Nur 208

Boundaries

"limits of individuals, objects, or relationships"

incivility

"rude or disruptive behavior that may result in psychological or physiological distress for the people involved and, if left unaddressed, may progress into threatening situations." Uncivil behavior exists along a continuum ranging from distracting, annoying, irritating behaviors (e.g., things that nurses often excuse by saying "so and so is having a bad day," eye rolling, sarcastic comments) to bullying, menacing, and potentially violent behavior (e.g., withholding vital client information, intimidating others, or making threats of physical harm)

Caring, the Human Mode of Being (Roach)

- All individuals are caring, and develop their caring abilities by being true to self, being real, and being who they truly are. Thus, caring is not unique to nursing. - visualizes caring to be unique in nursing however, because caring is the center of all attributes she uses to describe nursing. - Roach defines these attributes as the six C's of caring: compassion, competence, confidence, conscience, commitment, and comportment.

Nurse Presence

- As nurses and students increase their self-awareness and commitment to nursing, the ability to be authentically present to the other grows - Healing presence requires an openness and consciousness of the self and the client. - The nurse must create some space for awareness by being truly present and focused on the moment. The nurse is aware of his or her own thoughts and feelings, while also aware of an interconnectedness with the client. - Authentic presence involves empathy and openness to positive or negative feelings, nonpossessive warmth, a relaxed posture, and facial expressions that are congruent with other communications - Swanson's category being with provides a description of nursing presence. By being emotionally present to the client and family, the nurse conveys that they and their experiences matter. - Being present is a way of sharing in the meanings, feelings, and lived experiences of the client. Physical presence is combined with the promise of availability, especially during a time of need. ex. responding promptly to a call bell on a hospital unit or as complex as sitting with a parent who has just lost a child in a neonatal intensive care unit.

Theory of Human Care (Watson)

- Assumptions of Watson's theory and nursing interventions related to human care, or her carative factors - Watson emphasizes nursing's commitment to care of the whole person as well as a concern for the health of individuals and groups - The nurse and client are coparticipants in the client's movement toward health and wholeness. - This human connection is labeled transpersonal human caring, through which the nurse enters into the experience of the client, and the client can enter into the nurse's experience. -Watson emphasizes that the practice of nursing is both transpersonal and metaphysical. While the nurse maintains professional objectivity as a scientist, scholar, clinician, and moral agent, the nurse is also subjectively engaged in the interpersonal relationship with the client. - Within the actual caring situation, each person (nurse and client) seeks a sense of harmony within the mind, body, and soul, thereby actualizing the real self.

Ethical Knowing

- Goals of nursing include the conservation of life, alleviation of suffering, and promotion of health. - focuses on "matters of obligation or what ought to be done" and goes beyond observing the nursing code of ethics. - Nursing care involves a series of deliberate actions or choices that are subject to the judgment of right or wrong. - Occasionally, the principles and norms that guide choices may be in conflict. The more sensitive and knowledgeable the nurse is to these issues, the more "ethical" the nurse will be.

hypertension

- major problem for young African American adults, particularly men. - Many of the causes for this higher incidence of hypertension are unknown. - contributing factors may include smoking, obesity, a high-sodium diet, and high stress levels. -Hypertension is a major risk factor in the development of chronic heart disease or stroke (cerebrovascular accidents). - Blood pressure measurements are usually advised at least every 2 years for young adults to screen for hypertension.

Compassion

- The caring nurse is described as warm and empathetic, compassionate and concerned. To demonstrate empathy, the nurse must be able to identify with the client, appreciating the pain and discomfort of illness, or imagine "walking in his shoes" in regard to some part of the client's life experience. - Like empathy, compassion involves participating in the client's experience, with sensitivity to the person's pain or discomfort, and a willingness to share in their experience. Compassion is given as part of the caring relationship, as the nurse shares the client's joys, sorrows, pain, and accomplishments. Compassion requires courage and openness, as the nurse experiences his or her own humanness and interconnectedness with the client - Compassion is a gift from the heart, rather than an advanced skill or technique. - Attention to spiritual needs is part of compassionate care particularly in the face of death and bereavement. The nurse is aware that spiritual and religious beliefs are important coping mechanisms in dealing with issues of mortality (see Chapter 41 [Inline Image]). The nurse does not impose his or her own spiritual beliefs, but rather assists the client and family in drawing on their own beliefs as spiritual resources. Comfort is often associated with compassionate care and many nursing interventions are carried out to provide comfort. For example, bathing, positioning, talking, touching, and listening are often performed to increase the client's comfort level. Just like pain or discomfort, comfort is subjective and is defined as "whatever the client says it is," based on the individual's perceptions. Despite this subjectivity, comfort care is often the basis for nursing in settings ranging from intensive care to hospice, and serves as a motivator for nursing interventions. Nurses are challenged to be creative and innovative, basing interventions on knowledge of the client's preferences, in order to provide comfort care.

Knowing the client

- The nurse asks: Who is this person? What is the client's history? Needs? Desires? Dreams? Spiritual beliefs? Who loves and cares for this person at home? Where is home and what resources are there? What does this person need today, from me, right now? Can this person tell me what is needed? Personal knowledge of the client is a key in the caring relationship between nurse and client. - The nurse aims to know who the client is, in his or her uniqueness. This knowledge is gained by observing and talking with the client and family while using effective listening and communication skills. - Knowing the client and family ultimately involves the nurse and client in a caring transaction. By attending broadly to personal, ethical, aesthetic, and empirical knowledge, the nurse understands events as they have meaning in the life of the client. The nurse's knowing the client ultimately increases the possibilities for therapeutic interventions to be perceived as relevant.

Theory of Bureaucratic Caring (Ray)

- The theory suggests that caring in nursing is contextual and is influenced by the organizational structure and the role and position a person held. - the meaning of caring varied: an intensive care unit had a dominant value of technologic caring (i.e., monitors, ventilators, treatments, and pharmacotherapeutics), and an oncology unit had a value of a more intimate, spiritual caring (i.e., family focused, comforting, compassionate) - Staff nurses valued caring in terms of its relatedness to clients, whereas administrators valued caring as more system related, such as safeguarding the economic well-being of the hospital - spiritual-ethical caring influences each aspect of the bureaucratic system (technologic, physical, legal, political, economic, social-cultural, and educational). Each of these aspects is different, but they make up a whole bureaucratic system (e.g., a hospital). - Nurses make these choices with the interest of the client at heart and use ethical principles as the foundation for the basis of professional decision making. - "Spiritual-ethical caring for nursing does not question whether or not to care in complex systems, but intimates how sincere deliberations and ultimately the facilitation of choices for the good of others can or should be accomplished"

Empowering the Client

- Through knowing the client and engaging in a mutual relationship, the nurse is able to identify and build on client/family strengths. This empowering relationship includes mutual respect, trust, and confidence in the other's abilities and motives. According to Swanson, the caring behavior of enabling is defined as "facilitating the other's passage through life transitions and unfamiliar events". Enabling also includes coaching, informing, explaining, supporting, assisting, guiding, focusing, and validating. There are times when enabling involves substitutive care (doing for the client who is unable to do for oneself), but doing no more than is needed at the time. At other times, enabling involves providing an environment in which the client can function safely and effectively.

Sender

- a person or group who wishes to communicate a message to another, can be considered the source-encoder - This term suggests that the person or group sending the message must have an idea or reason for communicating (source) and must put the idea or feeling into a form that can be transmitted - Encoding involves the selection of specific signs or symbols (codes) to transmit the message, such as which language and words to use, how to arrange the words, and what tone of voice and gestures to use. For example, if the receiver speaks English, the sender usually selects English words. If the message is "Mr. Johnson, you have to wait another hour for your pain medication," the tone of voice selected and a shake of the head can reinforce it. The nurse must not only deal with dialects and foreign languages but also cope with two language levels—the layperson's and the health professional's.

Personal Knowledge

- concerned with the knowing, encountering, and actualizing of the concrete, individual self - Because nursing is an interpersonal process, the nurse's view of self, as well as the client, is a critical factor in the therapeutic relationship. - promotes wholeness and integrity in the personal encounter, achieves engagement rather than detachment, and denies the manipulative or impersonal approach.

Theory of Caring (Swanson)

- defines caring as "a nurturing way of relating to a valued 'other,' toward whom one feels a personal sense of commitment and responsibility" - An assumption of her theory is that a client's well-being should be enhanced through the caring of a nurse who understands the common human responses to a specific health problem. -The theory focuses on caring processes as nursing interventions. Swanson's theory was developed through interactions with parents at the time of pregnancy, miscarriage, and birth.

Culture Care Diversity and Universality (Leininger)

- emphasizes care as "distinct, dominant, unifying, and central focus of nursing" - Her theory of culture care diversity and universality is based on the assumption that nurses must understand different cultures in order to function effectively. - When nursing care fails to be reasonably congruent with the client's beliefs, lifeways, and values, signs of conflict, noncompliance, and stress may arise. - Culturally congruent care involves three action-decision care approaches: (1) preservation of the client's familiar lifeways (2) accommodations that help clients adapt to or negotiate for satisfying care (3) repatterning nursing care to help the client move toward wellness - further defines caring as "assistive, supportive, and enabling experiences or ideas towards others with evident or anticipated needs, to ameliorate or improve a human condition or lifeway"

Empirical Knowing

- nursing requires scientific competence - ranges from factual, observable phenomena (e.g., anatomy, physiology, chemistry) to theoretical analysis (e.g., developmental theory, adaptation theory) - for the purpose of describing, explaining, and predicting phenomena of special concern to the discipline of nursing

Nursing as Caring (Boykin and Schoenhofer)

- purpose of the discipline and profession of nursing is to know people and nurture them as individuals living and growing in caring - Respect for people as caring individuals and respect for what matters to them are assumptions underlying the theory of nursing as caring.

Aesthetic knowing

- the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of clients. - The nurse uses aesthetic knowing to provide care that is both effective and satisfying. - Empathy, compassion, holism, and sensitivity are important modes in the aesthetic pattern of knowing.

Clarity and Brevity

-Clarity is saying precisely what is meant -brevity is using the fewest words necessary. The result is a message that is simple and clear. An aspect of this is congruence, or consistency, where the nurse's behavior or nonverbal communication matches the words spoken. When the nurse tells the client, "I am interested in hearing what you have to say," the nonverbal behavior would include the nurse facing the client, making eye contact, and leaning forward. The goal is to communicate clearly so that all aspects of a situation or circumstance are understood. To ensure clarity in communication, nurses also need to enunciate (pronounce) carefully.

Nurse-client relationships are referred to by some as interpersonal relationships, by others as therapeutic relationships, and by still others as helping relationships. Helping is a growth-facilitating process that strives to achieve three basic goals

1. Help clients manage their problems in living more effectively and develop unused or underused opportunities more fully. 2. Help clients become better at helping themselves in their everyday lives. 3. Help clients develop an action-oriented prevention mentality in their lives. A helping relationship may develop over weeks of working with a client, or within minutes. The keys to the helping relationship are (a) the development of trust and acceptance between the nurse and the client and (b) an underlying belief that the nurse cares about and wants to help the client.

Baby boomers

1945 - 1964, 51-70yrs more highly educated and have a large percentage of women in the workforce occupying management roles, higher mean psychological empowerment score than Generation Xers.

Generation X

1965-1978, 37-51 yrs, frequently raised in two-worker households where long hours at work were common. They may now be less impressed with corporate values, more skeptical, and resist authority, but enjoy challenges and opportunities to creatively problem solve

Generation Y/ Millennials

1979-2000, 15-36 yrs, technologically sophisticated (and dependent), and enjoy public affirmation of their efforts

self help groups

A self-help group is a small, voluntary organization composed of individuals who share a similar health, social, or daily living problem. One of the central beliefs of the self-help movement is that people who experience a particular social or health problem have an understanding of that condition which those without it do not. • Members can experience almost instant kinship because the essence of the group is the idea that "you are not alone." • Members can talk about their feelings and listen to the concerns of others, knowing they all share this experience. • The group atmosphere is generally one of acceptance, support, encouragement, and caring. • Many members act as role models for newer members and can inspire them to attempt tasks they might consider impossible. • The group provides the opportunity for people to help as well as to be helped—a critical component in restoring self-esteem after significant losses.

COGNITIVE IMPAIRMENTS

Any disorder that impairs cognitive functioning (e.g., cerebrovascular disease, Alzheimer's disease, and brain tumors or injuries) may affect a client's ability to use and understand language. These clients may develop total loss of speech, impaired articulation, or the inability to find or name words. Certain medications such as sedatives, antidepressants, and neuroleptics may also impair speech, causing the client to use incomplete sentences or to slur words.

Comportment

Appropriate bearing, demeanor, dress, and language that are in harmony with a caring presence. Presenting oneself as someone who respects others and demands respect.

Telling stories

As expressions of human consciousness, stories help individuals gain a greater understanding of life. Stories communicate life experience and are often shared with clients and others to inspire and comfort. The language of stories allows nurses to begin to understand the deeper meaning of clinical situations. Stories are also a mechanism to deal with stress and move toward wholeness.

Compassion

Awareness of one's relationship to others, sharing their joys, sorrows, pain, and accomplishments. Participation in the experience of another.

GUIDED IMAGERY

Imagery is a mind-body intervention that uses the power of the imagination as a therapeutic tool. Imagery is used to promote relaxation, decrease anxiety, and enhance psychological or spiritual insight. Through forming mental images of an object, event, or situation, the individual can reframe negative responses into positive images, enhancing healing and emotional well-being.

Caring

Caring practice involves connection, mutual recognition, and involvement between nurse and client. Caring is central to nursing practice. Caring for self is central to caring for others.

Confidence

Comfort with self, client, and others that allows one to build trusting relationships.

Credibility

Credibility means worthiness of belief, trustworthiness, and reliability. Credibility may be the most important criterion of effective communication. Nurses foster credibility by being consistent, dependable, and honest. The nurse needs to be knowledgeable about what is being discussed and to have accurate information. Nurses should convey confidence and certainty in what they are saying, while being able to acknowledge their limitations (e.g., "I don't know the answer to that, but I will find someone who does").

Reflection on Practice

Critical thinking, self-analysis, and reflection are required in order to learn from one's experience. The student develops as a practitioner by thinking about how values and standards guide practical experience. Reflection is thinking from a critical point of view, analyzing why one acted in a certain way, and assessing the results of one's actions. To develop oneself as a caring practitioner, reflection on practice must be personal and meaningful.

language deficits

Determine the client's primary language for communicating and whether a fluent interpreter is required. The language skills of some clients who use English as a second language may be inadequate to meet their needs.

Box 22-2 Health Promotion Guidelines for Young Adults

HEALTH TESTS AND SCREENINGS • Routine physical examination (every 1 to 3 years for females; every 5 years for males) • Immunizations as recommended, such as tetanus-diphtheria boosters every 10 years, meningococcal vaccine if not given in early adolescence, hepatitis B vaccine • HPV vaccine for women up to 26 years old who have not yet received or completed the vaccine series (ACS, 2013c) • Regular dental assessments (every 6 months) • Periodic vision and hearing screenings • Professional breast examination every 1 to 3 years • Papanicolaou smear annually within 3 years of onset of sexual activity • Testicular examination every year • Screening for cardiovascular disease (e.g., cholesterol test every 5 years if results are normal; blood pressure to detect hypertension; baseline electrocardiogram at age 35) • Tuberculosis skin test every 2 years • Smoking: history and counseling, if needed SAFETY • Motor vehicle safety reinforcement (e.g., using designated drivers when drinking, maintaining brakes and tires) • Sun protection measures • Workplace safety measures • Water safety reinforcement (e.g., no diving in shallow water) NUTRITION AND EXERCISE • Importance of adequate iron intake in diet • Nutritional and exercise factors that may lead to cardiovascular disease (e.g., obesity, cholesterol and fat intake, lack of vigorous exercise) SOCIAL INTERACTIONS • Encouraging personal relationships that promote discussion of feelings, concerns, and fears • Setting short- and long-term goals for work and career choices

Competence

Having the "knowledge, judgment, skills, energy, experience and motivation required to respond adequately to the demands of one's professional responsibilities"

Caring for Self

Mayeroff (1990) describes caring for self as helping oneself grow and actualize one's possibilities. Self-care, when defined as responding to one's own needs to grow, is the opposite of the self-complacency that often accompanies egocentricity. Caring for self means taking the time to nurture oneself. This involves initiating and maintaining behaviors that promote healthy living and well-being. Although different activities may be helpful to different people, some examples of these activities include: • A healthy lifestyle (e.g., nutrition, activity and exercise, recreation) • Mind-body therapies (e.g., guided imagery, meditation, yoga). Self-care focuses on care of the self in the deepest sense. Self-awareness and self-esteem are intimately connected to self-care.

Conscience

Morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility.

Mayeroff

knowing, alternating rhythms, patience, honesty, trust, humility, hope, and courage (a) knowing means understanding the other's needs and how to respond to these needs; (b) alternating rhythms signifies moving back and forth between the immediate and long-term meanings of behavior, considering the past; (c) patience enables the other to grow in his own way and time; (d) honesty includes awareness and openness to one's own feelings and a genuineness in caring for the other; (e) trust involves letting go, to allow the other to grow in his own way and own time; (f) humility means acknowledging that there is always more to learn, and that learning may come from any source; (g) hope is belief in the possibilities of the other's growth; and (h) courage is the sense of going into the unknown, informed by insight from past experiences.

Caring Processes from Swanson's Theory of Caring -provide guidance to nurses who work with pregnant and postpartum clients.

KNOWING - Striving to understand an event as it has meaning in the life of the other Avoiding assumptions Centering on the one cared for Assessing thoroughly Seeing cues Engaging the self of both BEING WITH Being emotionally present to the other Being there Conveying ability Sharing feelings Not burdening DOING FOR Doing for the other as he/she would do for the self if it were at all possible Comforting Anticipating Performing competently/skillfully Protecting Preserving dignity ENABLING Facilitating the other's passage through life transitions and unfamiliar events Informing/explaining Supporting/allowing Focusing Generating alternatives/thinking it through Validating/giving feedback MAINTAINING BELIEF Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning Believing in/holding in esteem Maintaining a hope-filled attitude Offering realistic optimism "Going the distance"

WORK-RELATED SOCIAL SUPPORT GROUPS

Many nurses, for example, hospice, emergency, and acute care nurses, experience high levels of vocational stress. Various types of group support can buffer such stress. Group members who know about the work of others can encourage and challenge members to be more creative and enthusiastic about their work and to achieve more. For example, a nurse may help another team member consider alternative strategies for intervention. Members also can share the joys of success and the frustration of failure through active listening without giving advice or making judgments. This type of social support is best given outside of the work environment.

EATING DISORDERS

Many young adults battle with obesity. According to Healthy People 2020 goals and objectives for nutrition and weight status all Americans will avoid unhealthy weight gain (USDHHS, 2010a). The nurse needs to assess nutritional concerns, discuss diet and exercise patterns with the client, and assist in the development of an individualized wellness plan. Other areas of nutritional needs for young women include meeting calcium requirements and proper nutrition during the childbearing years

Timing Relevance

Nurses need to be aware of both relevance and timing when communicating with clients. No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure that words are heard. Moreover, the messages need to relate to the person or to the person's interests and concerns. This involves sensitivity to the client's needs and concerns. For example, a client who is fearful of the possibility of cancer may not hear the nurse's explanations about the expected procedures before and after gallbladder surgery. In this situation it is better for the nurse first to encourage the client to express concerns, and then to deal with those concerns. The necessary explanations can be provided at another time when the client is better able to listen. Another problem in timing is asking several questions at once. For example, a nurse enters a client's room and says in one breath, "Good morning, Mrs. Brody. How are you this morning? Did you sleep well last night? Your husband is coming to see you before your surgery, isn't he?" The client no doubt wonders which question to answer first, if any. A related pattern of poor timing is to ask a question and then not wait for an answer before making another comment. On the other hand, by allowing the client to respond to the social talk or chat, the nurse develops a rapport with the client that can help facilitate effective therapeutic communication.

Phases of the Helping Relationship

PREINTERACTION PHASE The nurse reviews pertinent assessment data and knowledge, considers potential areas of concern, and develops plans for interaction. Organized data gathering; recognizing limitations and seeking assistance as required. INTRODUCTORY PHASE- also referred to as the orientation phase or the prehelping phase, is important because it sets the tone for the rest of the relationship. During this initial encounter, the client and the nurse closely observe each other and form judgments about the other's behavior. The goal of the nurse in this phase is to develop trust and security within the nurse-client relationship 1. Opening the relationship Both client and nurse identify each other by name. When the nurse initiates the relationship, it is important to explain the nurse's role to give the client an idea of what to expect. When the client initiates the relationship, the nurse needs to help the client express concerns and reasons for seeking help. Vague, open-ended questions, such as "What's on your mind today?" are helpful at this stage. A relaxed, attending attitude to put the client at ease. It is not easy for all clients to receive help. 2. Clarifying the problem Because the client initially may not see the problem clearly, the nurse's major task is to help clarify the problem. Attentive listening, paraphrasing, clarifying, and other effective communication techniques discussed in this chapter. A common error at this stage is to ask too many questions of the client. Instead focus on priorities. 3. Structuring and formulating the contract (obligations to be met by both the nurse and client) Nurse and client develop a degree of trust and verbally agree about (a) location, frequency, and length of meetings; (b) overall purpose of the relationship; (c) how confidential material will be handled; (d) tasks to be accomplished; and (e) duration and indications for termination of the relationship. Communication skills listed above and ability to overcome resistive behaviors if they occur. WORKING PHASE Nurse and client accomplish the tasks outlined in the introductory phase, enhance trust and rapport, and develop caring. Listening and attending skills, empathy, respect, genuineness, concreteness, self-disclosure, and confrontation. Skills acquired by the client are nondefensive listening and self-understanding. 1. Exploring and understanding thoughts and feelings The nurse assists the client to explore thoughts and feelings and acquires an understanding of the client. The client explores thoughts and feelings associated with problems, develops the skill of listening, and gains insight into personal behavior. 2. Facilitating and taking action The nurse plans programs within the client's capabilities and considers long- and short-term goals. The client needs to learn to take risks (i.e., accept that either failure or success may be the outcome). The nurse needs to reinforce successes and help the client recognize failures realistically. Decision-making and goal-setting skills. Also, for the nurse: reinforcement skills; for the client: risk taking. TERMINATION PHASE Nurse and client accept feelings of loss. The client accepts the end of the relationship without feelings of anxiety or dependence. For the nurse: summarizing skills; for the client: ability to handle problems independently.

n/a

Personal space is the distance people prefer in interactions with others. Proxemics is the study of distance between people in their interactions. 1. Intimate: 0 to 1 1/2 feet 2. Personal: 1 1/2 to 4 feet 3. Social: 4 to 12 feet 4. Public: 12 feet and beyond.

Simplicity

Simplicity includes the use of commonly understood words, brevity, and completeness. Many complex technical terms become natural to nurses. However, laypersons often misunderstand these terms. Words such as vasoconstriction or cholecystectomy are meaningful to the nurse and easy to use but are ill advised when communicating with clients. Nurses need to learn to select appropriate, understandable, and simple terms based on the age, knowledge, culture, and education of the client. For example, instead of saying to a client, "I will be catheterizing you for a urine analysis" it may be more appropriate and understandable to say, "I need to get a sample of your urine, so I will collect it by putting a small tube into your bladder." The latter statement is more likely to elicit a response from the client asking why it is needed and whether it will be uncomfortable, because the client understands the message being conveyed by the nurse.

Barriers to Communication

Stereotyping Offering generalized and oversimplified beliefs about groups of people that are based on experiences too limited to be valid. These responses categorize clients and negate their uniqueness as individuals. "Two-year-olds are brats." "Women are complainers." "Men don't cry." "Most people don't have any pain after this type of surgery." Agreeing and disagreeing Similar to judgmental responses, agreeing and disagreeing imply that the client is either right or wrong and that the nurse is in a position to judge this. These responses deter clients from thinking through their position and may cause a client to become defensive. Client: "I don't think Dr. Broad is a very good doctor. He doesn't seem interested in his clients." Nurse: "Dr. Broad is head of the department of surgery and is an excellent surgeon." Being defensive Attempting to protect a person or health care services from negative comments. These responses prevent the client from expressing true concerns. The nurse is saying, "You have no right to complain." Defensive responses protect the nurse from admitting weaknesses in the health care services, including personal weaknesses. Client: "Those night nurses must just sit around and talk all night. They didn't answer my light for over an hour." Nurse: "I'll have you know we literally run around on nights. You're not the only client, you know." Challenging Giving a response that makes clients prove their statement or point of view. These responses indicate that the nurse is failing to consider the client's feelings, making the client feel it necessary to defend a position. Client: "I felt nauseated after that red pill." Nurse: "Surely you don't think I gave you the wrong pill?" Client: "I feel as if I am dying." Nurse: "How can you feel that way when your pulse is 60?" Client: "I believe my husband doesn't love me." Nurse: "You can't say that; why, he visits you every day." Probing Asking for information chiefly out of curiosity rather than with the intent to assist the client. These responses are considered prying and violate the client's privacy. Asking "why" is often probing and places the client in a defensive position. Client: "I was speeding along the street and didn't see the stop sign." Nurse: "Why were you speeding?" Client: "I didn't ask the doctor when he was here." Nurse: "Why didn't you?" Testing Asking questions that make the client admit to something. These responses permit the client only limited answers and often meet the nurse's need rather than the client's. "Who do you think you are?" (forces people to admit their status is only that of client) "Do you think I am not busy?" (forces the client to admit that the nurse really is busy) Rejecting Refusing to discuss certain topics with the client. These responses often make clients feel that the nurse is rejecting not only their communication but also the clients themselves. "I don't want to discuss that. Let's talk about. ..." "Let's discuss other areas of interest to you rather than the two problems you keep mentioning." Changing topics and subjects Directing the communication into areas of self-interest rather than considering the client's concerns is often a self-protective response to a topic that causes anxiety. These responses imply that what the nurse considers important will be discussed and that clients should not discuss certain topics. "I can't talk now. I'm on my way for coffee break." Client: "I'm separated from my wife. Do you think I should have sexual relations with another woman?" Nurse: "I see that you're 36 and that you like gardening. This sunshine is good for my roses. I have a beautiful rose garden." Unwarranted reassurance Using clichés or comforting statements of advice as a means to reassure the client. These responses block the fears, feelings, and other thoughts of the client. "You'll feel better soon." "I'm sure everything will turn out all right." "Don't worry." Passing judgment Giving opinions and approving or disapproving responses, moralizing, or implying one's own values. These responses imply that the client must think as the nurse thinks, fostering client dependence. "That's good (bad)." "You shouldn't do that." "That's not good enough." "What you did was wrong (right)." Giving common advice Telling the client what to do. These responses deny the client's right to be an equal partner. Note that giving expert rather than common advice is therapeutic. Client: "Should I move from my home to a nursing home?" Nurse: "If I were you, I'd go to a nursing home, where you'll get your meals cooked for you."

Malignancies

Testicular cancer is the most common neoplasm in young men. Seminoma testicular cancer most commonly affects men ages 30 to 45. The yolk sac tumor is most common in 20- to 35-year-olds Breast cancer is the most common cause of cancer in American women. Approximately one in eight women is diagnosed each year. It is the second leading cause of cancer death in women. The first leading cause of death is lung cancer Death rates from breast cancer have been declining, with the greatest decline in women younger than age 50. This is thought to be because of earlier detection, increased awareness, and improved treatment. • Breast self-exam (BSE) is an option for women starting in their 20s. • Women in their 20s and 30s should have a clinical breast exam (CBE) by their health care provider, preferably every 3 years. After age 40, this should be done annually. • Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. • Women ages 40 and older should have a screening mammogram annually as long as they are in good health. It is important that young women and men become vaccinated against human papillomavirus (HPV). Women who become infected are at risk for developing cervical cancer. The ACS (2013c) recommends that women ages 19 to 26 years be vaccinated if they have not been previously. All women should be screened for cervical cancer by age 21. Women ages 21 to 29 should be screened every 3 years. At age 30 screening should be combined with an HPV test every 5 years. Screening for cervical cancer is done by having a routine Papanicolaou (Pap) test. A Pap test is done by obtaining and examining cells from the uterine cervical os. The cells are obtained during a pelvic examination. The nurse should also screen for high-risk factors for cervical cancer: sexual activity at an early age, multiple sexual partners, or a history of syphilis, herpes genitalis, or Trichomonas vaginalis. Many young adults are reluctant to have these examinations and screenings. Therefore, it is important for nurses to explain the purpose of the test and to encourage all young women to begin this preventive measure.

sensory deficits

The ability to hear, see, feel, and smell are important adjuncts to communication. Deafness can significantly alter the message the client receives; impaired vision alters the ability to observe nonverbal behavior, such as a smile or a gesture; inability to feel and smell can impair the client's abilities to report injuries or detect the smoke from a fire. For clients with severe hearing impairments, follow these steps: • Look for a medical alert bracelet (or necklace or tag) indicating hearing loss. • Determine whether the client wears a hearing aid and whether it is functioning. • Observe whether the client is attempting to see your face to read lips. • Observe whether the client is attempting to use hands to communicate with sign language.

Commitment

The deliberate choice to act in accordance with one's desires as well as obligations, resulting in investment of self in a task or cause.

MIND-BODY THERAPIES

The interconnectedness of the mind and body is the basis for the complementary therapies. Imagery, meditation, storytelling, music therapy, and yoga are examples of complementary therapies that bring balance to thoughts and emotions. Practice of one or more mind-body therapies is an effective self-care strategy to help restore peace and balance.

teaching groups

The major purpose of teaching groups is to impart information to the participants. Examples of teaching groups include continuing education and client health care groups. Numerous subjects are often handled via the group teaching format: childbirth techniques, birth control methods, effective parenting, nutrition, management of chronic illness such as diabetes, exercise for middle-aged and older adults, and instructions to family members about follow-up care for discharged clients. A nurse who leads a group in which the primary purpose is to teach or learn must be skilled in the teaching-learning process

concreteness

The nurse must assist the client to be concrete and specific rather than to speak in generalities. When the client says, "I'm stupid and clumsy," the nurse narrows the topic to the specific by pointing out, "You tripped on the rug."

yoga

The practice of yoga unites the body, mind, and spirit. Through daily practice of the various postures and breathing practices of yoga, an individual can achieve increased balance and flexibility, mental alertness, and calmness. The bending, stretching, and holding properties of the postures help to relax and tone the muscles and improve function of the internal organs. Breath control is designed to still the mind and enhance awareness. Eliopoulos (2010) sums up the goal of yoga: to "create balance between movement and stillness, which is said to be the state of a healthy body"

Self- awareness and growth groups

The purpose of self-awareness and growth groups is to develop or use interpersonal strengths. The overall aim is to improve the person's functioning in the group to which they return, whether job, family, or community. From the beginning, broad goals are usually apparent, for example, to study communication patterns, group process, or problem solving. Because the focus of these groups is interpersonal concerns around current situations, the work of the group is oriented to reality testing with a here-and-now emphasis. Members are responsible for correcting inefficient patterns of relating and communicating with each other. They learn the group process through participation, involvement, and guided exercises.

message

The second component of the communication process is the message itself—what is actually said or written, the body language that accompanies the words, and how the message is transmitted. The method used to convey the message can target any of the receiver's senses. It is important for the method to be appropriate for the message, and it should help make the intent of the message clearer. For example, talking face to face with a person may be more effective in some instances than telephoning or writing a message. Recording messages on tape or communicating by radio or television may be more appropriate for larger audiences. Written communication is often appropriate for long explanations or for a communication that needs to be preserved. The nonverbal channel of touch is often highly effective

task group

The task group is one of the most common types of work-related groups to which nurses belong. Examples are health care planning committees, nursing service committees, nursing team meetings, nursing care conference groups, and hospital staff meetings. The focus of such groups is the completion of a specific task, and the leader and/or members define the format at the beginning. The methods vary according to the task to be completed.

Humor

The use of humor can be a positive and powerful tool in the nurse-client relationship, but it must be used with care. Humor can be used to help clients adjust to difficult and painful situations. The physical act of laughter can be an emotional and physical release, reducing tension by providing a different perspective and promoting a sense of well-being. When using humor, it is important to consider the client's perception of what is considered humorous. Timing is also important to consider. Though humor and laughter can help reduce stress and anxiety, the feelings of the client need to be considered.

therapy groups

Therapy groups work toward self-understanding, more satisfactory ways of relating to or handling stress, and changing patterns of behavior toward health. Members of a therapy group are chosen by health professionals after extensive selection interviews that consider the pattern of personalities, behaviors, needs, and identification of group therapy as the treatment of choice. Duration of therapy groups is not usually set. A termination date is usually mutually determined by the therapist and members.

suicide

a leading cause of death in the young adult age group. Many suicides may actually be mistaken for accidental death (motor vehicle crashes, combining alcohol and barbiturates, or discharging a gun while cleaning it). Suicide may result from problems with close relationships such as those with marriage partners or parents, or from depression related to perceived occupational, academic, or financial failure. - suicide results from the young adult's inability to cope with the pressures, responsibilities, and expectations of adulthood. - The nurse's role in the prevention of suicide includes identifying behaviors that may indicate potential problems: depression; a variety of physical complaints, including weight loss, sleep disturbances, and digestive disorders; and decreased interest in social and work roles along with an increase in isolation. - A young adult identified as at risk for suicide must be referred to a mental health specialist or a crisis center.

American Heart Association guidelines recommend that healthy adults, ages 18 to 65 years, engage in the following activities to promote and maintain health:

• At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes OR • At least 25 minutes of vigorous aerobic activity at least 3 days per week for a total of 75 minutes; or a combination of the two AND • Moderate to high intensity muscle-strengthening activity at least 2 or more days per week for additional health benefits.

ch 26

• Communication is a critical nursing skill used to gather assessment data for nursing diagnoses, to teach and persuade, and to express caring and comfort. • Communication is a two-way interpersonal process involving the sender of the message and the receiver of the message. It also involves intrapersonal messages, or self-talk, which can affect the message, the interpretation of the message, and the response. • The communication process includes four elements: sender, message, receiver, and response/feedback. The sender must encode the message and determine the appropriate form for transmitting it. The receiver must perceive the message, decode it, and then respond. • Verbal communication is effective when the criteria of pace and intonation, simplicity, clarity and brevity, timing and relevance, adaptability, credibility, and humor are met. • Nonverbal communication often reveals more about a person's thoughts and feelings than verbal communication; it includes personal appearance, posture, gait, facial expressions, and gestures. • When assessing verbal and nonverbal communication, the nurse needs to consider cultural influences and be aware that a single nonverbal expression can indicate any of a variety of feelings and that words can have various meanings. • The use of electronic communication, particularly e-mail, in nursing practice is evolving. Although e-mail provides positive advantages for improving communication and continuity of client care, the nurse needs to be aware of the risk to client confidentiality. • Many factors influence the communication process: development, gender, values and perceptions, personal space (intimate, personal, social, and public distances), territoriality, roles and relationships, environment, congruence, interpersonal attitudes, and boundaries. • Many techniques facilitate therapeutic communication: using silence, providing general leads, being specific and tentative, using open-ended questions, using touch, restating or paraphrasing, seeking clarification, perception checking or seeking consensual validation, offering self, giving information, acknowledging, clarifying time or sequence, presenting reality, focusing, reflecting, summarizing, and planning. • Techniques that inhibit communication include stereotyping, being defensive, challenging, testing, rejecting, changing topics and subjects, unwarranted reassurance, passing judgment, and giving common advice. • The effective nurse-client relationship is a helping relationship that facilitates growth of the client. • Four phases of the helping relationship include the preinteraction phase, the introductory phase, the working phase, and the termination phase; each has specific tasks and skills. • To help clients with communication problems, the nurse manipulates the environment, provides support, employs measures to enhance communication, and educates the client and support people. • Process recordings are frequently made by nurses to evaluate the effectiveness of their own communication. With them, nurses can analyze both the process and the content of the communication. • Effective communication between health professionals is vital for client safety. • Many nurses report disruptive behaviors from physicians and other nurses. Disruptive behavior is defined as behavior that interferes with effective communication among health care providers and negatively impacts performance and outcomes. Three common disruptive behaviors include incivility, lateral violence, and bullying. • A number of nursing organizations have issued statements regarding the harmful effects of disruptive behaviors on both nurses and client safety. Nurses must be as proficient in communication skills as they are in clinical skills. • Communication styles can differ between nurses and physicians. Nurses tend to be more narrative and descriptive and strive for consensus. Physicians focus on a need or problem and are trained to give and want information in bullet points. The SBAR model is one approach aimed at addressing these differences in communication style and approach. Studies have shown that interdisciplinary simulations can also enhance communication between nurses and physicians. • Assertive communication promotes client safety by minimizing miscommunication with colleagues. An important characteristic of assertive communication is to use "I" statements. • Nonassertive communication includes two types of interpersonal behaviors: submissive and aggressive.

Meditation

Through quieting the mind and focusing it on the present, meditation assists the individual in releasing fears, worries, and doubts. The technique involves both relaxation and focused attention. Guidelines for mindful meditation include choosing a quiet space, sitting comfortably, achieving progressive relaxation through deep breathing, and focusing attention on breathing or a mental image.

NONASSERTIVE COMMUNICATION

Two types of interpersonal behaviors are considered nonassertive: submissive and aggressive. SUBMISSIVE When people use a submissive or passive communication style they allow their rights to be violated by others (Kneisl & Trigoboff, 2013). They meet the demands and requests of others without regard to their own feelings and needs because they believe their own feelings are not important. Some experts believe that people who use the submissive behaviors or communication style are insecure and try to maintain their self-esteem by avoiding conflict (e.g., negative criticism and disagreement from others). AGGRESSIVE There is a fine line between assertive and aggressive communication. Assertive communication is an open expression of ideas and opinions while respecting the rights, opinions, and ideas of others. Aggressive communication is "directed toward what one wants without considering the feelings of others" (Kneisl & Trigoboff, 2013, p. 376). This type of communication is ineffective and leads to frustration for the nurse and the primary care provider.

Music Therapy

Using music as therapy includes listening, singing, rhythm, and body movement. Quiet, soothing music is often used to induce relaxation. Active rhythms can awaken feelings of power and control. Familiar music allows the listener to recall past events or feelings. Music can also serve as an effective distraction technique. Each person's likes and dislikes are taken into account in order to achieve the desired emotional response.

Table 26-1. Therapeutic Communication Techniques

Using silence Accepting pauses or silences that may extend for several seconds or minutes without interjecting any verbal response. Sitting quietly (or walking with the client) and waiting attentively until the client is able to put thoughts and feelings into words. Providing general leads Using statements or questions that (a) encourage the client to verbalize, (b) choose a topic of conversation, and (c) facilitate continued verbalization. "Can you tell me how it is for you?" "Perhaps you would like to talk about. ..." "Would it help to discuss your feelings?" "Where would you like to begin?" "And then what?" Being specific and tentative Making statements that are specific rather than general, and tentative rather than absolute. "Rate your pain on a scale of zero to ten." (specific statement) "Are you in pain?" (general statement) "You seem unconcerned about your diabetes." (tentative statement)" Using open-ended questions Asking broad questions that lead or invite the client to explore (elaborate, clarify, describe, compare, or illustrate) thoughts or feelings. Open-ended questions specify only the topic to be discussed and invite answers that are longer than one or two words. "I'd like to hear more about that." "Tell me more. ..." "How have you been feeling lately?" "What brought you to the hospital?" "What is your opinion?" "You said you were frightened yesterday. How do you feel now?" Using touch Providing appropriate forms of touch to reinforce caring feelings. Because tactile contacts vary considerably among individuals, families, and cultures, the nurse must be sensitive to the differences in attitudes and practices of clients and self. Putting an arm over the client's shoulder. Placing your hand over the client's hand. Restating or paraphrasing Actively listening for the client's basic message and then repeating those thoughts and/or feelings in similar words. This conveys that the nurse has listened and understood the client's basic message and also offers clients a clearer idea of what they have said. Client: "I couldn't manage to eat any dinner last night—not even the dessert." Nurse: "You had difficulty eating yesterday." Client: "Yes, I was very upset after my family left." Seeking clarification A method of making the client's broad overall meaning of the message more understandable. It is used when paraphrasing is difficult or when the communication is rambling or garbled. To clarify the message, the nurse can restate the basic message or confess confusion and ask the client to repeat or restate the message. Nurses can also clarify their own message with statements. "I'm puzzled." "I'm not sure I understand that." "Would you please say that again?" "Would you tell me more?" "I meant this rather than that." "I'm sorry that wasn't very clear. Let me try to explain another way." Perception checking or seeking consensual validation A method similar to clarifying that verifies the meaning of specific words rather than the overall meaning of a message. Client: "My husband never gives me any presents." Nurse: "You mean he has never given you a present for your birthday or Christmas?" Client: "Well—not never. He does get me something for my birthday and Christmas, but he never thinks of giving me anything at any other time." Offering self Suggesting one's presence, interest, or wish to understand the client without making any demands or attaching conditions that the client must comply with to receive the nurse's attention. "I'll stay with you until your daughter arrives." "We can sit here quietly for a while; we don't need to talk unless you would like to." "I'll help you to dress to go home, if you like." Giving information Providing, in a simple and direct manner, specific factual information the client may or may not request. When information is not known, the nurse states this and indicates who has it or when the nurse will obtain it. "Your surgery is scheduled for 11 AM tomorrow." "You will feel a pulling sensation when the tube is removed from your abdomen." "I do not know the answer to that, but I will find out from Mrs. King, the nurse in charge." Acknowledging Giving recognition, in a nonjudgmental way, of a change in behavior, an effort the client has made, or a contribution to a communication. Acknowledgment may be with or without understanding, verbal or nonverbal. "You trimmed your beard and mustache and washed your hair." "I notice you keep squinting your eyes. Are you having difficulty seeing?" "You walked twice as far today with your walker." Clarifying time or sequence Helping the client clarify an event, situation, or happening in relationship to time. Client: "I vomited this morning." Nurse: "Was that after breakfast?" Client: "I feel that I have been asleep for weeks." Nurse: "You had your operation Monday, and today is Tuesday." Presenting reality Helping the client to differentiate the real from the unreal. "That telephone ring came from the program on television." "Your magazine is here in the drawer. It has not been stolen." Focusing Helping the client expand on and develop a topic of importance. It is important for the nurse to wait until the client finishes stating the main concerns before attempting to focus. The focus may be an idea or a feeling; however, the nurse often emphasizes a feeling to help the client recognize an emotion disguised behind words. Client: "My wife says she will look after me, but I don't think she can, what with the children to take care of, and they're always after her about something—clothes, homework, what's for dinner that night." Nurse: "Sounds like you are worried about how well she can manage." Reflecting Directing ideas, feelings, questions, or content back to clients to enable them to explore their own ideas and feelings about a situation. Client: "What can I do?" Nurse: "What do you think would be helpful?" Client: "Do you think I should tell my husband?" Nurse: "You seem unsure about telling your husband." Summarizing and planning Stating the main points of a discussion to clarify the relevant points discussed. This technique is useful at the end of an interview or to review a health teaching session. It often acts as an introduction to future care planning. "During the past half hour we have talked about. ..." "Tomorrow afternoon we may explore this further." "In a few days I'll review what you have learned about the actions and effects of your insulin." "Tomorrow, I will look at your feeling journal.

impairments to communication

Various barriers may alter a client's ability to send, receive, or comprehend messages. These include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis. The nurse must assess each to determine their presence

VERBAL COMMUNICATION

Verbal communication is largely conscious because people choose the words they use. The words used vary among individuals according to culture, socioeconomic background, age, and education. As a result, countless possibilities exist for the way ideas are exchanged. An abundance of words can be used to form messages. In addition, a wide variety of feelings can be transmitted when people talk. Nurses need to consider the following when choosing words to say or write: pace and intonation, simplicity, clarity and brevity, timing and relevance, adaptability, credibility, and humor.

young adults

Young adults are typically busy people who face many challenges. They are expected to assume new roles at work, in the home, and in the community, and to develop interests, values, and attitudes related to these roles. People in their early 20s are in their prime physical years. The human body is at its most efficient functioning at about age 25 years. The musculoskeletal system is well developed and coordinated. This is the period when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency. • Is in the genital stage in which energy is directed toward attaining a mature sexual relationship, according to Freud's theory. • Is in the intimacy versus isolation phase of Erikson's stages of development. • Has the following developmental tasks, according to Havighurst: • Selecting a mate • Learning to live with a partner • Starting a family • Rearing children • Managing a home • Getting started in an occupation • Taking on civic responsibility • Finding a congenial social group. • Has the following characteristics, according to Newman and Newman (2015): • Identifies social and occupational roles. • Experiences stress related to changing roles. Young adults face a number of new experiences and changes in lifestyle as they progress toward maturity. They make choices about education and employment, about whether to marry or remain single, about starting a home, and about rearing children. Social responsibilities include forming new friendships and assuming some community activities. Many young adults have experienced the stressors of divorce of their parents and being raised in stepfamilies. As children of divorce, feelings of being "caught" between two divorced parents may be heavy burdens as they move into young adulthood. These added concerns may have implications for the development of intimate relationships in young adults. Occupational choice and education are largely inseparable. Education influences occupational opportunities; conversely, an occupation, once chosen, can determine the education needed and sought. Education enhances employment opportunities and usually ensures economic survival. As the role of women has changed, many women now choose to assume active careers and civic roles in society in addition to their roles as mother and/or wife (Figure 22-1 [Inline Image]). Some women work out of necessity, rather than choice. Remaining single is becoming the lifestyle of more and more young adults. Many people choose to remain single, perhaps to pursue an education and then to have the freedom to pursue their chosen vocation. Some unmarried individuals choose to live with another person of the opposite or same gender and share living arrangements and certain expenses. Some people who are gay or lesbian commit themselves legally to a partner as in marriage, and do not consider themselves to be "single." Although nontraditional lifestyles are becoming more acceptable in society, attitudes toward these various lifestyles can contribute social pressures that lead to stress responses. The multiple roles of adulthood (citizen, worker, taxpayer, homeowner, wife/husband, daughter/son, brother/sister, parent, friend, and so on) may also create role conflict, which can result in stress. Cognitive Development Young adults are able to use formal operations, characterized by the ability to think abstractly and employ logic. For example, young adults are able to generate hypotheses about what will happen, given a set of circumstances, and do not have to engage in trial-and-error behavior. Some have proposed a concept of postformal thought, which is thinking that goes beyond Piaget's formal operations. Postformal thought includes creativity, intuition, and the ability to consider information in relationship to other ideas. Postformal thinkers possess an understanding of the temporary or relative nature of knowledge. They can proceed from abstract reasoning to practical considerations. They are aware that most problems have more than one cause and more than one answer and some solutions will work better than others. They are able to comprehend and become more specialized and focused in particular areas of interest Moral Development Young adults who have mastered the previous stages of Kohlberg's theory of moral development enter the postconventional level. At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. When individuals perceive a conflict with society's rules or laws, they judge according to their own principles. For example, a person may intentionally break the law and join a protest group to stop hunters from killing wild animals, believing that the principle of wildlife conservation justifies the protest action. This type of reasoning is called principled reasoning. Spiritual Development According to Fowler (1981), the individual enters the individuating-reflective period sometime after 18 years of age. During this period, the individual focuses on reality. The religious teaching that the young adult had as a child may now be accepted or redefined. Health Risks Young adulthood is generally a healthy time of life. Health risks that do occur and are common in this age group include injury and violence, suicide, hypertension, substance abuse, sexually transmitted infections (STIs), eating disorders, and certain malignancies.

Caring and warmth

a feeling of emotional closeness, in contrast to an impersonal approach. Caring is more enduring and intense than warmth. It conveys deep and genuine concern for the person, whereas warmth conveys friendliness and consideration, shown by acts of smiling and attention to physical comforts. Caring involves giving feelings, thoughts, skill, and knowledge. It requires psychological energy and poses the risk of gaining little in return; yet by caring, people usually reap the benefits of greater communication and understanding.

substance abuse

a major threat to the health of young adults. Alcohol, marijuana, amphetamines, and cocaine, for example, can bring about feelings of well-being that may be highly valued by people with adjustment problems. Prolonged use can lead to physical and psychological dependency and subsequent health problems. Addiction, or physical and psychological dependence on a substance, is related to properties of the substance, the individual user, and the social network of the individual. For example, drug abuse during pregnancy can lead to fetal damage. Prolonged use of alcohol can lead to such diseases as cirrhosis of the liver and cancer of the esophagus. Nursing strategies related to drug abuse include teaching about the complications of their use, changing individual attitudes toward drug abuse, and counseling regarding problems that lead to drug abuse. In addition, assessment of the young adult for substance abuse may help the nurse identify a problem early on, and assist the young adult client to access intervention services. The most common reasons for smoking are independence from parents, reaching legal age to purchase tobacco, and the use of substances such as alcohol. The nurse's role regarding smoking is to (a) serve as a role model by not smoking; (b) provide educational information regarding the dangers of smoking; (c) help make smoking socially unacceptable, for example, by posting No Smoking signs in client lounges and offices; and (d) suggest resources such as hypnosis, lifestyle training, and behavior modification to clients who desire to stop smoking. Nurses can also promote health related to tobacco by being aware of marketing efforts that target young adults.

Elderspeak

a speech style similar to baby talk that gives the message of dependence and incompetence and is seen as patronizing by older adults. it doesn't communicate respect Many health care providers are not aware that they use elderspeak or that it can have negative meanings to the client. The characteristics of elderspeak include inappropriate terms of endearment (e.g., "honey", "grandma"), inappropriate plural pronoun use (e.g., "Are we ready for our bath"), tag questions (e.g., "You want to wear this dress"), and slow, loud speech

lateral violence

also known as horizontal violence and horizontal hostility, are terms that describe physical, verbal, or emotional abuse or aggression directed at RN coworkers at the same organizational level. It usually includes verbal or nonverbal (rather than physical) aggressive behaviors. Examples of these behaviors include gossiping, verbal abuse (speech that is intended to humiliate or embarrass another person), withholding information, snide remarks, abrupt responses, sabotage, scapegoating, not available to help, complaining to others about one individual, ostracism, and failure to respect the privacy of others

respect

an attitude that emphasizes the other person's worth and individuality. It conveys that the person's hopes and feelings are special and unique even though similar to others in many ways.

communication

any means of exchanging information or feelings between two or more people. It is a basic component of human relationships, including nursing.

group dynamics

communication that takes place between members of any group A number of interrelated factors and variables determine the manner of this communication. Each member of the group will have an effect on the group dynamics, based on their motivation for participating, their similarity to other group members, the maturity of the group members in expressing their feelings, and the goal of the group. Three main functions are required for any group to be effective. - It must maintain a degree of group unity or cohesion. - It needs to develop and modify its structure to improve its effectiveness. - it must accomplish its goals.

Adaptability

e nurse needs to alter spoken messages in accordance with behavioral cues from the client. This adjustment is referred to as adaptability. What the nurse says and how it is said must be individualized and carefully considered. This requires astute assessment and sensitivity on the part of the nurse. For example, a nurse who usually smiles, appears cheerful, and greets the client with an enthusiastic "Hi, Mrs. Brown!" notices that the client is not smiling and appears distressed. It is important for the nurse to then modify his or her tone of speech and express concern by facial expression while moving toward the client.

STIS

genital herpes, AIDS, syphilis, and gonorrhea are common infections in young adults. Chlamydia is the most prevalent STI, and in fact is the most prevalent infectious disease in the United States

response

is the message that the receiver returns to the sender. It is also called feedback. Feedback can be either verbal, nonverbal, or both. Nonverbal examples are a nod of the head or a yawn. Either way, feedback allows the sender to correct or reword a message. In the case of Mr. Johnson, the receiver may appear irritated or say, "Well, the nurse on the other shift gives me my pain medication early if I need it." The sender then knows the message was interpreted accurately. However, now the original sender becomes the receiver, who is required to decode and respond.

Caring pattern

knowing the client, nursing presence, empowering the client, compassion, and competence

Attentive Listening

listening actively and with mindfulness, using all the senses, and paying attention to what the client says, does, and feels as opposed to listening passively with just the ear. It is probably the most important technique in nursing and is basic to all other techniques. Attentive listening is an active process that requires energy and concentration. It involves paying attention to the total message, both verbal and nonverbal, and noting whether these communications are congruent. Attentive listening means absorbing both the content and the feeling the person is conveying, while putting aside your own judgments and ideas to really hear and focus on the client's needs. Attentive listening conveys an attitude of caring and interest, thereby encouraging the client to trust you, open up, and talk The nurse must be careful not to react quickly to the message. The nurse should not interrupt the speaker, and the nurse (the responder) should take time to think about the message before responding. As a listener, the nurse also should ask questions either to obtain additional information or to clarify. The message sender (i.e., the client) should decide when to close a conversation. When the nurse closes the conversation, the client may assume that the nurse considers the message unimportant. It is also important for nurses to be aware of their own biases. A message from a client that reflects different values or beliefs should not be discredited for that reason.

Caring practice

mutual recognition, connection, involvement between nurse and client

Nursing

nurturance or care

TERRITORIALITY

oncept of the space and things that an individual considers as belonging to the self. Territories marked off by people may be visible to others. For example, clients in a hospital often consider their territory as bounded by the curtains around the bed unit or by the walls of a private room. Health care workers must recognize this human tendency to claim territory. Clients often feel the need to defend their territory when it is invaded by others; for example, when a visitor or nurse removes a chair to use at another bed, the visitor has inadvertently violated the territoriality of the client whose chair was removed. Nurses need to obtain permission from clients to remove, rearrange, or borrow objects in their hospital area.

assertive communication

promotes client safety by minimizing miscommunication with colleagues. People who use assertive communication are honest, direct, and appropriate while being open to ideas and respecting the rights of others.

Caring

sharing deep and genuine concern about the welfare of another person.

nonverbal communication

sometimes called body language, includes gestures, body movements, use of touch, and physical appearance, including adornment.

emotional intelligence

the ability to form work relationships with colleagues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others. A nurse or primary care provider with emotional intelligence may be viewed as mature, approachable, or easygoing. In work environments, professionals can demonstrate emotional intelligence by accurately identifying their own emotions and the emotions of others, managing those emotions, and then deciding how to interact with colleagues constructively to achieve a positive outcome.

Intrapersonal communication

the communication that you have with yourself; another name is self-talk. Both the sender and the receiver of a message usually engage in self-talk. It involves thinking about the message before it is sent, while it is being sent, and after it is sent, and it occurs constantly. Consequently, intrapersonal communication can interfere with a person's ability to hear a message as the sender intended

unintentional injuries (primarily motor vehicle crashes)

the fifth leading cause of death for the total population, but the leading cause of death for people 1 to 44 years of age. Education about safety precautions and injury prevention is a major role of the nurse in promoting the health of young adults.

Pace and Intonation

the manner of speech, as in the rate or rhythm and tone, will modify the feeling and impact of a message. The tone of words can express enthusiasm, sadness, anger, or amusement. The rate of speech may indicate interest, anxiety, boredom, or fear. For example, speaking slowly and softly to an excited client may help calm the client.

homicide

the second leading cause of death among young people 15 to 24 years of age and the leading cause of death for African Americans in this age group. The elderly, females, and children continue to be targets of both physical and sexual assaults

receiver

the third component of the communication process, is the listener, who must listen, observe, and attend. This person is the decoder, who must perceive what the sender intended (interpretation). Perception uses all the senses to receive verbal and nonverbal messages. To decode means to relate the message perceived to the receiver's storehouse of knowledge and experience and to sort out the meaning of the message. Whether the message is decoded accurately by the receiver, according to the sender's intent, depends largely on their similarities in knowledge and experience and sociocultural background. If the meaning of the decoded message matches the intent of the sender, then the communication has been effective. Ineffective communication occurs when the receiver misinterprets the sent message. For example, Mr. Johnson may perceive the message accurately—"No pain medication for another hour." However, if experience has taught him that he can receive the pain medication early if a certain nurse is on duty, he will interpret the intent of the message differently.

boomerang kid

young adults have moved back into their parents' homes after an initial period of independent living. The factors contributing to this trend include high housing costs, high divorce rates, high unemployment rates, and the problems resulting from substance abuse and maladaptive behaviors. Some young people who are employed full time receive only minimum wage and are unable to earn enough money to be self-supporting.

Examples of Caring

• A client experiencing postoperative pain is given medication to control her symptoms, and then the nurse talks quietly and holds her hand for a few minutes as the pain resolves. The nurse's presence, in itself, provides comfort for the client. • After the student nurse washes the hair of an older woman who is immobilized and applies her makeup, she helps the woman into a wheelchair to greet her daughter and grandchildren. The woman is extremely grateful and her sense of dignity is enhanced by this personal care.

By the end of the introductory phase, clients should begin to:

• Develop trust in the nurse. • View the nurse as a competent professional capable of helping. • View the nurse as honest, open, and concerned about their welfare. • Believe the nurse will try to understand and respect their cultural values and beliefs. • Believe the nurse will respect client confidentiality. • Feel comfortable talking with the nurse about feelings and other sensitive issues. • Understand the purpose of the relationship and the roles. • Feel that they are active participants in developing a mutually agreeable plan of care.

Characteristics of a Helping Relationship

• Is an intellectual and emotional bond between the nurse and the client and is focused on the client. • Respects the client as an individual, including maximizing the client's abilities to participate in decision making and treatments, considering ethnic and cultural aspects, and considering family relationships and values. • Respects client confidentiality. • Focuses on the client's well-being. • Is based on mutual trust, respect, and acceptance.

Kneisl and Trigoboff (2013) point out the following blocks to listening that may prevent the nurse from hearing what the client is saying and hinder therapeutic communication:

• Rehearsing—being too busy thinking about what you want to say • Being concerned with yourself—the focus should be on the client • Assuming—thinking that you know what the client "really means" without validation • Judging—framing what you hear or see in terms of your judgment about the client as being immature, depressed, etc. • Identifying—focusing on your own similar experiences, feelings, or beliefs • Getting off track—changing the subject if you become uncomfortable, bored, or tired • Filtering—tuning out or only hearing certain things - Common responses are nodding the head, uttering "Uh huh" or "Mmm," repeating the words that the client has used, or saying "I see what you mean." Each nurse has characteristic ways of responding, and the nurse must take care not to sound insincere or phony.

Box 26-1 Guidelines for Visibly Tuning in to Clients: Empathic Presence Egan (2014) suggests specific nonverbal skills that a nurse can use to portray empathic presence through use of the acronym SOLER:

• S: Face the other person squarely. Adopt a posture that indicates involvement. This position says, "I am available to you." Moving to the side lessens the degree of involvement. • O: Adopt an open posture. The nondefensive position is one in which neither arms nor legs are crossed. It conveys that the person wishes to listen to what the other has to say. • L: Lean toward the person. People move naturally toward one another when they want to say or hear something—by moving to the front of a class, by moving a chair nearer a friend, or by leaning across a table with arms propped in front. The nurse conveys involvement by leaning forward, closer to the client. • E: Maintain good eye contact. In North American culture, mutual eye contact, preferably at the same level, recognizes the other person and denotes willingness to maintain communication. Eye contact neither glares at nor stares down another but is natural. In other cultures, too much eye contact, especially with someone in a position of authority, is out of order (Egan, 2014, p. 78). • R: Try to be relatively relaxed or natural. Total relaxation is not feasible when the nurse is listening with intensity, but the nurse can show relaxation by taking time to respond, allowing pauses as needed, balancing periods of tension with relaxation, and using gestures that are natural.

Social and Ethical Responsibilities of Nurses in Relation to Caring

• The nurse must care for the self in order to care for others. • Nurses must remain committed to human care ideals. • Cultivation of a higher/deeper self and a higher consciousness leads to caring. • Human care can only be demonstrated through interpersonal relationships. • Honoring the connectedness of all (unitary consciousness) leads to transpersonal caring-healing. • Education and practice systems must be based on human values and concern for the welfare of others.