2520 Final Exam
Caring – A Relational Process
Concept of Caring: A Relational Process:
Defined as an interpersonal process characterized by expert nursing, interpersonal sensitivity, and intimate relationships involving physical, emotional, and spiritual comfort and support
Expert of Nursing: Knowledge and skills but also advocating for your patient and empowering your patients to care for themselves
It can be an innate quality but can also be learned or developed.
Requires mastery of health, pathophysiology, technology, and psychomotor skills to have more time for caring relationships
Scope of Caring: Ranges from complete absence of caring (hurried, task-oriented, mechanical, emotionally detached) to complete presence of caring (evidence-based, responsive to holistic needs, person-centered care, culturally safe).
Attributes of Caring:
Relationship: Caring begins with a connection formed when a nurse feels motivated to address a patient’s identified need; it is built on foundations of trust, intimacy, and a sense of responsibility, nurtured through a nurse’s personal qualities such as openness, sincerity, love and patience
Have to be willing and able to connect with a patient
The nurse is motivated to respond to an identified client need. Example: Nurse meets with the Director of Nursing to advocate for increased staffing during peak hours in the Urgent Care.
Action: Specific things a nurse does in response to the patient’s needs, including direct nursing care, using touch appropriately, being present with the patient, & demonstrating competency in skills
These actions carry moral and ethical weight, which requires nurses to ensure their interventions are based on current evidence and knowledge
Occurs in response to the identified client needs. Example: Nurse consults spiritual care for patients and family members in a palliative care unit.
Attitude: The manner in which a nurse approaches their work and interacts with their patients, involving a positive attitude and demonstrating visible concerns and compassion for others
Caring attitude includes: reflective self-knowledge, ethical values, courage to act on those values
Accomplished through a particular way of acting: positive attitude and work style that integrates visible concern and compassion for others. Example: Nurse offers extra help to reduce the stress of colleagues who have been mandated to stay for overtime.
Acceptance: Belief that every human being deserves dignity and respect
Operating from a place of accepting the inherent worth of each individual they encounter, regardless of their circumstance
Belief that all human beings are worthy of dignity and respect. Example: Nurse provides equitable care to all patients regardless of their socio-economic status.
Variability: Caring is not a rigid set of behaviours but rather a flexible process that is adapted to the unique situation of each interaction; the ability to modify their caring interventions improves over time as they gain more experience
Process by which caring behaviours are shaped by the unique circumstances of each encounter between the Nurse and client. Example: Nurse makes adjustment to their care of a cognitively intact and fully mobile patient who likes to go for a walk outside of the unit at different times of the day.
Caring as Relational Practice: Recognizes that every single individual is influenced by/connected to contextual factors: interpersonal factors (age, gender, ability), interpersonal factors (people, relationships, families, and communities), and social structure factors (*social determinants of health: economic stability, education access, health care access, neighbourhood and built environment, social and community context).
Contextual factors shape the lived experiences of individuals.
Mastery of health, pathophysiology, technology, and psychomotor skills to have more time for caring relationships
Knowing the Other: "To care for someone, I must know many things... who the other is, what his powers and limitations are, what his needs are, and what is conducive to his growth. I must know how to respond to his needs and what my own powers and limitations are."
Caring as Human Mode of Being: Can be "achieved through relationships with others and valuing them" (Roach, 2002).
Link between Relational Practice and Culturally Safe Care: Person-Centered Care includes Cultural Safety
Cultural Safety: Health care actions toward equity... recognition and respect for cultural identity so that power balance exists.
Cultural Humility: Nurses continually engage in self-reflection and self-critique…being comfortable with a position of not knowing and not being the expert
Person-Centered Care (Morgan & Yoder, 2012): "Care that is respectful and responsive to individual preferences, needs, and values, and ensuring that patient values guide all clinical decisions."
Holistic – Values whole persons.
Individualized – Understanding the person’s life situation.
Respectful – Recognizes and respects inherent value.
Empowering – Individuals have input to their own care.
Communication
Definition of Communication: A process of interaction between people in which symbols are used to create, exchange, & interpret messages about ideas, emotions, & mind states.
Scope of Communication: Ranges from effective communication to no communication. Forms include verbal, nonverbal, symbolic, & metacommunication.
Verbal: Spoken & written word, conveying meaning through a collection of words.
Nonverbal: All communication that is not spoken or written, such as eye contact, personal space, & facial expression
S - Sit at an angle
U - Uncross arms/legs
R - Relax
E - Eye contact
T - Touch
Y - Your intuition
S - Sit facing the patient
O - Keep an open posture
L - Lean toward the patient
E - Establish & maintain eye contact (ensure culturally safe/appropriate)
R - Relax
Symbolic: Incorporating art & music to enhance meaning.
Metacommunication: Factors that comprise the context of the message b/c the ultimate goal is to create meaning, affects how messages are received & interpreted, including internal personal states, environmental stimuli & contextual variables.
Process of Complementary Exchange: Dynamic & reciprocal reception & transmission of messages. Sender encodes, transmits. Receiver perceives, interprets, responds (encodes, transmits back).
In the act of communication, the reception & transmission of messages between participants is dynamic & reciprocal. The sender encodes a message using symbols (both verbal & nonverbal) & transmits a message to the receiver. The receiver perceives the message, interprets the symbols, & then responds by encoding & transmitting a response back to the sender.
Basic Communication Theory: A way to analyze and discuss the processes, events, and commitments that make up communication: includes the sender, message, & receiver.
Context Affects Communication: Environment, relationship between participants, internal mood states, mental & physical condition, experience & education, external noise. Hierarchical relationships affect communication.
Characteristics of the environment in which the communication occurs → affects perception, & subsequent interpretation of messages by participants (including relationship between participants, internal mood states, mental & physical condition, experience & education & external noise emitted from the environment)
Why does communication have to be effective & appropriate? There are a multitude of factors affecting communication, understanding each one of the factors allow the sender & receiver (ones in communication) to understand & get the message directly (by interpreting not only the context but also their internal personal states, etc.)
Therapeutic Communication: Facilitates positive nurse-patient relationship & actively involves the patient in care. Involves listening, silence, touch, acceptance & encouragement.
Nurse-Patient Helping Relationship: Nurse is responsible for establishing, directing, & taking responsibility. Patient’s needs prioritized. Nonjudgmental acceptance.
Phases: Pre-interaction (before meeting), Orientation (getting to know), Working (problem-solving), Termination (ending).
Communication: An exchange of information that facilitates the formation of a positive nurse-patient relationship & actively involves the patient in all areas of their care
Therapeutic Communication: Need to listen to them (allows patients to be listened & build trust), silence (allows time to organize thoughts) Touch (deliver warmth), acceptance & encouragement
Read “Nurse-Patient Helping Relationships”. How is therapeutic communication different from communicating with your friends?
As a nurse, you're responsible for establishing, directing & taking responsibility for their interaction, & the patient’s needs take priority over the nurse’s needs. There is also nonjudgmental acceptance of the patient
Pre-interaction: What a nurse has to do before meeting a patient
Reviews available data, including the medical & nursing history
Talks to other caregivers who may have information about the patient
Anticipates health care concerns or issues that may arise
Identifies a location and setting that will foster comfortable, private interaction with the patient
Plans enough time for the initial interaction
Orientation: When nurse & patient meet & get to know one another
Sets the tone for the relationship by adopting a warm, empathetic, caring manner
Recognizes that the initial relationship may be superficial, uncertain, and tentative
Expects the patient to test the nurse's competence and commitment
Closely observes the patient and expects to be closely observed by the patient
Begins to make inferences and form judgements about patient messages and behaviours
Assesses the patient's health status
Prioritizes the patient's problems and identifies the patient's goals
Clarifies the patient's and nurse's roles
Negotiates a contract with the patient that specifies who will do what
Lets the patient know when to expect the relationship to be terminated
Working phase: Nurse & patient work together to solve problems & achieve goals
Encourages and helps the patient to express feelings about his or her health
Encourages and helps the patient to explore own feelings and thoughts
Provides information that the patient needs to understand and to change behaviour
Encourages and helps the patient to set goals
Takes actions to meet the goals set with the patient
Uses therapeutic communication skills to facilitate successful interactions
Uses appropriate self-disclosure and confrontation
Termination phase: At the end of the relationship
Reminds the patient that relationship termination is near
Evaluates goal achievement with the patient
Reminisces about the relationship with the patient
Separates from the patient by relinquishing responsibility for his or her
Facilitates a smooth transition for the patient to other caregivers as needed
Therapeutic Communication Techniques: Sharing observations, empathy, hope, humour, feelings; using touch, silence; providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self-disclosure, confrontation.
Sharing observations: Making observations by commenting on how the patient looks, sounds, or acts + different from assumptions (drawing unwarranted conclusions about the patient w/out validating them) Ex: “you look tired, where you up all night?”
Sharing empathy: Ability to emotionally & intellectually understand another person’s reality to accurately perceive unspoken feelings & to communicate this understanding to the other person
Sharing hope: Essential for healing, Appropriate encouragement and positive feedback —without minimizing the reality of an illness situation or instilling false hope → instill hope
Sharing humour: underused b/c using negative humour to deal with extreme tension and stress in the workplace, but this can be problematic. What is referred to as "grey zone" humour constitutes behaviours like teasing, practical jokes, and sarcasm. "Gallows humour" speaks to the more grim or dark style of humour, often used in very difficult situations to relieve anxiety or release anger in order to transform negative feelings into something lighter in mood
Use humour appropriately
Sense of humour is a useful coping strategy for some individuals
Potential challenges – jokes may be misunderstood
When its used carefully - can be highly therapeutic
One in every 18 patients hospitalized in acute care setting will experience at least one “experience” (Canadian Institute of Health Information (2016))
indicates that communication errors contribute to many of these errors
80% of safety research tells us that communication issues exist in adverse safety events
Sharing feelings: Emotions are subjective feelings that result from thoughts and perceptions. Feelings are not right, wrong, good, or bad, although they may be experienced as pleasant or unpleasant. You also have to be aware of your emotions b/c strong feelings are difficult to hide
Using touch: Patients may feel isolated relating to their personal & social contexts, increasing the importance of communicating a human connection (conveys many messages, such as affection, emotional support, encouragement, tenderness, & personal attention)
Using silence: Allows nurse & patient to observe each other, to really listen & sort out their feelings, allows patients to talk freely w/out the constraint of relying on particular patterns of question & answer
Providing information: Empowers patient to make informed decisions, experience less anxiety & feel safe & secure, health teaching
Clarifying: Check whether understanding is accurate, restate an unclear or ambiguous message to clarify the sender’s meaning or ask the other person to rephrase it
Focusing: Key elements or concepts of a message; use it when the patient is rambling but don't used it when they're discussing an important issue
Paraphrasing: Restating another person’s message more briefly in your own words, let the patient know you are actively involved in the search for understanding
Asking relevant questions: Seek information needed for decision making, only ask one question at a time, and questions should follow a logical sequence & proceed from general to more specific
Summarizing: Concise Review of key aspects of an interaction, focusing on key issues & adding relevant information as needed
Self-disclosure: Subjectively true, personal experiences about the self are intentionally revealed to another person, ability to choose to share experiences or feelings
Confrontation: Confronting someone in a therapeutic way, allows the other person to become more aware of the inconsistencies of their feelings, attitudes, beliefs, & behaviours
Non-Therapeutic Communication Techniques: Asking personal questions, giving personal opinions, changing the subject, automatic responses (stereotyping), false reassurance, sympathy, asking for explanations ("why"), approval/disapproval, defensive responses, passive/aggressive responses, and arguing.
Asking personal questions: Relevant to situation, not out of curiosity (invasive & unnecessary)
Giving personal opinions: Takes decision making away from the patient, inhibits spontaneity, stalls problem solving, & creates doubt
Changing the subject: Shows lack of empathy & mutuality, blocks further communication, & the sender then withholds important messages or fails to openly express feelings, ideas become tangled, & information may be inadequate
Automatic responses: Labels - generalized beliefs held about people; tends to dismiss the other person’s feelings & minimize the importance of their message
False reassurance: Offering reassurance not supported by facts if based in reality typically does more harm than good
Sympathy: Concern, sorrow, sadness, or pity for the patient generated by personal identification w/ patient’s needs (subjective vision of another person’s viewpoint that prevents a clear perspective of the issues confronting that person
Asking for explanations: Asking a person “why” questions tend to interrupt patients’ descriptions of their feelings & experience & cause them to refocus their energy into intellectual or defensive responses → can cause resentment, insecurity, & mistrust
Approval or disapproval: Don’t impose your personal attitudes, values, beliefs, & moral standards on other people while in the professional helping role → other people should have the right to speak their minds & make their own decisions
Defensive responses: Becoming defensive in response to criticism implies that the person has no right to an opinion ⇒ Sender’s concerns are ignored when you focus on the need for self-defense, defense of the health care team, or defense of other people
Passive or aggressive response: Serve to avoid conflict or sidestep issues, reflect feelings of sadness, depression, anxiety, powerlessness, & hopelessness
Arguing: Challenge or argue against perceptions denies that they’re lying, misinformed, or uneducated ⇒ Skillful nurses give information or present reality in a way that avoids argument
Emotional Intelligence: Capacity to identify, comprehend, and manage one's own emotions and those of others, to the precise level suited to the given situation, thus enhancing relationships
Five Elements:
Self-awareness - ability to identify, understand, and evaluate own feelings
Improve: Start by keeping a journal of your thoughts, induce any reaction to a situation that provokes an emotion either positive or negative. This activity can help in developing self awareness. Also, try slowing down, when you experience anger or strong emotions, take a deep breath & examine the reasons for the emotions. Remember, regardless of the situation, reactions can always be chosen & controlled
Self-regulation - ability to understand emotions and control moods and feeling's
Improve: Start by keeping a journal of your thoughts, induce any reaction to a situation that provokes an emotion either positive or negative. This activity can help in developing self awareness. Also, try slowing down, when you experience anger or strong emotions, take a deep breath & examine the reasons for the emotions. Remember, regardless of the situation, reactions can always be chosen & controlled
Motivation - having a strong inner drive to succeed
Improve: Reexamine why you’re in the nursing profession. Make sure your goal statements are stll aligned w/ what you want. If you need to improve motivation, look for resource to renew your enthusiasm. Remain hopeful & optimistic by finding something good in everything that happens
Empathy - ability to recognize and understand others' feelings
Improve: If you want to earn respect & loyalty from others, show others you care by being empathetic. Give constructive feedback & listen actively. Put yourself in someone’s else position to respond accurately. Watch other people’s body language to detect nonverbal cues
Social skills - have good relationships, build networks, and help others develop their skills
Improve: Strive for great communication & avoid offending others w/ your words. Be a good listener, & pay attention to others when they speak. be generous w/ praise to inspire others.
Documentation: Communication between health providers, meets legislative requirements, quality improvement, research, legal proof. (Accuracy, communication, continuity, legality, accountability)
Five Items Included in Quality Documentation:
The process used to get informed consent and any signed consent forms
Discharge planning and discharge information (to discharge, any referrals required to facilitate
discharge, the client’s condition at discharge, any teaching or education for self-care and any follow- up appointments)
Communication with family or other significant supports
Telephone health advice provided
Health education and psychosocial support provided
Fundamentals Rules of Documentation
Use permanent ink and ensure your writing is legible – this may require you to print. This is an issue of patient safety as illegible writing can be misinterpreted and may not bring value to client care.
Never leave blank lines as it may allow someone to add incorrect information to empty spaces.
Events should be recorded chronologically (or sequentially and logically).
Record date and time with each professional contact (to support clear communications is it best to write the date in full by month-day-year (e.g. October 9, 2016 at 2010 hrs. NOT: 10/09/12 at 8:10) or as outlined in your organizational policy.
Document in a timely manner, meaning as close to real time as possible in order to ensure accuracy of details and timely communication to the team.
Do not chart in advance of the event or care provided. Pre-charted information is not credible or accountable.
Include your signature and designation on each entry in both hand written and electronic formats (e.g. GN, RN, GNP, RN(EP) or RN(NP)). Education credentials are optional.
Use professional language and terminology.
Avoid using abbreviations. Abbreviations may not be understood or may be misinterpreted.
Only include notes of the care you provided. An exception to this rule may occur in the role of
designated recorder during emergency event. Please check your organizational policy.
Do not include bias (document only conclusions that can be supported by data).
Clear vs Unclear Documentation: Documentation should paint the entire picture of the client and the care provided from the time the client entered the health-care system until his or her discharge. Vague or opinionated documentation can interfere with continuity of care and misrepresent your assessment findings.
Corrections: Mistakes can happen when documenting. What should you do if you realize you made an error in a client record? Fix it as soon as you can. When making a correction, follow these rules:
always keep the original;
draw a single line through the entry and write “error” along with your initials;
document the corrected information;
record the date and time the correction was entered;
do not use white out or eliminate an entry entirely;
do not remove pages from a paper record; and
if you have already distributed the record, write your correction and resend the updated version in
an addendum.
When using electronic health records, make sure you know how to make a correction using these principles. Forensic examination of the records can determine which entry was made before another.
Late Entry: If you forget to chart something in the client record, you should:
identify the new entry as a “late entry”;
ensure the date and time of your additional note is clearly indicated;
clearly identify the event or previous note to which the new note is concerned;
sign all new entries and include your designation; and
never leave blank lines.
SOAPIE:
Subjective - what the patient & family tells you
Objective - what you observe & measure
Assessment - conclusion based on S&O: patient clinical issue(s)
Plan - long & short-term plans to address problem
Intervention - specifically what you did at this time
Evaluation - evaluate effectiveness of plan & intervention
Reducing Communication Errors
I-SBAR-R (for Handoff):
Identification: Who are you calling & what are you calling about?
Identity yourself & role
Identify your unit, patient #, & the room #
Situation: What is the situation you’re calling about? briefly state the problem:
What is it
When it started
What is the severity
Background: Provide background information related to the situation, including all or some of the following:
Admissions diagnosis, day of admissions, & pertinent medical history
List of current medications, allergies, intravenous fluids & laboratory tests
Laboratory results (date & time each test was performed & results of previous tests for comparison
Other clinical information
Code/ACP status
Assessment: What is your assessment of the situation?
Most recent vital signs
Changes in vital signs or assessment from previous assessments
Recommendation: what is your recommendation or what do you want?
Patient to be admitted or transferred
New medication or further tests
Patient to be seen now
Order to be changed
Repeat Back:
Repeat back the orders that have been given
Clarify any questions
Receiving Feedback:
Feedback is based on whether a student met the requirements of an assignment, test, skills demo, clinical performance, etc.
In the clinical setting, feedback may be given by other members of the health care team.
Feedback is generally provided to develop a student's professional growth.
At times, a student may not agree with the feedback.
How should I react when receiving feedback from others?
Emotional Intelligence
Relationships always affect communication process. In some relationships, there is a hierarchy relationship includes Nurse-patient, Nurse-student, and faculty member-student
Key to managing difficult situations, including receiving feedback from others, is Emotional Intelligence.
Emotional Intelligence is the capacity to identify, comprehend, and manage one's own emotions and those of others, to the precise level suited to the given situation, thus enhancing relationships
Clinical Connection
Ask for feedback.
"Here is my plan for the day/shift."
"Should I add/change anything to my plan of care?"
This is what I know based on my assessment. Am I on the right track?
"Sorry, I missed that. I will do better next time."
Thank you for guiding me with my IV start. Do you have any suggestions with my technique?
Clinical humility -"... To be humble means to appreciate the limits of your abilities, understanding and importance.. accepting that anyone can make a mistake."
Ethics
Ethics Definition (Bennett-Woods, 2025): Ethics is the study of moral principles that guide human behavior, helping individuals determine what is right and wrong in various situations. In nursing, ethics involves applying values like compassion, integrity, and respect to make difficult decisions that impact patient care. Ethical practice requires moral sensitivity, reflection, and decision-making to ensure actions align with both professional standards and personal integrity.
Scope of Ethics:
Societal Ethics: Societal ethics establish the foundation for ethical behavior through laws and regulations that protect the public and ensure accountability in healthcare. Legal standards, such as clinical care, liability, and malpractice, set minimum expectations for professionals, while regulatory guidelines define education, scope of practice, and facility operations. Compliance with these laws is essential for maintaining a nursing license, but legal standards alone do not resolve all moral dilemmas—controversial issues like abortion and provider-assisted dying highlight ongoing ethical conflicts within society.
Societies have laws that reflect beliefs of society
Organizational Ethics: Principles and values that guide an organization’s decisions, actions, and culture. These ethics are reflected in policies, practices, and procedures designed to ensure ethical operations. Failures in organizational ethics, such as healthcare fraud and abuse, can have serious financial and ethical consequences. Ideally, an organization’s ethics influence everything from its mission and employee treatment to its financial practices and community impact.
Policies, rules, & guidelines within an organization
Bioethics: Related to research ethics
Professional Ethics: Higher ethical standards and expectations that guide nurses in their practice. Unlike legal requirements, professional ethics focus on ideal principles such as compassion, respect, and patient advocacy, as outlined in the ANA Code of Ethics. The nurse-patient relationship is inherently ethical, requiring nurses to uphold dignity, fairness, and integrity in all interactions. While no one is perfect, each nurse must interpret and apply these ethical principles in real-life situations, continuously striving for ethical excellence in their practice.
Nurses are held to a higher standard of behaviour, i.e. CNA Code of Ethics
Personal Ethics: Describes an individual’s own ethical foundations and practice. Our personal ethics continuously intersects with these other categories of ethics; however, they do not perfectly overlap, so there is much potential for conflict. In addition, the sources of our ethics change over time just as we continue to change with time.
Individuals “moral compass”. May change over time w/ education & life experience
A nurse’s personal ethics may conflict w/ the ethics of colleagues, organization, etc.
Ethical Principles:
Respect for Persons: Ethical principle that recognizes the inherent worth, dignity, and value of every individual. A key extension of this is autonomy, which emphasizes a patient’s right to self-determination and informed decision-making regarding their treatment. Closely related is veracity, or truth-telling, which ensures patients receive honest, understandable information about their condition and treatment options, allowing them to make fully informed choices
Treat others w/ dignity & respect. People can make their own decisions (autonomy). Telling the truth (veracity).
Nonmaleficence: Ethical principle that requires healthcare providers to avoid causing harm, including pain, disability, or death. However, in healthcare, some harm (such as surgery or medication side effects) may be necessary to prevent greater harm. The challenge is to minimize risks and ensure that any harm inflicted is justified and does not cause unnecessary suffering.
As much as possible, minimize harm to the patient
Beneficence: An obligation to do good by acting in ways that promote the welfare and best interests of others.12 Patients can reasonably expect that you, as a nurse, will promote their health and well-being. However, much like harm, the concept of good is difficult to define. A patient may define his or her best interests very differently than the nurse or other healthcare professionals
Do good to promote the welfare of others
Justice: Justice in healthcare is about fairness, equity, and ensuring all patients receive non-discriminatory care. Nurses must treat everyone equally, regardless of social status, personal characteristics, or medical conditions, as emphasized by the ANA Code of Ethics. A key issue is distributive justice, which deals with the fair allocation of limited healthcare resources—whether based on equal distribution, individual need, or contribution. Other aspects include compensatory justice, such as malpractice settlements, and procedural justice, which ensures fair systems for decisions like organ transplants. Ultimately, justice in nursing means providing ethical, unbiased care to all patients.
Providing equitable care, Advocating for patients from marginalized backgrounds
Fidelity: Being loyal, keeping promises, fulfilling duties, and being trustworthy. While it seems simple, it
often creates conflict because nurses owe loyalty to many parties—patients, families, healthcare teams, employers, professional ethics, and the law. This can lead to tough situations where personal beliefs, patient wishes, workplace policies, and legal or professional obligations may not align.
Keeping your word. Patients need to be able to trust you as their care provider
Canadian Nurses Association (CNA) Code of Ethics: Statement of ethical values, responsibilities & endeavours of nurses. Regulatory tool. Guides ethical relationships, behaviours, & decision making in practice, education, administration & research.
Developed by nurses for nurses.
Purpose: Serves as an ethical basis from which curses can advocate for quality practice environments that support the delivery of safe, compassionate, competent & ethical care.
Relevancy:
Responding Ethically to Incompetent, Non-Compassionate, Unsafe or Unethical Care:
Nurses question, intervene, report & address unsafe, non-compassionate, unethical or incompetent practices or conditions that interfere w/ their ability to provide safe, compassionate, competent & ethical care; & they support those who do the same
Nurses are honest & take all necessary actions to prevent or minimize patient safety incidents. They learn from near misses & work w/ others to reduce the potential for future risks & preventable harms
Nurses intervene & report when necessary when others fault to respect the dignity of a person they are caring for or a colleague (including students), recognizing that to be silent & passive is to condone the behaviour. They speak up, facilitate conversation & adjudicate disputes, as appropriate/required
Ethical Considerations in Addressing Expectations That Are in Conflict with One’s Conscience:
If nurses can anticipate a conflict w/ their conscience, they notify their employees or persons receiving care (if the nurse is self-employed) in advance so alternative arrangements can be made
Nurses may not abandon those in need of nursing care. However, nurses may sometimes be opposed to certain procedures 7 practices in health care & find it difficult to willingly participate in providing care that others have judges to be morally acceptable
Ethical Considerations for Nurses in a Natural or Human-Made Disaster, Communicable Disease Outbreak or Pandemic:
Nurses carefully consider their professional role, their duty to provide care & other competing obligations to their own health, to family & to friends
During a natural or human-made disaster, including a communicable disease outbreak, nurses provide care using appropriate safety precautions in accordance w/ legislations, regulations & guidelines provided by government, regulatory bodies, employers, unions & professional associations
Ethical Considerations in Relationships with Nursing Students:
Nursing Students are expected to meet the standards of care for their level of learning. They advise their faculty clinical instructor & their clinical unit nurse supervisors if they don’t believe they’re able to meet this expectation
Primary Responsibility: Assignment & care of the person remains that of the primary nurse to whom the person has been assigned
Nursing faculty, preceptors, & nursing students “place the safety & well-being of the [persons in care] above all other objectives, including fulfilling educational obligations
Nursing Values & Ethical Responsibilities:
Providing safe, compassionate, competent and ethical care: Nurses engage in compassionate care & build relationship w/ patients. They are patient-first (advocate, educate) to foster a safe & welcoming environment.
Promoting health and well-being: Nurses provide first & direct care for the health & well-being of the persons in their care, which includes advocating for them & collaborating w/ other health care workers
Promoting and respecting informed decision-making: Nurses ensure that the persons receiving care has the information they need to make informed, respect the wishes of capable persons receiving care, & that nursing care is provided w/ the person’s informed consent.
Honouring dignity: Nurses respect (care, privacy), support, advocate, provide comfort & intervene for the patient. They maintain professional boundaries & they understand the law to consider how to respond to medical assistance in dying.
Maintaining privacy and confidentiality: Nurses respect the interests & policies, collect, use & disclose health information, & in all new areas of practice, nurses safeguard the impact new & emerging technologies that have a on patient privacy & confidentiality
Promoting justice: Nurses don’t discriminate on the basis of a person’s race, ethnicity, culture political, & spiritual beliefs, respect the history & interests of Indigenous Peoples. They refrain from judging, labelling, stigmatizing & humiliating behaviours
Being accountable: Nurses are honest & practice w/ integrity in all their professional interactions. They maintain their fitness to practice, if they were aware that they don't have the necessary physical, mental, or emotional capacity to practice completely, they withdraw from their provision of care.
Morality: An accepted set of social standards that guide behaviour
Ethics: Foundation for moral behaviour
The examination of mortality through a # of different approaches
Ethical Process: Ethical Sensitivity(there is a problem) → Ethical Reflection & Analysis (rank ethical obligations & priorities) → Ethical Decision-Making (What is the right thing to do?)
Moral Distress: Arises when nurses are unable to act according to their moral judgement
Feel they know the right thing to do, but system structures or personal limitations make it nearly impossible to pursue the right course of action
Societal Ethics: Societies have laws that reflect beliefs of society
Professional Ethics: Nurses are held to a higher standard of behaviour, i.e. CNA Code of Ethics
Bioethics: Related to research ethics
Organizational Ethics: Policies, rules, & guidelines within an organization
Personal Ethics: Individuals “moral compass”. May change over time w/ education & life experience
A nurse’s personal ethics may conflict w/ the ethics of colleagues, organization, etc.
CNA Code of Ethics Nursing Values & Responsibilities to provide guidance in selected scenarios at a beginner level
“It is important for all nurses to work toward adhering to the values in the Code at all times for persons receiving care — regardless of attributes such as age, race, gender, gender identity, gender expression, sexual orientation, disability, and others — in order to uphold the dignity of all. Nurses recognize the unique history of
— and the impact of the social determinants of health on
— the Indigenous Peoples of Canada.”
Part 1. Nursing Values & Ethical Responsibilities
Describes the ethical responsibilities central to ethical nursing practice articulated through seven primary values & responsibility statements. These statements are grounded in nurses’ professional relationships w/ persons receiving care as well w/ students, nursing colleagues & other health-care providers. The 7 primary values are:
Providing safe, compassionate, competent, & ethical care
Promoting health & well-being
Promoting & respecting informed decision-making
Honouring dignity
Maintaining privacy & confidentiality
Promoting justice
Being accountable
Fitness to Practice
Definition: All the qualities and capabilities of an individual relevant to their practice as a nurse, including but not limited to freedom from any cognitive, physical, psychological or emotional condition and dependence on alcohol or drugs that impairs their ability to practise nursing
According to the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses, if nurses become aware that they do not have the necessary physical, mental, or emotional capacity to practice safely and competently, they have specific responsibilities. These responsibilities include the following:
They must withdraw from the provision of care after consulting with their employer.
If they are self-employed, they must arrange for someone else to attend to their clients’ health-care needs.
Nurses are then required to take the necessary steps to regain their fitness to practise, in consultation with appropriate professional resources.
This falls under the ethical responsibility of maintaining their fitness to practise as part of being accountable for their actions and answerable for their practice as members of a self-regulating profession.
Why it Matters: Patient Safety, Ethics. Staying healthy = practicing safely.
Components: Cognitive health, physical health, psychological/emotional health (good coping strategies, emotional intelligence such as self-awareness, self-regulation, motivation, empathy, social skills), knowledge, skills, and abilities.
Requisite Skills & Abilities
Expect their health-care system to provide safe, competent & ethical service
Includes ensuring that RNs demonstrate the application of knowledge, skills, judgment & personal attributes required for the delivery of safe, competent & ethical registered nursing care
Cognitive
Ability to perform skills which demonstrate thinking capacity
Recall information over time
Demonstrate complex computation skills
Demonstrate critical inquiry skills
Prioritize tasks
Demonstrate concentration skills
Demonstrate problem-solving skills
Communication
Ability to express & receive written, verbal or non-verbal information & the ability to interact w/ others in a clear, respectful & professional manner. This includes:
English language proficiency (reading, writing, listening & speaking)
Recognizing own non-verbal communication & the ability to interpret non-verbal communication of others
Ability to document & understand information, in writing as well as electronically, in the patient’s chart/health record
Sensory
Ability to perceive w/ each of the following senses well enough to provide care & participate in educational activities:
Sight
Touch
Hearing
Smell
Hand-eye coordination (manual dexterity)
Physical
Ability to perform each of the following requisites well enough to provide client care & participants to educational activities:
Lift
Carry
Stand & maintain balance
Perform repetitive actions
Push & pull
Climb
Bend
Reach
Walk
Move within confined spaces
Sleep Pattern (on paper)
Importance: w/out much sleep, cognitive isn’t at optimal condition; could lead to unprofessional behaviour, sluggishness
Behavioural
Ability to conduct oneself in a professional manner
Accept individual differences
Take direction
Behave in a professional manner
Practise in a manner consistent w/ established client safety policies & procedures
Provide care in an unpredictable environment
Manage time & establish timelines
Stress as a Threat:
Sources of stress for nursing students:
Managing academic workload – Developing ability to manage time and prioritize
Nursing program harder than anticipated – Heavy course workload, assignment due dates, clinical
Learning how to learn – Previous learning strategies, i.e., memorization may no longer work
Higher stress if moved to attend school – Being away from loved ones, familiar surroundings
Balancing roles and relationships outside of school – Family, work, community roles and responsibilities.
Need to negotiate expectations of family and friends.
Comparing self with other students – As much as possible, students can choose to focus on their own performance. Each student has their own journey, strengths, and limitations.
Stressors related to clinical: Complexity of clinical practice, receiving feedback from CEF, lack of knowledge, fear of making mistakes
As nursing students learn to identify, enhance, and/or develop their protective factors, they will be better equipped to effectively manage perceived adversity and stress. The cumulative successes of these events will lead to increased resilience demonstrated by enhanced coping/adaptive abilities and well-being.
Strategies to Improve/Maintain:
Resilience (Stephens, 2013): Individualized development using personal protective factors to navigate stress. Growth Mindset (embrace challenges, persist, effort to mastery, learn from criticism, inspiration from others).
Personal Protective Factors (Stephens, 2013):
Social Support – Loved ones, friends, colleagues, instructors
Self-Efficacy – Belief in their ability to succeed in a particular situation
Willing to seek help – Clarify, ask questions, reach out to support persons
Learn from mistakes – How do I grow from my mistakes?
Stress Reduction & Self-Care:
Connect with social supports
Sleep
Mindfulness techniques
Exercise
Healthy diet
Goal settinG
Time management techniques
▪ Self-compassion – If you can forgive others, can you forgive yourself?
Interpersonal Violence
Interpersonal Violence Definition: Intentional use of physical force or power against oneself, another, or a group, resulting in harm. Directed toward another individual.
Bullying and Harassment (MNU Front Lines Magazine, 2013): Bullying behind all forms of harassment. Repeated, deliberate, and disrespectful behavior harming the target. Addressed in Canada’s Criminal Code, Manitoba’s Workplace and Health Amendment Act, and Human Rights Act.
Types of Bullying:
Verbal - name calling, sarcasm, spreading rumours
Social - mobbing, scapegoating, excluding others from a group
Physical - hitting, poking, punching, stealing belongings, menacing behaviours
Cyber - using internet or social media to intimidate, put down, spread nurses
Why Targeted: Bullies are predatory and opportunistic. Other reasons: being good at job, being the expert, having vulnerability, showing independence.
Bullying Experienced by Student Nurses:
Occurs at all levels:
Veritcal Violence: between... persons on different levels of the hierarchical system”
Also referred to as “Top-down” violence, i.e., Unit Manager intimidates their staff Nurse with verbal threats.
Bottom-up violence: A hospital support staff bullies a Unit Nurse
Horizontal or Lateral Violence:
Historically seen as rite of passage.
“Nurses eat their young.”
Unfortunately, in some settings, this behaviour is “so tolerated and commonplace.
Bullying Experienced by Nurses (MNU Front Lines Magazine, 2013; American Nurse Journal, 2013): Occurs at all levels. Vertical violence (top-down or bottom-up). Horizontal or lateral violence ("nurses eat their young"). Often tolerated.
Consequences of Bullying:
Recipient: Mourning, anger, fear, irritability, loss of confidence/self-esteem, decreased ability to learn/care. High stress/anxiety, physical problems, frequent illness, poor concentration/memory, irritability, anger, shattered self-confidence, low self-worth/esteem/love.
Organizational/Systemic: Increased absenteeism, staffing challenges, decreased motivation, financial cost due to turnover.
Safety and Patient Outcomes:
Avoidance of communication
Impaired concentration at work
Avoidance of safety concerns
Fear of seeking help
Poor patient satisfaction/complaints
Falls
Medication/treatment errors
Delayed care/injury/mortality
Prolonged admissions
If Experiencing Bullying: Connect with CEF (Clinical Education Facilitator). If CEF is bully, contact Clinical Course Leaders, Director of Clinical Education, Director of Undergraduate Nursing Program, Associate Dean. Utilize Rady Faculty of Health Sciences "Speak Up" and U of M Student Counselling Centre.
Stop Bullying Behaviour:
CAREFRONTING: Clearly name behaviour, concrete examples, allow response, articulate desired change, consequences → report behaviour.
"XYZ" Statement: I feel (X) when you (Y) because (Z). I would like....
Was it your intent to.... (repeat what the action was and then stop. Do not respond until there is a response).
In the future... (What behaviour would you like to see?)
If there isn’t a change...... (What’s the consequence?)
“At today’s staff meeting, was it your intent to put me on the spot or embarrass me by calling me out on forgetting to sign for a medication from last week?” [allow for response]
“In the future, I would appreciate if you would bring up these issues to me one-on-one at the time, rather than in a public setting.
If this behaviour continues (If there is not a change), I will have to file with a complaint.”
Role of the Bystander: Everyone's responsibility to maintain respectful workplace. Acknowledge, practice what to say, let bully know it's unacceptable, document and report, support target. Employers required to have harassment prevention policy.
Professional Identity
Definition: A sense of oneself, and in relation to others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse
Thinking, Acting, Feeling like a nurse: Shaped by characteristics, norms, values.
Characteristics of Nursing (RNAO, 2007): Knowledge, spirit of inquiry, accountability, autonomy, innovation, collaboration, ethics & values, advocacy.
Scope: Professional Identity distinct from Personal Identity.
CRNM Practice Expectations: Responsibility of all RNs to understand and apply practice expectations (Professional Practice, Communication, Ethical Practice, Client-Centered Practice, Collaborative Care).
Characteristics of Nursing
Knowledge
Spirit of inquiry
Accountability
Autonomy
Innovation
Collaboration
Ethics & Values
Advocacy
Formation and Development (Crigger & Godfrey, 2014, 2011):
Social expectations (rules, codes, standards, etc.).
Has responsibilities to society, recipients of care, other professionals, and to self.
Character development. Development of attributes and values that are internalized: courage, humility, forgiveness, integrity, and compassion.
Ethical aspect of a professional becomes paramount – has a compass that guides many decisions in everyday practice.
Development of higher order critical and situated thinking.
Deep commitment to professional ideals.
Maintain a level of moral excellence and moral resiliency.
Should strive to be a better professional than one that just meets standards, rules, and codes.
Going up the stairs represents a nurse who flourish and grow over the course of their career.
A step down or a “slip” represents an error or misconducts and hopefully the nurse is morally resilient to correct it.
Attributes of Professional Identity:
Doing: Societal and professional codes, standards, skills.
Based on a sociological and consensus perspective, emphasizing societal and professional codes, standards, and skills necessary for the role. This approach highlights how nurses function within a group, with an early career focus on external expectations and task completion. Historically, this was evident in 1950s diploma nursing education, where nurses had clearly defined roles and duties, and success was measured by how well they fulfilled those responsibilities (e.g., administering medications, assisting physicians, and following strict procedural guidelines). This skill-based, functionalist approach remains relevant in modern nursing, as seen in structured training programs and competency-based assessments. However, while "doing" is an essential part of becoming a nurse, it does not fully explain the deeper transformation from layperson to professional, which also involves internal identity development, critical thinking, and ethical decision-making
Being: Personal and psychological commitment to doing right, moral integrity, attitudes, behaviours aligning with nursing values.
Focuses on the personal and psychological commitment to doing what is right, even without external enforcement. It goes beyond rules and standards, emphasizing moral integrity, attitudes, and behaviours that align with nursing values. This internal drive shapes how a nurse thinks, feels, and acts, fostering professionalism through compassion, ethical decision-making, and a deep sense of responsibility. For example, a nurse staying with a distressed patient after their shift demonstrates "being" a professional. This concept extends beyond nursing, influencing other healthcare roles, and works alongside "doing" to form a complete professional identity
Acting Ethically: Upholding ethical standards (confidentiality, avoiding inappropriate relationships).
Acting ethically is a vital part of professional identity in nursing, as it reflects both societal and professional values. Socrates emphasized that truly living well means following one's principles, which in nursing includes upholding ethical standards like maintaining patient confidentiality and avoiding inappropriate relationships with patients. Ethical behaviour is essential to trust and integrity in the profession, and society acknowledges this—evident in nurses being ranked as the most honest and ethical profession in the Gallup Poll since 2002
Flourishing: Transformational growth, engaging with profession's purposes, strong identity, seeing world through profession's lens, aligned habits.
Understanding the doing and being of nursing must be paired with transformational growth for a nurse’s professional identity to fully develop. Not all professionals reach expert status—some remain experienced but do not deepen their understanding. Sustainable, lifelong growth requires key qualities such as deeply engaging with the profession’s public purposes, developing a strong professional identity, seeing the world through the lens of the profession’s moral purposes and standards, and using habits of response to patients, families, and colleagues that are aligned with the profession’s standards and ideals. It is emphasized in programs like the Magnet Recognition Program, where striving for excellence is a core value. Rooted in ancient Greek philosophy, the concept of human flourishing highlights that each person has a purpose, and in nursing, this means continuously growing to fulfill one’s professional potential.
Changing Identities: Ongoing process of balancing and integrating multiple identities.
An ongoing process, requiring individuals to rework their sense of self as new identities emerge. Unlike a smooth developmental transition, this process often feels like disequilibrium, where multiple identities (e.g., student, employee, family member) must be balanced and integrated. The ability to recognize and adapt to these changing identities is the final key aspect of developing a professional identity
In the "Practice Direction: Practice Expectations for RNs," client-centered practice is defined as a partnership between the RN and the client, where the client retains control over their care and is supported by the nurse's knowledge and skills to develop a realistic plan and access resources. This involves a comprehensive approach in clinical settings, including assessing the client's needs, collaboratively developing a care plan considering their preferences and culture, evaluating outcomes with the client, ensuring timely and understandable communication for informed decisions, making appropriate referrals, and supporting self-management. Conversely, collaborative care mandates that RNs work cooperatively with clients, families, and other health-care providers, emphasizing effective communication, understanding roles, respecting other professionals, and utilizing collaborative decision tools to provide comprehensive care.
Interventions to Achieve Formation:
Hear Expectations Clearly – Nursing education can be overwhelming due to its complexity, so it is essential to actively listen to expectations, instructions, and advice from faculty, mentors, and experienced nurses. Understanding these guidelines will set the foundation for success
Value Debriefing & Feedback from Role Models – Mentorship and role modeling play a crucial role in professional growth. Studies emphasize that the most impactful learning comes from supportive yet challenging relationships with faculty or mentors. These relationships help shape a nurse’s professional identity and provide valuable guidance, both during education and throughout their career
Engage in Reflection – Reflection is a powerful learning tool, helping students process experiences, internalize lessons, and adjust perspectives. It may occur through guided assignments, post-clinical debriefs, or spontaneous self-reflection on patient interactions. Reflection enhances critical thinking and emotional intelligence, both essential for nursing practice
Actively Adopt a Professional Identity – Developing a strong professional identity means understanding and embracing nursing values such as integrity, compassion, courage, humility, advocacy, and human flourishing. Recognizing how these principles shape nursing practice helps clarify a nurse’s role in relation to patients, families, and colleagues
Take Responsibility for Learning & Be Accountable – Self-efficacy, or belief in one's ability to influence their own success, is key to professional growth. Taking ownership of learning by being proactive, engaged, and accountable will help build confidence and competence in the nursing profession
Build Relationships with Those Around You – Meaningful connections with peers, faculty, and healthcare professionals are essential for both learning and professional identity formation. Engaging in collaborative learning and hands-on experiences fosters deeper understanding and prepares nurses for teamwork in healthcare settings
Develop Personal Self-Care Habits – The American Nurses Association (ANA) Code of Ethics stresses the importance of self-care in maintaining a strong professional identity. Prioritizing physical, emotional, and mental well-being ensures that nurses can provide the best care to others without experiencing burnout
Embrace Opportunities for Patient Experiences – Both real and simulated patient interactions are essential in shaping professional identity. Early exposure to patient care, whether through clinical rotations, simulations, or case studies, helps develop critical thinking, confidence, and hands-on skills, reinforcing the values and responsibilities of nursing
Safety
Definition of Patient Safety (Institutes of Medicine, 2001; Canadian Nurses Protective Society, 2005): Freedom from accidental injury; ensuring the patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur
Types of Events:
Adverse Event: Medical care resulting in unintended harm due to human error, not underlying condition.
Near Miss:Error that potentially could have harmed a patient but did not due to: Prevention processes catching the error before it could be carried out (Ex: Two nurse check on an insulin dose catching a medication error before the insulin is administered
Mitigation processes reacting to an error in time to counteract error (Ex: administering an antidote such as Narcan before effects of a narcotic dosage error are experienced)
Sentinel Event: Unintended event/error resulting in serious &/or irreversible physical or psychological injury or death. Signals the need for immediate investigation of practices or processes to prevent
Attributes & Criteria:
Knowledge: Need to possess the understanding to recognize and make distinctions between safe and unsafe practices
Skills: Utilization of tools (technology and/or standardized practices) to contribute to safer systems
Lack of communication skills are a leading cause of inadvertent patient harm
Attitudes: Personal and professional attitudes which shape nursing practice, recognition of personal limitations, and dedication to maintaining safe practice
Types of Errors:
Diagnostic: Result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing
Treatment: In performance of operation/procedure/ test; administration of treatment; dose or method of administration of drug; avoidable delay in treatment or responding to an abnormal test
Preventative: Occur when there are failures to provide prophylactic treatment and inadequate monitoring or follow-up of treatment
Communication: Lack of clarity in communication can lead to many types of errors (verbal, written)
Negative patient outcomes may be a result of different types of errors potentially at each end (sharp and blunt ends)
Placement of Error
Active (sharp end) error: Made by those providers (e.g., nurses, physicians, and technicians) who are providing patient care, responding to patient needs where as potential contributing factors that are hidden and lie inactive in the healthcare delivery system, originating at more remote aspects of the healthcare system, far removed from the active end
Latent (blunt end) error: More organizational, contextual, and diffuse in nature or design-related. A flaw in the system (organizational or “blunt end”) that does not lead immediately to an accident, a triggering event may lead to an error
Culture of Safety: A commitment to core values and principles by organizational leadership and healthcare workers to recognize the inseparable integration of worker safety and patient safety
Difference from culture of blame: When an error occurred, the focus was often on identifying the clinician at fault.
Just Culture: Systematic values of reporting errors & near misses without punishment, reprisal, or personal risk
Prioritizes learning from mistakes over discipline
Accountability
Mistakes, slips and lapses vs intentional harmful behavioural choices
Apology Act: Apologizing does not create legal liability (not admissible in court), doesnt apply to criminal offences, IMPORTANT, help lessen emotional impact, repairs trust, demonstrates humanity, heals practitioners involved
When an error happens, disclosure to a patient MUST occur:
Must happen ASAP
Genuinely apologize “I’m sorry”
Acknowledge that something has happened
Explain the facts of what happened & how it might affect them
Explain what will be done in response, and what changes will be made so the mistake doesn’t happen again
Document the conversation and follow up with the affected
Why do patients need to receive an apology?
An apology, given sincerely, can help lessen the emotional impact of the harm, be therapeutic for the patient and health professional as well as lead to healing, regaining trust, and a greater possibility of reconciliation. Apologizing – demonstrating our humanity and the concern we feel makes it possible for the patient and family to forgive
Are you admitting liability by apologizing?
No. An apology can’t be admitted as evidence of fault or legal liability. The majority of Canadian Provinces and Territories, including Manitoba4, have enacted apology legislation which prohibits apologies from being used in court
What is included in an apology?
Acknowledge that something (e.g. a critical incident) has happened
Explain the facts of what has happened without accepting or assigning blame
Explain how the incident will affect the health of the patient
Make a genuine apology for the incident that shows remorse, humility and compassion. Consider using words like “I feel badly for what happened.” “We are sorry.” “We know that what happened has caused you unnecessary pain/anguish/health complications....”
Explain what can happen to help remedy the situation
Document the conversation with the patient and family
If possible, explain what will change so this same situation is less likely to happen to other patients in the future. People usually want to know that some good may come about as a result of the situation that has caused them emotional or physical pain
Once the event has been reviewed, follow-up with the patient to see how they are doing and advise them on what progress has taken place to reduce the likelihood that it does not happen again to other
Other Considerations:
Human Factors: Interdependence of individuals and systems, design systems to avoid hazards, proactive error prevention.
Crew Resource Management: Originated from transport/aviation history
A set of practices that focuses on threat and error management, communication, situational awareness, decision-making and leadership skills in environments where human error can impact on safety
Need to standardize procedures/communication, improve teamwork and training methods.
Consider human factors that contribute to errors. Examples in Nursing context include I-SBARR, “Do Not Disturb” sign in the med room to minimize distractions, pre-operative checklists, bedside reports, etc.
High Reliability Organizations: Hospitals apply principles to manage work that “involves hazardous environments.”
(1) Sensitivity to Operations (Situational Awareness) (2) Focused on eliminating errors (3) Reluctance to simplify. (4) Deference to expertise (5) Commitment to reliance – quickly contain error and functioning despite setbacks.
Clinical Judgment
Definition: An interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches; or improvise new ones as deemed appropriate by the patient’s response
Requires: Applying explicit (written, communicated) and tacit (practice, experience) knowledge to make sense of the situation and respond appropriately in context.
Tacit: Knowledge that is acquired through practice and experience. It is difficult to
communicate through language
Explicit: Knowledge that is easily written down, explained and communicated to others.
Scope of Approaches:
Standards-Based:
Involves use of algorithms, decision trees, patient care guidelines, or standards of care to standardize approaches.
• Useful to support safe patient care
• E.g. Algorithm for cardiopulmonary arrestHowever...
• May not ALWAYS be the best possible care for EVERY patient in EVERY situation. May limit options and creative solutions.
Evidence-Based:
A problem-solving approach to clinical decision-making that combines the best available scientific evidence with best available patient and practitioner experiential evidence toward optimal healthcare outcomes.
• Accurate assessment of patient and care context.
• Several Nursing best-practice guidelines exist, e.g., Preventing Falls and Reducing Injuryfrom Falls
However...
Nurses need to question current practices and consider when best-practice guidelines need to be updated based on current evidence
Interpretivist:
“Life experiences are culturally bound”, and care is situated in what the nurse personally beings to the care encounter, including experiences, values, and emotions.
One approach is often not appropriate for everyone.
Nursing care is guided by individual patient circumstances and context of care, tacit knowledge and scientific evidence
Reasoning may involve “rule of thumb” methods and be intuitive.
Rules-based approaches are reductionistic and may fail to grasp the entirety of a care situation.
Theoretical Links: Tanner’s Model, NCSBN Clinical Judgment Measurement Model.
Clinical Judgement Measurement Model (NCSBN, 2019)
NCSBN Clinical Judgment Measurement Model:
Recognize Cues:
Identify relevant and important information from different sources (e.g., medical history, vital signs).
What information is relevant/irrelevant?
What information is most important
What is of immediate concern?
Do not connect cues with hypotheses just yet.
Analyze Cues:
Organizing & linking cues to the clinical presentation.
What client conditions are consistent with the cues?
Cues that support or contraindicate a particular condition?
Why is a particular cue or subset of cues of concern?
What other information would help establish the significance of a cue or set of cues?
Prioritize Hypotheses:
Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).
Which explanations are most/least likely?
Which possible explanations are the most serious?
Generate Solutions
Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
What are the desirable outcomes
What interventions can achieve those outcomes?
What should be avoided?
Take Action:
Implementing the solution(s) that addresses the highest priorities.
Which intervention or combination of interventions is most appropriate?
How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)?
Evaluate Outcomes:
Comparing observed outcomes against expected outcomes.
What signs point to improving/declining/ unchanged status?
Were the interventions effective?
Would other interventions have been more effective?