N1003 Final Review

communication

a process of interaction between people in which symbols are used to create, exchange, and interpret messages about ideas, emotions, and mind states

why is communication between nurses so important?

- impacts the delivery of care
- better health outcomes
- enhanced patient understanding their conditions
- greater patient satisfaction
- enhanced job satisfaction
- decreased health care costs
- decreased length of hospital stays

verbal communication

spoken or written words

Non-verbal communication

- body language
- use of congruent non-verbal behaviours
- touch
- proxemics
- silence
- attend to the patients non-verbal body cues

meta-communication

words and non-verbal behaviours do not have meaning; the meaning resides in the people who express or interpret them

Denotation

the literal meaning of a word

Conotation

implied meaning of a word

verbal styles

- pitch and tone
- vary vocalizations
- encourage involvement
- validate an individual's worth
- advocate
- provide information when needed

self-concept

an organized network of ideas, feelings, and actions which every person has a consequence of experiences and interactions with other people

self-esteem

a persons personal sense of worth and well-being. the extent to which we like, accept, or approve of ourselves or how much we value ourselves.

why is self-concept important?

- it has a protective factor when coping with an illness or health challenge
- helps explain behaviour
- it can serve as a source of strength
- it can be a conceptual framework for decision making
-shapes expectations

self-concept in interpersonal relationships

- when individuals communicate, their perceptions are influenced by each person's self-concept's and levels of self esteem
- language is influential in forming perceptions of the self and others
self-concept can be impacted by communication (microassaults, microinsults, microinvalidations)

characteristics of self-concept

Dynamic - becomes more diverse as you go through life
Holistic - whole is greater than the sum
Unique

how does the self develop?

- appraisals are made by significant others about the self
- these appraisals are repeated and become incorporated into the self
- behaviour emerges to match the appraisals
- the self is open for reappraisal

factors that influence self-concept

- societal and cultural norms
- life experiences
- interpersonal and interpersonal influences
- social media

Maslow's Hierarchy of Needs

everyone has basic needs but the overall goal is self-actualization.

Carl Rogers Humanistic Theory

when the "actual self" and the "ideal self" are similar, a person is likely to have a positive self-concept and self-esteem. the "self" as a public persona versus the true nature of a person; introvert vs extrovert

Erik Erikson's Theory of Psychosocial Development

- personality develops through eight stages of psychosocial development, from infancy to adulthood
- identity formation is lifelong
- in each stage a person experiences a psychosocial crisis which could have a negative or positive outcome for personality
- there are specific goals a person needs to achieve to develop and maintain a positive identity
- personality development is not linear or sequential

concepts of self concept

- physical
- cognitive
- emotional
- spiritual

self-awareness

- the ability to see yourself clearly and objectively through reflection and introspection
- a reflective process of personal values, feelings, attitudes, motivations, strengths, and limitations and how these affect nursing practice and patient relationships

why do we need to develop self awareness?

- to discover more about ourselves to differentiate ourselves from others
- to learn the conscious use of self
- to become more fluent with the use of therapeutic communication/interventions

self-concept vs self-awareness

self awareness influences self concept. it involves conscious awareness of ones own thoughts, feelings, behaviours, and traits. to have fully developed self-concept, a person must have some level of self awareness

reflection of self awareness

- provides the opportunity to look back and analyze practices for further development
- appreciate the positive-strengths
- learn from weaknesses

nurse-client relationship

a planned, time-limited and goal directed connection between a registered nurse and a client for the purpose of meeting a client's needs

therapeutic relationships

- based on trust, respect, and personal integrity
- include the provision of: physical care, emotional support and health education.
- have specific boundaries, purposes and behaviours
are client focused and mutually defined by the client and the nurse
- enhance the well-being of client and the professional growth of the nurse
- no choice about being in the relationship

social relationships

- may or may not be goal directed
- can last a lifetime or may be at any point
- needs of both parties can receive equal attention
- behaviour can be spontaneous for both
- self-disclosure is expected equally
- individuals choose to enter into the relationship

goals of therapeutic relationship

- enhance the clients well-being
- promote recovery
- promote self-care and independence of the client

client-centred approach

- clients needs are the focus of the professional relationship
- begins where the client is at present and try to meet the needs of each client
- clients react differently to various techniques
- illness/hospitalization may heighten emotional responses

establishing trust

- convey respect
- show warmth and caring
- actively listen
- use attending posture
- maintain Confidentiality

establishing respect

- demonstrate genuine respect for clients
- encourage clients to verbalize and share
- do not assume what a client wants or needs, it is important to include them in the dialogue and take your cues from them
- avoid phrases like "honey" and "dear" or referring to the client in third person during their presence
- demonstrate active listening and collaborative communication

empowerment

- helping individuals to advocate for their own needs
- an interpersonal process for providing appropriate tools, resources and environment to build, develop, and increase the individuals ability to set and reach their own goals
- focus is on self-care and the client being a partner in their relationship

professional boundaries

- invisible structures imposed by legal, moral, and professional standards of nursing that respect nurse and patients rights
- responsibilities include: defining the length and time of contact, maintaining confidentiality, and providing an appropriate setting

warning signs of over involvement

- extra time and attention to certain patients
- visiting outside of regular working hours
- discounting the actions/care of other staff
- feeling resentment about how others care for the patient
- believing that you are the only one who understands the patients needs

therapeutic use of self

- requires the nurse to be authentic and clear about their personal values, feelings, and thoughts in response to the client
- requires a keen sense of self-awareness

empathy

the ability to be sensitive to and communicate understanding of the patients feelings. the ability to put yourself in someone else's shoes

self-disclosure

- occurs when the RN intentionally reveals personal experiences or feelings to a client
- the nurse regulates the amount of self disclosure
- the nurse needs to redirect the conversation back to the client

pre-interaction phase

- client is not involved in this phase
- information about the client is obtained from the chart and/or health care providers
- preparation planning for the first meeting
- anticipates potential client issues

orientation phase

- the nurse-client relationship formally begins during this phase
- simple introductions to establish rapport and beginnings of trust (built by demonstrating acceptance and non-judgemental attitude)
- the nurse's nonverbal behaviour needs to support the words used during the conversation
- clarify the purpose, roles, and process of the interaction

communication strategies

- conversation and behaviour are usually of the superficial nature
- neutral topics are generally discussed
- client will be assessing the nurses trust and worthiness
consistency, dependability, and honouring commitments

patient observation

- observe behaviour, mental status and anxiety level
- data collection related to the illness is crucial, but it is also important to focus on the emotional context; explore feelings
- observe what is being said, as well as what is not being said
- note discrepancies between verbal and non-verbal behaviour
- if client is a poor historian, it will be necessary to elicit information from other significant sources

working phase

the focus of mutual clarification of ideas and expectations
the nurse and the client:
- develop goals and decide on a type of assistance need
the nurse:
- helps clients seek out and use health services and personal strengths in resolving issues
- must foster the clients self direction and self management

tasks of the working phase

- defining the challenge/problem/concern
- pacing
- developing realistic goals
- planning alternate solutions
- implementing the plan
- challenging the resistant behaviours
- referral

termination phase

- refers to the ending of the relationship
- preparation for termination should begin in the orientation phase
- time to summarize major achievements, evaluate progress and goal achievement
- the client may react in a variety of ways to the termination; he/she must be allowed to express feelings about termination

caring

an intentional human action characterized by commitment and a sufficient level of knowledge and skill to allow you to support the basic integrity of your client. its central to helping professions and is offered to patients through therapeutic relationships

the ability of care is influenced by

- communication skills
-self awareness about feelings and attitudes
- previous thoughts, attitudes, and involvements in caring

what are the six C's of professional caring

- compassion
- competence
- confidence
- conscience
- commitment
- comportment

steps in the caring process

C - connect
A - appreciate
R - respond
E - empower

barriers in relationships result in

- poor communication
- reduced quality of care
- less favourable health outcomes
- lower patient and nurse satisfaction

nursing related barriers to therapeutic relationships

- conflicting values
- lack of a strong sense of self
- lack of value placed on caring
- conflicting professional commitments

client related barriers to therapeutic relationships

- anxiety
- stereotyping
- personal space

violation of personal space

- loss of control over this may cause the patient to experience loss of individuality and self esteem

cultural barriers

- can exist when the culture of your client differs from your own
- culturally competent care is characterized by a willingness to try and understand and respond to a patients values and beliefs

Ineffective Communication Techniques

- moralizing
- belittling comments
- being defensive
- asking probing questions
- changing the subject or topic
- giving advice or false reassurance
- unwelcoming posture
- facial expression

overcoming barriers

- establish and maintain trust
- demonstrate caring and empathy
- recognize and reduce anxiety
- use plain language
- use active listening techniques

therapeutic communication

a goal directed, focused form of dialogue used as a tool in health care to promote a client's well-being and positive response to treatment

purpose of therapeutic communication

- develop, maintain, and terminate the therapeutic nurse-patient relationship
- build rapport and establish trust and respect
- to provide a safe place for the client to express feelings and concerns
- to help the client cope more effectively with their situation

active listening

- a dynamic interactive process in which the nurse hears the client's message, decodes its meaning and provides feedback to the client
- a cognitive and emotional process, that may be based on the listener's values, attitudes, and feelings
- validation and self awareness is required
- requires critical thinking skills

concepts of active listening

1. give the speaker your undivided attention
2. demonstrate that you are listening
3. provide feedback
4. remain non-judgemental
5. respond appropriately

active listening themes

- observe communication patterns
- observe what is being said, as well as what is not being said
- note the discrepancies between verbal and non-verbal behaviour
- intuitive communication
- explore feelings

open ended questions

- prompts a patient to share more information
- cannot be answered by a yes or no question, or a one word response

close ended question

- can be answered with yes or no
- can limit a pattens response and thought expression
- may take several questions to obtain information

focused questions

- require more than yes or no responses
- limit the topic to be addressed
- can be useful in emergency situations

clarifying questions

- a type of open ended question used by the nurse to ensure he/she fully understands what the patient means
- enhance an understanding of the patients frame of reference
- when asked, the patient has the opportunity to confirm if the nurse does or does not understand them

minimal cues and leads

- demonstrates you are listening and encourage the patient to continue speaking
- non-verbal signals/behaviour and short phrases that are verbal prompts for the patient to continue the conversation
e.x., go on, mhmm, and then what, etc.

clarification

- the nurse seeks more information or elaboration on a point
- avoid questions that start with why

restatement

- encourages the client to reflect on previous comments
- allows the patient to elaborate on his or her concerns and the nurse to obtain more information

paraphrasing

- takes the clients original message and transforms it into your own words without losing the original meaning
- helps the nurse confirm their interpretation of the message

reflection

focuses on the emotional part of the message

summarization

- pulls several ideas and feelings together
- should be completed before the end of the conversation

silence

- when used appropriately, this technique can permit time for the patient and nurse to gather their thoughts and formulate a response, if required
- can be a powerful communication technique

touch

- can be a powerful technique when used appropriately
- must be used carefully
- e.x., playing hand on clients hand

giving broad openings

an open ended question that allows patients to direct the flow of conversation and decide what to talk about
e.x., "what's on your mind today?"

observations

- appearance, demeanor, or behaviour of patients can help draw attention to areas that might pose a problem for them
- incongruence between verbal communication and non-verbal behaviour can highlight patient concerns

focusing

- during an interaction, a patient may mention something particularly important; the nurse can focus on a statement, prompting the patient to discuss it further
- the nurse can select the most important health topic to be the focus of the interaction

confronting

- this technique should only be applied after trust has been established
- it can be vital to the care of patients to disagree with them, present them with reality, or challenge their assumptions
- can help reduce resistance, promote insight, break destructive routines and result in changes in behaviour, emotions and actions

documentation

- the process of organizing, obtaining, and conveying patient health information in a paper based or electronic format
- provides an accurate description of the care or service provided (legal documentation)
- a vital component of safe, ethical, and effective nursing practice

why is documentation necessary?

- to facilitate communication between health care providers
- to communicate the patients plan of care
- to demonstrate the patients plan of care
- to demonstrate accountability
- to meet legal requirements
- to promote quality assurance

what should be documented?

- clear, concise, factual, accurate, truthful, and client centred information
- relevant assessment data
- all ongoing monitoring and communications
- care/service provided
- evaluation of outcomes; clients response and follow up
- consultant and education
- do NOT document personal judgements, opinions, conclusions regarding a client

when should you document?

- at the time or as soon as possible after the care or event
- NEVER before care/service has been provided

purpose of records

- communication and care planning
- legal documentation
- education
- funding and resource management
- research
- auditing-monitoring

documentation guidelines

- if its not documented, it is considered not done
- information should be factual, accurate, complete, timely, current, organized, and complaint with standards
- must be legible
- avoid grammar and spelling errors, blank spaces, and vague words
- use only accepted acronyms, abbreviations and symbols
- do not alter or delete another persons documentation
- correct errors per agency policy
- include full signature per agency policy
- document chronologically & indicate if entry is late

narrative documentation

- story like format
- traditional format of charting
- includes information on interventions as well as clients response
- chronological order
- entries should be organized in a clear, coherent manner
- cons: does not necessarily focus on health problems, and is time consuming

problem-oriented medical record documentation

- includes database, problem list, care plan, and progress notes.
- identified list of health problems
- each member charts in one common section
- team member refers to a particular problem by listed name or number
- SOAP (focuses on specific patient problems)
(S) subjective data
(O) objective data
(A) assessment
(P) plan

source record documentation

a separate section for each discipline

charting by exception documentation

- focuses on documenting deviations
- based on predetermined standards of care protocols
- only abnormal or significant deviations called exceptions are charted in long hand by description format
initials indicate performance of a task

case managements plan and critical pathway documentation

incorporate a multidisciplinary approach

focus charting

- intended to make patients concerns or health need and strengths the focus of care
- progress notes are organized using the following categories:
(D) data
(A) action
(R) response
- charted in columns
- used column format to separate topics from the body of notes
- lists focus
- provides a quick description of the clients current status
- used by all disciplines

focus statement

- what you are writing about
- an observed finding
- an acute change in patients condition
- any significant or unusual result
- an exception to the expected outcome
- is not a diagnosis

(D) data

- subjective/objective data
- finding that indicate that action needs to be taken

(A)

- the actions that you took to respond to the specific foci
- future actions or plan you have initiated
- a treatment or teaching protocol you may have implemented

(R) response

- what happened to the patient as a result of the action/intervention
- patient outcomes
- does the patients condition/behaviour match the desired outcome/care plan goal

computerized documentation

- software programs allow nurses to enter assessment data, create and revise plans of care, and document patient progress
- computers generate nursing care plans and documentation

safety measures for electronic documentation

- personal records should never be shared with anyone
- never leave a terminal unattended, if you have logged on
- protect patient information displayed on the monitor
- always log off when finished
- notify managers when a community breach has occurred

common record keeping forms

- admission nursing history forms
- flow sheets and graphic records
- patient education record
- patient care summary or kardex
- acuity records or workload measurement systems
- standardized care plans
- discharge summary forms

kardex

- contains the information needed for the daily care of the client. its accessible to all members of the health care team
- contains demographic information, lab data, medication, IV therapy, dressings, etc.

types of communication shared within the health care system

- records or charts
- reports
- consultations
- referrals

reporting

- can be verbal or written
- examples include: SBAR< change of shift report, telephone reports, telephone or verbal orders, transfer reports, occurrence reports

SBAR

- communication tool used between members of the health care system
- used to standardize how information is shared between health care providers
- provides a succinct way to deliver information
- promotes critical thinking
- helps to ensure completeness of information and reduces the likelihood of missed data

S - situation

- include your name
- include patients name
- what is the major concern
- when did it start

B - background

- what are the pertinent facts
- what is the admitting diagnosis
- what medications are order
- current treatments