (31-34). Therefore, when it comes to voluntary childlessness, questions such as who chooses to be childless, reasons for this choice, and confronted stigma are also raised (14, 35, 36). Various stereotypes are often attributed to childless women, such as being psychologically dissatisfied or maladjusted, unfeminine, anti-children, selfish
58 CURRENT ISSUES IN NURSING I and less warm, emotionally troubled, cold and materialistic, and voluntarily violating a strict rule regarding motherhood and care for children (14, 28). Given that this social norm is directed at mothers, the question of why someone chooses not to have children is particularly relevant to women in cultures where pro-natalist discourses are dominant and the construction of a feminine identity is synonymous with motherhood and motherhood (28). Many studies have reported additional factors. Like preferring to be free from the economic responsibilities of child care (28). Additionally, to be free, pursue careers, and wish to focus on themselves. Negative impact on marital harmony, lack of maternal instinct, lack of a compelling reason to have children, and perceived or real inability to be a parent, and the desire to reduce concerns about world population growth are reasons for remaining childless (28, 29). 4.2. Childlessness and Stigma In a social world where having children is the prevailing norm and consciously choosing to remain childless contradicts many social norms, the impact of this decision on individuals is of great significance. Individuals who consciously choose not to have children have reported being perceived negatively by society, facing pity and criticism, being accused of being too preoccupied with work, and being seen as selfish, cold, and materialistic (3). It is known that women who voluntarily remain childless are socially excluded, stereotyped, and stigmatized (37). Voluntarily childless individuals employ numerous coping strategies to combat these negative stereotypes and social pressures. Some individuals conceal their true beliefs by claiming to be infertile or postponing having children for now. Individuals who employ this strategy often express discomfort with revealing their conscious decision not to have children, so when the topic is broached, they dismiss it with a simple “maybe someday.” Similarly, some voluntary childless individuals appear to conform to social norms by concealing their true views, citing reasons such as considering adoption, postponing childbearing until they reach a certain goal related to their education, career, or financial situation, or being infertile (3, 32). Another explanation of not wishing to have children is the idea of not everyone has to be a parent. The only way to children care is not to bring them into the world biologically, and that not bringing new children into the world is actually an altruistic act (32). Some volunteers who are childless are also taking on an educational role, working to break down the negative stereotypes faced by childless volunteers and to organize. These individuals, who consciously choose
NEW TRENDS IN FAMILY HEALTH AND VOLUNTARY CHILDLESSNESS . . . 59 not to have children, are increasingly communicating with each other online or through social media, striving to gain social acceptance for their lifestyles (3, 32, 38). Women are held primarily responsible for making reproductive decisions and, consequently, for the negative consequences of not being a parent. It demonstrates that childless women are subject to stigma not only for not having children but also for their lack of desire to have them. Because motherhood is perceived as normative or “good” femininity in dominant narratives, childless women are subject to stigma and marginalization. Research shows that women who cannot express their gender authentically as mothers are viewed as “failed,” diminishing their power in society. Thus, voluntarily childless women are portrayed as unnatural and abnormal (4, 39). However, studies analysing the gendered nature of stigma have revealed that men and women face different responses due to their childless identities. For example, when women request sterilization procedures, they face unique stigma during medical consultations, with doctors recommending they deny access to the procedure based on pronatalist assumptions that women will later regret their decision (4, 40, 41). As a result, it is known that women who voluntarily remain childless are socially ostracized, stereotyped, and stigmatized. Women who voluntarily remain childless are most often stigmatized by being told they will change their minds, warned they will regret their choices, perceived as unfeminine, and accused of selfishness. To counter this stigma, individuals who remain childless have developed coping strategies, such as claiming they are infertile, that they are postponing childbearing for the time being, and that childbearing is not a woman’s sole duty (3, 32, 37, 38). 5. Family Health and Community-Based Family Health Centers Family health is defined as the overall health and well-being of family members, influenced by life stages, health needs, social inequities, and the responsibilities of society and health systems to support families in maintaining health and preventing disease. Family health issues encompass various phases, including marital status, fertility and pregnancy, infancy, childhood, adolescence, adulthood, and old age, as well as the relationships among family members. Each phase has specific health risks in which prevention and other health services play an important role (42). Family health is defined as a concept that encompasses maintaining overall well-being by ensuring that members are healthy and focused on their goals at
60 CURRENT ISSUES IN NURSING I the highest level of functional capacity. The construct of family health lacks consensus and precision. Analysis of family health must include both health and illness simultaneously, as well as the individual and the collective. They underscore the growing evidence that the stress of a family member’s serious illness exerts a powerful influence on family function and health, and that families’ behavior patterns or reactions to the illness influence the individual family members. The World Health Organization (WHO) defines “health” as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity. This definition applies to individuals as well as to families. The term “family health” is often used interchangeably with the terms “family functioning,” “healthy families,” or “familial health.” To some, family health is the composite of the physical health of individual family members, because it is impossible to make a single statement about the whole family’s physical health. Optimally functioning families show the following: ● Consistently demonstrate high degrees of capable negotiation skills in dealing with problems ● Are clear, open, and spontaneous in their expression of a wide range of feelings, beliefs, and differences ● Are respectful of members’ feelings ● Encourage the autonomy of their members ●Expect members to take personal responsibility for their actions ● Demonstrate closeness and warmth toward each other, with parents taking the leadership ● Express optimism and enjoyment with each other (43) However healthy families have a number of characteristics in common ● A legitimate source of authority, established and supported over time ● A stable rule system established and consistently acted on ● Stable and consistent sharing of nurturing behavior ● Effective and stable child-rearing and marriagemaintenance practices ●A set of goals toward which the family and each individual work ● Sufficient flexibility and adaptability to accommodate normal developmental challenges as well as unexpected crisis ● Commitment to the family and its individuals ● Appreciation for each other (i.e., a social connection) ● Willingness to spend time together ● Effective communication patterns
NEW TRENDS IN FAMILY HEALTH AND VOLUNTARY CHILDLESSNESS . . . 61 ● A high degree of religious/spiritual orientation ● Ability to deal with crisis in a positive manner (i.e., adaptability) ● Encouragement of individuals ● Clear roles (43) Thus, healthy families are both an ideal and a reality. Among these listed points, “Effective and stable child-rearing and marriage maintenance” is one of the main items, also in cultural and social practices. To be seen as a family, “child rearing” is seen as an important role (44). 5.1. Community-Based Family Health Centers Family Health Centers stand out among all family-focused initiatives. These centers are community-based and easily accessible for all ages. As part of the health transformation program in the Türkish health care system, family health centers are basic health care centers at the primary health care level. This transition began in Düzce province in 2005. The Family Medicine Practice Regulation came into effect in 2010, and the family medicine system was implemented in all 81 provinces. The 2015 Community Health Center and Affiliated Units Regulation established the framework and procedures for preventive health services provided to our community (45-47). Services Provided at the Family Health Center are as follows; · Outpatient Clinic Services · Preventive Health Services · Monitoring for Women Aged 15-49 · Monitoring for Pregnant and Postpartum Women · Monitoring for Babies and Children · Obesity Monitoring · Family Planning Services · Injection and Dressing Services · Testing and Analysis Services Family planning (FP) is a practice that allows individuals to prevent unwanted pregnancies, regulate the interval between pregnancies. Have the desired number of children when they want, and enable childless individuals to have children. Individuals’ knowledge about FP methods and access to FP methods significantly influence the decision to use contraception and also
62 CURRENT ISSUES IN NURSING I their choice of method. Individuals have the right to decide the number of children they want and when they want to have them. FP services are provided to individuals to enable them to make informed and free decisions about their fertility (48). Reproductive/sexual health rights are included among individual rights and concern both genders. All people have the right to easily accessible and high-quality reproductive health services. “Deciding whether to have children” is also among reproductive health rights. One of the crucial factors in individuals exercising their right to decide whether to have children is access to contraceptive methods and the ability to use these methods effectively through proper counseling (49). In recent years, developments in family planning and reproductive technology and increased participation of women in the workforce have led to a decline in childbearing rates (3). Whether to have children is a decision that should be left to the free will of individuals, as is the decision not to have children. Just as society supports those who choose to have children, it should also support those who choose not to. Midwives and nurses, especially those working in primary care settings, should offer family planning counseling services and provide the necessary counseling to individuals who voluntarily choose not to have children. They should inform individuals about family planning methods they can use for longer periods of time, leaving the final decision up to them (50, 51). 6. Conclusion In conclusion, society is dynamic. Social changes and trends within society must be considered in all areas, including health. The field of health is affected by economic and social changes and trends. The increasing preference for childlessness in recent years, for various reasons, is among these changes. Concepts such as the duties, responsibilities, and expectations attributed to women within society, the definition of family, the importance placed on children, and the purpose of marriage all influence this situation. These characteristics should be taken into account in the provision of health services. Thinking and living differently from the majority of society often leads to social pressure. It is important for healthcare professionals working in family health centers, which are often within walking distance of all individuals, to conduct comprehensive individual assessments and diagnoses, providing an unbiased, unbiased diagnosis in each area, without incorporating individual biases.
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SPIRITUAL WELL-BEING IN NURSING 71 poor spiritual well-being experience mental health issues such as anxiety disorders and depression. They encounter situations such as hopelessness and meaninglessness, struggle to cope, and face consequences that can lead to suicide. In contrast, they found that individuals with high spiritual well-being had hope for life, found meaning in life, were satisfied, had self-confidence, coped more effectively with crises and were healthier psychologically and mentally. Furthermore, it has been reported that these individuals believe in a higher power and strive to turn a crisis into a positive experience. This enables them to cope with the situation and feel better about themselves. (22) Another study reported that spiritual well-being enables people to lead fulfilling lives, live in peace and harmony, and establish harmonious relationships with others. (23) A study by Özgenel et al. (2020) reported that individuals who have attained spiritual wellbeing are extremely satisfied with life. They are self-actualised individuals who derive fulfilment from their relationships with God, a higher power, themselves and their surroundings. (25) Another study reported that spiritual well-being is crucial for effectively managing death anxiety and reducing the fear of death, even under adverse conditions. The study also found that spiritual well-being enables individuals to overcome difficulties and increases their life satisfaction. (31) Leung et al. (2021) found that university students with high spiritual wellbeing were less likely to experience symptoms of depression, stress and anxiety. The researchers also recommended offering spiritual counselling to students experiencing psychological difficulties. (32) Gomez et al. (2003) reported that spiritual well-being can provide individuals with satisfaction, a sense of identity and wholeness, beauty and joy, contentment and love, respect and a positive attitude, inner peace and harmony, and a sense of meaning and purpose in life. (19) Juškauskienė et al. (2023) reported that spiritual well-being is the most effective quantitative indicator of the relationship between spirituality and health. It encompasses a fundamental aspect of people’s health and wellbeing. (33) Jafari et al. (2010) reported that religious and existential well-being were significant predictors of mental health, with higher scores observed in women. (24) Kerkez et al. (2023) found that second-year students taking part in the First Aid and Emergency Care Programme’s clinical practice had higher levels of depression and lower levels of spiritual well-being than students in other departments. It is also recommended that university students participate in relevant psychosocial programmes that address factors negatively affecting their mental health, and that these programmes are incorporated into school curricula. (34) A study has reported that teachers who are mentally healthy are better able
72 CURRENT ISSUES IN NURSING I to cope with stress, develop positive relationships with students and improve learning outcomes. The study also recommended that teachers receive support to integrate spirituality into their daily lives, with the aim of enhancing teaching quality and improving the learning environment. (35) Pong (2022) found that Chinese teachers who reported high levels of spiritual well-being were less likely to experience burnout. (36) According to Roychowdhury (2019), spiritual well-being plays an important role in achieving athletic excellence, acting as a buffer against a wide range of stress factors and negative behaviours. (37) Oglesby et al. (2021) found that spiritual well-being acts as a protective factor against burnout among university sports coaches. (38) Fisher (2015) reported that the most significant aspect of spiritual well-being among primary school pupils is their relationship with God, a finding that also holds true for young people and adults. (39) Smith et al. (2013) reported that spiritual well-being reduces the appeal of risky behaviour among young people, and that spiritual well-being and resilience are interrelated and ecologically linked. (40) 3. Spiritual Well-Being in Nursing It has been reported that spiritual well-being can help individuals to create meaning and purpose in their lives, improve their quality of life, influence their perception of health, and encourage compliance with treatment. (6, 41) In order for patients to have a high level of spiritual well-being, it is important that nurses also have a high level of spiritual well-being. It has been reported that nurses with high spiritual well-being cope better with stress, experience less burnout and psychological distress, enjoy a better quality of life, are more aware of their patients’ spiritual needs and contribute to their spiritual well-being by meeting these needs. (2) Kim et al. (2018) reported that intensive care nurses had moderate levels of spiritual well-being, which was significantly related to their levels of burnout. They found that nurses experiencing high levels of burnout were younger and had low spiritual well-being, and had previously experienced bereavement. It has been reported that high spiritual well-being can protect intensive care nurses against burnout and be used as a strategy to reduce and prevent it. (42) Moeini et al. (2015) reported that the spiritual well-being levels of nurses were above average. They also found that these levels showed a negative correlation with barriers to providing spiritual care. These barriers included taking on more responsibility for alleviating patients’ physical problems, as well as their own anxieties and personal issues. Another barrier was the lack of training
SPIRITUAL WELL-BEING IN NURSING 73 programmes on spiritual care. (43) Yoon (2009) reported a positive correlation between the spiritual well-being of nurses caring for cancer patients and the provision of spiritual nursing care. He found that nurses’ spiritual well-being was relatively high, while their provision of spiritual nursing care was relatively low. To provide spiritual nursing care, it has been recommended that nurses engage in greater spiritual development, receive more training regarding their responsibilities, and regularly attend church services. (44) Alquwez et al. (2021) reported that nurses’ spiritual well-being consists of four fundamental themes: trust in God, spiritual encouragement, spiritual qualities in the workplace, and spiritual development. They also reported that spirituality played a critical role in helping nurses overcome the challenges they faced during the COVID-19 pandemic. (45) Sepideh et al. (2018) found that nurses who received training in spirituality experienced improved spiritual well-being. The researchers also found a positive and significant correlation between spiritual well-being and the provision of spiritual care. (46) Another study found that the guidance, education and psychosocial support provided by nurses may contribute to the spiritual well-being of individuals with chronic illnesses. (47) A study has reported that, for immobile patients who have suffered a stroke, an increase in spiritual well-being is associated with an increase in hope. Spiritual well-being has been found to be related to physical, mental, interpersonal and social health, and spirituality has been identified as an effective coping mechanism for the psychological stress caused by physical illness. (48) Another study has reported that spiritual well-being can be a source of prosperity for individuals experiencing happiness or unhappiness, and that it can facilitate the recovery process. (12) Suliman et al. (2022) reported a positive correlation between self-transcendence and spiritual well-being among stroke patients. This suggests that strategies aimed at increasing self-transcendence should be developed for vulnerable individuals. (49) Kılıç et al. (2025) reported that spiritual well-being reduces the need for supportive care among palliative care patients, haemodialysis patients, and the elderly. It facilitates the process of adapting to illness, thereby improving overall quality of life. It has also been reported that implementing spiritual care initiatives and religious coping methods contributes to the recovery process by enhancing patients’ spiritual well-being. Spiritual well-being has been found to have a positive impact on overall health outcomes, improving patients’ emotional well-being and increasing their adherence to treatment. (41) Chen et al. (2018) reported that spiritual care provided to patients with terminal illnesses had a positive effect on their quality of life and spiritual
74 CURRENT ISSUES IN NURSING I well-being levels. (50) LI et al. (2021) reported a significant negative correlation between spiritual well-being and physical symptom distress, depression and sleep disorders in patients with chronic kidney disease. They also found that patients with better sleep quality who accepted haemodialysis treatment had higher spiritual well-being. (51) Garduño-Ortega et al. (2021) reported that spiritual well-being, as determined by its meaning and peace factors, is the main factor in improving quality of life and reducing depression levels in breast cancer survivors. (52) Sharif Nia et al. (2021) found that patients’ quality of life was influenced by their spiritual well-being and sense of hope. They also found that the religious and existential dimensions of spiritual well-being improved both hope and quality of life scores. (53) Vespa et al. (2018) reported that carers with low spiritual well-being experience a lower quality of life and exhibit problematic psychological traits, such as a low acceptance of their own emotions, an inability to connect with these emotions and self-rejection. (54) Kahraman et al. (2023) reported that the spiritual well-being of lung cancer patients had a positive effect on their perception of the disease. They stated that providing holistic care could improve patients’ perception of the disease and compliance with treatment, and that assessing their spiritual well-being levels could help identify areas for improvement. (55) Huang et al. (2025) reported that spiritual well-being levels varied among early-stage lung cancer patients and that personalised spiritual care was necessary to address these variations. Furthermore, it has been reported that providing comprehensive social support can increase patients’ spiritual well-being and improve clinical outcomes. (56) 4. Conclusion To provide holistic care to patients and the injured, it is necessary to assess their spiritual well-being. Nurses must first understand their own spiritual perceptions before assessing the spiritual needs of patients. Nurses who have a positive attitude towards their spirituality are more likely to be sensitive to and responsive to the spiritual concerns of others. Those with high spiritual well-being cope better with stress, experiencing less burnout, mental distress and sleep problems. Furthermore, nurses who derive greater satisfaction from life become more aware of their patients’ spiritual needs. Recognising these needs enables nurses to contribute to patients’ spiritual well-being by meeting them. Patients who feel good spiritually may experience an increase in hope and quality of life, and may adapt better to illness and treatment processes.
SPIRITUAL WELL-BEING IN NURSING 75 They may also experience improvements in emotional well-being, sleep quality and mental health issues such as depression. In this regard, it would be highly valuable for nurses to increase their knowledge of spirituality and spiritual well-being, focus more on spiritual development and receive training in spiritual care and responsibilities. In this regard, increasing nurses’ knowledge of spirituality and spiritual well-being and encouraging them to pursue further spiritual development, providing them with more training on spiritual care and responsibilities, incorporating spirituality modules into the nursing curriculum, integrating spiritual assessment into holistic nursing care plans, and expanding spiritual support programs in hospitals and care centers conducting more research on spiritual well-being in the nursing field is highly valuable. References 1. Erer MT, Akbaş M, Yıldırım G. Hemşirelik sürecinin evrimsel gelişimi hemşirelik süreci. Lokman Hekim Dergisi. 2017;7(1):1-5. 2. Çevik B. Sprituel iyi oluş ve hemşirelik; hemşirelerin sprituel iyi oluş durumlarının hasta bakımına ve kendilerine yansımaları. Gazi Sağlık Bilimleri Dergisi. 2022;7(2):111-117. 3. Bayındır SK, Biçer S. Holistik hemşirelik bakımı. İzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi. 2019;4(1):25-29. 4. Gönenç İM, Akkuzu G, Altın RD, Möroy P. Hemşirelerin ve ebelerin manevi bakıma ilişkin görüşleri. GÜSBD. 2016;5(3):34-38. 5. Gedik MS, Akben S, Mangır L. A rare case of severe cutaneous reaction associated with high-dose quetiapine in the emergency department. Eurasian J Tox. 2025;7(2):37-39. 6. Tirgari B, Khaksari M, Soltani Z, Mirzaee M, Saberi S, Bashiri H. Spiritual well-being in patients with chronic diseases: A systematic review and meta-analysis. Journal of Religion and Health. 2022;61(5):3969-3987. 7. Bahadır-Yılmaz E, Şahin M, Yüksel A. Spiritual well-being and psychological well-being among hemodialysis patients in Turkey: A descriptive and correlational study. Journal of Religion and Health. 2022;62(6):4347-4362. 8. Seshadri S, Sugiura K, Mirham M, Aamodt WW, Kluger BM. Spirituality and spiritual distress in Parkinson’s disease caregivers: A scoping review. Journal of Religion and Health. 2023;62(6):4222-4243. 9. Koç S, Güler H, Koç R. Aile danışmanlığında spiritualitenin yeri. Journal of Health Sciences Institute. 2023;8(1):65-72.
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CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 87 and missed follow-up visits may lead to delayed detection and management of complications. Experiences from the COVID-19 pandemic have underscored the profound impact of such disruptions on chronic disease management (27,28). 3.2. Patient Safety For individuals with chronic diseases, patient safety during disasters and epidemics encompasses several critical components, including medication management, infection control, the safe use of medical devices, verification of patient identity, and the continuity of care (16,27,28). The prioritization of these elements varies across the different phases of the disaster cycle. Both before and after disasters, comprehensive medication reconciliation processes should be undertaken, current medication inventories developed, emergency medication plans established, and alternative supply sources identified. Patients dependent on medical devices such as oxygen concentrators or CPAP/BiPAP machines should be registered in advance, and arrangements for portable power sources and oxygen supply contracts should be secured prior to potential disaster events (22,29). During this phase, educational initiatives for citizens and patients should be implemented, focusing on infection prevention practices such as proper hand hygiene, appropriate labeling and storage of respiratory therapy equipment, and adherence to vaccination recommendations (28). A common observation during the acute phase following a disaster is the loss of medications and medical records. Findings from investigations into the 2023 Kahramanmaraş earthquakes indicate that such circumstances increase the likelihood of administrative and clinical errors. However, the implementation of nurse-issued rapid medication information cards, complemented by brief medical records, can significantly mitigate this risk (6,30). During this critical period, strict adherence to field infection control protocols and the maintenance of sanitation services are essential particularly in mass accommodation settings (27,28). Accurate verification of patient identity through triage wristbands, identification documents, and concise medical summaries is also crucial to prevent errors, especially when conventional data management systems are compromised (16,23). Ensuring continuity of care and restructuring follow-up plans are vital for maintaining patient safety throughout the recovery process. The standardization of tele-triage protocols, the use of portable patient summaries, and effective communication with mobile healthcare teams facilitate the delivery of
88 CURRENT ISSUES IN NURSING I sustainable, safety-oriented care (22,27,28). Moreover, nurses must account for the indirect effects of psychosocial stress on patient safety and foster a culture of safety at both the societal and individual levels by educating patients about early warning signs and self-monitoring practices (30). 4. Management by Chronic Disease Type 4.1. Diabetes and Metabolic Disorders The management of diabetes and metabolic disorders during epidemics and disasters is associated with an increased risk of morbidity and mortality due to disruptions in healthcare services and alterations in living conditions. Exposure to disasters has been linked to adverse cardiometabolic outcomes, including poor glycemic control, hypertension, and obesity. These effects are mediated by heightened physiological stress responses, restricted access to healthcare services, and interruptions in the continuum of care (8,31). Accordingly, nursing care for individuals with diabetes must be carefully structured and implemented within competency-based plans across all phases of the disaster cycle (32). Prior to disasters, nurses should assist individuals with diabetes in preparing personal emergency kits, ensuring adequate medication supplies, and maintaining cold-chain integrity for insulin storage. Emergency preparedness should include at least a 14-day medication and insulin plan, with regular replenishment of supplies stored in waterproof containers (33-35). An accessible medical summary detailing diagnoses, medications, allergies, and previous interventions should be maintained for rapid reference. Nurses also play a vital role in patient education, emphasizing food hygiene and basic food safety principles during emergencies. Individualized nutrition plans should be developed for the first 72 hours following a disaster and for the subsequent recovery period, taking into account each patient’s energy, fluid, and micronutrient requirements (36,37). Nurses collaborate with transient distribution points and pharmacies to reduce disruptions to medication access and to ensure the safe prioritization of therapeutic alternatives. (38,39) Insulin must be kept below 25°C if access to a refrigerator is not possible, for up to four weeks. Frozen or degraded insulin must under no circumstances be used. (40) Glucometers, test strips, and glucagon and ketone strips must be easily accessible in the kit for the treatment of hypoglycemia and hyperglycemia. In disaster locations in Turkey,
CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 89 it is desirable to be able to access prescription medications through the use of the “484 Natural Disaster Warning Code” and Turkish Republic ID number for practical convenience. (41) Following a disaster, the activities of nursing mostly focus on restoring the continuity of care and preventing complications. However, the wider economic impact of the disaster, combined with access to medications and medical equipment at the individual level, creates serious risks for the continuation of treatment. (3) In this context, the use of triage and continuous glycemic control is necessary. As access to fresh food is enhanced through nutrition support, it is important that individualized diet plans be adjusted similarly. Educational projects and counseling should also continue during the post-disaster period to reinforce individuals’ self-management abilities. Furthermore, diabetes units should take up standard procedures with respect to monitoring, treatment, and teaching during the acute, subacute, and rehabilitation phases. (40) The standard recommended content is summarised in Table 1. (33-35,42) Table 1. Disaster and Pandemic Emergency Kit Items for Diabetics Category Suggested Content Drugs and Medical Supplies ● Sealed bottled water and pre● cooked ready-to-eat nonperishable food for the first 72 hours ● At least two-week supply of prescription medications. ● Over-the-counter products (e.g., analgesics, antacids, and vitamin supplements) Diabetes-related needs ● Pump supplies and insulin for 14 days ● Test strip, glucometer, lancets, batteries ● Reader/cgm sensor ● Ketone test strips ● Hypoglycemia kit (glucose tablets/gels, juice, and glucagon) ● Heat-insulated insulin carrying case ● Antiseptic pads/cotton wool ● Smartphone application or logbook of measurements ● Sharps box Additional emergency provision ● Flashlight and batteries, battery-powered radio, first aid kit, protective clothes and shoes, hygiene items, identification and brief medical abstract, and prescription printouts.
90 CURRENT ISSUES IN NURSING I 4.2. Cardiovascular Disorders The management of patients with cardiovascular disease (CVD) during disasters and epidemics requires an integrated, multidisciplinary nursing approach that encompasses all phases of the disaster cycle. Deterioration in living conditions, interruptions in access to essential medications, and heightened psychosocial stress can substantially increase the risk of acute coronary syndromes, stroke, and exacerbations of heart failure (43-45). In the pre-disaster phase, nurses play a pivotal role in ensuring that individuals with CVD possess personal emergency kits containing their daily medications and copies of their prescriptions. In accordance with the World Health Organization’s Interagency Emergency Health Kit (IEHK, 2024) and Noncommunicable Diseases Kit (NCDK, 2022) guidelines, these kits should include life-saving antihypertensive, antianginal, and antithrombotic agents, as well as validated monitoring equipment such as blood pressure monitors and pulse oximeters (46,47). Equally important is patient education on home-based self-monitoring techniques, including appropriate cuff selection, resting before measurement, and consistent sequential recording of results. These practices promote patient autonomy, enhance early detection of deterioration, and facilitate continuity of care during periods of healthcare system disruption (48,49). The underlying objective of disaster care is continuation of care and treatment. It is required that nurses assess vital signs, provide supplemental oxygen in patients with hypoxemia, take a 12-lead ECG when medically appropriate, and arrange expedient transport of patients to the correct medical center. In aid of early identification of emergency medical symptoms such as acute coronary syndrome and stroke, patients and families need to be educated in early identification of symptoms. Because of logistical constraints sometimes encountered in disaster operations that can increase door-to-balloon times, nurses’ actions in expedient pre-referral and pre-assessment hold supreme importance. (43,50) Nursing procedures for the post-disaster recovery period focus on the prevention of complications and the improvement of quality of life. Models of sustainable care for this period benefit patients in the course of the long term and encourage environmental care. (11) Exercise, nutrition counseling, and stress management-based rehabilitation programs for the heart must be resumed. Psychosocial support services, including screenings for anxiety and depression and grief counseling, must also be included. (44,45Isolation precautions for
CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 91 infections must be included in care procedures for pandemics by utilizing the use of masks, hygiene procedures, ventilation, and allocation of separate flows of patients based on the advice of the WHO and CDC. (51,52) Table 2 was completed by utilizing the WHO’s IEHK 2024 and NCDK 2022 kits and advice from the literature to ensure consistency in the care of cardiovascular diseases during disasters and epidemics. (46,47,49,52,53) Table 2. Emergency Kit Material for Cardiovascular Disease Patients in Disaster and Epidemic Situations Category Suggested Content Drugs and medical supplies ● 2-4 week supply of non-specialist regular CVD medication at least ● Prescription blank pages ● Medications as needed (e.g., ● An underwater storage case for medicine Cardiovascular-related specifications ● Aspirin (in emergencies) ● Glyceryl trinitrate (nitroglycerin) ● An approved blood pressure monitor ● A pulse oximeter ● An instrument logbook or smartphone app Emergency and support supplies ●Brief medical overview (diagnoses, pharmacotherapy, and allergic reactions) ●Identification and contact information ●A basic first medical aid kit ●Adequate hydration and minor food items ●Personal protection equipment, such as masks and sanitizers. 4.3. Chronic Obstructive Pulmonary Disease and Asthma Nursing of asthma and COPD patients during disasters and epidemics must be holistic, evidence-oriented, and patient-centered to ensure that their needs are addressed. Access disruption to medications, exposure to the environment, and disruption of healthcare organizations increase the risk of morbidity and mortality in these patients’ populations. (16, 54-56) In the pre-disaster preparation period, securing inhalers and bronchodilators, portable oxygen stores, and emergency bronchodilator kits are important. Nurses should instruct patients in the use of inhaler techniques and educate them
92 CURRENT ISSUES IN NURSING I concerning emergency plans. (30,57) Patients should be counseled concerning the use of masks and safe conditions for sheltering against environmental hazards, including dust, gas, and chemicals. (54,58) Nurses can provide early bronchodilator therapy, safely maintain oxygen, monitor vital signs and oxygen saturation, and refer patients to higher treatment centers when necessary in the acute disaster phase. Emergency care for exacerbations of COPD and asthma early is particularly critical to prevent mortality. (55,56,59) Disaster relief teams and patients can be reminded to use personal protection against toxic gases that can induce acute inhalation injury. (58) For patients with chronic obstructive pulmonary disease (COPD) and asthma during the recovery period after disasters, nurses need to advocate for pulmonary rehabilitation programs to maintain respiratory function. Nurses also need to educate patients on breathing exercises and conduct clinical followups at regular intervals. Anxiousness, uncertainty, and social support loss can provoke COPD and asthma exacerbations, especially after disasters. Nurses should therefore be sensitive to psychosocial counseling and patient and family educations. These trainings enhance self-care abilities and societal resilience. (54,55) Table 3 was formulated following recommendations from sources of literature to ensure patients with COPD and asthma receive sustainable care during disasters and epidemics. (57,59) Table 3. Items for Emergency Kit for Individuals Suffering from COPD and Asthma under Disaster and Pandemic Situations Category Suggested Content Drugs and medical supplies You will need at least two weeks’ supply of systemic medications and inhalers, portable oxygen tank/concentrator, nasal cannula or adult-sized mask, analgesics, and vitamin supplements. Respiratory specific requirements Also required are SABA and maintenance (LABA, ICS) inhalers, a nebulizer and consumables, a pulse oximeter, emergency bronchodilator solutions, a filter mask, and a humidifier. Emergency and support supplies Also required are a concise medical abstract (diagnosis, medications, and allergies), personal protection equipment (mask and gloves), fundamental hygiene and first aid kits, and a rugged carrying case.
CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 93 4.4. Cancer Patients The management of cancer patients during epidemics and disasters focuses on maintaining continuity of medical treatment, minimizing infection risk, ensuring adequate pain control, and strengthening psychosocial support. Individuals with cancer are particularly vulnerable during the acute and subacute phases of disasters due to immunosuppression and disruptions in healthcare service delivery. Breakdowns in registration and communication systems, interruptions in access to care, and loss of coordination among healthcare providers can significantly increase morbidity and mortality in this patient population (60,61). Pre-disaster recommendations for individuals with cancer include maintaining up-to-date medication lists and treatment summaries in accessible formats, preparing personal emergency kits, and establishing reliable communication plans. Nurses play a crucial role in preparing patients and families to maintain treatment adherence and in providing guidance on alternative modes of care delivery, such as telemedicine and telephone counseling (62,63). It is also essential to develop alternative medication plans and ensure robust inventory management to mitigate potential disruptions in the oncology medication supply chain (64). During the acute phase of disasters, life-sustaining therapies for cancer patients must be maintained without interruption. Short-term treatment delays or protocol modifications may be considered for low-risk patients when clinically appropriate (61,62). Nurses should perform continuous assessments of analgesic care to ensure adequate pain relief, promote the safe administration of opioids, and facilitate access to comfort measures (65). At this stage, infection prevention is a top priority. Patients and their families must receive targeted education on hand hygiene, appropriate mask use, social distancing, and the correct application of personal protective equipment (PPE) (63,66). During the recovery phase, nurses should provide individualized counseling and family education to alleviate psychosocial distress and maintain patients’ quality of life. Telemedicine should be utilized not only to ensure continuity of clinical care but also to support adjuvant therapy and psychosocial counseling (60,65). The central focus of chronic care management in this context is the development of individualized follow-up plans, adherence to infection prevention protocols, and reinforcement of rehabilitation activities (67).
94 CURRENT ISSUES IN NURSING I Nurses are entrusted with key leadership responsibilities in disaster planning and response, including patient triage, coordination of multidisciplinary care, health education, and the preparation of personalized care plans. Table 4 summarizes the recommended contents of personal emergency kits to facilitate the continuity of care for cancer patients during disasters and epidemics (61,65-67). Table 4. Recommended Emergency Kit Materials for Cancer Patients in Disaster or Epidemic Situations Category Suggested Content Medicines and Medical Equipment ●Generally Administered adjunctive drug agents (antiemetics, analgesics, and cort ● Prescription drug sufficient to provide at least two to four weeks ● Supplements of vitamins and minerals ● Personal hygiene items such as soap, sanitizer for hands, and moist towelettes. Therapy-specific needs of ● Current medicine list and concise medical summary (medication diagnosis, medication protocol and allergies) ● Portable pain pump or pain management medication ●Mask, gloves, and antiseptic products for infection prophylaxis ● Port/catheter care kit when necessary Emergency and support supplies ● Identification and medical discharge paperwork. ● Phone numbers ● Long-lasting carrying case ● Thermometer and basic first aid kit -Electric power supply (portable charger or spare batteries) 4.5. Chronic Kidney Failure The management of patients with chronic kidney disease (CKD) during pandemics and disasters carries a high risk of morbidity and mortality, primarily due to disruptions in the continuity of care. Nursing care in this context underscores the critical importance of maintaining uninterrupted dialysis treatment, ensuring optimal fluid and electrolyte balance, providing appropriate renal nutrition, and implementing strict infection prevention and control measures (68,69). Experiences from the Hurricane Katrina disaster and the 2023 Kahramanmaraş earthquakes highlight the essential role of nursing education and anticipatory preparedness in safeguarding patient outcomes (70-72).
CHRONIC DISEASE MANAGEMENT IN DISASTERS AND EPIDEMICS 95 During the pre-disaster planning phase, nurses hold a pivotal responsibility for identifying alternative dialysis facilities, establishing networks with partner centers, arranging patient referrals, and ensuring readiness of personal emergency kits. In the pre-disaster warning stage, it is crucial to schedule dialysis sessions in advance to prevent extending the interdialytic interval beyond five to ten days (70). At the facility level, emergency supply boxes should be prepared, electronic health records backed up, and contingency plans for volunteer staffing developed. Additionally, ensuring the availability of reliable communication tools such as satellite phones, amateur radios, and GPS systems is vital for sustaining operations under disrupted infrastructure conditions (73). For acute care, nurses are active participants in early detection and care for fluid and electrolyte disturbances. Regular observations need to be made regarding vital signs, body weight, edema, and urine output. Where lab facilities are scarce, an ECG can be employed to screen for hyperkalemia-related change. (74) The nurse should work with doctors to synchronize emergency care decisions and educate patients with structured teachings about fluid restriction and low sodium/potassium intake. (75) One should also mention here that food rations prepared at shelters (e.g., MRE) are high-potassium and high-sodium foods. Nurses should recommend safe substitutes. (70) Nutritional management is key during this phase. The nurse should determine whether the food prepared at shelters is suitable for renal diets and promote restriction of potassium/sodiumrich products. (68,69) Special training regarding management of hypoglycemia needs to be given to patients with comorbid diabetes. Infection control is one of the key determinants influencing dialysis mortality. The nurse takes a lead in ensuring asepsis techniques are carried out at full stretch coupled with fastidious care of catheters/fistulas with adequate care for wounds and isolation practice. As exposure to contaminated water during disasters can cause catheter site infection, it is extremely vital to frequently check water quality and disinfect equipment. (70,76) The education of patients and increased ability to care for themselves during the period of recovery is a priority for nurses. Preparing individuals is crucial to preventing complications once access to dialysis services is terminated. (71) As a result, patients and their families need to be educated by nurses to assemble personal emergency kits, maintain continuation of medication, follow fluid and dietary protocols, and prevent infection. Table 5 includes a summary of recommended basic contents among patients with CKD. (70,71,73)
96 CURRENT ISSUES IN NURSING I Table 5. Materials for Emergency Kits Allocated to Patients with Chronic Kidney Failure During Disasters and Epidemics. Category Suggested Content Medicines and Medical Equipment ●Sealed bottled water for limited consumption during the first 72 hours ●Two weeks’ supply of prescription medication when possible (e.g., antihypertensives, phosphorus binding agents) ●As needed over-the-counter medications (e.g., analgesics, antacids, vitamin CKD-specific medical requirements ●ID Milano dialysis card or copy prescription 14 days’ supply of dialysis/hemodialysis equipment and peritoneal sets and PD solution) ●Emergency medications to reverse hyperkalemia (e.g., Kayexal ●Glucometer and test strips (in case you travel with diabetes) ●Antiseptic solution ● Gauze ● Catheter/fistula care kit ● Waste containers with lids Emergency and support supplies Flashlight and extra batteries; battery-powered radio; fire starter or matches and candles (in a safe area); first aid kit; raincoat and blanket and spare socks for protection; and personal hygiene aids (soaps, sanitizing gel, wet wipes, and toiletries). In addition to these items, carry identification, emergency contact information, and a concise medical summary. 6. Conclusion and Recommendation Disasters and pandemics represent critical circumstances that profoundly impact the management of chronic diseases and challenge the overall resilience of healthcare systems. During such crises, disruptions in the supply chains of essential medications and medical equipment, difficulties in accessing healthcare services, and psychosocial stressors collectively contribute to elevated morbidity and mortality rates among individuals living with chronic conditions. Nurses occupy a pivotal role throughout the phases of preparedness, response, and recovery by ensuring continuity of care, safeguarding patient safety, and fostering patients’ self-management skills. In this context, the sustainable and effective management of chronic diseases during disasters and pandemics necessitates the implementation of the following strategic and policy-oriented actions:
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105 CHAPTER VIII BEHAVIORAL ADDICTIONS Sibel POLAT OLCA1 (Assoc. Prof), İstanbul Aydın University, Department of Nursing, E-mail: [email protected] ORCID: 0000-0002-6274-6989 1. Introduction Behavioral addictions are defined as clinical syndromes characterized by an individual’s loss of control over a specific behavior, a compulsive desire to replicate the behavior, and the resultant significant impairment in psychosocial functioning, all occurring without the use of chemical substances. (1) Behavioral addictions is utilized as an umbrella term encompassing addictions that do not involve the consumption of psychoactive substances. In this context, the term represents a high-level category used to classify compulsive and dysfunctional behavioral patterns that do not necessitate the ingestion of a chemical agent. (2) Behavioral addictions are listed under substance use disorders in the DSM-5, and gambling disorder has been included as a diagnosis within the addiction framework. (3) The ICD-11 also added online gaming disorder as an independent diagnosis. (4) In recent years, the prevalence of behavioral addictions has been steadily increasing worldwide. In a meta-analysis study covering 32 countries by Cheng et al. (2021), the prevalence of social media addiction was 14.7%. (5) Gentile et al. (2017) reported the rate of internet gaming addiction in children and adolescents as 9.3%. (6) The prevalence of gambling disorder worldwide ranges from 0.2% to 5%. (7) Behavioral addictions cause serious psychological distress in individuals, such as anxiety, depression, social isolation, and decreased life satisfaction. (8) At the societal level, the effects are multidimensional, involving academic failure, loss of labor productivity, financial problems, and family conflicts. (9) The escalating rates of internet and social media addiction, particularly within the youth population, necessitate the urgent development of preventive public health strategies. (9). Recent
106 CURRENT ISSUES IN NURSING I research indicates that behavioral addictions should be examined not only at the individual level but also across societal, neurobiological, and psychosocial dimensions. (10) Specifically, brain imaging studies reveal that behavioral addictions share similar neurobiological mechanisms with substance addictions. (11) Furthermore, key areas of focus in the contemporary literature include the effectiveness of online interventions, the relationship between personality traits and addictive tendencies, and cross-cultural differences in prevalence and presentation. (12, 13) 2. Behavioral Addiction Behavioral addiction is defined as a compulsive pattern of engaging in an activity—which functions both for hedonic reward generation and relief from internal distress—marked by: (1) persistent inability to control the behavior; and (2) its maintenance even in the face of major adverse outcomes. (14) The discipline of behavioral science posits that any stimulus activity can escalate into an addiction once it transforms into a compulsive necessity (or obligation). This form of addiction is characterized by a compulsive engagement in the activity for immediate rewards, despite the presence of negative longterm costs, thereby mirroring substance dependence through its associated features of compulsivity and loss of control. Common manifestations of behavioral addiction, defined as obsessive habits that disrupt daily functioning, encompass a wide spectrum of issues. These include Gaming, Gambling, and Social Media Addiction; Internet Addiction; excessive and detrimental habits such as Shopping, Exercise, Work (Workaholism), and Sex/Porn Addiction; disordered patterns like Eating Disorders and Compulsive Skin/Hair Picking (Trichotillomania/Dermatillomania). (15) The Behavioral Addiction Theory posits that addiction extends beyond physiological necessity, emphasizing that the condition is significantly sustained and influenced by underlying cognitive and emotional mechanisms. (Griffiths, 1996). (16) Diagnostic criteria for behavioral addictions proposed by Goodman (1990) (14); Core Determinants (A) Recurrent Failure to Resist: Repeated inability (impotence) to resist the impulses to engage in the specified behavior. (B) Increasing Tension: A mounting, subjective sense of tension or affective arousal immediately preceding the initiation of the behavior.
BEHAVIORAL ADDICTIONS 107 (C) Pleasure or Relief: The experience of marked pleasure or internal relief (tension reduction) at the time of engaging in the behavior. (D) Lack of Control: A feeling of diminished control over the behavior while engaging in it, or an inability to manage its duration or intensity. Additional Clinical Criteria (Five or More Required) (E) Scope of Symptoms: The presence of at least five of the following nine indicators: 1. Frequent Preoccupation: Recurrent cognitive preoccupation with the behavior itself or with activities preparatory to the behavior. 2. Exceeding Intent: Frequently engaging in the behavior to a greater extent or over a longer period than originally intended. 3. Repeated Efforts to Control: Making repeated, yet unsuccessful, efforts to reduce, control, or cease the behavior. 4. Time Consumption: Spending a great deal of time in activities necessary for the behavior, engaging in the behavior, or recovering from its effects. 5. Obligation Interference: Frequently engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations. 6. Activity Reduction: Giving up or significantly reducing important social, occupational, or recreational activities because of the behavior. 7. Continuation Despite Harm: Continuation of the behavior despite the knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior. 8. Tolerance: The need to increase the intensity or frequency of the behavior to achieve the desired effect, or a diminished effect with continued engagement at the same intensity. 9. Restlessness/Irritability: Experiencing restlessness or irritability when unable to engage in the behavior. Duration Criterion (F) Persistence: Some symptoms of the disturbance must have persisted for at least 1 month, or have occurred repeatedly over a longer period of time. Griffiths (2005) (17) describes the structural analysis of behavioral addiction as six key criteria (components) that indicate that an activity has become a pathological compulsion: 1. Salience: The behavior becomes the preeminent event in the individual’s life, dominating their thoughts, emotions, and actions.
108 CURRENT ISSUES IN NURSING I 2. Mood Modification: The individual utilizes the activity as a means of achieving a desired psychological state, whether as a form of psychological escape (dissociation) or a way to elicit a pleasant arousal or euphoric experience. 3. Tolerance: The development of a need to increase the frequency, duration, or intensity of the behavior over time in order to achieve the same intensity of the previously enjoyed mood-altering effects or satisfaction. 4. Withdrawal Symptoms: The manifestation of unpleasant physiological and psychological discomfort—such as tension, irritability, and dysphoria— when the individual significantly reduces or ceases the behavior. 5. Conflict: The negative consequences arising from the compulsive behavior’s interference with the individual’s interpersonal relationships (e.g., family, colleagues) and/or their intrapsychic processes (e.g., internal conflicts, guilt), often leading to social withdrawal. 6. Relapse: The strong tendency for the individual to revert to the pathological pattern of the addictive behavior, even after a period of attempted abstinence or controlled engagement. (17) 2.1. Types of Behavioral Addictions According to DSM-5 and ICD-11 Behavioral addictions, a relatively new category of addiction in psychiatry, were first incorporated into the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) and officially accepted in 2022. (18) They were subsequently added to the ICD-11 (International Classification of Diseases, 11th Revision) in 2024. (19) In the DSM-5, only Gambling Disorder and Internet Gaming Disorder (online gaming) are formally recognized as behavioral addictions. In contrast, the ICD-11 has sought to expand this categorization. Currently, the behavioral addiction types included in the ICD-11 are divided into three main groups: Gaming Disorder (which includes both online and offline gaming) and Gambling Disorder (the two disorders accepted by the DSM-5), plus a category designated as “other specified disorders.” (19) There are ongoing efforts to increase the number of specified behavioral addictions listed under the “other specified disorders” category in the ICD11. (15) This push stems from the recognition that behaviors such as social media addiction, disordered eating, compulsive buying, excessive exercise, workaholism, technology overuse, and problematic sexual behaviors exhibit clinical, diagnostic, and psychopathological features consistent with behavioral addictions. (20)
BEHAVIORAL ADDICTIONS 109 2.2. Etiology of Behavioral Addictions Behavioral addictions have a multi-dimensional etiology, developing as a result of the complex interplay between neurobiological, psychosocial, cognitive, genetic, and environmental factors. (10) Therefore, adopting a biopsychosocial approach is crucial for understanding the underlying causes of these addictions. 2.2.1. Neurobiological Foundations Neuroimaging studies consistently reveal overactivation in the dopaminergic reward system in individuals with behavioral addictions. (11) Specifically, alterations have been observed in the function of brain regions such as the ventral striatum, prefrontal cortex, and amygdala.These areas are essential for regulating reward anticipation, impulse control, and decisionmaking mechanisms. (10) Brain imaging studies have shown that individuals with gambling disorder release more dopamine during gambling. (21) It has also been determined that there is increased activation in the mesolimbic dopamine system, which provides reward sensitivity, in online gaming disorder. (6) 2.2.2. Psychosocial Factors Psychosocial factors play a role in the development of behavioral addictions. Situations such as childhood trauma, family problems, lack of social support, and peer bullying increase the risk of behavioral addiction. (22) Studies have shown that the risk of social media addiction is higher in individuals experiencing social isolation, and peer pressure increases online gaming addiction. (5, 13) 2.2.3. Personality Traits and Cognitive Factors Impulsive behavior, lack of self-control, high reward and pleasure seeking, and metacognitive beliefs are risk factors for behavioral addictions. (9) Impulsive behavioral tendencies are particularly prevalent in gambling and gaming addicts. (7) A significant relationship has also been demonstrated between online gaming disorder and Attention Deficit HyperactivityDisorder (ADHD) symptoms. (23) 2.2.4. Genetic and Environmental Interactions Between 40-60% of behavioral addictions have a genetic predisposition. (24) Genetic risk alone is not a determining factor; environmental influences are also crucial in the development of this risk. Epigenetic studies indicate that stressors affect dopamine receptors and may thus increase the risk of addiction.
110 CURRENT ISSUES IN NURSING I Therefore, the development of behavioral addictions is associated with the interaction of genetic predisposition and environmental factors. (11) 2.3. Epidemiology of Behavioral Addictions It is stated that the prevalence of behavioral addictions worldwide is between 5% and 20%. (22) A systematic review and meta-analysis encompassing 94 studies from forty countries (N=40), with a total of 237,657 participants, reported an overall prevalence rate of behavioral addiction at 11.1%. These meta-analytic data indicated considerable variation across addiction types: Smartphone Addiction (30.7%) and Eating Disorders (21.0%) demonstrated the highest prevalence, while Social Media Addiction (15.1%), Internet Addiction (10.6%), Sex Addiction (9.4%), Gambling (7.2%), Shopping Addiction (7.2%), and Exercise Addiction (7.0%) also represented significant public health concerns. Video Gaming addiction was reported to have the lowest specific prevalence rate at 5.3%. (25) The global prevalence of Gambling Disorder in the adult population ranges from 0.2% to 5%. (7) Studies conducted in Australia, Canada, and the United States report rates exceeding 2%. While rates in European countries are typically around 1%, they appear to be lower in Asian societies. (11) Online gaming addiction is rapidly increasing globally, particularly among children, adolescents, and young adults. Gentile et al. (2017) reported the rate of gaming addiction among children and adolescents in the US as 9.3%. (6) A meta-analysis by Zhuang et al. (2023), covering 14 countries, found the average rate in adolescents to be 8.5%. (13) Studies among university students have reported rates of online gaming addiction reaching up to 12%. The prevalence of gaming addiction is significantly higher in males compared to females. (5) According to the meta-analysis by Cheng et al. (2021), which covered 32 countries, the global prevalence of social media addiction was found to be 14.7%. This rate exceeds 20% in Asian countries, while it is reported to be around 12% on average in European countries. (5) Females are at a higher risk of social media addiction compared to males, and the time spent on social media is rapidly increasing, particularly among adolescents and young adults. (9) 3. Gambling Disorder Gambling Disorder is the first behavioral addiction category defined and formally recognized in the DSM-5. (3) This disorder is characterized by the individual’s inability to control their gambling behavior, which results in significant impairment in social, occupational, and psychological functioning.
BEHAVIORAL ADDICTIONS 111 Gambling addiction develops through the interaction of impulsivity, rewardseeking, psychosocial stressors, and neurobiological mechanisms. (11) According to the DSM-5, Gambling Disorder shares similar features with substance use disorders and is categorized within the addiction spectrum. (3) The act of gambling repeatedly stimulates the individual’s reward system, which increases dopamine release in the brain and fuels the addiction cycle. (11) The ICD-11 defines Gambling Disorder as the inability to control gambling behavior, an increase in the duration of gambling, and the continuation of the behavior despite negative consequences. (19) The etiology of gambling addiction is multidimensional, arising from the interplay of neurobiological, psychosocial, and cognitive factors. Neurobiologically, there is hyperactivation in the reward system in brain regions such as the ventral striatum, orbitofrontal cortex, and amygdala. Dysregulation in dopamine release is one of the core mechanisms that reinforce the gambling behavior. (21) Neurobiological investigations over the last two decades have demonstrated that the etiopathogenesis of Gambling Disorder involves the dysfunctional participation of a network of critical neural structures. Key brain regions implicated in this cycle include the ventral prefrontal cortices (comprising the medial and lateral orbitofrontal cortices), the medial prefrontal cortex and the adjacent anterior cingulate cortex, the striatum, the amygdala, the hippocampus, and the insula. Available data strongly suggest that functional abnormalities within these specific neural circuits correlate with impairments across various processes and functions that constitute the disorder’s clinical phenotype, such as hypersensitivity to reward and excitement, the maintenance of the hazardous pursuit known as chasing losses, dysregulation of stress systems, and pronounced socio-emotional dysfunctions. (11) Psychosocial factors include low self-regulation, stress, economic difficulties, social pressure, and childhood trauma. (22) Research indicates that individuals exposed to gambling at an early age have a significantly higher risk of addiction. (7) 3.1. DSM-5 and ICD-11 Diagnostic Criteria for Gambling Disorder According to the DSM-5, a diagnosis of Gambling Disorder requires meeting at least four of the following nine criteria within a 12-month period: 1. Preoccupation with gambling. 2. Need to increase the amount gambled to achieve the desired excitement.
112 CURRENT ISSUES IN NURSING I 3. Repeated unsuccessful efforts to control, cut back, or stop gambling. 4. Restlessness or irritability when attempting to cut down or stop gambling. 5. Gambling as a way to escape from problems or relieve dysphoria. 6. Chasing losses: gambling again to get even after losing money. 7. Lying to conceal the extent of gambling behavior. 8. Jeopardizing or losing a significant relationship, job, or educational/ career opportunity. 9. Relying on others to provide money to relieve a desperate financial situation caused by gambling. (18) The ICD-11 criteria are similar, defining the disorder by the impaired control over gambling behavior, the increasing priority and intensity of the behavior, and its continuation despite negative consequences. (19) 3.2.TheEffectsofGamblingDisorderonMentalHealth Gambling Disorder shows a high rate of comorbidity with depression, anxiety, impulse control disorders, and substance use disorders. (26) Metaanalyses indicate that 40% of individuals with Gambling Disorder experience symptoms of Major Depressive Disorder. (27) Moreover, gambling addiction leads to multidimensional psychosocial problems, including an increased risk of suicide attempts, social isolation, family conflicts, and significant economic losses. (7) 3.3. Treatment and Prevention Approaches to Gambling Disorder Treatment for Gambling Disorder commonly involves Cognitive Behavioral Therapy (CBT), motivational interviewing, group therapies, and pharmacotherapy. (20) CBT focuses on restructuring the individual’s irrational beliefs and improving impulse control. Prevention strategies emphasize public awareness campaigns, increasing financial literacy, and the implementation of early screening programs. (11) In terms of pharmacotherapy, opioid antagonists (naltrexone), SSRI antidepressants, and mood stabilizers are frequently used. Recently, online treatment programs and mobile applications have emerged as innovative methods to increase access to care. (26) Eight pharmacological agents—specifically naltrexone, nalmefene, paroxetine, fluvoxamine, citalopram, escitalopram, lithium, and topiramate— examined in a body of literature that includes both randomized controlled and open-label trials, demonstrated small to moderate effect sizes in reducing Gambling Disorder (GD) symptoms during post-hoc analyses in
BEHAVIORAL ADDICTIONS 119 13. Zhuang X, Zhang Y, Tang X, Ng TK, Lin J, Yang X. Longitudinal modifiable risk and protective factors of internet gaming disorder: A systematic review and meta-analysis. J Behav Addict. 2023;12(2):375-392. doi:10.1556/2006.2023.00017 14. Goodman A. Addiction: Definition and implications. Br J Addict. 1990;85(11):1403-1408. doi:10.1111/j.1360-0443.1990.tb01620.x 15. Thakur P, Kashyap S. Behavioral addiction: A review of current understanding and emerging perspectives. J Addict Dis. 2025;11:1-16. 16. Griffiths MD. Behavioral addictions: An issue for everybody? Employee Councelling Today. 1996;8(3):19-25. doi:10.1108/13665629610116872 17. Griffiths M. A ‘components’ model of addiction within a biopsychosocial framework. J Subst Use. 2005;10(4):191-197. 18. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev. Washington: American Psychiatric Association; 2022. 19. Mortality and Morbidity Statistics. Geneva: WHO; 2024. 20. Kervin R, Berger C, Moon S, Hill H, Park D, Kim J. Behavioral addiction and autism spectrum disorder: A systematic review. Res Dev Disabil. 2021;117:1-9. 21. Ioannidis K, Hook R, Wickham K, Grant JE, Chamberlain SR. Impulsivity in Gambling Disorder and problem gambling: a meta-analysis. Neuropsychopharmacology. 2019;44(8):1354-1361. doi:10.1038/s41386-0190393-9 22. Derevensky JL, Hayman V, Lynette Gilbeau. Behavioral Addictions: Excessive Gambling, Gaming, Internet, and Smartphone Use Among Children and Adolescents. Pediatr Clin North Am. 2019;66(6):1163-1182. doi:10.1016/j. pcl.2019.08.008 23. Hawi NS, Samaha M. Relationships of gaming disorder, ADHD, and academic performance in university students: A mediation analysis. PLoS ONE. 2023;18(9):e0300680. doi:10.1371/journal.pone.0300680 24. Yau YH, Potenza MN. Gambling disorder and other behavioral addictions: recognition and treatment. Harv Rev Psychiatry. 2015;23(2):134146. doi:10.1097/HRP.0000000000000051 25. Alimoradi Z, Lotfi A, Lin CY, Griffiths MD, Pakpour AH. Estimation of Behavioral Addiction Prevalence During COVID-19 Pandemic: A Systematic Review and Meta-analysis. Curr Addict Rep. 2022;9(4):486-517. doi:10.1007/ s40429-022-00435-6
120 CURRENT ISSUES IN NURSING I 26. Farkouh R, Audette-Chapdelaine S, Brodeur M. Pharmacotherapy and gambling disorder: a narrative review. J Addict Dis. 2024;42(4):274-288. doi:1 0.1080/10550887.2023.2229725 27. Eriksen JW, Fiskaali A, Zachariae R, et al. Psychological intervention for gambling disorder: A systematic review and meta-analysis. J Behav Addict. 2023;12(3):613-630. doi:10.1556/2006.2023.00034 28. Saunders JB, Hao W, Long J, King DL, et al. Gaming disorder: Its delineation as an important condition for diagnosis, management, and prevention. J Behav Addict. 2017;6(3):271-279. 29. Bozzola E, Spina G, Agostiniani R, et al. The Use of Social Media in Children and Adolescents: Scoping Review on the Potential Risks. Int J Environ Res Public Health. 2022;19(16):9960. doi:10.3390/ijerph19169960 30. De D, El Jamal M, Aydemir E, Khera A. Social Media Algorithms and Teen Addiction: Neurophysiological Impact and Ethical Considerations. Cureus. 2025;17(1):e77145. doi:10.7759/cureus.77145 31. Hoşgör HK, Güngördü H. Sosyal Medya Bağımlılığı ve Psikolojik Sıkıntı Arasındaki İlişki: Meta-Analitik Bir Çalışma. Kıbrıs Türk Psikiyatri ve Psikoloji Dergisi. 2025;7(3):226-235. 32. American Nurses Association. Addictions Nursing: Scope and Standards of Practice. 3rd ed. Maryland: American Nurses Association; 2022. 33. Sutandi A, Zakiyah, Tio Helena Manurung S. Nursing Approach for Caring of Patient with Addictive Behaviour. In: IntechOpen. IntechOpen; 2025. doi:10.5772/intechopen.115602
121 CHAPTER IX NURSING APPROACHES TO EMERGENCY AND DISASTER PREPAREDNESS FOR CHILDREN Sinem ÖZTÜRKLER (Lecturar Dr) Kocaeli University, Faculty of Heatlth Sciences, Department of Pediatric Nursing E-mail: [email protected] ORCİD: 0000-0002-1686-516X 1. Introduction Emergencies, disasters, and catastrophes are issues that require the attention of both communities and governments alike in order to prevent and mitigate their effects. (1) The World Health Organization (WHO) defines a disaster as “destructive events that disrupt normal living conditions and cause suffering beyond the capacity of the affected community to cope.” (2) Every year, millions of people are affected by disasters, and many lose their lives as a result. (3) The World Disaster Report, published by the United Nations, reveals that 97.5 million people worldwide were affected by disasters in 2020, with 24,396 fatalities. (4) Due to its geopolitical location, morphological characteristics, and climatic conditions, Turkey frequently experiences human-induced disasters such as earthquakes, landslides, floods, and avalanches. (5) According to the 2018 data from the Global Risk Index (INFORM), Turkey ranks 45th out of 191 countries in the ‘high risk’ group. (5) A review of the literature shows that not only individuals but also certain groups are disproportionately affected by disasters. (6,7) Among these vulnerable groups, children are the most vulnerable and susceptible community due to factors such as their developmental stages, cognitive abilities, and dependence on parental care and physical frailty. (7) Nurses play a vital role in caring for and protecting of these children, (8) helping to minimise their risks, protecting them from harm and death,
122 CURRENT ISSUES IN NURSING I and maintaining their quality of life. (9) They also identify children’s mental health needs, providing acute psychological first aid, assessments, crisis intervention, resilience building, and referrals to mental health providers when necessary. (10) 2. The Concept of Natural Disasters and Child-Centred Disaster Management The term ‘disaster’ can encompass a wide range of events, from a car accident resulting in the death of a child’s parents, to fleeing to a refugee camp in another country due to war. (11) For an event to be considered a disaster, it must disrupt daily life, resulting in material and moral losses. It must also challenge the response of local authorities and cause damage to settlements. (12) Natural disasters include events such as earthquakes, storms, tsunamis, fires, volcanic eruptions, floods, and droughts. (13) Human-induced disasters include industrial accidents, nuclear leaks, terrorist attacks, wars, internal conflicts and environmental disasters caused by humans (12) Table 1. Types of Disasters (7) Geological disasters Earthquakes, Tsunamis - Landslides - Volcanic eruptions, etc. Climatic Disasters Flood, Hail, Hurricane, Drought, Air pollution, Forest fires, Avalanche, Tornado, etc. Climate disasters Savaşlar, Yangınlar, Göçler, Terör saldırıları vb. Biological disasters Wars, Fires, Migrations, Terrorist attacks, etc. Technological disasters Industrial accidents, Mining accidents, Nuclear accidents, Transportation accidents, etc. Disaster management is defined as a set of activities that includes identifying, controlling and planning, or risks, as well as determining policies and implementing training programmes. Although it is fundamentally a public administration function, it requires the involvement of different disciplines. (14) Turkey has a Disaster Management Strategy Document and Action Plan covering all existing and new disaster risks in Turkey, all types of disasters and emergencies, and all disaster management processes. (15) The disaster management system is divided into two categories: risk management and emergency management. The former covers the stages of planning, risk reduction, preparedness, and prevention, while the latter covers post-disaster response, recovery and reconstruction. (16)
NURSING APPROACHES TO EMERGENCY AND DISASTER PREPAREDNESS . . . 123 Risk Management Preparedness and Prevention Response Recovery and Reconstruction DISASTER Risk Reduction Emergency Management Figure 1. Disaster Management Scheme (5) In order to be considered child-centred, disaster management plans must first meet the basic requirements of existing plans. 2. The Impact of Emergencies and Disasters on Children’s Health 2.1. Newborn Health in Disasters (0-29 Days) Within the healthcare control system, disruption to prenatal and postnatal care, which are critical factors corresponding to maternal and child mortality rates, is commonplace in the event of natural disasters. (17) In disasters, pregnant women’s access to the healthcare facilities they need for a safe delivery is limited by the destruction of transportation and hospital infrastructure, the exposure of healthcare personnel to the same conditions, and the inability to access sterile equipment and medications, among many other reasons. (18) Newborns are at high risk of health problems such as trauma, meconium aspiration, and respiratory distress due to unsafe delivery environments. Therefore, implementing clean and safe delivery practices during disasters is a crucial intervention in newborn care. (19) This process involves keeping the baby warm, feeding, keeping the umbilical cord clean, and monitoring many conditions such as fever, diarrhea, nutritional status, and immunization. Delayed diagnosis of complications during this period and delayed appropriate care and treatment can lead to illness, disability, and death. (17) Therefore, attention must be paid to maternal and newborn health in disaster situations. Furthermore, a mass intensive care event affecting neonates in the NICU may place many vulnerable neonates at risk for limited life-threatening interventions due to shortages of facilities, supplies, or personnel, and therefore, for optimal care of neonates, specific advanced plans for acute care, stabilization, triage, transfer, and evacuation must be implemented (20).
124 CURRENT ISSUES IN NURSING I 2.2. Infant Health During Disasters (1 Month-1 Year) In this group, which is entirely dependent on adults for survival after a disaster, the priority is infant care and feding arw the priorities. The safest method of feeding babies is breastfeeding, so the most beneficial assistance is to provide mothers with direct support, food and clean water so they can continue to breastfeed. This reduces the risk of babies contracting diseases associated with formula use. (21). Ensuring relactation when lactation is disrupted in disaster settings is another important consideration. The process of relactation, which is the process of enabling mothers of infants under one year of age who have stopped breastfeeding to continue producing breast milk and start breastfeeding again, is also supported by global organizations such as The Operational Guidance on Infant and Young Child Feeding in Emergencies and WHO. (22) To achieve this, approaches such as providing a comfortable place for the mother, discontinuing the use of pacifiers and bottles, family and partner support, health professional counseling, correct breastfeeding technique, and longer feeding times can facilitate relactation in disaster settings. (19) 2.3. Toddlers (1-3 Year) Children of this age who are eager to explore their surroundings may not be able to do so during or after a disaster, when it may not be safe for them to do so. At this stage, families should understand their children’s desire to develop independent attitudes and explore at this stage, and make the necessary preparations. (23) 2.4. Preschool Age (4-5 Years) Children in the preschool period find it very difficult to adapt to changes in their lives and accept losses due to disasters because of the breadth of their imagination, and as a result, they may experience anxiety and insecurity. (7) Children in this period generally cannot express that they have been affected by the disaster in words, but they show that they are anxious and sad through their behavior. These behaviors can lead to various symptoms such as bedwetting, sleep disturbances, avoidance behaviors, thumb sucking, excessive attachment, panic attacks, and fear. (23). 2.5. School-Age Childhood (6-11 Years) Children in this age range experience fear and excessive anxiety, so they do not want to be separated from their families and are reluctant to go to school,
NURSING APPROACHES TO EMERGENCY AND DISASTER PREPAREDNESS . . . 125 fearing that a disaster will strike again while they are away from home. (7) Looking at the reactions of children in this period, behavioral problems such as sleep disorders and nightmares, as well as inability to eat or overeating, can be observed. (24) After a disaster, they may exhibit characteristics such as stomachaches and headaches, sleep disorders, distancing themselves from their peers, a decline in school performance, regression behaviors, and constantly thinking about the disaster and the safety measures to be taken against it. (25) 2.6. Adolescence (12-18 years old) A disaster occurring during adolescence, a period characterized by the search for identity, can bring out adolescents’ search for identity and other personal crises. After a disaster, adolescents may struggle to continue their daily activities and education, experience problems in their peer relationships, and struggle with feelings of helplessness and hopelessness after their experiences. (23) 3. Nursing Approaches for Children in Disasters The International Council of Nurses (ICN) first defined the competencies of disaster nursing within the disaster cycle in 2009 Table 2. Competencies of Disaster Nursing (26) Risk reduction/ prevention Preparation Intervention Recovery/ Rehabilitation ● Risk reduction ● Disease prevention and health promotion ● Policy development and planning ● Ethical practice, legal compliance, and accountability ● Communication and information sharing ● Training and preparation ● Community care ● Care for individuals and families ● Psychological care ● Care for vulnerable/sensitive individuals ● Long-term, individual, family, and community recovery In order to minimise health problems and life-threatening harm that may arise in disaster situations, nurses take on the role of health management and care throughout the disaster process. (26) In order for nurses who will be on duty during disasters to fulfill their expected roles and responsibilities, they must be knowledgeable about disaster training, scope of services, and disaster nursing
126 CURRENT ISSUES IN NURSING I practices. (27) Nurses form the largest group among health professionals and, due to their working conditions, are accustomed to working in emergency situations, systematic work, triage practices, and determining care priorities. Therefore, they play a critical role in every stage of disaster management. (28) Pediatric nurses have a comprehensive understanding of the factorthat put children at increased risk during disasters. According to the National Association of Pediatric Nurse Practitioners (NAPNAP), the central role of pediatric nurses in disaster preparedness is to provide guidance and care in disasters affecting children and families. (29) Pediatric nurses regularly facilitate communication among healthcare providers and coordinate care under stressful conditions. Consequently, pediatric nurses should collaborate with their local communities, including schools, churches, daycare centers, and local governments, as well as in their own practice or acute care settings, to ensure disaster preparedness. (30) Providing a safe care process for children and families in a post-disaster crisis situation is one of the most important tasks. Other issues that require attention include preventing illness, ensuring clean nutrition and fluid intake, and identifying children separated from their parents in all settings. (31) The roles and responsibilities of pediatric nurses who will be assigned to natural disaster relief efforts can be listed as follows: -Participating in the development of disaster preparedness guidelines that address both children and families, ensuring that children have access to appropriate services and support before, during, and after disasters, -Participating in the development of the country’s disaster preparedness efforts, including managing of pediatric medical supplies to be used before, during, and after disasters, the establishing of child disaster management teams, and the providing appropriate equipment. - The programme should include disaster management education for children, -Research can be conducted into necessary disaster relief services, rescue efforts, and disaster management, - Children affected by the disaster should be identified, their relatives located, and relevant care institutions contacted if they have lost their parents, -Special attention should be given to the mental health needs of children and families after a disaster, and psychological first aid should be provided. -Support breastfeeding mothers and their babies before, during, and after disasters, providing a safe place for breastfeeding,
NURSING APPROACHES TO EMERGENCY AND DISASTER PREPAREDNESS . . . 127 -Providing primary disaster preparedness health screening and services, including vaccination to prevent disease, -All healthcare workers should be encouraged to develop their own personal disaster plans. (29,31) 4. Conclusion Natural disasters and emergencies are complex events that can have physical and psychological effects on children. Child-centred disaster management is crucial for ensuring the safety and well-being of children by addressing their specific needs. Disasters can have a detrimental effect on children’s health, causing injuries, nutritional problems, infectious diseases and psychological trauma. Nurses support children’s recovery process by preparing for disasters in advance, responding quickly during disasters and providing psychosocial support afterwards. Child-focused nursing approaches are effective when collaborating with families and coordinating with multidisciplinary teams. Greater specialisation in child-centred disaster management in nursing education will, in the future, increase social resilience by ensuring that children suffer the least harm from disasters. Referans 1. Rodríguez-Coca D, Espejo-Díaz JA, Guerrero WJ. Pre-disaster and response activities in disaster management: Insights from an experts’ survey and document analysis. Revista Facultad de Ingeniería Universidad de Antioquia. 2025;116:21-33. 2. World Health Organization (WHO). International Statistical Classification of Diseases and related health problems: Alphabetical index. 2004; 3. 3. Rahman MA, Alam MS, Sultana R, Sultana R. Assessing the interrelationship between monsoon flood disasters and major crop production in Bangladesh. International Journal of Disaster Risk Reduction. 2025;121:105401. 4. The International Federation of Red Cross and Red Crescent Societies (IFRC). World Disasters Report 2020, 5. Afet ve Acil Durum Yönetimi Başkanlığı. (AFAD). Kahramanmaraş’ta Meydana Gelen Depremler Hk. Basın Bülteni-36. 2023. 6. Onyejesi CD, Alsabri M, Del Castillo Miranda JC, et al. Pediatric emergency disaster preparedness: a narrative review of global disparities,
128 CURRENT ISSUES IN NURSING I challenges, and policy solutions. International Journal of Emergency Medicine. 2025;18(1):91-102. 7. Limoncu S, Atmaca AB. Çocuk Merkezli Afet Yönetimi. Megaron. 2018;13(1):132-143. 8. Wang W, Li H, Huang M. A literature review on the impact of disasters on healthcare systems, the role of nursing in disaster management, and strategies for cancer care delivery in disaster-affected populations. Frontiers in oncology. 2023;13:1178092. 9. Arslanlı SE, Duru H, Bakır, E, Pulat P. Exploring the disaster experiences and psychosocial support needs of children affected by the Kahramanmaras earthquake in Turkey through drawing narratives. Journal of Pediatric Nursing. 2024;78:e260-e269. 10. The National Association of Pediatric Nurse Associates & Practitioners (NAPNAP) Pediatric nurse practitioners role in disasters involving children Journal of Pediatric Health Care. 2011;25(4):A9-A10. 11. Olness K. Children’s mental health at times of disasters: a narrative review. Pediatric Medicine. 2022;5(17):1-10. 12. Duruel M. Afet yönetiminde yerel yönetimlerin etkinliği: 6 şubat depremi Hatay örneği. International Journal of Social and Humanities Sciences Research (JSHSR). 2023;10(99):2404-2418. 13. Spiridonov V, Ćurić M, Novkovski N. Exploring Natural Hazards: From Earthquakes, Floods, and Beyond. In Atmospheric Perspectives: Unveiling Earth’s Environmental Challenges. 2025;271-306. 14. Karaman ZT. Afetlerde Hızlı Çevresel Etki Değerlendirmesi Ve Kriz Yönetiminde Kritik Sorgulama. Hastane Öncesi Dergisi. 2016;1(1):1-16. 15. Afet ve Acil Durum Yönetimi Başkanlığı (AFAD). Açıklamalı Afet Yönetimi Terimleri Sözlüğü 2023. 16. Avaner T, Çoşkun AM. Karşılaştırmalı Afet Yönetimi Türk Ve Fransız Jandarması Örneği. Ömer Halisdemir Üniversitesi İktisadi ve İdari Bilimler Fakültesi Dergisi. 2025;18(1):341-360. 17. Barman P, Sarif N,Saha, A. Association between natural hazards and postnatal care among the neonates in India: a step towards full coverage using geospatial approach. BMC Emergency Medicine. 2023;23(1):76. 18. Lafarga Previdi I, Welton M, Díaz Rivera , Watkins DJ, Día Z, Torres H, ...Vélez Vega CM. The impact of natural disasters on maternal health: Hurricanes Irma and María in Puerto Rico. Children. 2022;9(7):940. 19. Kaya B, Ekşioğlu A, Yücel U. Ebelik Hizmetlerinin Afetlerde Yenidoğan ve Çocuk Sağlığının Korunmasına Etkisi: Afetlerde Yenidoğan ve
THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 135 ● Learners play a central role in mediating and controlling their own learning. ● The existing knowledge, beliefs, and attitudes of learners are considered during the construction of new knowledge. ● Collaborative learning is used to expose learners to alternative perspectives. ● It promotes communication, interaction, and the development of collective idea generation among learners. ● It equips learners with 21st-century skills and workplace competencies, improving their quality of life (4). ● It supports higher-order thinking skills such as creativity, critical thinking, and decision-making. ● Assessment is authentic and integrated with instruction (3). 2.5. Fundamental Principles of Constructivist Learning According to Fosnot (2007), for learning to occur in a constructivist environment, certain foundational principles must be present. These are (32): ● Learners should be challenged with ideas and experiences that create internal cognitive conflict or disequilibrium. Mistakes should be viewed positively, as opportunities for both learners and educators to uncover conceptual understanding. ● Learners should be encouraged to ask questions and form hypotheses. ● Learners should be supported in expressing, defending, and justifying their opinions, thoughts, and ideas to others. ● Learners should be guided to formulate ideas that possess the power to generalize across experiences and disciplines. ● Learning occurs through reflective abstraction. Therefore, learners should be given time to think deeply through journaling, drawing, modeling, and discussion. ● The learning environment should offer broad opportunities for interaction. Brooks and Brooks (1993) outline additional principles and considerations for constructivist learning (7,33): ● Meaning requires understanding parts within the context of wholes. Thus, the learning process should focus on core concepts, and new knowledge should be presented not as abstract ideas but through practices that connect to real life.
136 CURRENT ISSUES IN NURSING I ● Learning is a search for meaning. It should begin with learners actively constructing meaning, starting from their prior knowledge and experiences to link with new information. ● For learning to be meaningful, learners must fill in the gaps themselves. This strengthens their independence and enables them to access accurate information from diverse sources to address their challenges. ● The goal of learning should be for the learner to construct personal meaning, not merely to memorize “correct” answers or repeat the understanding of someone else. ● The learning environment should consist of small groups engaged in dialogue and collaborative problem-solving. ● Educators should identify the mental models that learners use to perceive the world and the assumptions they rely on to support these models. ● Assessment should be an integral part of the teaching-learning process and provide learners with feedback on the quality of their learning. Von Glasersfeld (1987) proposed three core principles of constructivism: 1. Knowledge acquisition occurs through active participation, not passive reception. 2. In specific environments, individual behavior becomes more adaptive. 3. Knowledge is formed through the interpretation of personal experiences and is inherently adaptable (34). 2.6. Types of Constructivist Learning In the literature, various types of constructivist learning have been identified, each highlighting distinct dimensions of the model. The most widely accepted types are: Cognitive Constructivism, Social Constructivism, and Radical Constructivism (6,35). 2.6.1. Cognitive Constructivism Developed by Jean Piaget, cognitive constructivism is grounded in objectivity and metaphysical realism, asserting that an objective reality exists independent of the educator’s thoughts and opinions (6,36). According to Piaget, knowledge is constructed based on the existing knowledge and experiences of learners. The perceptions of learners are continuously revised and restructured through exposure to new experiences, and individual differences play a role
THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 137 in how knowledge is constructed (6,37). The process of acquiring knowledge is active and dynamic. Learners formulate hypotheses about their experiences and test them, systematically evaluating their understanding of the real world (36). In the organization of mental structures and processes, especially during states of equilibrium and disequilibrium, assimilation, accommodation, and balancing are critical (19,36,37,38). When learners are continuously exposed to objects and events in their environment, they acquire specialized knowledge through a blend of formal and informal learning experiences (39). According to Skaalid, cognitive constructivism involves learners recognizing that their existing knowledge is insufficient to define conceptual topics, prompting them to adapt prior knowledge to new information (37). In cases of incompatibility between old and new knowledge, learners may need to revise their existing understanding. Thus, new knowledge emerges only through adaptation to new experiences (6). In this framework, knowledge is not passively received but actively constructed through a self-regulated cognitive process (19). To enhance learning through increased experience or pattern formation, activities should be designed to support the development of cognitive structures aligned with mental maps (40). The educational environment must incorporate both assimilation and accommodation processes (41). 2.6.2. Social Constructivism Social constructivism, developed by Lev Vygotsky, is grounded in the assumption that “knowledge is constructed as learners make sense of their experiences” and is fundamentally based on social interaction (13). In this framework, the life experiences of learners are considered critical factors in learning, progress, and development, and social interaction is seen as shaping how learners think. The perspective of Vygotsky emphasizes that knowledge is not passively received from the environment but actively constructed from reality. He argued that learning is enhanced through collaboration with others, knowledge begins at the social level before becoming individual, and a social environment is essential for learning. Language and thought are key components of this interaction. In other words, society plays a vital role in the interpretation and construction of knowledge (6,19). According to Glasersfeld, knowledge is shaped by personal experience and interaction with others (12,42). Thus, learning is individually constructed but socially supported (43). Social constructivism posits that knowledge is formed through the values and meanings individuals assign to their lives, and societal elements influence these meanings. Learners
138 CURRENT ISSUES IN NURSING I are seen as reflections of the society they live in, and language, culture, and social structures are emphasized as key factors in shaping social reality (24,44). Domains such as politics, ideology, values, belief systems, and economics also influence the formation and structure of knowledge and human development. This approach focuses on how learners construct formal and informal understandings of their lives through personal knowledge and experience (13). Because social constructivism emphasizes both cultural and social cognition, collaboration and group learning are central (37). Social constructivism highlights the situational and contextual nature of learning. It affects what we learn, how we learn it, and how we transfer it to new situations (45). The role of the educator is to be responsive to the efforts of learners and provide support (37). Learning environments should incorporate real-life applications and facilitate interaction with the external world. In such environments, learners engage with one another as if they were in real-life settings (46). 2.6.3. Radical Constructivism Radical constructivism, introduced by Ernst von Glasersfeld in the 1980s, asserts that reality exists independently of the individual (12). According to Glasersfeld, in radical constructivism, knowledge is not passively received but mentally constructed. It is adaptable and serves not the discovery of ontological reality, but the organization of experiential reality (6,47). At its core lies the principle of internal and individual coherence. Knowledge is subjective, and there is no singular truth or reality (48). External reality cannot be definitively known. Instead, it is interpreted through the perspective of the observer. Knowledge is constructed from everyday observations and scientific understanding and cannot be judged as ontological or metaphysical truth (13). Radical constructivism is centered around learners who interpret, understand, and generate knowledge. Knowledge is not discovered, but it is actively constructed by learners. Therefore, the experiences of learners are the primary source of knowledge formation (38,49). Knowledge abandons its philosophical position as a representation of a fundamental reality external to the world. It is actively built by learners, socially validated, and shaped through shared concepts (22). It is evaluated subjectively, and individual activity plays a central role in its construction. There is no requirement for knowledge to reflect the external world. The most significant distinction between radical and cognitive constructivism lies in the control of the knowledge construction process. In radical constructivism, every stage of knowledge formation is governed by the learner. It is based on the premise that the only reality is subjective (32).
THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 139 2.7. Advantages and Limitations of Constructivist Learning Compared to traditional learning, constructivist learning offers numerous advantages. These can be summarized as follows: ● It introduces alternative assumptions about learning and new instructional principles. Rather than supplementing existing learning paradigms, it replaces them, making its contribution especially significant (50). ● It is learner-centered (51). ● It is grounded in self-directed learning. ● The curriculum is presented holistically and structured around core ideas. ● Knowledge is dynamic (4). ● Knowledge is reconstructed by the learner, with emphasis placed on the process rather than the outcome (51). ● It promotes collaborative group work. ● The learner is viewed as a constructor of knowledge and a thinker (34). ● Instructional design is shaped by the perspectives of learners. Their conceptual understanding, needs, and interests are used to prepare lessons and topics (4). ● Learners are encouraged to ask questions, and questioning is considered essential (34). Their ideas and opinions are solicited to ensure active participation. ● Learner-centered methods such as concept mapping and group work are employed (34,52). ● Small group collaboration is emphasized. Learners are guided to work in teams and grouped according to their interests and abilities to carry out diverse projects (53). ● The ability of learners to apply knowledge is enhanced, their adaptability to new information is supported, and conceptual misunderstandings are reduced (45). ● Problem-solving skills are developed, motivation and self-confidence are increased, and learners are encouraged to interact with their environment as knowledge becomes an integral part of life (44,51,54,55). ● The learning environment is designed to facilitate the co-construction of knowledge and skills between learners and educators. ● Assessment is integrated with instruction. The presentations, projects, and portfolios of learners are regularly observed and evaluated (4).
140 CURRENT ISSUES IN NURSING I The limitations of constructivist learning include the following (18,35): ● Learners may have limited access to technological resources. ● Because it involves self-directed learning, learners may feel isolated during the process of accessing and constructing knowledge. ● Educators may require significant time and effort to design course content, select instructional methods and materials, and implement them effectively. ● Educators must possess sufficient expertise to address each topic in depth, which demands extensive preparation. ● The assessment process may be challenging. 2.8. The Role of the Educator in Constructivist Learning Implementing constructivist learning in an educational setting is complex, demanding, and requires mastery. This necessitates a substantial transformation in the roles of educators. Most educators have been trained in environments dominated by traditional methods, which means adopting constructivist learning involves not only shifting paradigms but also replacing familiar practices with unconventional ones (3,7). Therefore, for an educator to design and evaluate instruction based on constructivist learning, it is essential that they be trained within a constructivist framework (56). The responsibilities and roles of the educator in constructivist learning include: ● Using raw data and primary sources beyond manipulative, interactive, and physical materials. ● Employing cognitive terminology such as “classify,” “analyze,” “predict,” and “construct” when defining tasks and responsibilities. ● Selecting and willingly using instructional methods, techniques, and materials that promote deep thinking, enhance retention, and help learners reconstruct their understanding of concepts (7,57). ● Considering learner evaluations and restructuring lessons, content, instructional methods, techniques, and materials accordingly. ● Probing the conceptual understanding of learners. ● Allowing time for learners to build relationships and create metaphors. ● Nurturing the curiosity of learners (7). ● Recognizing the importance of alternative ideas brought into the learning environment alongside scientifically accepted views (58).
THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 141 ● Understanding how learners think and ensuring continuity in their development, while possessing knowledge across multiple disciplines (48). ● Favoring knowledge, skill, and complex environments (59). ● Allowing specific goals to emerge and ensuring that real-life problemsolving aligns with the individual needs of learners. For example, rather than teaching a version of history, the goal should be to teach learners how to think like historians. ● Assuming that each learner has a unique perspective and rejecting the notion of an “average learner” (50). ● Motivating learners and creating a context with meaningful content and resources (14). ● Supporting learners in working collaboratively, communicating, and interacting with one another (29,37,60). Facilitating learning from one another’s life experiences (12). ● Encouraging learners to ask their own questions and helping them develop hypotheses and models (61). ● Planning instruction with awareness of the perceptions, comprehension levels, interpretations, and varied responses and needs of learners (4). ● Providing guidance and intervening only when necessary to steer learners in the right direction (3,6,19). ● Creating environments that encourage learners to develop solutions to complex, real-life problems, organize knowledge around ideas, and generate new understanding. ● Offering clear guidance to help learners fully grasp concepts (37,62). ● Facilitating connections between the existing knowledge and new experiences of learners (27). ● Supporting the development of the analytical, synthetic, interpretive, and evaluative skills of learners through reflective thinking, case analysis, and discussion. ● Promoting reflective practices and integrating the perspectives of learners into the teaching-learning process. ● Contributing to the autonomy of learners and encouraging them to take responsibility and accountability for their own learning. ● Evaluating learners through the observation of their work and perspectives rather than through exams (37). ● Valuing both the learning product and the learning process (57).
142 CURRENT ISSUES IN NURSING I ● Ensuring the necessary support and participation for learners to achieve expected learning outcomes. ● Establishing explicit or implicit interactions based on mutual respect, trust, and the sharing of personal experiences (12). ● Being inquisitive, investigative, and observant (53). ● Prioritizing personal development, centering the learner, and learning alongside learners (29). 2.9. The Role of the Learner in Constructivist Learning Constructivism defines knowledge as non-objective, provisional, developmental, and socially and culturally mediated. Meaning is not discovered, but it is constructed. Although shared language and culture may lead many individuals to interpret things similarly, the unique experiences of learners lead them to assign different meanings to the same concepts. For this reason, learners construct their own meanings in varied forms and structures, engaging in six modes of learning: constructive, reflective, collaborative, active, developmental, and inquiry-based (54). According to Driver et al. (1994), learners in a constructivist learning environment undergo changes in several areas: the development of existing ideas, differentiation between existing ideas, the integration of existing ideas, the transformation of existing ideas, and the introduction of new ideas. Among these, the most challenging is the transformation of existing ideas. Socratic questioning and the presentation of contradictory events, which are methods that provoke cognitive conflict, disequilibrium, and inconsistency, are among the most effective strategies. These methods help learners revise existing ideas and generate new ones. Once ideas are evaluated, they are adapted to new situations. Newly acquired knowledge is then compared to prior knowledge and ideas. After meanings are constructed, they are either accepted or rejected. This way, learners assume responsibility for their own learning (63). The responsibilities and roles of the learner in constructivist learning include: ● Striving to interpret new information rather than memorize it and analyzing it based on existing knowledge. ● Engaging in social interaction and collaboration with educators and other learners to construct meaning (45,64).
THE CONSTRUCTIVIST LEARNING MODEL IN NURSING EDUCATION 143 ● Organizing and managing actions that maximize desired outcomes and minimize undesired ones (47). ● Maintaining control over the learning process. To facilitate learning, learners must consider their past experiences, learning styles, readiness levels, and perspectives on the subject and life. ● Acting in alignment with personal interests and goals. ● Utilizing and developing personal abilities (3). ● Being active and selective (29). ● Building bridges between existing knowledge and the knowledge expected to be acquired (13). ● Being constructive, curious, autonomous, and enterprising. ● Taking responsibility for learning and designing learning activities with purpose. ● Developing self-directed learning skills (3). ● Conducting research, analysis, and observation using various methods and materials to acquire information that is needed or of interest. ● Analyzing and synthesizing data, asking questions to solve problems with a critical perspective. ● Interpreting acquired knowledge, constructing meaning, and explaining interpretations with rationale (17,29). ● Applying new concepts to familiar situations and familiar concepts to new situations (9). ● Maintaining high motivation to enhance the success of learning (65). ● Reflecting continuously on experiences, recognizing the complexity of acquired ideas and knowledge, and developing new and robust skills to integrate new knowledge with existing knowledge (3). 2.10. Classroom Environment in Constructivist Learning Learning is a complex process that is internally constructed by learners as they process their world and continuously revise their understanding. The effectiveness of the learning environment is a function of multiple interrelated factors, including the curriculum, instructional methodology, learner motivation, and developmental readiness (60). The constructivist learning environment refers to a setting grounded in constructivist principles, designed to support learners in the process of constructing knowledge (45). In constructivist learning, the classroom environment is one in which learners benefit from the experiences of one another, reconstruct knowledge through active engagement, learn by
144 CURRENT ISSUES IN NURSING I doing and experiencing, reflect learning into real life, and utilize technological resources (66). According to Wilson, the classroom environment in constructivist learning is collaborative, interactive, purposeful, and supportive. Learners work together to solve problems using shared sources of knowledge, methods, and materials (67,68). The characteristics of the classroom environment in constructivist learning include: ● Encouraging learners to make better use of prior knowledge and promoting both individual and group understanding (69). ● Centering the learner, allowing opportunities to construct personal knowledge, and considering individual needs and interests while incorporating primary sources such as technology. ● Ensuring that learners are not passive recipients, but they are engaged in interaction and communication with one another, learning through active participation (4). ● Enabling learners to synthesize, analyze, interpret, and evaluate acquired knowledge (54). ● Promoting meaningful and lasting learning by encouraging learners to take responsibility for their own learning (6,53). ● Deepening multiple perspectives and shifting focus from memorization to understanding, interpreting, and applying concepts (3,4,53). ● Supporting the development of diverse viewpoints on a topic, revealing the experiences and insights of learners, and integrating new experiences with existing knowledge (23). ● Encouraging learners to formulate their own questions and reach their own conclusions (27). ● Motivating learners and capturing their interest in the subject matter (70). ● Aligning with real-life experiences and supporting the sharing of these experiences. ● Enriching both in-class and out-of-class activities to enhance the effectiveness and permanence of learning (29). ● Facilitating the development of cognitive skills rather than merely acquiring information. ● Presenting a structured environment with meaningful content rather than abstract instruction (70).