N301 Exam 1 Study Guide

Therapeutic and non-therapeutic communication skills, critical thinking, differentiating fact vs. opinion, and nursing history and professionalism

Core Conditions for Therapeutic Relationship

• Empathy: highly correlated to positive patient outcomes

• Positive regard: extending warm positivity

• Caring: the effort to soothe and comfort

• Thoughtful language: clearly, accurately, in understandable words

• Interest: wanting to know what another is experiencing

• Listening: openness to fully hearing and processing

• Non-judgment: listening to understand, to see how and why the person’s actions made sense to them at the time

• Objectivity: view situation through the patient’s eyes

• Genuineness/authenticity: what is said is congruent with what you feel; your demeanor, words, and gestures all match

Social Relationships

Both parties share experiences, insights, joys, and sorrows; they support each other through life events

• The focus is on both persons’ needs

• Not goal-directed; more spontaneous

• Reciprocal self-disclosure

Professional Relationships

The professional person (nurse) seeks to understand the patients’ experiences of illness and distress to provide support and to better assist the patient in using resources, applying interventions, and obtaining services

Key Characteristics of Professional Relationships

• Focus is on the patient

• The patient discloses personal information and the nurse does not (except in rare instances)

• The nurse does not seek advice, comfort, or insight from the patient

• The nurse’s private life remains private from the patient

Common Mistake: Jumping to Problem Solving Too Soon

• This is the biggest pitfall of beginning clinicians

• Inhibits patient expression of issues and concerns

• Undermines patient ability to figure it out for themselves

• Solution: Ask questions and process issues and concerns to encourage the patient to present their thoughts in a logical, sequential fashion that helps the patient examine the issues more objectively

• Nursing Care: Guide patients through their own examination of their thoughts and feelings (Socratic method)

Socratic Method

• Taps into powers of reason through slow, deliberate questions that enhances the patient’s problem-solving analysis

• Nursing Questions:

  • “What’s your biggest concern"?”

  • “What do you need to know now to help you take the next step in planning your care?”

  • “Who do you need to talk to to get more information?”

  • “How can I or your family members help you get this process started?”

Barriers to Helping: Drama Triangle

1. Victim: Nurse sees patient as a helpless victim

2. Persecutor: Nurse sees family members or other professionals in black-and-white ways (such as good guys vs. bad guys) in effort to help or harm the patient

3. Rescuer: Nurse can fall into rescuer trap (ego-enhancing but leads to burnout); nurse takes over to fix things, but it’s rarely in the patient’s best interest

5 Core Principles of Patient-Centered Care

1. Focus is on the patient (and family’s) needs and concerns

2. Collaborative partnerships form between clinicians and patients

   1. Nurse recognizes patient’s and family’s expertise

   2. Nurse encourages empowerment rather than dependence

   3. Nurse respects unique characteristics, cultures, and values of the patient and their family

   4. Nurse gives open access to health/illness information

3. Community based (if possible)

4. Care is coordinated and integrated → One plan of care among all professionals

5. Emphasis on the patient’s and family’s strengths

   1. Problem-only focuses can demoralize the patient

   2. Solutions are built on strengths

   3. Nurse mobilizes natural support systems, not just formal services

   4. Nurse uses individualized approaches to address unique features of illness and patient/family resources

Therapeutic Conversations

*Guide the patient in telling their story, and let the patient control the flow

• Ask broad open-ended questions and then narrow down information by asking more specific questions if need be

  • “Tell me what brought you in today”

  • “Tell me about what was going on before you came to the hospital”

• Balance your focus on patient’s and family’s strengths and concerns

• Encourage patient to express their views without judging them

Mindfulness

Developing an awareness of subtle shifts in one’s internal emotional climate sometimes through observing one’s internal dialogue

• Observe and monitor your own internal states (thoughts, emotions, sensations)

• Acknowledge those states and describe them

• Examine triggers and aggravators

• Anticipate how those ideas or triggers, if left unexamined, could interfere with their behaviors

• Accept these internal experiences are important

• Avoid reflexively and unconsciously operating from them

• Choose a more effective course of action

Active Listening

The practice of fully focusing on, understanding, and responding to what another person is saying instead of just passively hearing their words

• Deliberate communication: ask the patient to gage if you understood them correctly

• Check if your interpretations are correct

• Paraphrase (not parroting) what the patient has said

• Ask clarifying questions

• Prompt further exploration → “Could you give an example?” or “Could you describe that in more detail?”

• Acknowledge the feelings you observed

Barriers to Listening

• Information overload: You are preoccupied with providing data

• Pseudo-listening: Biding time until you can talk again

• Psychological noise: Anxiety, anger, shame, or other distractions

• Rapid thoughts: Thinking about what you are going to say next, your mind wanders

• Changing message to fit with our pre-conceived ideas

• Defensive listening: Seeing innocent comments as personal attacks

• Insensitive listening: ignoring non-verbal communication or just ‘filling out the check-list’ to ‘get the job done’

Motivational Interviewing

A patient-centered communication style that helps nurses guide patients through ambivalence and promote positive health behavior changes

SLANT Method

S- Sit up: Assume the posture of an attentive listener

L- Listen: Bring your attention back to the speaker (lean in)

A- Ask: Question, be curious, and seek to understand

N- Nod: Use your body to demonstrate interest and understanding

T- Track: Look and focus on the speaker’s words and emotions

LUV Method of Enhancing Important Relationships

L- Listen: Stop talking and allow the other person to express themselves, even if you disagree with their ideas, assumptions, reactions, etc.

• Ask questions in a way that helps you enter the speaker’s world

• The goal is to help the speaker process their feelings, reactions and interpretations through your efforts in “seeking to understand”

U- Understand: See the situation from the speaker’s POV, and express empathy for their experiences

V- Validate: Offer a sense that you understand and acknowledge the speaker’s right to have feelings about and reactions to an event/situation

Critical Thinking (Paul & Elder)

• “Is self-directed, self-disciplined, self-monitored, and self-corrective thinking”

• “It presupposes assent to rigorous standards of excellence and mindful command of their use”

• “It entails effective communication and problem-solving abilities, and a commitment to overcome out native egocentrism and sociocentrism'“

Egocentric Thinking

• It’s human nature to assume each of us innately knows the way things “really are”

• We believe in our intuitive perceptions- no matter how inaccurate those perceptions may be

• Rarely do we hold up our thinking to scrutiny

• Scrutiny makes us anxious because it calls into questions our own judgments

Common Mishaps in Thinking (Paul & Elder)

• “It’s true because I believe it”

• “It’s true because we believe it”

• “It’s true because I have always believed it”

• “It’s true because it is in my own self-interest to believe it”

Essential Intellectual Traits (Paul & Elder)

• Intellectual Humility vs Arrogance → Wanting to know if, and admitting when, we are wrong

• Intellectual Courage vs Cowardice → Being able to muster the courage to admit wrongheadedness to ourselves and others

• Intellectual Empathy vs Close-Mindedness → Seeing the humanness in everyone and feeling for those who are different

• Intellectual Autonomy vs Conformity → Being willing to think differently from those we care about, even if we disagree with them

• Intellectual Integrity vs Hypocrisy → Acting from a place of honesty when we actually live by our well-scrutinized thinking

• Intellectual Perseverance vs Laziness → A willingness to gather fact-based information to draw the most reality-based conclusions

• Confidence in Reason vs Distrust of Reason and Evidence → Accepting that trust is not infallible but it’s pursuit, using intellectual rigor, is the best we can try to obtain a truer picture

• Fairmindedness vs Intellectual Unfairness → Accepting that there are many ways of seeing situations and our way is only one

Fact vs Opinion

• Fact → undeniable, evidence-backed, and driven by rational thinking

• Opinion → arguable, based on belief or personal view, driven by emotions

Domains of Mindfulness

• Emotion Mind: Emotional thinking dominates; whether emotions are positive or negative, they play a critical role in informing us about the nature of our experience

• Body Mind: Awareness of our physical experiences, the way in which the body is responding to stimuli; by scanning our bodies for data, we detect that we are more emotionally activated them we realize or that a physical discomfort is interfering with our ability to focus

• Reason Mind: The metaphorical place where more analytical, measured, and controlled thoughts enter our consciousness

• Wise Mind: The area of overlap between the other 3 domains; houses analytic processes that identify as metacognition, wherein we think about our thinking

Philadelphia, 1732

• Local government established “almshouse” to care for sick when family could not provide that care

• Other cities followed

• These almshouses later became general hospitals

Florence Nightengale

• Argued for nurses training rather than simply learning from experience

• 1873: Three nursing schools opened based on her principles

• Supported nursing education for white women only

Principles:

• An endowment ensuring the independence of the training school

• A Superintendent of Nurses reporting only to the head of the hospital

• A strong emphasis on sanitary knowledge

• Clearly defined lecture and ward time for students

• Insistence on the important of technical skill and disciplined character in nurses

Nursing Before Nightengale

• Several physicians argued for and established training programs for nurses; physicians established the curriculum

• May represent the beginning of nurses answering to physicians or women answering to men

• Midwives had, historically, been independent practitioners but were not licensed or formally trained; they learned through apprenticeship

1879

• Mary Elizabeth Mahoney, the first African American professional nurse, graduated from the New England Hospital and Training School for Women and Children

• The New England Hospital for Women and Children’s charter provided for the admission of one African American student and one Jewish student per year; both groups were regularly excluded from most nurses’ training schools

Segregation in Nursing

As formal training for nurses became more of the norm, specific populations were banned from participation; those groups began their own programs

1886

• Spelman Seminary (later Spelman College) in Atlanta, Georgia, begins a nursing program for African American women

• African American men and women experience severe discrimination in attempting to obtain a nursing education; Few gained admission to nursing schools in either the north or south

• The black community set up schools of nursing in traditionally black hospitals and educational institutions

• The segregated nurse education system, established in the late 19th century, prevailed until the mid-20th century

Lincoln Hospital, Durham, NC

• Established from 1901-1976

• Housed 123 beds

• Hospital for African Americans

• Healthcare in the US was segregated until the 1960s

• Hospitals sometimes had Black Wards which were separate, often run down, and sometimes in the basement of buildings

• In 1966, hospitals had to integrate all rooms, waiting areas, and staff to receive Medicare funding (which occurred toward the end of the Civil Rights Movement)

Trust and the Patient-Clinician Relationship

• Health disparities: differences in health outcomes, life expectancy, and disease rates between different groups

• These disparities occur in part from: unequal access to medical care, insurance coverage, and quality treatment

• Can you trust your clinicians to take expert care of you despite any differences that may exist between you?

• Can your patients trust you to take expert care of them despite any differences that may exist between you?

1893 Lillian Wald

• Established the Henry Street Settlement House in New York City

• Wald’s insistence that sickness should be considered in its social and economic context led to innovative and pragmatic reforms in healthcare, industry, education, recreation, and housing

• She coined the term public health nurse and originated the ideas that eventually led to the establishment of the Children’s Bureau, the provision of school nurses in primary and secondary schools, insurance coverage for home care, and the first national nursing service: the Red Cross Town and Country Nursing Service

1893 Howard University

• Opened the first nursing education program in the country in a university setting

• Marked the entrance of nursing education into university by initiating a very long process, remaining incomplete today, to educate nurses in institutions of higher education

Debate: Entry into Practice

• 1965: ANA proposed that professional nursing education be done only within higher education settings

• Hospital based training:

  • 3 year programs with heavy clinical experiences

  • Began to be phased out in the 1970s

  • Some still exist; concentrated in PA and NJ

• Associates Degree: 2 year community college programs

• Bachelor’s Degree: 4 year program with strong liberal arts components and socialization into, and consistency with, “the professions”

Characteristics of a Profession

• Specialized knowledge and theoretical foundations

• A rigorous education and training process

• A commitment to public service and ethical conduct guided by a code of ethics

• A degree of autonomy in practice

• Accountability for actions and decisions licensure or certification to practice

Debate: Is Nursing a Profession?

• Some argue that nurses simply carryout doctor’s orders (myth, and nursing cannot meet the “autonomy” aspect of a profession

• Others contest that nursing has its own body of knowledge, and nursing practice often reflects that body of knowledge, meeting the criterion of autonomy

• That body of knowledge was not clearly articulated until nurse theorists began more fully describing nursing’s unique fund of knowledge

Nursing in 2026

• The US Department of Education RISE initiative omitted nursing from categories of “professional degrees,” paving the way to limit loan amounts for graduate education in nursing

• The outcry against this action and loud and clear from multiple organizations, including some outside of nursing

• A federal judge blocked the move

• Interim adjustments to the rule allow for MSN & DNP ed to receive full loan amounts but not PhD education

Kristen Swanson

• Former dean at UNC SON and nursing theorist

• According to Swanson (1991), caring is a “nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility”

• In this theory, the ultimate goal of nurse caring is to enable clients to achieve well-being

Merle Mishel

• Former UNC SON faculty member and nursing theorist

• Created a conceptual framework for exploring how uncertainty shapes a patient’s experience with illness, treatment, and hospitalization

• Her seminal paper remains one of the top 50 most-cited publications in nursing journals

What is Medicine?

• The science and practice of maintaining and restoring health through the diagnosis, prevention, and treatment of diseases

• Simplified: it is the diagnosis and treatment of disease

What is Nursing? (ANA)

• Nursing is the art and science of care that promotes, protects, and optimizes health for individuals, families, and communities, encompassing the prevention of illness, treatment of disease, facilitation of healing, and alleviation of suffering

• Involves diagnosis and treatment of human responses to health and illness, with nurses acting as autonomous and collaborative caregivers in diverse settings from hospitals to communities

• The profession integrates specialized knowledge and compassion, focusing on patient-centered care, health policy, advocacy, and improving health systems

• Simplified: ???

What is Profesionalism?

• Professional appearance

• Reliable

• Ethical behavior

• Organized

• Accountable

• Professional language

• Separates personal and professional

• Positive attitude

• Emotional control

• Effective time management

Inequality

The level of health between 20-year-olds and 70-year-olds is unequal but the inequality is explained by unavoidable decline in health related to aging

Inequity

When health differences are preventable and unnecessary, allowing them to persist is unjust; to achieve equity there needs to be intentional efforts to remove access barriers and allocate high-quality, need-based resources

Explanations for Health Inequities

• Material: food, shelter, exposure to pollutants, and income

• Psychosocial: social exclusion, discrimination, stress, and low social support

• Behavioral: eating habits, smoking, substance abuse (these are influenced by upstream factors)

• Biomedical: genetic predisposition (may result from long-term material and psychosocial factors)

Heather and Fern Case Study

• Heather experiences many more psychosocial and economic stressors than Fern

• When injured, both Heath and Fern receive healthcare but the quality and accessibility of that care varies greatly

• Heather experiences more negative outcomes, in large part because of the societal, economic and environmental disadvantages she faces

Social Determinants of Health

Those social factors that result in one group carrying heavier illness burden than another group

Nursing Considerations for Health Inequities

• Context: the circumstances surrounding the patient; the situation needs to be fully assessed and understood by clinicians

• What factors make the patient’s recovery more challenging? → the care plan needs to address these circumstances

• Get involved in efforts to fix inequity

• Circumstances to Consider: living arrangement, family support, income, ability to work, access to quality healthcare, urban vs. rural, transportation, education level, family stressors

Moral Courage

• The willingness to act on your ethical values and do what is right, even when it comes at personal risk or cost

• Standing up and protecting or advocating for others

• Putting ethical principles into action