Basics of Communication, Evidence-Based Practice, Critical Thinking, and the Nursing Process
Basics of Nursing Communication and Practice
Communication is defined as a lifelong learning process.
It is recognized as one of the most difficult skills to educate; while tools are provided in a clinical setting, nurses must implement and strengthen the "muscle" of communication.
Communication is essential for: - Establishing nurse-patient relationships. - Delivering patient-centered care. - Ensuring patient safety.
Benefits of good communication among healthcare professionals include: - Improved patient outcomes. - Increased patient satisfaction. - Reduced risk of errors.
Caring relationships formed by a nurse and those affected by the nurse’s practice are at the core of nursing.
Fundamental Principles: - All behavior communicates. - All communication influences behavior. - Each patient is a unique individual with specific communication needs. - Nurses should embrace a nonjudgmental, holistic view of each person.
Developing Communication Skills
Nurses who develop critical thinking skills make the best communicators because they have the knowledge and confidence to understand nursing dynamics.
Critical thinking helps nurses overcome perceptual biases or stereotypes that might interfere with accurately perceiving and interpreting messages.
Patients respond more readily to a self-confident attitude.
Humility is necessary to recognize when a nurse needs to better communicate or intervene, especially regarding cultural needs or emotional states.
Illness frequently causes anxiety; effective communication helps patients overcome these feelings.
Nurses should think about every interaction and how it can be improved.
Elements of the Communication Process
The circular transactional communication process model indicates that each person in the interaction is simultaneously a speaker and a listener.
Key Elements: - Referent: The motivation for communication. - Sender and Receiver: The individuals involved in the exchange. - Message: The specific content being communicated. - Channels: The method of sending the message (visual, auditory, tactile). - Feedback: The response to the message. - Interpersonal Variables: Factors within both the sender and receiver that influence communication. - Environment: The physical or emotional setting of the interaction.
Forms of Communication
Verbal Communication: The use of spoken or written words. - Vocabulary: Using words the receiver understands. - Denotative and Connotative Meaning: Awareness that words can have different implications. - Medical Jargon: Should be avoided as it can be misconstrued. - Pacing: The speed at which one speaks. - Intonation: Tone of voice. - Clarity and Brevity: Being clear and to the point. - Timing and Relevance: Ensuring the conversation is appropriate for the moment.
Nonverbal Communication: Includes the five senses and everything not involving spoken or written words. - Personal appearance. - Posture and gait. - Facial expressions. - Eye contact. - Gestures. - Sounds. - Territoriality and personal space.
Zones of Personal Space and Touch
Special Zones of Touch: - Social Zone (Permission Not Needed): Hands, arms, shoulder, back. - Consent Zone (Permission Needed): Mouth, wrists, feet. - Vulnerable Zone (Special Care Needed): Face, neck, front of body. - Intimate Zone (Permission and Great Sensitivity Needed): Genitalia, rectum.
Personal Space Distances: - Intimate Distance: . Examples: Holding a crying infant, performing a physical assessment. - Personal Distance: . Examples: Sitting at a patient’s bedside, teaching a patient. - Social Distance: . Examples: Giving directions to visitors in a hallway, giving verbal report to a group of nurses. - Public Distance: or more. Example: Lecturing students.
Nurse-Patient Caring Relationships
These relationships serve as the foundation of clinical nursing practice.
Nurses assume a professional role, caring for health needs, human responses, and patterns of living.
The goal is to promote a psychological climate that encourages positive change and growth, aiding the patient in attaining health-related goals.
Narrative interaction: Encouraging patients to share personal stories helps nurses gain insight and learn what is meaningful to the patient.
Rapport Building Techniques: - Be prompt. - Make camera contact (if virtual). - Use soft, diffused light. - Make patients feel heard. - Take a Socratic approach. - Create a professional background. - Build amazing experiences.
Phases of a Helping Relationship
Pre-interaction Phase: Occurs before meeting the patient. Includes reviewing available data (medical/nursing history) and anticipating health concerns.
Orientation/Opening/Introduction Phase: Occurs when the nurse and patient meet. Includes setting a warm, empathetic tone, assessing health status, and recognizing the relationship may initially be superficial or uncertain.
Working Phase: The nurse and patient work together to solve problems and accomplish goals. Includes encouraging the expression of feelings and providing information to change behavior.
Termination Phase: Occurs at the end of the relationship. Includes reminding the patient that the end is near, evaluating goal achievement, and ensuring a smooth transition to the next phase of care.
Professional and Interprofessional Relationships
Nurse-Family Relationships: Requires understanding complex family dynamics; the same principles of individual communication apply.
Interprofessional Relationships: Communication with other healthcare team members. Breakdowns in communication, lack of education, and poor accountability are frequent causes of serious injuries.
SBAR Communication Tool: - S: Situation. - B: Background. - A: Assessment. - R: Recommendation.
Elements of Professional Communication: - Appearance, demeanor, and behavior. - Courtesy. - Use of names. - Trustworthiness. - Autonomy and responsibility. - Assertiveness.
Therapeutic vs. Nontherapeutic Techniques
Therapeutic Techniques: - Active listening, sharing observations, sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, using silence, providing information, clarifying, focusing, paraphrasing, validation, asking relevant questions, summarizing, self-disclosure, and confrontation.
Nontherapeutic Techniques: - Asking personal questions, giving personal opinions, changing the subject, automatic responses, false reassurance, sympathy, asking for explanations, approval or disapproval, defensive responses, passive or aggressive responses, and arguing.
Questioning Styles: - Open-ended: Used for narrative responses; states topics in general terms. Good for beginning an interview or introducing new topics. - Closed/Direct: Asks for specific information (one- or two-word answers). Used for filling in details, getting facts about past health, or moving the interview along.
Evidence-Based Practice (EBP)
EBP looks for the best scientific and clinical evidence for treating and managing problems.
Benefits: Improves quality/safety, increases nurse satisfaction, and reduces costs.
Sources of Evidence: - Well-designed research studies in peer-reviewed journals. - Textbooks and health care literature. - Clinical expertise and patient preferences/values.
Steps of EBP: - 0. Cultivate a spirit of inquiry. - 1. Ask a clinical question in PICOT format. - 2. Search for the best evidence. - 3. Critically appraise the evidence. - 4. Integrate the evidence. - 5. Evaluate the outcomes. - 6. Communicate the outcomes.
PICOT Framework: - P: Patient population of interest. - I: Intervention of interest. - C: Comparison of interest. - O: Outcome. - T: Time.
Critical Thinking and Clinical Judgment
Critical Thinking: A systematic, logical, and continuous process characterized by open-mindedness and inquiry. It involves recognizing issues, analyzing information, and drawing conclusions.
Clinical Judgment: A conclusion about a patient's needs or health problems influenced by experience and knowledge.
Reflection: Purposefully reviewing a past situation to discover meaning and improve problem-solving. It is not intuitive; it requires visualization and honest review.
Critical Thinking Competencies: - Scientific Method. - Problem Solving. - Decision making. - Diagnostic Reasoning. - Clinical Decision Making.
Developmental Tools: Reflective journaling, meeting with colleagues, and concept mapping (visual representation of patient problems and interventions).
The Nursing Process (ADPIE)
Defined as a cyclical, goal-directed, systematic framework for organizing nursing care.
Steps: 1. Assessment: Gathering subjective data (what the patient tells you) and objective data (what the nurse observes/measures via five senses). Includes physical, emotional, developmental, and sociocultural factors. 2. Analysis/Diagnosis/Data Collection: Interpreting the data to recognize patterns, comparing data to standards, and arriving at conclusions. 3. Planning: Setting priorities, establishing measurable client outcomes (short-term and long-term goals), and selecting interventions. 4. Implementation: Performing nursing actions, delegating tasks, and documenting responses based on evidence-based rationales. 5. Evaluation: Determining the effectiveness of the plan and modifying it as needed. Outcomes must be specific and measurable.
Documentation and Health Records
Rule: "If it is not documented, it has not been done!"
Purposes of Documentation: - Interprofessional communication. - Legal record of care (accuracy is the best defense). - Financial billing and reimbursement. - Auditing, monitoring, and quality evaluation. - Education and research.
EHR vs. EMR: - Electronic Health Record (EHR): Lifetime computerized record. - Electronic Medical Record (EMR): Record for a specific individual visit/admission.
HIPAA and PHI: Nurses are legally/ethically obligated to protect Health Information. Protected Health Information (PHI) includes names, addresses, dates (birth, admission), phone numbers, and email addresses.
Guidelines for Quality Documentation: - Factual: Descriptive and objective. - Accurate: Correct and precise. - Current: Documented as events occur (using military time). - Organized and Complete.
Documentation Methods: - Flow Sheets: Quick entry by body systems. - SOAP Notes: Subjective, Objective, Assessment, Plan. - Charting by Exception: Only documenting findings that deviate from the standard (WNL - Within Normal Limits).
Provider Communication: Nurses must document every call to a provider, including Telephone Orders (TO) and Verbal Orders (VO). All orders must be "Read Back" to the provider per Joint Commission rules.