N 310 Exam !

Contempt

- Lip corner tightened and raised on only one side of face

Disgust

- Nose wrinkling - Upper lip Raised

Negative Humor

- Not helpful - Uncomfortable, demeaned, or defensive - Sarcasm or put downs - Stereotype, racist, ageist, or sexist undertones - Could temporarily relieve tension, but is unprofessional and disrespectful - NOT BE USED

Humor

- Put people at ease, be used to celebrate shared victories, and relieve tension - Important tool in the nurse-patient relationship that should be used appropriately and judciously

Package clinical information so it is likely to be understood:

- Report clinically essential info and explain your findings in context - Describe environmental and economic factors affecting patient's condition - Turn a conversation into an opportunity to collaborate

Inappropriate or a lack of facial expressions are noteworthy

- Some diseases can cause a flat affect and minimize expressions (Depression and Stroke)

Cultural variations exist in facial expressions, particularly eye contact

- Some may interpret raising the eyebrows or a direct gaze as hostile or insulting

Communication occurs on two levels

- The relationship level - The content level

Culture

- The shared beliefs, values, ideas, language, communication, norms, practices, and behaviors of a large group of people - Individual's values, beliefs, and practices related to health and illnesses are influenced by culture

Body Space

- Varies with type of relationship and cultural background - Social distance is usually considered about 3 to 4 feet between people - Nurses often must come closer to provide care or interventions (time permitting, ask permission, or at least inform patient about what is to happen) - Circumstances can change the amount of space between nurse and patient (More space for a patient with psychiatric issues)

United States is becoming more racially, ethnically, and culturally diverse

1. 35% of population in 2010 were AA, Hispanic, Asian, and Native peoples. 2. Nurses are overwhelmingly white Culture competence is an essential component of making education and practice

Express Empathy (MI)

1. Acceptance facilitates change 2. Skillful reflective listening is fundamental 3. Ambivalence is normal

Professional Standards

ANA's Code of Ethics for Nurses ANA's Social Policy Statement (2010) ^ guidelines are the basis for state Nurse Practice Acts

Nonverbal communication

The process of relaying or receiving information without sounds - Account for more than half of communications

Anger

eyebrows down and together, eyes glare, narrowing of the lips

In healthcare, ____ cues can be used to interpret the verbal communication

nonverbal! - Nonverbal cues include body language (touch, posture) and verbal qualities (tone, volume)

Models of Communication

- Health Beliefs Model - Orlando's Theory of the Deliberative Nursing Process - Rogerian Model - Social Information Processing Model

Body Posture

- Indicate how receptive on person feels towards another - Being seated or leaning toward a person conveys an interest in what they are saying - Rigid posture can convey reluctance to engage in meaningful conversation - Crossed legs could show self-protection

Maslow's hierarchy of human needs

(Top to bottom) 1. Self-Actualization: Pursues talent, creativity, fulfillment 2. Self-Esteem: Achievement, mastery, recognition 3. Belonging: Friends, family, community 4. Safety: Security and Shelter 5.Physiological: Food, warm, warmth

Work at developing relationships

- Assumse that you & the physician are on the same team - Recognize that you are equal to the physician - Arrange a meeting with a physician you usually talk to by phone - Report good news about the patient - Be prepared for conflict

Positive Humor

- Builds relationships and releases tension - Constructive, joyful, creative, gentle - Nurses can use positive humor to share joy and humility - The highest form is the ability to laugh at oneself (perspective and reassures patients)

Summary of Chapter 1

- Communication is the sharing of information between individuals. - It is dynamic and reciprocal, affecting each person in the relationship - Theoretical frameworks to help understand nurse- patient communication include the Health Belief Model, Orlando's theory of the deliberative nursing process, the Rogerian model, and the social information processing model.

Crick and Dodge Model: Nurses Learn to

- Control internal Reactions to patient communication - Develop self-efficacy (confidence) - Decide on responses - Enact a response that helps both patient and nurse attain their goals

Hand and Arm Gestures

- Convey info about both the message and messenger - Open hands and arms may demonstrate openness and honesty - Folded arms and closed hands or laced fingers might indicate reluctance to talk or need for self-protection

Define Communication Strategies

- Discuss preferred methods of communication - Ask about the best way to contact the physician for an urgent matter - Know what you want to find out or report - Agree upon an approach to family members

Sadness

- Drooping upper eyelids, losing focus in eyes, slight pulling down of lip corners

Nurses develop and grow

- During formal education - After graduation - During years of practice

Fear

- Eyebrows raised and pulled together - Raised upper eyelids - Tensed lower eyelids - Lips slightly stretched horizontally back to ears

The Health Belief Model

- Focuses on patient's perspective - Demographic characteristics can influence patient beliefs - Cues to action are incorporated into interventions - Examples: Teens are more susceptible to cigarette ads

Black humor

- Gallows Humor - Cautiously used among hospital staff, it may provide relief during tense situations --- Psychological escape from harsh realities --- May strengthen staff relationships --- Comic Relief - Never share with patients!

Communication and Malpractice

- Good communication may be an excellent way to prevent clinical problems from being cited as reasons for malpractice claims - Patients who feel that they were treated with respect and compassion sue healthcare providers less frequently

Active Listening, Silence

1. Active listening: Carefully hearing the patient's message, understanding the meaning of the words, and providing feedback 2. Barriers to active listening include the setting, timing and anxiety (patient or nurse) 3. Silence can be one of the most potent parts of listening. Silence can allow emotion to dissipate, convey respectful presence, allow active listening, acknowledge a powerful message, permit formulation of a response

Setting Boundaries: Self-Disclosure

1. As time or the relationship permits, sharing of information may be appropriate. - But never intimate details about the nurse

Roll with Resistance (MI)

1. Avoid arguing for change 2. Do not directly oppose resistance 3. Patient is primary source of finding answers and solutions 4. Resistance is a signal to respond differently

Objectivity and Reliability

1. Being objective means trying to remove one's own beliefs and prejudices from the patient's words and behaviors 2. The nurse must be objective to obtain accurate information during an interview 3. Reliability can be enhanced by using a standardized nursing assessment form

Respect: Unconditional Positive Regard

1. Carl Rogers defined respect, or unconditional positive regard, as the ability to accept another person's beliefs despite your own personal feelings. 2. Each patient brings a lifetime of responding and coping with changes. 3. Nurses accept people without negatively judging their basic worth 4. Acceptance does not mean approval or agreement, but rather a nonjudgemental attitude about the patient as a whole

Ethical Issues in Nursing

1. Commitment: Patients, Professionalism and Boundaries 2. Respect: Dignity Autonomy and Relationships

Orlando's Theory of the Deliberative Nursing Process

1. Communication b/w nurses and patients involves: - Patient's behavior (sends a cue or cues) - Nurse's reaction (his/her response to patient cues) - Nurse's activity (automatic, or deliberative nursing process) --- Deliberative nursing process allows nurses to identify patients needs and to help the patient 2. Two types of nurse responses - Non-observable response (consisting of thoughts, perceptions, and feelings) - Nurse's activity (observable final response to patient's behavior) 3. Nurse-patient relationship is involves reciprocity, is dynamic and collaborative 4. Nurse confirms her/his perceptions, thoughts and feelings with the patient for validation prior to selecting the activity

Rogerian Model

1. Communication is client centered because the patient is the focus of interactions 2. Nurse communicates with: - Empathy - Positive regard (respect) - Congruence (genuineness) 3. Facilitates patient's adjustment to circumstances and movement toward health 4. Importance of "ACTIVE LISTENING"

Cultural Competence Model - Campinha-Bacote

1. Cultural Awareness - Self Examination of one's own cultural background, leading to the recognition of biases, prejudices, and assumptions about individuals of differing cultures (than the nurse) 2. Knowledge - Of worldviews, varied definitions of health and illness and difference in treatment beliefs and preference based upon racial and ethnic groups 3. Skill - Can perform culturally based assessment and physical exam along with respectful cross-cultural communication 4. Encounters - Opportunies to engage in cross-cultural interactions - helps nurses to refine or modify existing beliefs to prevent stereotyping 5. Desire - "the motivation to 'want" rather than 'have' to engage in cultural encounters

Belcher and Jones Article

1. Developing a trusting relationship 2. Building rapport 3. Communication 4. Personality 5. Experience 6. Bedside manner 7. Taking the time 8. Feeling successful in establishing trust

Empathy Definition

1. Empathy: Educated compassion, or the intellectual understanding of the emotional state of another person.

Trust

1. Establishing trust is the foundation of all interpersonal relationships 2. Trust is vitally important to development of the therapeutic relationship in nursing 3. According to Freud, development of a sense of trust is a primal human need. 4. Trust is a choice that a person makes, based on the need to trust others

Four General Principles of Motivational Interviewing

1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support self-efficacy

Types of responses

1. Gaining more information requires actively listening to the patient, followed by responding from the nurse. 2. Three types of responses may be useful in gathering accurate data during assessment: -Restatement: paraphrasing, use sparingly - Reflection: Restate + Reflect emotional overtones - Clarification: Make clear, concise statements about patients experience

Styles of Questions

1. General open-ended questions: What brings you to the ER today? 2. Specific open-ended questions: Tell me more about the dizziness? 3. Closed-ended directed questions: Have you vomitted today? 4. Menu questions: Do you feel nauseous when you lie down, sit up, or when you start to move? 5. Combination of diff question styles

Setting Boundaries

1. Help establish the roles of nurse and patient 2. Setting boundaries for appropriate topics lets nurses effectively function in their roles.

Time, Self-Disclosure

1. If possible, time should be allotted for careful interviewing 2. Many patients, such as elderly individuals, might not be able to understand questions that convey information rapidly. 3. Self-disclosure is a gradual process that occurs in steps over time and requires judgment. May be more appropriate, over time with long-term patients

Summary CH 6

1. Interviewing skills are part science and part art. 2. With clinical experience, nurses develop a focused approach to obtaining reliable and useful information from patients 3. A variety of questions and responses can be used. 4. Acknowledging the presence and intensity of emotional undertones will help the therapeutic relationship

Ways to Show Respect

1. Introduce yourself by name and professional status; always wear a name tag 2. Ask patients what they like to be called; begin with Mr., Ms. And Mrs. 3. Always arrange for patient comfort, modesty and privacy 4. Prepare patients before doing any procedure 5. Communicate in a way that conveys a desire to listen, understand and help

Barriers to Effective Cross-Cultural Communication

1. Lack of cultural Awareness and knowledge - Both of oneself and of patients. - Can lead to misunderstandings, mistrust, and poor patient outcomes 2. Ethnocentrism - A universal tendency - Occurs when someone believes his or her cultural values, beliefs, and practices are the very best

Facilitating Trust

1. Listen carefully; Patients will feel understood and cared for 2. Treat patients respectfully; patients will feel like valuable human beings 3. Be honest and consistent; patients will feel that nurses are trustworthy 4. Follow through on commitments; patients will feel that their care is predictable and dependable 5. Have an accepting attitude; patient's will feel more comfortable sharing information about themselves

Summary CH 7&8

1. Nonverbal communication and body language can relay important info during interactions 2. Evaluating these is part of active listening 3. Nurses also convey messages with their body posture 4. Understanding nonverbal communication is an important part of nursing assessment and intervention 5. Humor can be a useful tool when communicating with patients

Confidentiality

1. Nurses are morally and legally obliged not to share patient information with others 2. Patients also need to know that their personal information will be kept confidential 3. The only exceptions to nurse-patient confidentiality are if there is: - Suspicion of abuse of minors or elders - Commission of crime - Threat or potential threat of harm to oneself or others.

Patient-Centered Interviewing

1. Nurses may be perceived as being in control and having more power by patients (May impede disclosure) 2. Accurate assessment of patient verbal and nonverbal behavior, and appropriate questions, will improve the relationship and information gathered during the interview

The Role of Student Nurses

1. Nursing students should accurately identify themselves and their role to parents 2. All nurses including students, will not have answers to all questions that patients ask. 3. The student can be confident: - In established skills - In the ability to find information to help patients

Peplau's 5 phases of Nurse-Patient Relationship

1. Orientation - Patient seeks help; nurse assists patient to identify the problem and extent of help needed 2. Identification - Patient relates to the nurse, who assures patients s/he understands the meaning of patient's situation 3. Exploitation - Patient uses the nurse's services and other resources according the patient's needs 4. Resolution - Patient's old needs resolved; more mature goals emerge 5. Termination - Patient and nurse evaluate progress, review time together, end their relationship

Hildegard & Three phases of nurse-patient relationship

1. Orientation phase - Nurse and patient develop partnership 2. Working phase - 2a. Identification: Nurse & patient clarify ideas and expectations. Nurse develops nursing care plan 2b. Exploitation: Nurse helps patient identify healthcare services and personal resources and implement strategies to resolve health issues 3. Resolution/Termination phase - Nurse and patient evaluate patient's health status; nurse makes referrals as needed

Develop Discrepancy (MI)

1. Patient rather than the nurse should present the arguments for change 2. Change is motivated by perceived discrepancy between present behavior and important personal goals or values 3. Cognitive dissonance: The discomfort felt by a person when they hold conflicting beliefs, attitudes or values at the same time

Chapter 3 Summary

1. People enter a healthcare setting with certain rights and individual values 2. Institutions, professions, and government authorities create standards, guidelines, codes of ethics, and laws. 3. Goal is to protect the patient 4. Nursing care should incorporate professional guidelines, ethical principals, and patient's value

Support Self-Efficacy (MI)

1. Person's belief in the possibility of change is an important motivator 2. The patient, not the nurse, is responsible for choosing and carrying out the change 3. Nurse's own belief in the person's ability to change becomes a self-fulfilling prophecy

Different types of humor

1. Positive 2. Negative 3. Black

Principles of Therapeutic Relationship

1. Respect 2. Genuineness 3. Empathy 4. Active Listening 5. Trust 6. Confidentiality

Patient's Bill of Rights

1. Right to considerate and respectful care 2. Right to privacy, including confidentiality of records of patient's care. 3. .Right to make decisions about patient's care, including right to refuse care or treatment 4. Right to review all medical records 5. Right to refuse to participate in research studies. 6. Right to make statements about care, including living will and advance care directives. 7. Right to be informed of resources in hospital to resolve disputes or grievances.

Genuineness

1. Rogers described genuineness as congruence, the willingness to be open and genuine and not hide behind a professional facade 2. Genuineness, even as a student or new nurse, is freeing.

Hildegard Peplau & six roles

1. Stranger role - patient is stranger, but nurse promotes trust 2. Resource role - nurse gives info, answers questions, etc. 3. Teaching role - nurse gives instruction and training 4. Counseling role - provides guidance and encouragement 5. Surrogate role - nurse works on patient's behalf 6. Active leadership role - helps patient achieve responsibility

Nurse-Patient Relationship

1. Symbolizes an agreement between nurse and patient to work together for the good of the patient. 2. Peplau identified five phases:

Sympathy vs Empathy

1. Sympathy involves sharing the feelings of another and actually experiencing what another person is feeling. - Sympathy may impair the nurse's ability to care for the patient, because the nurse's emotional experience may cloud professional judgement 2. Empathy involves the desire to understand what the patient is feeling, from the patient's perspective - Empathy allows the nurse to see the world from the patient's point of view without experiencing the emotional content. Helps identify patient concerns and intervene more effectively

Summary of CH 4

1. The United States continues to become more culturally diverse. 2. Culture exerts a strong influence on a person's values and behaviors related to healthcare. 3. Nurses need to acknowledge barriers that can cause cultural misunderstandings. 4. Strategies should be used to promote respectful, culturally sensitive care.

Summary of Chapter 5

1. The nurse-patient relationship is the cornerstone of nursing care. 2. The nurse facilitates establishment of this patient-centered, goal-oriented relationship 3. Patient expectations and the intricacies of interpersonal communication can complicate the relationship 4. Within boundaries, there are limitless possibilities for therapeutic communication

Appropriate Use of Humor

1. Timing and Context are everything 2. Consider: 2a. How long nurse has known patient 2b. Patient's Age 2c. Patient's personality 2d. Acuity of the clinical situation 2e. Cultural background 3. Should be: 3a Intended to be therapeutic 3b. Neither disparaging, sarcastic, nor cynical 4. Example 4a. A corworker uses humor well with patients might be an inspiriation or teacher 4b. Patients set the tone, and the nurse needs to response accordingly 4c. Should be able to laugh at themselves and with their patients

Summary of Chapter 2:

1. Understanding the self as product of a family system allows for introspection and growth 2. Nurses need to take responsibility for their personal growth 3. Self-acceptance allows nurses to be more sensitive and compassionate 4. Understanding oneself allows nurses to be effective caring providers

Strategies to Improve Cross-Cultural Clinical Encounters

1. Use a cultural humility approach - Demonstrates sincere respect for the patient - Seeks to establish a collaborative and ethnosensitive relationship with the patient. 2. Use an inquiry process - "patient as teacher" - Explore family perspective, male - female roles and sexual behavior, dietary beliefs and customs, pain expression and management, end-of-life care and decision making.

Structres of an Assertive Response

1. When you ___ (describe other persons' behavior) 2. I feel/felt ___ (express feelings) 3. I would appreciate __ (request behavior change)

Empathy

2. Allows nurses the ability to see the world from the patient's point of view - Without experiencing the emotional content 3. Nurses incorporate empathy with a compassionate goal to alleviate suffering

Barriers to Effective Cross-Cultural Communication

3. Bias and Prejudice - Nurses may have biases about people from other racial or cultural groups (over or unconscious) - Based on discrimination, patients may have developed distrust of healthcare providers or institutions

Strategies to Improve Cross-Cultural Clinical Encounters

3. LEARN about the patient's perspective on health and illness 4. Use trained interpreters

Barriers to Effective Cross-Cultural Communication

4. Stereotyping - Students learn about other cultures through a categorical approach ---- For example, healthcare do's and dont's for vietnamese or mexicans ---- Ignores the significant variation within cultural groups. 5. Lack of understanding of key cultural characteristics - For example, collectivist versus individual 6. Language Barriers - Interpreters may be needed, and family members may not be the best interpreters

Erikson described personality development as a lifelong process

8 stages of personality development

Values Definition

A person's beliefs about the truth, beauty, and worth of any thought, object, or behavior. - Give direction and meaning to life - Guide decision-making process Nurses need to focus on patients' based on patients' values - Recognizing that these needs and values may differ from nurses' own

Motivational Interviewing

A specific type of interviewing approach that has at its core, the principles of collaboration, evocation and autonomy. - Johann Wolfgang von Goethe " If you treat an individual as he is, he will stay as he is"

What principles guides nursing intervention?

Self - Determination or Autonomy (Roots are in tradition of respect for persons)

Self-awareness:

Active process of learning about the components of the self.

Crick and Dodge Model

Circular depiction of emotional and cognitive processes involved in learning to respond to social cues

Patient-provider communication

Communication between patient, family members, and providers during visits to receive healthcare.

Ego Defense Mechanisms

Denial: Lack of acceptance of a proven condition Projection: Placing one's own emotions onto another Rationalization: Justifying illogical feelings with seemingly reasonable explanations

Johari's Window

Diagram of the interpersonal behavior of individuals that reveals the degree of openness with which they meet other people and their level of awareness of themselves

The ___ can convey a wide range of emotions

Face - There is a congruence when the facial expression and verbal message are the same

Why is it important to understand the self?

Facilities therapeutic interactions with patients. Helps to separate nurses' personal reactions from patients' needs.

T or F: Better to say Client than Patient

False: Always recognize them as patients!

Rogers' two essential characteristics in the helper or nurse are

Genuineness and unconditional positive regard or respect

Touch

Good Touch - Refocus rambling patients - Reduce anxiety in stressful situations - Convey interest in the patient's experience - Create human connections - Express caring - Provide physical care Bad Touch - Harmful - Controlling - Sexual

Self-Concept:

Judgements and attitudes about the self

LEARN acronym

L - listen with empathy and understanding E - Explain your perceptions and understandings. A - Acknowledge and discuss differences R - Recommend care respecting preferences N - Negotiate agreement as authentic partners

Surprise

Lasts for only one second - Eyebrows raised - Eyes widened - Mouth open

Legal Standards, Confidentiality

Laws define the boundaries and expectations of the nursing profession - Reasonable standard of care" is based in tort law - Used as a benchmark in court to judge criminal negligence Confidentiality stems from ethical tradition of right to privacy - Applies to patient's confidential communication

Scope of practice

Legal and ethical parameters of nursing practice

Body Language

Messages can be conveyed without words through body posture, arm position, hand gestures, eye contact, and smiles

Deontological or duty-based

Rightness based on respect for the person, rights of the individual and best interests of the patient

Possible Responses when upset by someone or something someone did

Passive -> Assertive -> Aggressive

Patients

People seeking and/or receiving healthcare services from healthcare providers

Self:

Personal definition of oneself that is distinct from other people

Human rights-based

Rightness based on the rights of the patient

Utilitarian

Rightness of an action based on the consequences and contribution to the overall good of an action

Code of Ethics for Nurses

Published by ANA Description of nursing practice that should drive and guide all nursing care

Communication

Sharing of health-related information between patient & nurse. - BOTH patient & nurse sending & receiving information - Communication is interactional by its nature Can be verbal, written or spoken, culturally appropriate, personal or impersonal, issue specific, relationship oriented. Ideally facilitates health, growth, and healing

Ethics Reasoning and Decision Making

Situations may be viewed from one of three decision making models - Utilitarian - Deontological or Duty-based - Human Rights-based

Known self:

That part of the self that is consciously acknowledged

Cultural Competence

The ability of healthcare providers and organizations to understand and respond effectively to cultural and language needs brought by patient to the healthcare encounter

Genuineness Definition

The ability to be oneself within the context of a professional role

Freud's concepts

Transference - A patient's projection of attitudes or feelings from the past onto people in the present Countertransference - Feelings nurse may develop about patient's behavior that have roots in nurse's past

True or False: Nurses and patients use body language

True!

T or F: Patients have the right to make choices about their healthcare

True! Includes DNR orders

The Nurse as a Person

Understanding oneself as a person is a lifelong goal. - Allows fuller participation in life as a nurse and human being No one grew up in a perfect home. Unhealthy families can produce "early helpers." - May enter "helping" professions to meet conscious or unconscious needs