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5 concepts of spirituality
Sense of authentically connecting to one's inner self
The belief that a force outside of and greater than the person exists beyond the material world
Spirituality offers a sense of connectedness intrapersonally (connected within oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power).
- Allows people to have firm beliefs despite lack of physical evidence. It enables them to believe in and establish transpersonal connections.
- It is an acceptance of what reasoning cannot explain. Sometimes faith involves a belief in a higher power, spirit guide, God, or Allah. Faith is also the manner in which a person chooses to live. It gives purpose and meaning to an individual's life, allowing for action.
- has several meanings that vary on the basis of how it is being experienced; it usually refers to an energizing source that has an orientation to future goals and outcomes
- When a person has the attitude of something to live for and look forward to, hope is present.
spiritual well being
The concept of spiritual well-being is often described as having two dimensions. The vertical dimension supports the transcendent relationship between a person and God or some other higher power. The horizontal dimension describes positive relationships and connections that people have with others. Has a positive effect on health
Religion is associated with the “state of doing,” or a specific system of practices associated with a particular denomination, sect, or form of worship.
religion vs. spirituality
- When providing spiritual care to a patient, it is important to understand the differences between religion and spirituality.
- Religious practices encompass spirituality, but spirituality does not need to include religious practice. Religious care helps patients maintain their faithfulness to their belief systems and worship practices. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships and a relationship with a higher being or life force.
- People gain spiritual health by finding a balance between their values, goals, and beliefs and their relationships within themselves and others.
- Illness and loss sometimes threaten and challenge the spiritual developmental process. Older adults often express their spirituality by turning to important relationships and giving of themselves to others
- the “impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself”. Spiritual distress causes a person to feel doubt, loss of faith, and a sense of being alone or abandoned.
- Spiritual distress also occurs when there is conflict between a person's beliefs and prescribed health regimens or the inability to practice usual rituals.
- Acute illness Often conflicts develop around a person's beliefs and the meaning of life. Anger is common; and patients sometimes express it against God, their families, themselves, or the nurse.
BELIEF assessment tool
- B—Belief system
- E—Ethics or values
- I—Involvement in a spiritual community
- F—Future events
Potential nursing diagnoses for the spiritual health
- • Anxiety
- • Ineffective coping
- • Fear
- • Complicated grieving
- • Hopelessness
- • Powerlessness
- • Readiness for enhanced spiritual well-being
- • Spiritual distress
- • Risk for spiritual distress
readiness for enhanced spiritual well-being
Other important resources to patients are spiritual advisors and members of the clergy. Many hospitals have pastoral-care departments. Pastoral-care professionals have expertise in understanding how an illness influences a person's beliefs and how the beliefs of the person influence illness and recovery. Ask if patients desire to have a member of the clergy visit during their hospitalization. When requested by patients or families, keep clergy informed of any physical, psychosocial, or spiritual concerns affecting the patient. Show respect for patients’ spiritual values and needs by allowing time for pastoral-care members to provide spiritual care and facilitating the administration of sacraments, rites, and rituals.
Meditation effectively creates a relaxation response that reduces daily stress. It reduces blood pressure, reduces stress and pain, and enhances the function of the immune system
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
Pain and government
Congress declared 2000 to 2010 the Decade of Pain Control and Research, yet pain continues to be a leading public health problem in the United States. Providing pain relief is a basic human right and is in the Pain Care Bill of Rights. According to the American Bar Association (2009), pain management is a basic right of people who are seriously ill. Nurses are legally and ethically responsible for managing pain and relieving suffering.
nature of pain
The pain experience is complex, involving physical, emotional, and cognitive components. Pain is subjective and highly individualized. Its stimulus is physical and/or mental in nature. Pain uses a person's energy. It interferes with personal relationships and influences the meaning of life. You cannot measure it objectively. Only the patient knows whether pain is present and how the experience feels. It is not the responsibility of patients to prove that they are in pain; it is a nurse's responsibility to accept their report
Physiology of Pain
- Cellular damage caused by thermal, mechanical, or chemical stimuli results in the release of excitatory neurotransmitters such as prostaglandins, bradykinin, substance P, and histamine (Box 43-1). These pain-sensitizing substances surround the pain fibers in the extracellular fluid, creating an “inflammatory soup,” spreading the pain message and causing an inflammatory response (Pasero and McCaffery, 2011). The pain stimulus enters the spinal cord via the dorsal horn and travels one of several routes until ending within the gray matter of the spinal cord. At the dorsal horn substance P is released, causing a synaptic transmission from the afferent (sensory) peripheral nerve to spinothalamic tract nerves, which cross to the opposite side (Pasero and McCaffery, 2011) (Fig. 43-1).
- Nerve impulses resulting from the painful stimulus travel along afferent (sensory) peripheral nerve fibers. Two types of peripheral nerve fibers conduct painful stimuli: the fast, myelinated A-delta fibers and the very small, slow, unmyelinated C fibers. The A fibers send sharp, localized, and distinct sensations that specify the source of the pain and detect its intensity. The C fibers relay impulses that are poorly localized, burning, and persistent. For example, after stepping on a nail, a person initially feels a sharp, localized pain, which is a result of A-fiber transmission. Within a few seconds the pain becomes more diffuse and widespread, until the whole foot hurts because of C-fiber innervations (Pasero and McCaffery, 2011).
- Along the spinothalamic tract, pain impulses travel up the spinal cord (Fig. 43-2). After the pain impulse ascends the spinal cord, the thalamus transmits information to higher centers in the brain, including the reticular formation, limbic system, somatosensory cortex, and association cortex. Once a pain stimulus reaches the cerebral cortex, the brain interprets the quality of the pain and processes information from past experience, knowledge, and cultural associations in the perception of the pain (Pasero and McCaffery, 2011). Perception is the point at which a person is aware of pain. The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center.
- As a person becomes aware of pain, a complex reaction occurs. Psychological and cognitive factors interact with neurophysiological ones in the perception of pain. Perception gives awareness and meaning to pain, resulting in a reaction. The reaction to pain includes the physiological and behavioral responses that occur after an individual perceives pain.
- Once the brain perceives pain, there is a release of inhibitory neurotransmitters such as endogenous opioids, serotonin, norepinephrine, and gamma aminobutyric acid (GABA), which work to hinder the transmission of pain and help produce an analgesic effect. This inhibition of the pain impulse is the fourth and last phase of the nociceptive process known as modulation.
- A protective reflex response also occurs with pain reception
Pain and neurotransmitters
List the excitatory neurotransmitters
- • Generated from the breakdown of phospholipids in cell membranes
- • Thought to increase sensitivity to pain
- • Released from plasma that leaks from surrounding blood vessels at the site of tissue injury
- • Binds to receptors on peripheral nerves, increasing pain stimuli
- • Binds to cells that cause the chain reaction producing prostaglandins
- Substance P
- • Found in the pain neurons of the dorsal horn (excitatory peptide)
- • Needed to transmit pain impulses from the periphery to higher brain centers
- • Causes vasodilation and edema
- • Produced by mast cells causing capillary dilation and increases capillary permeability
- • Released from the brainstem and dorsal horn to inhibit pain transmission
List the inhibitory neurotransmitters
- Neuromodulators (Inhibitory)
- • Are natural supply of morphine-like substances in the body
- • Activated by stress and pain
- • Located within the brain, spinal cord, and gastrointestinal tract
- • Cause analgesia when they attach to opiate receptors in the brain
- • Present in higher levels in people who have less pain than others with a similar injury
Gate Control Theory of Pain
- According to this theory, gating mechanisms located along the central nervous system regulate or even block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed. Closing the gate is the basis for nonpharmacological pain-relief interventions. You gain a useful conceptual framework for pain management by understanding the physiological, emotional, and cognitive influences on the gates. For example, factors such as stress and exercise increase the release of endorphins, often raising an individual's pain threshold (the point at which a person feels pain). Because the amount of circulating substances varies with every individual, the response to pain varies.
- Physiological Responses
- As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system. Pain of low to moderate intensity and superficial pain elicit the fight-or-flight reaction of the general adaptation syndrome (see Chapter 37). Stimulation of the sympathetic branch of the autonomic nervous system results in physiological responses (Table 43-1). Continuous, severe, or deep pain typically involving the visceral organs (e.g., with a myocardial infarction or colic from gallbladder or renal stones) activates the parasympathetic nervous system. Sustained physiological responses to pain sometimes seriously harm individuals. Except in cases of severe traumatic pain, which causes a person to go into shock, most people adapt to their pain, and their physical signs return to normal. Thus patients in pain do not always have changes in their vital signs. Changes in vital signs more often indicate problems other than pain.
- Acute pain is protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response.
- Acute pain seriously threatens a patient's recovery by resulting in prolonged hospitalization, increased risks of complications from immobility, and delayed rehabilitation.
- Complete pain relief is not always achievable, but reducing pain to a tolerable level is realistic. Thus a primary nursing goal is to provide pain relief that allows patients to participate in their recovery.
Chronic/persisten non cancer pain
- Unlike acute pain, chronic pain is not protective and thus serves no purpose. Chronic pain lasts longer than 6 months and is constant or recurring with a mild-to-severe intensity. It does not always have an identifiable cause and leads to great personal suffering.
- Chronic pain is a major cause of psychological and physical disability, leading to problems such as job loss, inability to perform simple daily activities, sexual dysfunction, and social isolation.
- The person with chronic noncancer pain often does not show obvious symptoms and does not adapt to the pain. Rather, he or she seems to suffer more with time because of physical and mental exhaustion. Associated symptoms of chronic pain include fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, and anger.
- Often a person with chronic pain who consults with numerous health care providers is labeled a drug seeker, when he or she is actually seeking adequate pain relief.
- Pain centers offer a holistic approach to chronic pain using both nonpharmacological and pharmacological strategies for pain management
Not all patients with cancer experience pain. For those who do, as many as 90% are able to have their pain managed with relatively simple means. Some patients with cancer experience acute and/or chronic pain. The pain is nociceptive and/or neuropathic. Cancer pain is usually caused by tumor progression and related pathological processes, invasive procedures, toxicities of treatment, infection, and physical limitations.
pain by inferred pathological process
Nociceptive pain includes somatic (musculoskeletal) and visceral (internal organ) pain. Neuropathic pain arises from abnormal or damaged pain nerves.
Idiopathic pain is chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition. An example of idiopathic pain is complex regional pain syndrome (CRPS). Research is needed to better identify the causes of idiopathic pain, thus leading to a more effective treatment
factors involving pain
Pain is a complex process, involving physiological, social, spiritual, psychological, and cultural influences
neurological function regarding pain
A patient's neurological function influences the pain experience. Any factor that interrupts or influences normal pain reception or perception (e.g., spinal cord injury, peripheral neuropathy, or neurological disease) affects the patient's awareness of and response to pain. Some pharmacological agents (analgesics, sedatives, and anesthetics) influence pain perception and response and thus require close monitoring.
Attention regarding pain
The degree to which a patient focuses attention on pain influences pain perception. Increased attention is associated with increased pain, whereas distraction is associated with a diminished pain response. This concept is one that nurses apply in various pain-relief interventions such as relaxation, guided imagery, and massage. By focusing patients’ attention and concentration on other stimuli, their perception of pain declines
previous experience regarding pain
Each person learns from painful experiences. Prior experience does not mean that a person accepts pain more easily in the future. Previous frequent episodes of pain without relief or bouts of severe pain cause anxiety or fear. In contrast, if a person repeatedly experiences the same type of pain that was relieved successfully in the past, the patient finds it easier to interpret the pain sensation. As a result, the patient is better prepared to take necessary actions to relieve the pain.
Anticipatory phase of pain/preoperative education
In the anticipatory phase of the pain experience, you need to prepare a patient with a clear explanation of the type of pain to expect and methods to reduce it.
nursing diagnoses with pain
- Your assessment often directs you to diagnoses other than that of acute or chronic pain. The extent to which pain affects a patient's function and general state of health determines whether other nursing diagnoses are relevant. For example, your assessment reveals that a patient has pain of the hands and shoulders as a result of crippling arthritis for over 3 years. As a result the patient is unable to remove or fasten necessary items of clothing. The nursing diagnoses for this patient are dressing/grooming self-care deficit and chronic pain. The diagnosis of self-care deficit requires involvement by members of the interdisciplinary health care team to provide the patient with assistive devices for performing self-care. Examples of other diagnoses that are applicable to patients experiencing pain include the following:
- • Activity intolerance
- • Anxiety
- • Ineffective coping
- • Fatigue
- • Fear
- • Hopelessness
- • Impaired physical mobility
- • Imbalanced nutrition: less than body requirements
- • Insomnia
- • Powerlessness
- • Chronic low self-esteem
- • Impaired social interaction
- • Spiritual distress
non-pharmaceutical pain relief
- Distraction, prayer, relaxation, guided imagery, music, and biofeedback are examples. Physical approaches aim to provide pain relief, correct physical dysfunction, alter physiological responses, and reduce fears associated with pain-related immobility. Chiropractic therapy and acupuncture/acupressure therapy are examples. Complementary and alternative medicine (CAM) therapies such as therapeutic touch also help to alleviate pain in some patients. The Agency for Health Care Policy and Research guidelines for acute pain management cite nonpharmacological interventions to be appropriate for patients who meet the following criteria:
- • Find such interventions appealing
- • Express anxiety or fear
- • Possibly benefit from avoiding or reducing drug therapy
- • Are likely to experience and need to cope with a prolonged interval of postoperative pain
- • Have incomplete pain relief after use of pharmacological interventions
- Relaxation, distraction, guided imagery, music, cutaneous stimulation
Massage and pain relief
- Massage is effective for producing physical and mental relaxation, reducing pain, and enhancing the effectiveness of pain medication. Massaging the back, shoulders, hands, and/or feet for 3 to 5 minutes relaxes muscles and promotes sleep and comfort. reported a significant decrease in pain, anxiety, and tension in patients with cardiac problems who received a 20-minute massage. In older adults slow back massage and a 20-minute hand massage improved pain, anxiety, tension, and insomnia. Massages communicate caring and are easy for family members or other health care personnel to learn.
- Cold and heat applications (see Chapter 48) relieve pain and promote healing. The selection of heat versus cold interventions varies with patients’ conditions
Another form of cutaneous stimulation is transcutaneous electrical nerve stimulation (TENS), involving stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires an order from a health care provider. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain. Remove any hair or skin preparations before attaching the electrodes. The patient turns the transmitter on when feeling pain. This creates a buzzing or tingling sensation. The patient adjusts the intensity and quality of skin stimulation and applies the tingling sensation until pain relief occurs. TENS is effective for postsurgical and procedural pain control.
Patient controlled analgesia
- A drug delivery system called patient-controlled analgesia (PCA) is a safe method for pain management that many patients prefer. It is a drug delivery system that allows patients to self-administer opioids (morphine, hydromorphone, and fentanyl) with minimal risk of overdose. The goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing. Systemic PCA traditionally involves IV or subcutaneous drug administration; however, a controlled analgesia device for oral medications, Medication on Demand (MOD), is now available. This device allows patients access to their own oral prn mediations, including opioids and other analgesics, antiemetics, and anxiolytics, at the bedside.
- Patient preparation and teaching is critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to “push the button” for the patient. Use Authorized Agent Controlled Analgesia (AACA) guidelines to authorize a family member or nurse to administer the analgesic, when appropriate
the local infiltration of an anesthetic medication to induce loss of sensation to a body part. Health care providers often use local anesthesia during brief surgical procedures such as removal of a skin lesion or suturing a wound by applying local anesthetics topically on skin and mucous membranes or by injecting them subcutaneously or intradermally to anesthetize a body part. The drugs produce temporary loss of sensation by inhibiting nerve conduction. Local anesthetics also block motor and autonomic functions, depending on the amount used and the location and depth of an injection.
Regional anesthesia is the injection of a local anesthetic to block a group of sensory nerve fibers. Tissues are anesthetized layer by layer as the surgeon or anesthesia provider introduces the agent into deeper structures of the body. Kinds of regional anesthesia include epidural anesthesia, pudendal blocks, and spinal anesthesia. Epidural analgesia is common for the treatment of acute postoperative pain, labor and delivery pain, and chronic cancer pain. It permits control or reduction of severe pain and reduces the patient's overall opioid requirement, thus minimizing adverse effects.
the study of conduct and character. It is concerned with determining what is good or valuable for individuals, for groups of individuals, and for society at large. Acts that are ethical reflect a commitment to standards beyond personal preferences (i.e., standards that individuals, professions, and societies strive to meet). However, when decisions must be made about health care, differing values and opinions among individuals can result in disagreement about the right thing to do, as the previous scenario illustrates. Understandable conflict occurs among health care providers, families, patients, friends, and people in the community about the right thing to do when ethics, values, and perceptions about health care collide. This chapter describes tools for you to use to embrace the role of ethics in your professional life and to participate and promote resolution when ethical dilemmas develop.
autonomy refers to freedom from external control. Similarly in health care, respect for autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient's independence.
Beneficence refers to taking positive actions to help others.
Maleficence refers to harm or hurt; thus nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but the equal commitment to do no harm. The health care professional tries to balance the risks and benefits of care while striving at the same time to do the least harm possible.
Justice refers to fairness. The term is most often used in discussions about access to health care resources, including the just distribution of resources. Discussions about health insurance, hospital locations and services, even organ transplants generally refer to issues of justice. The term just culture refers to the promotion of open discussion whenever mistakes occur, or nearly occur, without fear of recrimination. By fostering open discussion about errors, members of the health care team become informed participants, able to design new systems that prevent harm.
Fidelity refers to the agreement to keep promises. As a nurse you keep promises by following through on your actions and interventions. If you assess a patient for pain and offer a plan to manage the pain, the standard of fidelity encourages you to monitor the patient's response to the plan. Professional behavior includes revision of the plan as necessary to try to keep the promise to reduce pain. Fidelity also refers to the unwillingness to abandon patients even when care becomes controversial or complex.
Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy.
Accountability refers to the ability to answer for one's actions. You learn to ensure that your professional actions are explainable to your patients and your employer.
ANA code of ethics
- A nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
- • The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
- • The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
- • The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.
- • The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
- • The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
- • The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
- • The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
- The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
- A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior.
- The values that an individual holds reflect cultural and social influences, and these values vary among people and develop and change over time.
- Ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas one needs to distinguish among value, fact, and opinion.
Deontology defines actions as right or wrong based on their “right-making characteristics” such as fidelity to promises, truthfulness, and justice. It specifically does not look to consequences of actions to determine right or wrong. Instead it examines a situation for the existence of essential right or wrong.
A utilitarian system of ethics proposes that the value of something is determined by its usefulness. This philosophy is also known as consequentialism because its main emphasis is on the outcome or consequence of action.
Feminist ethics critiques conventional ethics such as deontology and utilitarianism. It looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible. Writers with a feminist perspective tend to concentrate more on practical solutions than on theory.
ethics of care
- The ethics of care and feminist ethics are closely related. Both promote a philosophy that focuses on understanding relationships, especially personal narratives.
- An early proponent of the ethics of care, Nel Noddings (1984), used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient. In adopting this language Noddings hoped to emphasize the role of feelings.
- Ethics of care may even address issues beyond individual relationships such as ethical concerns about the structures within which individual caring occurs such as health care facilities.
- To distinguish an ethical problem from other kinds of problems, Curtin (2004) proposes that, if the issue is an ethical one, it entails at least one of the following:
- • You are unable to resolve it solely through a review of scientific data.
- • It is perplexing. You cannot easily think logically or make a decision about the problem.
- • The answer to the problem will have a profound relevance for areas of human concern.
- Health care institutions establish ethics committees to process ethical dilemmas. Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation. Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.
- You also process ethical issues in settings other than a committee. Nurses provide insight about ethical problems at family conferences, staff meetings, or even in one-on-one meetings.
- Many ethical problems begin when people feel misled or are not aware of their options and do not know when to speak up about their concerns. You address such concerns in a variety of constructive settings. Ethics committees serve to complement relationships within the workplace and the community and offer a valuable resource for strengthening these relationships.
Key points with ethics
- • Ethics is the study of conduct and character. It is concerned with determining what is good or valuable for individuals and society at large.
- • The ANA code of ethics provides a foundation for professional nursing.
- • Professional nursing promotes accountability, responsibility, advocacy, and confidentiality.
- • Standards of ethics in health care include autonomy, beneficence, nonmaleficence, justice, and fidelity.
- • The process of values clarification helps you to explore values and feelings and decide how to act on personal beliefs and respect values of others, even if they differ from yours.
- • Ethical problems arise in the presence of differences in values, changing professional roles, technological advances, and social issues that influence quality of life.
- • A process for resolving ethical dilemmas that respects differences of opinions and all participants equally helps health care providers resolve conflict about right actions.
- • A nurse's point of view offers a unique voice in the resolution of ethical dilemmas.
legal limits of nursing
- The legal guidelines that nurses follow come from statutory law, regulatory law, and common law
- Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state.
regulatory law or administrative law
Regulatory law, or administrative law, reflects decisions made by administrative bodies such as State Boards of Nursing when they pass rules and regulations.
protect the rights of individuals within our society and provide for fair and equitable treatment when civil wrongs or violations occur
protect society as a whole and provide punishment for crimes, which are defined by municipal, state, and federal legislation
standards of care
Standards of care are the legal requirements for nursing practice that describe minimum acceptable nursing care. Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession
Nurse Practice Act
- define the scope of nursing practice, distinguishing between nursing and medical practice and establishing education and licensure requirements for nurses.
- All nurses are responsible for knowing the provisions of the Nurse Practice Act of the state in which they work and the rules and regulations enacted by the State Board of Nursing and other regulatory administrative bodies.
The Joint Commission
The Joint Commission (TJC) (2011a) requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform these tasks.
lawsuit for malpractice
In a lawsuit for malpractice or nursing negligence, a nursing expert testifies to the jury about the standards of nursing care as applied to the facts of the case. A nurse may be requested to give evidence in a deposition; this appearance needs to be taken seriously. The jury uses the standards of care to determine whether the nurse acted appropriately. Nurse experts base their opinions on existing standards of practice established by Nurse Practice Acts, professional organizations, institutional policies and procedures, federal and state hospital licensing laws, TJC standards, job descriptions, and current nursing research literature. Usually nurses are responsible for meeting the same standards as other nurses practicing in similar settings. Specialized nurses such as nurse anesthetists, operating room (OR) nurses, intensive care nurses, or certified nurse-midwives have specially defined standards of care and skills. Ignorance of the law or of standards of care is not a defense against malpractice. The best way for nurses to keep up with the current legal issues affecting nursing practice is to maintain familiarity with standards of care and the policies and procedures of their employing agency and to read current nursing literature in their practice area
Americans with Disabilities Act
The Americans with Disabilities Act (ADA) (1990) is a broad civil rights statute that protects the rights of people with physical or mental disabilities. The ADA prohibits discrimination and ensures for persons with disabilities equal opportunities in employment, state and local government services, public accommodations, commercial facilities, and transportation.
Emergency Medical Treatment and Active Labor Act
As a result of patients being transferred from private to public hospitals without appropriate screening and stabilization (referred to as patient dumping), Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) (1986). This act provides that, when a patient comes to the emergency department or the hospital, an appropriate medical screening occurs within the capacity of the hospital. If an emergency condition exists, the hospital is not to discharge or transfer the patient until the condition stabilizes.
Mental Health Parity Act
- Health insurance plans are free to eliminate coverage for certain specialties and impose limits on the amount of coverage that they will pay for certain illnesses. However, if health insurance plans provide mental health benefits, the Mental Health Parity Act of 1996 forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits.
- Even after the passage of this law, mental health has taken a back seat to physical health.
The Affordable Care Act (aka "Obamacare) reinforces this and requires health insurance plans to comply with this older law with stronger enforcement.
The Patient Self-Determination Act (PSDA) (1991) requires health care institutions to provide written information to patients concerning their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. Under the act the patient's record needs to document whether or not the patient has signed an advance directive.
Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this legal document the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. Living wills are often difficult to interpret and not clinically specific in unforeseen circumstances. Each state providing for living wills has its own requirements for executing them. If health care workers follow the directions of the living will, they should be immune from liability
Durable power of attorney for health care (DPAHC)
- A health care proxy or durable power of attorney for health care (DPAHC) is a legal document that designates a person or persons of one's choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient's wishes
- In cases involving the patient's right to refuse or withdraw medical treatment, the courts balance the patient's interest with the interest of the state in protecting life, preserving medical ethics, preventing suicide, and protecting innocent third parties.
Uniform Anatomical Gift Act
- The National Organ Transplant Act of 1984 prohibits the purchase or sale of organs.
- The United Network for Organ Sharing (UNOS) has a contract with the federal government and sets policies and guidelines for the procurement of organs.
HIPAA-Health Insurance Portability and Accountability Act
- The Health Insurance Portability and Accountability Act of 1996 (HIPAA) represents one of the more recent federal statutory acts affecting nursing care. This law provides rights to patients and protects employees. It protects individuals from losing their health insurance when changing jobs by providing portability. It allows employees to change jobs without losing coverage as a result of preexisting coverage exclusion as long as they have had 12 months of continuous group health insurance coverage (Carter, 2010).
- In the privacy section of the HIPAA, there are standards regarding accountability in the health care setting (Carter, 2010). These rules create patient rights to consent to the use and disclosure of their protected health information, to inspect and copy one's medical record, and to amend mistaken or incomplete information. It limits who is able to access a patient's record. It establishes the basis for privacy and confidentiality concerns, viewed as two basic rights within the U.S. health care setting
Privacy and confidentiality
Privacy is the right of patients to keep personal information from being disclosed. Confidentiality protects private patient information once it has been disclosed in health care settings.
- The Federal Nursing Home Reform Act (1987) gave residents in certified nursing homes the right to be free of unnecessary and inappropriate restraints.
- The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. There are many alternatives to the use of restraints, and you should try all of them before using restraints.
- A State Board of Nursing licenses all registered nurses in the state in which they practice.
- All states use the National Council Licensure Examinations (NCLEX®) for registered nurse and licensed practical nurse examinations.
- The State Board of Nursing suspends or revokes a license if a nurse's conduct violates provisions in the licensing statute based on administrative law rules that implement and enforce the statute. For example, nurses who perform illegal acts such as selling or taking controlled substances jeopardize their license status. Because a license is a property right, the State Board has to follow due process before revoking or suspending a license.
good samaritan laws
Nurses act as Good Samaritans by providing emergency assistance at an accident scene. All states have Good Samaritan laws enacted to encourage health care professionals to assist in emergencies. These laws limit liability and offer legal immunity if a nurse helps at the scene of an accident. For example, if you stop at the scene of an automobile accident and give appropriate emergency care such as applying pressure to stop hemorrhage, you are acting within accepted standards, even though proper equipment is not available. If the patient subsequently develops complications as a result of your actions, you are immune from liability as long as you acted without gross negligence. Although Good Samaritan laws provide immunity to the nurse who does what is reasonable to save a person's life, if you perform a procedure for which you have no training, you are liable for any injury resulting from that act. You should only provide care that is consistent with your level of expertise. In addition, once you have committed to providing emergency care to a patient, you must stay with that patient until you can safely transfer his or her care to someone who can provide needed care such as emergency medical technicians (EMTs) or emergency department staff. If you leave the patient without properly transferring or handing him or her off to a capable person, you may be liable for patient abandonment and responsible for any injury suffered after you leave him or her. Three states (Louisiana, Minnesota, and Vermont) have enacted “failure-to-act” laws that make it a crime not to provide Good Samaritan care
Public Health Laws
- State legislatures enact statutes under health codes, which describe the reporting laws for communicable diseases and school immunizations and those intended to promote health and reduce health risks in communities.
- The purposes of public health laws are protection of public health, advocating for the rights of people, regulating health care and health care financing, and ensuring professional accountability for care provided. Community and public health nurses have the legal responsibility to enforce laws enacted to protect public health (see Chapter 3). These laws include reporting suspected abuse and neglect such as child abuse, elder abuse, or domestic violence; reporting communicable diseases; ensuring that patients in the community have received required immunizations; and reporting other health-related issues enacted to protect public health. To encourage reports of suspected cases, states provide legal immunity for the reporter if the report is made in good faith. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action.
The Uniform Determination of Death Act
There are essentially two standards for the determination of death. The cardiopulmonary standard requires irreversible cessation of circulatory and respiratory functions. The whole-brain standard requires irreversible cessation of all functions of the entire brain, including the brainstem. The reason for the development of different definitions is to facilitate recovery of organs for transplantation. Even though the patient is legally “brain dead,” the patient's organs are sometimes healthy for donation to other patients.
When a patient's death has occurred under suspicious circumstances or if the patient died within 24 hours of admission to a health care facility, the decision to conduct a postmortem examination is made by the medical examiner. When the patient's death is not subject to a medical examiner review, consent must be obtained.
- The Oregon Death with Dignity Act (1994) was the first statute that permitted physician or health care provider–assisted suicide. The statute stated that a competent individual with a terminal disease could make an oral and written request for medication to end his or her life in a humane and dignified manner. A terminal disease is an “incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within 6 months.”
- The American Nurses Association (ANA) (2008) has held that nurses’ participation in assisted suicide violates the code of ethics for nurses. The American Association of Colleges of Nursing (AACN) supports the International Council of Nurses’ mandate to ensure an individual's peaceful end of life (Guido, 2010). The positions of these two national organizations are not contradictory and require nurses to approach a patient's end of life with openness to listening to the patient's expressions of fear and to attempt to control the patient's pain.
- A tort is a civil wrong made against a person or property. Torts are classified as intentional, quasi-intentional, or unintentional. Intentional torts are willful acts that violate another's rights such as assault, battery, and false imprisonment.
- False imprisonment
Assault is any action that places a person in apprehension of a harmful or offensive contact without consent. No actual contact is necessary. It is an assault for a nurse to threaten to give a patient an injection or to threaten to restrain a patient for an x-ray procedure when the patient has refused consent. Likewise, it is an assault for a patient to threaten a nurse
- Battery is any intentional touching without consent. The contact can be harmful to the patient and cause an injury, or it can be merely offensive to the patient's personal dignity. In the example of a nurse threatening to give a patient an injection without the patient's consent, if the nurse actually gives the injection, it is battery.
- The key component is the patient's consent
- In some situations, consent is implied
The tort of false imprisonment occurs with unjustified restraint of a person without legal warrant. This occurs when nurses restrain a patient in a confined area to keep the person from freedom. False imprisonment requires that the patient be aware of the confinement. An unconscious patient has not been falsely imprisoned
- Invasion of privacy
- Defamation of character
invasion of privacy
- Typically invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, or the patient's family.
- Sometimes the patient is a public figure whose physical condition is newsworthy. There are also cases in which information about a scientific discovery or a major medical breakthrough is newsworthy, as with the first heart transplant case or the first artificial heart recipient. If an event falls into any of these categories, guide information through the public relations department of the institution to ensure that invasion of privacy does not occur. It is not the nurse's responsibility to decide independently the legality of disclosing information.
defamation of character
Defamation of character is the publication of false statements that result in damage to a person's reputation. Slander occurs when one speaks falsely about another. For example, if a nurse tells people erroneously that a patient has gonorrhea and the disclosure affects the patient's business, the nurse is liable for slander. Libel is the written defamation of character (e.g., charting false entries in a medical record).
- Negligence is conduct that falls below a standard of care.
- In general, courts define negligence in car accident cases and other negligence cases as that degree of care that an ordinarily careful and prudent person would use under the same or similar circumstances.
- Malpractice is one type of negligence and often referred to as professional negligence. When nursing care falls below a standard of care, nursing malpractice results. Certain criteria are necessary to establish nursing malpractice: (1) the nurse (defendant) owed a duty to the patient (plaintiff), (2) the nurse did not carry out that duty, (3) the patient was injured, and (4) the nurse's failure to carry out the duty caused the injury.
- In general, courts define nursing malpractice as the failure to use that degree of skill or learning ordinarily used under the same or similar circumstances by members of the nursing profession
- The best way for nurses to avoid malpractice is to follow standards of care, give competent health care, and communicate with other health care providers. You also avoid malpractice by developing a caring rapport with the patient and documenting assessments, interventions, and evaluations fully. Nurses need to know the current nursing literature in their areas of practice. Know and follow the policies and procedures of the institution where you work. Be sensitive to common sources of patient injury such as falls and medication errors. Finally, communicate with the patient, explain tests and treatments, document that you provided specific explanations to him or her, and listen to his or her concerns about treatments. You are accountable for reporting any significant changes in the patient's condition to the health care provider and documenting these changes in the chart. Timely and truthful documentation is important to provide the communication necessary among health care team members. Be certain that documentation is legible and signed
A signed consent form is required for all routine treatment, hazardous procedures such as surgery, some treatment programs such as chemotherapy, and research involving patients
- Informed consent is a person's agreement to allow something to happen such as surgery or an invasive diagnostic procedure, based on a full disclosure of risks, benefits, alternatives, and consequences of refusal. Informed consent creates a legal duty for the health care provider to disclose material facts in terms the patient is able to understand to make an informed choice. Failure to obtain consent in situations other than emergencies will possibly result in a claim of battery. Without informed consent a patient may bring a lawsuit against the health care provider for negligence.
- Informed consent is part of the health care provider–patient relationship. It must be obtained and witnessed when the patient is not under the influence of medication such as opioids. Because nurses do not perform surgery or direct medical procedures, in most situations obtaining patients’ informed consent does not fall within the nursing duty. The person responsible for performing the procedure has the responsibility to obtain the informed consent.
- The nurse's signature witnessing the consent means that the patient voluntarily gave consent, the patient's signature is authentic, and the patient appears to be competent to give consent (Guido, 2010). When nurses provide consent forms for patients to sign, they must ask the patients if they understand the procedure for which they are giving consent. If patients deny understanding or you suspect that they do not understand, notify the health care provider or nursing supervisor. Health care providers must inform a patient refusing surgery or other medical treatment about any harmful consequences of refusal. If the patient persists in refusing the treatment, this rejection needs to be written, signed, and witnessed. It is important to note that nursing students cannot and should not be responsible for or asked to witness consent forms because of the legal nature of the document.
- if the patient is unconscious, you must obtain consent from a person legally authorized to give it on the patient's behalf.
- In emergencies, if it is impossible to obtain consent from the patient or an authorized person, a health care provider may perform a procedure required to benefit the patient or save a life without liability for failure to obtain consent. In such cases the law assumes that the patient would wish to be treated.
- Patients with mental illnesses must also give consent. They retain the right to refuse treatment until a court has legally determined that they are incompetent to decide for themselves.
- Legal problems occur if there are not enough nurses to provide competent care or if nurses work excessive overtime
- If nurses are assigned to care for more patients than is reasonable, they need to bring this information to the attention of the nursing supervisor. If nurses have to accept unreasonable assignments, they need to make written protests to nursing administrators. Although these protests do not relieve nurses of responsibility if a patient suffers an injury because of inattention, it shows that the nurses were attempting to act reasonably. Whenever you make a written protest, keep a copy of this document in your personal file.
Nurses are sometimes required to “float” from the area in which they normally practice to other nursing units based on census load and patient acuities. In one case a nurse in obstetrics was assigned to an emergency department. A patient entered the emergency department and complained of chest pain. The patient received an incorrect dose of lidocaine by the obstetrical nurse and died after suffering irreversible brain damage and cardiac arrest. The nurse lost the malpractice lawsuit. Nurses who float need to inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They also need to request and receive an orientation to the unit.
health care provider's orders
- Nurses follow health care providers’ orders unless they believe the orders are in error or harm patients. Therefore you need to assess all orders; if you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, inform the supervising nurse or follow the established chain of command.
- A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the patient suffers.
- one of the most frequently litigated issues is whether the nurse kept the health care provider informed of the patient's condition. To inform a health care provider properly, you perform a competent nursing assessment of the patient to determine the signs and symptoms that are significant in relation to the attending health care provider's tasks of diagnosis and treatment. Be certain to document that you notified the health care provider and his or her response, your follow-up, and the patient's response.
- Nurses verify the complete order or test results by reading verbal orders back to the health care provider. Nursing students never take verbal orders.
- Risk management is an organization's system of ensuring appropriate nursing care by identifying potential hazards and eliminating them before harm occurs
- Occurrence reporting provides a database for further investigation in an attempt to determine deviations from standards of care and corrective measures needed to prevent recurrence and to alert risk management to a potential claim situation. These are also known as "incident reports".
- As a nurse, you are responsible for providing information in the medical record about the occurrence. Never document in the patient's medical record that you completed an occurrence report.
- Patient education is one of the most important roles for a nurse in any health care setting
- Patients have the right to know and be informed about their diagnoses, prognoses, and available treatments to help them make intelligent, informed decisions about their health and lifestyle
standards for patient education
- For example, The Joint Commission (TJC, 2011) sets standards for patient and family education.
- Educational efforts should be patient-centered by taking into consideration patients’ own education and experience, their desire to actively participate in the educational process, and their psychosocial, spiritual, and cultural values. It is important to document evidence of successful patient education in patients’ medical records. Standards such as these help to direct your patient education.
Maintenance and Promotion of Health and Illness Prevention
As a nurse you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace you provide information and skills that enable patients to assume healthier behaviors. For example, in childbearing classes you teach expectant parents about physical and psychological changes in the woman and fetal development. After learning about normal childbearing, the mother who applies new knowledge is more likely to eat healthy foods, engage in physical exercise, and avoid substances that can harm the fetus. Promoting healthy behavior through education allows patients to assume more responsibility for their health. Greater knowledge results in better health maintenance habits. When patients become more health conscious, they are more likely to seek early diagnosis of health problems
Restoration of Health
Injured or ill patients need information and skills to help them regain or maintain their levels of health. Patients recovering from and adapting to changes resulting from illness or injury often seek information about their condition. For example, a woman who recently had a hysterectomy asks about her pathology reports and expected length of recovery. However, some patients find it difficult to adapt to illness and become passive and uninterested in learning. As the nurse you learn to identify patients’ willingness to learn and motivate interest in learning. The family often is a vital part of a patient's return to health. Family caregivers often require as much education as the patient, including information on how to perform skills within the home. If you exclude the family from a teaching plan, conflicts can occur. However, do not assume that the family should be involved; assess the patient-family relationship before providing education for family caregivers.
Coping with impaired functions
Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients to continue activities of daily living. For example, a patient loses the ability to speak after larynx surgery and has to learn new ways of communicating. Changes in function are physical or psychosocial. In the case of serious disability such as following a stroke or a spinal cord injury, the patient's family needs to understand and accept many changes in his or her physical capabilities. The family's ability to provide support results in part from education, which begins as soon as you identify the patient's needs and the family displays a willingness to help. Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises). Families of patients with alterations such as alcoholism, mental retardation, or drug dependence learn to adapt to the emotional effects of these chronic conditions and provide psychosocial support to facilitate the patient's health. Comparing the desired level of health with the actual state of health enables you to plan effective teaching programs.
Teaching is an interactive process that promotes learning. It consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills
Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills
Role of the nurse in teaching and learning?
- Nurses have an ethical responsibility to teach their patients (Heiskell, 2010). In The Patient Care Partnership, the American Hospital Association (2003) indicates that patients have the right to make informed decisions about their care. The information required to make informed decisions must be accurate, complete, and relevant to patients’ needs.
- TJC's Speak Up Initiatives helps patients understand their rights when receiving medical care (TJC, 2010). The assumption is that patients who ask questions and are aware of their rights have a greater chance of getting the care they need when they need it. The program offers the following Speak Up tips to help patients become more involved in their treatment:
- • Speak up if you have questions or concerns. If you still do not understand, ask again. It is your body, and you have a right to know.
- • Pay attention to the care you get. Always make sure that you are getting the right treatments and medicines by the right health care professionals. Do not assume anything.
- • Educate yourself about your illness. Learn about the medical tests that are prescribed and your treatment plan.
- • Ask a trusted family member or friend to be your advocate (advisor or supporter).
- • Know which medicines you take and why you take them. Medication errors are the most common health care mistakes.
- • Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully evaluated.
- • Participate in all decisions about your treatment. You are the center of the health care team.
- In addition, patients are advised that they have a right to be informed about the care they will receive, obtain information about care in their preferred language, know the names of their caregivers, receive treatment for pain, receive an up-to-date list of current medications, and expect that they will be heard and treated with respect.
Domains of learning
- Psychomotor learning
- Basic learning principles
domains of learning definition
Learning occurs in three domains: cognitive (understanding), affective (attitudes), and psychomotor (motor skills). Any health topic involves one or all domains or any combination of the three. You often work with patients who need to learn in each domain. For example, patients diagnosed with diabetes need to learn how diabetes affects the body and how to control blood glucose levels for healthier lifestyles (cognitive domain). In addition, patients begin to accept the chronic nature of diabetes by learning positive coping mechanisms (affective domain). Finally, many patients living with diabetes learn to test their blood glucose levels at home. This requires learning how to use a glucose meter (psychomotor domain). The characteristics of learning within each domain influence the teaching and evaluation methods used. Understanding each learning domain prepares the nurse to select proper teaching techniques and apply the basic principles of learning
- Cognitive learning includes all intellectual behaviors and requires thinking. In the hierarchy of cognitive behaviors the simplest behavior is acquiring knowledge, whereas the most complex is evaluation. Cognitive learning includes the following:
- • Knowledge: Learning new facts or information and being able to recall them
- • Comprehension: The ability to understand the meaning of learned material
- • Application: Using abstract, newly learned ideas in a concrete situation
- • Analysis: Breaking down information into organized parts
- • Synthesis: The ability to apply knowledge and skills to produce a new whole
- • Evaluation: A judgment of the worth of a body of information for a given purpose
- Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Values clarification is an example of affective learning. The simplest behavior in the hierarchy is receiving, and the most complex is characterizing. Affective learning includes the following:
- • Receiving: Being willing to attend to another person's words
- • Responding: Active participation through listening and reacting verbally and nonverbally
- • Valuing: Attaching worth to an object or behavior demonstrated by the learner's behavior
- • Organizing: Developing a value system by identifying and organizing values and resolving conflicts
- • Characterizing: Acting and responding with a consistent value system
- Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity such as the ability to walk or use an eating utensil. The simplest behavior in the hierarchy is perception, whereas the most complex is origination. Psychomotor learning includes the following:
- • Perception: Being aware of objects or qualities through the use of sense organs
- • Set: A readiness to take a particular action; there are three sets: mental, physical, and emotional
- • Guided response: The performance of an act under the guidance of an instructor involving imitation of a demonstrated act
- • Mechanism: A higher level of behavior by which a person gains confidence and skill in performing a behavior that is more complex or involves several more steps than a guided response
- • Complex overt response: Smoothly and accurately performing a motor skill that requires a complex movement pattern
- • Adaptation: The ability to change a motor response when unexpected problems occur
- • Origination: Using existing psychomotor skills and abilities to perform a highly complex motor act that involves creating new movement patterns
basic learning principles
- To teach effectively and efficiently, you first need to understand how people learn . Motivation addresses a person's desire or willingness to learn. The patient's willingness to become involved in learning influences your teaching approach. Previous knowledge, experience, attitudes, and sociocultural factors influence a person's motivation. The ability to learn depends on physical and cognitive attributes, developmental level, physical wellness, and intellectual thought processes. An ideal learning environment allows a person to attend to instruction.
- A person's learning style affects preferences for learning. People process information in the following ways: by seeing and hearing, reflecting and acting, reasoning logically and intuitively, and analyzing and visualizing. Some people learn information gradually, whereas others learn more sporadically. Effective teaching plans include a combination of approaches that meet multiple learning styles
- Motivation is a force that acts on or within a person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way
- A social motive is a need for connection, social approval, or self-esteem. People normally seek out others with whom they can compare opinions, abilities, and emotions. For example, new parents often seek validation of ideas and parenting techniques from others whom they have identified as role models in their social environment or health care workers with whom they have established a relationship.
- Task mastery motives are based on needs such as achievement and competence. For example, a high school senior who has diabetes begins to test blood glucose levels and make decisions about insulin dosages in preparation for leaving home and establishing independence. The ability to successfully manage diabetes provides the motivation to master the task or skill. After a person succeeds at a task, he or she is usually motivated to achieve more.
- Often patient motives are physical. Some patients are motivated to return to a level of physical normalcy. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices. Knowledge that is necessary for survival, problem recognition, and critical decision making creates a stronger stimulus for learning than knowledge that merely promotes health.
- Many do not adopt new health behaviors or change unhealthy behaviors unless they perceive a disease as a threat, overcome barriers to changing health practices, and see the benefits of adopting a healthy behavior.
Use of theory to enhance motivation and learning
- Health education often involves changing attitudes and values that are not easy to change by simply teaching facts.
- Social learning theory provides one of the most useful approaches to patient education because it explains the characteristics of the learner and guides the educator in developing effective teaching interventions that result in enhanced learning and improved motivation
- Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. When people believe that they are able to execute a particular behavior, they are more likely to perform the behavior consistently and correctly (Bandura, 1997).
- Self-efficacy beliefs come from four sources: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states (Bandura, 1997). Understanding the four sources of self-efficacy allows you to develop interventions to help patients adopt healthy behaviors. For example, a nurse who is wishing to teach a child recently diagnosed with asthma how to correctly use an inhaler expresses personal belief in the child's ability to use the inhaler (verbal persuasion). Then the nurse demonstrates how to use the inhaler (vicarious experience). Once the demonstration is complete, the child uses the inhaler (enactive mastery experience). As the child's wheezing and anxiety decrease after the correct use of the inhaler, he or she experiences positive feedback, further enhancing his or her confidence to use it (physiological and affective states). Interventions such as these enhance perceived self-efficacy, which in turn improves the achievement of desired outcomes.
greif and adaptation
- A temporary or permanent loss of health is often difficult for patients to accept. They need to grieve, and the process of grieving gives them time to adapt psychologically to the emotional and physical implications of illness.
- Readiness to learn is related to the stage of grieving (Table 25-1). Patients cannot learn when they are unwilling or unable to accept the reality of illness. However, properly timed teaching facilitates adjustment to illness or disability.
Learning occurs when the patient is actively involved in the educational session
ability to learn
The capability for learning and the type of behaviors that children are able to learn depend on the child's maturation. Without proper physiological, motor, language, and social development, many types of learning cannot take place. However, learning occurs in children of all ages. Intellectual growth moves from the concrete to the abstract as the child matures. Therefore information presented to children needs to be understandable, and the expected outcomes must be realistic, based on the child's developmental stage
Teaching adults differs from teaching children. Adults are able to critically reflect on their current situation and sometimes need help to see their problems and change their perspectives (Redman, 2007). Because adults become independent and self-directed as they mature, they are often able to identify their own learning needs (Billings and Halstead, 2009). Learning needs come from problems or tasks that result from real-life situations. Although adults tend to be self-directed learners, they often become dependent in new learning situations. The amount of information provided and the amount of time that is spent with the adult patient vary, depending on the patient's personal situation and readiness to learn. An adult's readiness to learn is often associated with his or her developmental stage and other events that are occurring in his or her life. Resolve any needs or issues that the patient perceives as extremely important so learning can occur.
- To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or the inability to grasp objects tightly cannot learn to apply an elastic bandage. Therefore do not overestimate the patient's physical development or status. The following physical characteristics are necessary to learn psychomotor skills:
- • Size (height and weight match the task to perform or the equipment to use [e.g., crutch walking])
- • Strength (ability of the patient to follow a strenuous exercise program)
- • Coordination (dexterity needed for complicated motor skills such as using utensils or changing a bandage)
- • Sensory acuity (visual, auditory, tactile, gustatory, and olfactory; sensory resources needed to receive and respond to messages taught)
- Any condition (e.g., pain or fatigue) that depletes a person's energy also impairs the ability to learn.
- After working with a patient, assess the patient's energy level by noting the patient's willingness to communicate, the amount of activity initiated, and his or her responsiveness toward questions. Temporarily stop teaching if the patient needs rest.
- Factors in the physical environment where teaching takes place make learning either a pleasant or a difficult experience
- The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature.
- It is also important to choose a quiet setting. A quiet setting offers privacy; infrequent interruptions are best.
motivation to learn
- Ask questions that identify and define the patient's motivation. These questions help to determine if the patient is prepared and willing to learn. Assess the following motivational factors:
- • Behavior (e.g., attention span, tendency to ask questions, memory, and ability to concentrate during the teaching session)
- • Health beliefs and sociocultural background—Sociocultural norms, values, and traditions all influence a patient's beliefs and values about health and various therapies, communication patterns, and perceptions of time (see Chapter 9).
- • Perception of the severity and susceptibility of a health problem and the benefits and barriers to treatment
- • Perceived ability to perform health behaviors
- • Desire to learn
- • Attitudes about health care providers (e.g., role of patient and nurse in making decisions)
- • Learning style preference—Patients who are visual learners learn best when you use pictures and diagrams to explain information. Patients who prefer auditory learning are distracted by pictures and prefer listening to information (e.g., podcasts). Kinesthetic learners learn best while they are moving and participating in hands-on activities. Demonstrations and role playing work well with these learners (Eshleman, 2008). Patients who learn best by reasoning logically and intuitively learn better if presented with a case study that requires careful analysis and discussion with others to arrive at conclusions.
ability to learn
- Determine the patient's physical and cognitive ability to learn. Health care providers often underestimate patients’ cognitive deficits. Many factors impair the ability to learn, including fatigue, body temperature, electrolyte levels, oxygenation status, and blood glucose level. In any health care setting several of these factors often influence a patient at the same time. Assess the following factors related to the ability to learn:
- • Physical strength, endurance, movement, dexterity, and coordination—Determine the extent to which the patient can perform skills. For example, have the patient manipulate equipment that will be used in self-care at home.
- • Sensory deficits (see Chapter 49) that affect the patient's ability to understand or follow instruction
- • Patient's reading level—This is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. One way to assess a patient's reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning (see the discussion of health literacy, p. 337).
- • Patient's developmental level—This influences the selection of teaching approaches (see Box 25-3).
- • Patient's cognitive function, including memory, knowledge, association, and judgment
- • Pain, fatigue, anxiety, or other physical symptoms that interfere with the ability to maintain attention and participate—In acute care settings a patient's physical condition can easily prevent a patient from learning.
- The environment for a teaching session needs to be conducive to learning. Assess the following environmental factors:
- • Distractions or persistent noise—A quiet area is essential for effective learning.
- • Comfort of the room, including ventilation, temperature, lighting, furniture, and size
- • Room facilities and available equipment
resources for learning
- A patient frequently requires the support of family members or significant others. If this support is necessary, assess the readiness and ability of a family caregiver to learn the information necessary for the care of the patient. Also review resources within the home environment. Assess the following:
- • Patient's willingness to have family caregivers involved in the teaching plan and provide health care—Information about the patient's health care is confidential unless the patient chooses to share it. Sometimes it is difficult for the patient to accept the help of family caregivers, especially when bodily functions are involved.
- • Family caregiver's perceptions and understanding of the patient's illness and its implications—Family caregivers’ perceptions should match those of the patient; otherwise conflicts occur in the teaching plan.
- • Family caregiver's willingness and ability to participate in care—If the patient chooses to share information about his or her health status with family members, they need to be responsible, willing, and physically and cognitively able to assist in care activities such as bathing or administering medications. Not all family members meet these requirements.
- • Resources—These include financial or material resources such as having the ability to obtain health care equipment.
- • Teaching tools, including brochures, audiovisual materials, or posters—Printed material needs to present current information that is written clearly and logically and matches the patient's reading level.
Health literacy and learning disabilities
Functional illiteracy, the inability to read above a fifth-grade level, is a major problem in America today. The National Assessment of Adult Literacy Survey (NAALS), conducted in 2003 by the National Center for Education Statistics, assessed the extent of literacy skills in Americans over the age of 16 (Kutner et al., 2006). Results from the NAALS reflected that over 75 million American adults had basic or below-basic levels of health literacy. Approximately 14% of adults could not understand a basic patient education pamphlet, and 36% could not perform moderately difficult tasks
define health literacy
The World Health Organization (2011) defines health literacy as the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. Health literacy includes patients’ reading and mathematics skills, comprehension, ability to make health-related decisions, and successful functioning as a consumer of health care
goals of patient education
Goals of patient education indicate that a patient achieves a better understanding of the information provided and is able to attain health or better manage illness.
Include the patient when determining priorities for patient education. Base priorities on the patient's immediate needs, nursing diagnoses, and the goals and outcomes established for him or her.
incorporating teaching with nursing care
Many nurses find that they are able to teach more effectively while delivering nursing care. This becomes easier as you gain confidence in your clinical skills.
Perhaps the most common method of instruction is one-on-one discussion. When teaching a patient at the bedside, in a physician's office, or in the home, the nurse shares information directly. You usually give information in an informal manner, allowing the patient to ask questions or share concerns. Use various teaching aids such as models or diagrams during the discussion, depending on the patient's learning needs. Use unstructured and informal discussions when helping patients understand the implications of illness and ways to cope with health stressors.
Some nurses choose to teach patients in groups because of the advantages associated with group teaching. Groups are an economical way to teach a number of patients at one time, and patients are able to interact with one another and learn from the experiences of others. Learning in a group of six or less is more effective and avoids outburst behaviors. Groups also foster the development of positive attitudes that help patients meet learning objectives (Bezalel et al., 2010). Group instruction often involves both lecture and discussion. Lectures are highly structured and efficient in helping groups of patients learn standard content about a subject. A lecture does not ensure that learners are actively thinking about the material presented; thus discussion and practice sessions are essential. After a lecture, learners need the opportunity to share ideas and seek clarification. Group discussions allow patients and families to learn from one another as they review common experiences. A productive group discussion helps participants solve problems and arrive at solutions toward improving each member's health. To be an effective group leader, the nurse guides participation. Acknowledging a look of interest, asking questions, and summarizing key points foster group involvement. However, not all patients benefit from group discussions, and sometimes the physical or emotional level of wellness makes participation difficult or impossible.
- Patients frequently face unfamiliar tests or procedures that create significant anxiety. Providing information about procedures often decreases anxiety because patients have a better idea of what to expect during the procedure, which helps to give them a sense of control. The known is less threatening than the unknown. Use the following guidelines for giving preparatory explanations:
- • Describe physical sensations during a procedure. For example, when drawing a blood specimen, explain that the patient will feel a sticking sensation as the needle punctures the skin.
- • Describe the cause of the sensation, preventing misinterpretation of the experience. For example, explain that a needlestick burns because the alcohol used to clean the skin enters the puncture site.
- • Prepare patients only for aspects of the experience that others have commonly noticed. For example, explain that it is normal for a tight tourniquet to cause a person's hand to tingle and feel numb.
- Use demonstrations when teaching psychomotor skills such as preparation of a syringe, bathing an infant, crutch walking, or taking a pulse. Demonstrations are most effective when learners first observe the teacher and then, during a return demonstration, have the chance to practice the skill. Combine a demonstration with discussion to clarify concepts and feelings. An effective demonstration requires advanced planning:
- 1 Be sure that the learner can easily see each step of the demonstration. Position the learner to provide a clear view of the skill being performed.
- 2 Assemble and organize the equipment. Make sure that all equipment works.
- 3 Perform each step slowly and accurately in sequence while analyzing the knowledge and skills involved and allow the patient to handle the equipment
- 4 Review the rationale and steps of the procedure.
- 5 Encourage the patient to ask questions so he or she understands each step.
- 6 Judge proper speed and timing of the demonstration based on the patient's cognitive abilities and anxiety level.
- 7 To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions that will be experienced at home or in the place where the skill is to be performed. For example, when a patient needs to learn to walk with crutches, the nurse simulates the home environment. If the patient's home has stairs, the patient practices going up and down a staircase in the hospital.
- Learning occurs when a teacher translates complex language or ideas into words or concepts that the patient understands. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose. Follow these general principles when using analogies:
- • Be familiar with the concept.
- • Know the patient's background, experience, and culture.
- • Keep the analogy simple and clear.
During role play people are asked to play themselves or someone else. Patients learn required skills and feel more confident in being able to perform them independently. The technique involves rehearsing a desired behavior. For example, a nurse who is teaching a parent how to respond to a child's behavior pretends to be a child who is having a temper tantrum. The parent responds to the nurse who is pretending to be the child. Afterward the nurse evaluates the parent's response and determines whether an alternative approach would have been more appropriate.
Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion you pose a pertinent problem or situation for patients to solve. For example, patients with heart disease plan a meal that is low in cholesterol and fat. The patients in the group decide which foods are appropriate. You ask the group members to present their diet, providing an opportunity to identify mistakes and reinforce correct information.
evaluation of patient education
- Patient education is not complete until you evaluate outcomes of the teaching-learning process (see Care Plan). Engage patients in the evaluation process to determine if they have learned essential material. It is also important to determine if patients believe they have the information necessary to continue self-care activities within the home.
- You evaluate success by observing a patient's performance of each expected behavior. Success depends on a patient's ability to meet the established outcome and goals.
Increased output of fluid through the GI tract is a common and important cause of fluid, electrolyte, and acid-base imbalances that requires careful assessment. Vomiting and diarrhea, either acute or chronic, can cause ECV deficit, hypernatremia, clinical dehydration, and hypokalemia by increasing the output of fluid, Na+, and K+. In addition, chronic diarrhea can cause hypocalcemia and hypomagnesemia by decreasing electrolyte absorption. Removal of gastric acid from the body through vomiting or nasogastric suction can cause metabolic alkalosis. In contrast, removal of the bicarbonate-rich intestinal or pancreatic fluids through diarrhea, intestinal suction, or fistula can cause metabolic acidosis.
the emotional bonding that couple and family members have toward one another
family actions to manage stressors that tax family resources. Indicators of family coping include confronting family problems, involving family members in decision making, using family-centered stress reduction activity, and seeking family assistance when appropriate.
breakdown of a family system which may be associated with parental overburdening or loss of significant others who served as role models for children or support systems for family members. Family disorganization can contribute to the loss of social controls that families usually impose on their members.
capacity of the family system to meet the needs of its members through developmental transitions.
shared beliefs and values of a group that are passed from generation to generation
the process by which a person learns the norms, values, and behaviors of a culture, similar to socialization.
the process of acquiring new attitudes, roles, customs, or behaviors as a result of contact with another culture. Both the host culture and the culture of origin are changed as a result of reciprocal influences
a process by which a person gives up their original identity and develops a new cultural identity by becoming absorbed into the more dominant cultural group.4 Usually in assimilation, the dominant group imposes their values on the minority group, with the assumption that the less dominant group must change. In assimilation, the less dominant group does not have a choice about what aspects of a culture it wishes to adopt.
refers to a common ancestry that leads to shared values and beliefs.
- There are several attributes related to the concept of culture, in other words, conditions common to all cultures. These include that culture is learned through families and other group members; culture is changeable and adaptive to new conditions; and cultural values, beliefs, and behaviors are shared by all within a group.
- Subcultures can include members of racial and ethnic minorities; people of indigenous or aboriginal heritage; professions, such as nursing; people of different socioeconomic levels, such as the “culture of poverty”
- Power distance is the acceptance of an unequal distribution of power as legitimate or fair versus illegitimate from the point of view of the less powerful.
- People from cultures with greater inequality of power distance may be unwilling to disagree with or question the authority of a health care provider, whereas people from cultures where there is an expectation of equality of relationships may not be hesitant in expressing their wishes and needs for their own health care.
Emic and etic
Berry, a cross-cultural psychologist, and Leininger, a nurse anthropologist and the leading theorist in culture care, emphasized the importance of understanding human behavior in the context of culture.42-44 They applied the concepts of “emic” and “etic,” which referred to an approach to understanding behaviors. The term emic refers to an approach to understanding culture from within (i.e., the insider's viewpoint) whereas etic refers to the application of constructs external to a culture, to discover universal characteristics common to all cultures
Healthy people 2020
One of the major goals of Healthy People 2020 is the elimination of health care disparities. Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
culturally competent care
Cultural competence is an expected component of nursing education and professional nursing practice. Culturally competent care means conveying acceptance of the patient's health beliefs while sharing information, encouraging self-efficacy, and strengthening the patient's coping resources
how does a nurse become culturally competent?
- The process of cultural competence consists of four interrelated constructs: self-awareness, cultural knowledge, cultural skill, and cultural desire; the pivotal construct is cultural desire.
- Self-awareness, knowledge, and skills are the broad components of cultural competency
RESPECT is an acronym for Respect, Explanatory model, Sociocultural context, Power, Empathy, Concerns and fears, and Therapeutic alliance/trust. Respect and empathy are attitudes that demonstrate to the patient that his/her concerns are valued and he/she is understood. The nurse can further assess for the patient's explanatory model, or understanding of what is the cause of his/her illness; and the sociocultural context, which are factors in a person's life that may contribute to the current state of health and expectations for treatment, such as poverty, stress, and social support. Power refers to the importance of acknowledging that the patient is in a vulnerable position and that there is a difference between patients and health care providers in terms of access to resources, knowledge level, and control over outcomes. The loss of power and control that a patient faces can contribute to concerns and fears about treatment, illness outcomes, and the future. Bearing in mind the meaning of these concepts in the nursing relationship enhances communication and assessment skills between patient and nurse and creates a therapeutic alliance and trust.
defined as the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes. The term impaired tissue integrity reflects varying levels of damage to one or more of those groups of cells
disrupted skin integrity
- Disrupted skin integrity ranges from superficial or partial-thickness injury of the epidermis to deep or full-thickness injury of the dermis and deeper tissues
- Tissue trauma or injury includes intentional and unintentional damage that can range from a superficial abrasion or scrape to a deep wound penetrating the skin and subcutaneous layers, with possible extension to muscle, internal organs, and bone
- A surgical incision is an example of an intentional injury to the skin
aging skin integrity
Changes related to the aging process increase the risk of impaired skin integrity. These changes include a loss of lean muscle mass; decreases in skin thickness, strength, moisture, and elasticity; decreased arterial and venous blood flow; and a diminished perception of pain and pressure that may prevent early recognition of tissue injury.8 Skin changes often associated with aging are a result of sun and environmental damage over a long period of time, leading to a wrinkled and leathery appearance. In addition, hair and nail growth slow with aging and a decrease in sebaceous gland activity can result in rough, dry, and itchy skin
health factors related to impaired skin integrity
There are a number of risk factors that increase risk for impaired skin integrity. Health conditions associated with poor peripheral perfusion, malnutrition, obesity, fluid deficit or excess, impaired physical mobility, and immunosuppression increase the risk of tissue disruption.
In 2007, about 1 of every 100 residents of nursing homes was reported to have 1 or more pressure ulcers. The Healthy People 2020 initiative has established an objective of reducing the prevalence of pressure ulcers by 10% from the 2007 rate.10 Recognition of risk factors is critical for meeting this goal. Risk factors include those with impaired cognition or sensory perception, immobility, friction and shearing, poor nutrition, impaired perfusion or oxygenation, impaired sensation, and incontinence/moisture.
- The skin, as an external surface, protects other body tissues and organs from mechanical trauma, fluid loss, chemical disruption, and infectious organisms. The nerves in the skin layer provide a safety mechanism as sensations of pain, temperature, and touch inform a person about the environment and reveal the need to take actions that prevent or limit damage to the skin and deeper structures. The integument is made up of the two layers commonly known as skin, the epidermis and the dermis, and the underlying subcutaneous or fat tissue (Figure 24-2). Sweat glands and the small muscles in the dermal layer that control piloerection (goosebumps) help to maintain body temperature in a fairly narrow range despite widely varying air temperatures. Subcutaneous tissue, under the dermal layer, contains fat cells that assist in temperature regulation as well as additional sweat glands.
- Mucous membranes are those epithelial tissues, located continuously with the skin, that line the eyelids, nose and mouth, ears, genital area, urethra, and anus. Some, but not all, mucous membranes secrete thick, slippery mucus that helps protect the body from infection
- Tissue injuries and wounds heal by processes of primary, secondary, or tertiary intention. Primary intention healing occurs when wound margins are well approximated, as in a sutured surgical incision or a simple laceration, and takes place more rapidly than the other types of healing. Secondary intention healing processes occur when wounds such as ulcerations have edges that do not approximate; repairing the larger wound surface area takes longer because it requires generating granulation tissue to fill the gap. Tertiary intention healing processes occur when a wound is sutured closed only after a long period of healing, and results in more scarring than wounds closed with primary intention. Tertiary closure takes place when a wound closure is delayed until resolution of infection or wound contamination; then the clean and partially healed wound is sutured to facilitate continued wound healing.
- There are three phases of wound healing: inflammatory, granulation, and maturation. The inflammatory phase lasts 3 to 5 days while blood clots form at the site of injury and platelets release growth factors to begin the healing process. A matrix of cells and debris forms at the site and is later removed by macrophages. During the granulation phase, new vessels and collagen structures are formed, resulting in a very vascular pink wound. White blood cells continue to remove debris while epithelium begins to grow from the edges toward the center of the wound.
- The maturation phase, which may continue for months or years, involves collagen fiber remodeling and contraction of the scar
- Wounds may be mechanically protected to promote healing in a moist but not soggy environment using a simple adhesive bandage or more complex dressings. Dry dressings are used to absorb excessive exudates whereas moist dressings are used to maintain a slightly damp environment to promote tissue repair. Nonadherent dressings are useful when the wound drainage is slight and may dry between dressing changes, causing the dressing to stick to the fragile wound surface wound and then disrupt the wound during dressing removal. Occlusive and semiocclusive dressings are used for clean wounds that have minimal drainage but need to be protected from environmental pathogens, such as a central intravenous catheter puncture site. Hydrocolloid, hydrogel, and alginate dressings are used to absorb exudates while maintaining a therapeutically moist wound surface to promote healing. Vacuum-assisted closure systems are special dressings for complex wounds attached to a device that maintains negative pressure at the wound surface, aiding in removal of large amounts of exudates.12
- The Institute for Clinical Systems Improvement21 suggests that multiple aspects of care be integrated when treating a person with a pressure ulcer
Since 1999, the national Gallup poll has found nursing to be the most trusted of 19 professions, with nurses admired for their honesty and ethical standards.
- broad concept that applies across disciplines. Professionalism refers to the application of ideal qualities of an individual within a specific professional field. Health care professions share many professional attributes; the unique characteristics for each profession are described through professional identity.
- For the purposes of this concept analysis, professionalism is defined as the assimilation of nursing skills and knowledge integrated with dignity and respect for all human beings, incorporating the assumptions and values of the profession while maintaining accountability and self-awareness.
made up of the knowledge, skills, and attitudes together with values and beliefs of the profession. One might say that professionalism is the comportment that creates professional identity in an individual.
The word “identity” is commonly described as a set of definitive characteristics and behaviors that differentiate one individual from another. Personal identity distinguishes the specific uniqueness of each person—it differentiates both how the person perceives and interacts with the surroundings and how the person is perceived by others. Professional identity, on the other hand, is comprised of a compilation of the skills, values, and expertise common to a group of individuals who are part of the same profession. The public recognizes nurses through the fidelity and honesty they exhibit.
- Professional identity encompasses personal values, beliefs, and perceptions about the work to be done
- Education, clinical judgment, ethics, comportment, and therapeutic communication are among the most commonly addressed professional attributes. Other important attributes include accountability, leadership, respect, and self-awareness.
- The picture that begins to develop of a professional nurse is someone who is highly skilled, recognizes patient needs, remains calm and confident, and provides thoughtful, empathetic care to patients.
scope of professional identity
The scope of professional identity in nursing includes autonomy, knowledge, competence, professionhood, accountability, advocacy, collaborative practice, and commitment (Figure 35-1). These eight elements are described by Baumann and Kolotylo as the sum of professional factors in nursing.10 Attributes such as education and participation in professional associations are implicit components of the professional elements.
A new wave of leadership theory based on complexity science has begun to emerge in nursing. Complexity science is the interdisciplinary study of complex adaptive systems in physical, life, and management sciences. Four main features of complex adaptive systems have implications for leadership in health care. First, complexity science posits that interactions of the parts within a system are more important than the individual parts; thus leaders should look at the system as a whole. Second, complexity science has shown that a few simple rules can stimulate progress towards achieving a difficult goal. Consequently, leaders can initiate problem solving by pointing employees in the right direction, establishing boundaries for the solution, and giving staff the resources and permission to create solutions. Third, complexity science suggests that employees routinely change their behaviors (i.e., self-organize) to cope with changing demands. Thus leaders should search for the factors that attract employees to change, rather than battling their resistance to change. Fourth, leaders can expect variation and uncertainty as features of any complex adaptive system and use these features to their advantage.21 Nurses are beginning to advocate for the use of complexity science as a way to strengthen nursing leadership and improve patient care and patient outcomes
Association between formal leadership and outcomes
- There is a small body of research linking formal nursing leadership to outcomes. Investigations have shown that nursing leadership based on consideration and visibility in the clinical setting is positively related to staff nurses’ job satisfaction, feelings of empowerment, and autonomy. These studies also showed that visible and considerate leadership is associated with higher work commitment and retention of staff nurses.20,28 Nursing leadership based on emotional intelligence is positively associated with work environment characteristics that support professional nursing practice, such as more opportunities for staff development, good work relations and teamwork between nurses and physicians, positive work culture, and greater utilization of research in practice.16,20,29 An investigation of the influence of nursing leadership on patient outcomes showed that hospitals with emotionally intelligent nursing leadership had significantly lower 30-day mortality rates in a population of patients with medical conditions. In an integrated research review positive nurse leadership practices were found to be associated with patient satisfaction, improved patient safety, and reduction of adverse events and patient complications
- Consequently, clinical leadership is increasingly the purview of staff nurses, clinical educators, and advanced practice nurses. These nurses do not hold formal management positions; instead their colleagues perceive some of them to be clinical leaders because of their specific clinical knowledge. Clinical leaders typically are experienced clinicians involved in direct patient care who serve as visible role models. They are effective communicators and decision makers, motivated, open, and approachable. Regardless of their title, position, or grade, they are passionate about patient care and display their beliefs and values about patient care while fulfilling their responsibilities. They are change agents, guiding other nurses through the change process. They foster teamwork and show respect for others. Clinical leaders use an evidence-based approach to care and are reflective practitioners who learn from their experiences. They stay abreast of advances in clinical care and the standards of practice in their specialty.2,11,31,33 Consistent with the aforementioned characteristics, their influence in the clinical setting is based on referent, expert, and informational power. A new role, the clinical nurse leader, has been introduced in some health care agencies, but even in those settings staff nurses exercise clinical leadership in their daily work with patients.
- Every registered nurse has the potential to be a clinical leader; lifelong learning will enable them to hone the clinical and nonclinical skills needed to fulfill this potential
ANA (American Nurses Association)
The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations (ANA, 2010b). The International Council of Nurses (ICN, 2010) has another definition: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
- Nursing has responded and always will respond to the needs of its patients. In times of war the nursing response was to meet the needs of the wounded in combat zones and military hospitals in the United States and abroad. When communities face health care crises such as disease outbreaks or insufficient health care resources, nurses establish community-based immunization and screening programs, treatment clinics, and health promotion activities. Our patients are most vulnerable when they are injured, sick, or dying.
- Since the beginning of the profession, nurses have studied and tested new and better ways to help their patients. A classic article described Florence Nightingale's work during the Crimean War. She studied and implemented methods to improve battlefield sanitation, which ultimately reduced illness, infection, and mortality (Cohen, 1984). Take time to reflect about Nightingale's actions centuries ago and think about the impact of her actions. She set the stage for using evidence to direct practice.
- Today nurses are active in determining the best practices for skin care management, pain control, nutritional management, and care of older adults, to cite just a few examples. Nurse researchers are leaders in expanding knowledge in nursing and other health care disciplines. Their work provides evidence for practice to ensure that nurses have the best available evidence to support their practices (see Chapter 5).
- Nursing is a combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies needed for safe, quality patient-centered care (Gugliemi, 2010). It continuously responds and adapts to new challenges. Nurses are in a unique position to refine and shape the future of health care.
- In Notes on Nursing: What It Is and What It Is Not, Florence Nightingale established the first nursing philosophy based on health maintenance and restoration (Nightingale, 1860). She saw the role of nursing as having “charge of somebody's health” based on the knowledge of “how to put the body in such a state to be free of disease or to recover from disease” (Nightingale, 1860). During the same year she developed the first organized program for training nurses, the Nightingale Training School for Nurses at St. Thomas’ Hospital in London.
- Nightingale was the first practicing nurse epidemiologist (Cohen, 1984). Her statistical analyses connected poor sanitation with cholera and dysentery. She volunteered during the Crimean War in 1853 and traveled the battlefield hospitals at night carrying her lamp; thus she was known as the “lady with the lamp.” The sanitary, nutrition, and basic facilities in the battlefield hospitals were poor at best. Eventually she was given the task to organize and improve the quality of the sanitation facilities. As a result, the mortality rate at the Barracks Hospital in Scutari, Turkey, was reduced from 42.7% to 2.2% in 6 months
Civil War to the Beginning of the twentieth century
- The Civil War (1860 to 1865) stimulated the growth of nursing in the United States. Clara Barton, founder of the American Red Cross, tended soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death. The U.S. Congress ratified the American Red Cross in 1882 after 10 years of lobbying by Barton. Dorothea Lynde Dix, Mary Ann Ball (Mother Bickerdyke), and Harriet Tubman also influenced nursing during the Civil War (Donahue, 2011). As superintendent of the female nurses of the Union Army, Dix organized hospitals, appointed nurses, and oversaw and regulated supplies to the troops. Mother Bickerdyke organized ambulance services and walked abandoned battlefields at night, looking for wounded soldiers. Harriet Tubman was active in the Underground Railroad movement and assisted in leading over 300 slaves to freedom (Donahue, 2011).
- The first professionally trained African American nurse was Mary Mahoney. She was concerned with relationships between cultures and races; and as a noted nursing leader she brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color, or religion.
- Isabel Hampton Robb helped found the Nurses’ Associated Alumnae of the United States and Canada in 1896. This organization became the ANA in 1911. She authored many nursing textbooks, including Nursing: Its Principles and Practice for Hospital and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907) and was one of the original founders of the American Journal of Nursing (AJN) (Donahue, 2011).
- Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City (Donahue, 2011). Nurses working in this settlement were some of the first to demonstrate autonomy in practice because they frequently encountered situations that required quick and innovative problem solving and critical thinking without the supervision or direction of a health care provider.
- In the early twentieth century a movement toward developing a scientific, research-based defined body of nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities. She became the first professor of nursing at Columbia University Teachers College in 1906 (Donahue, 2011). In addition, the Goldmark Report concluded that nursing education needed increased financial support and suggested that university schools of nursing receive the money.
- As nursing education developed, nursing practice also expanded, and the Army and Navy Nurse Corps were established. By the 1920s nursing specialization was developing. Graduate nurse-midwifery programs began; in the last half of the century specialty-nursing organizations were created. Examples of these specialty organizations include the American Association of Critical Care Nurses; Association of Operating Room Nurses (AORN); Emergency Nurses Association (ENA); Infusion Nurses Society (INS); Oncology Nursing Society (ONS); and Wound, Ostomy, Continence Nurses Society (WOCN).
- Nursing practice and education continue to evolve to meet the needs of society. In 1990 the ANA established the Center for Ethics and Human Rights (see Chapter 22). The Center provides a forum to address the complex ethical and human rights issues confronting nurses and designs activities and programs to increase ethical competence in nurses (ANA, 2010c).
- Today the profession faces multiple challenges. Nurses and nurse educators are revising nursing practice and school curricula to meet the ever-changing needs of society, including bioterrorism, emerging infections, and disaster management. Advances in technology and informatics (see Chapter 26), the high acuity level of care of hospitalized patients, and early discharge from health care institutions require nurses in all settings to have a strong and current knowledge base from which to practice. In addition, nursing and the Robert Wood Johnson Foundation are taking a leadership role in developing standards and policies for end-of-life care through the Last Acts Campaign (see Chapter 36). The End-of-Life Nursing Education Consortium (ELNEC) offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center has brought end-of-life care and practices into nursing curricula and professional continuing-education programs for practicing nurses
Influences on Nursing
Multiple external forces affect nursing, including demographic changes of the population, human rights, increasing numbers of medically underserved, and the threat of bioterrorism.
Health Care Reform
Health care reform not only affects how health care is paid for but how it is delivered. There will be greater emphasis on health promotion, disease prevention, and illness management in the future. This model impacts the delivery of nursing care. More services will be in community-based care settings. As a result, more nurses will be needed to practice in community care centers, schools, and senior centers. This will require nurses to be more adept at assessing for resources, service gaps, and how the patient adapts to returning to the community. Nursing must respond to such changes by exploring new methods to provide care, changing nursing education, and revising practice standards
The U.S. Census Bureau (2008a) predicts that between 2010 and 2050 there will be a steady rise in the population. This change alone requires expanded health care resources. Add to the population change a steady increase in the population of people 65 years and older (U.S. Census Bureau, 2008b). To effectively meet all the health care needs of the expanding and aging population, changes need to occur as to how care is provided, especially in the area of public health, to address health care reform and meet the needs of the changing population. The population is still shifting from rural areas to urban centers, and more people are living with chronic and long-term illness (Presley, 2010). Not only are there expansions of outpatient settings, but more and more people want to receive outpatient and community-based care and remain in their homes or community
The rising rates of unemployment, underemployment and low-paying jobs, mental illness, and homelessness and rising health care costs all contribute to increases in the medically underserved population. Caring for the medically underserved population is a global issue; the social, political, and economic factors of a country affect both access to care and resources to provide and pay for these services (Huicho et al., 2010). In the United States some of the medically underserved population are poor and on Medicaid. Others are part of the working poor (i.e., they cannot afford their own insurance, but they make too much money to qualify for Medicaid and as a result do not receive any health care). In addition, the number of underserved patients who require home-based palliative care services is increasing. This is a group of patients whose physical status does not improve and heath care needs increase. As a result, the cost for home-based care continues to rise, to the point that some patients opt out of all palliative services because of costs (Fernandes et al., 2010). Today nurses and schools of nursing are developing partnerships to improve health outcomes in underserved communities. Nurses work in these community-based settings providing health promotion and disease prevention to the homeless, mentally ill, and others who have limited access to health care or who lack health care insurance
rising health care costs
Skyrocketing health care costs present challenges to the profession, consumer, and the health care delivery system. As a nurse you are responsible for providing the patient with the best-quality care in an efficient and economically sound manner. The challenge is to use health care and patient resources wisely. Chapter 2 summarizes reasons for the rise in health care costs and its implications for nursing.
Nursing as a profession
- Nursing is not simply a collection of specific skills, and you are not simply a person trained to perform specific tasks. Nursing is a profession. No one factor absolutely differentiates a job from a profession, but the difference is important in terms of how you practice. To act professionally you administer quality patient-centered care in a safe, conscientious, and knowledgeable manner. You are responsible and accountable to yourself and your patients and peers. A profession has the following primary characteristics:
- • It requires a basic liberal foundation and an extended education of its members.
- • It has a theoretical body of knowledge leading to defined skills, abilities, and norms.
- • It provides a specific service.
- • Members of a profession have autonomy in decision making and practice.
- • The profession as a whole has a code of ethics for practice
Scope and Standards of Practice
Since 1960 the ANA has engaged in documenting the scope of nursing and developing standards of practice (ANA, 2010b). Within this document are the Standards of Practice and Standards of Professional Performance. It is important that you know and apply these standards in your practice. The document is usually available in most schools of nursing and practice settings. The goal of this document is to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standard-based practice
ANA Standards of Nursing Pratice
- 1 Assessment: The registered nurse collects comprehensive data pertinent to the patient's health and/or the situation.
- 2 Diagnosis: The registered nurse analyzes the assessment data to determine the diagnoses or issues.
- 3 Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation.
- 4 Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
- 5 Implementation: The registered nurse implements the identified plan.
- 5a Coordination of Care: The registered nurse coordinates care delivery.
- 5b Health Teaching and Health Promotion: The registered nurse uses strategies to promote health and a safe environment.
- 5c Consultation: The graduate level–prepared specialty nurse or advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change.
- 5d Prescriptive authority and treatment: The advanced practice registered nurse uses prescriptive authority, procedures, referrals, treatment, and therapies in accordance with state and federal laws and regulations.
- 6 Evaluation: The registered nurse evaluates progress toward attainment of outcomes.
Standards of practice
The Standards of Practice describe a competent level of nursing care (Box 1-1). The levels of care are demonstrated by the critical thinking model known as the nursing process: assessment, diagnosis, outcomes identification and planning, implementation, and evaluation (ANA, 2010b). The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to patients
Standards of professional performance
The ANA Standards of Professional Performance (Box 1-2) describe a competent level of behavior in the professional role (ANA, 2010b). These standards provide objective guidelines for nurses to be accountable for their actions, their patients, and their peers. The standards provide a method to assure patients that they are receiving high-quality care, that the nurses know exactly what is necessary to provide nursing care, and that measures are in place to determine whether care meets the standards.
Codes of Ethics
The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It is important for you to also incorporate your own values and ethics into your practice. As you incorporate these values, you explore what type of nurse you will be and how you will function within the discipline (ANA, 2008, 2010c). Ask yourself: how do your ethics, values, and practice compare with established standards? The ANA has a number of publications that address ethics and human rights in nursing. The Code of Ethics for Nurses with Interpretive Statements is a guide for carrying out nursing responsibilities that provide quality nursing care; it also outlines the ethical obligations of the profession (ANA, 2008). Chapter 22 provides a review of the nursing code of ethics and ethical principles for everyday practice.
ANA Standards of Professional Performance
- 7 Ethics: The registered nurse practices ethically.
- 8 Education: The registered nurse attains knowledge and competency that reflects current nursing practice.
- 9 Evidence-Based Practice and Research: The registered nurse integrates evidence and research findings into practice.
- 10 Quality of Practice: The registered nurse contributes to quality nursing practice.
- 11 Communication: The registered nurse communicates effectively in all areas of practice.
- 12 Leadership: The registered nurse demonstrates leadership in the professional practice setting and the profession.
- 13 Collaboration: The registered nurse collaborates with health care consumer, family, and others in the conduct of nursing practice.
- 14 Professional Practice Evaluation: The registered nurse evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
- 15 Resources: The registered nurse uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible.
- 16 Environmental Health: The registered nurse practices in an environmentally safe and healthy manner.
Nursing requires a significant amount of formal education. The issues of standardization of nursing education and entry into practice remain a major controversy. In 1965 the ANA published a position paper on nursing education that emphasizes the role of education for the advancement of the science of the profession (ANA, 1965). Most nurses agree that nursing education is important to practice and that education needs to respond to changes in health care created by scientific and technological advances. There are various education preparations for an individual intending to be an RN. In addition, there is graduate nurse education and continuing and in-service education for practicing nurses.
Professional Registered Nurse Education
- Currently in the United States the most frequent way to become a registered nurse (RN) is either through completion of an associate or baccalaureate degree program. Graduates of both programs are eligible to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) to become RNs in the state in which they will practice.
- The associate degree program in the United States is a 2-year program that is usually offered by a university or community college. This program focuses on the basic sciences and theoretical and clinical courses related to the practice of nursing.
- The baccalaureate degree program usually includes 4 years of study in a college or university. The program focuses on the basic sciences; theoretical and clinical courses; and courses in the social sciences, arts, and humanities to support nursing theory. In Canada the degree of Bachelor of Science in Nursing (BScN) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Science in Nursing (BSN) in the United States. The Essentials of Baccalaureate Education for Professional Nursing (AACN, 2008a) delineates essential knowledge, practice and values, attitudes, personal qualities, and professional behavior for the baccalaureate-prepared nurse and guides faculty on the structure and evaluation of the curriculum. The National League for Nursing Accreditation Council (NLNAC) published the NLNAC Standards and Criteria Baccalaureate Programs in Nursing—2008. This document identifies core competencies for the professional nurse and supports the Pew Health Commission and the competencies of the Institute of Medicine (IOM) for health professionals (NLNAC, 2008). In addition, one of the IOM's recommendations is that 80% of nurses be prepared with a baccalaureate in nursing by 2020
After obtaining a baccalaureate degree in nursing, you can pursue graduate education leading to a master's or doctoral degree in any number of graduate fields, including nursing. A nurse completing a graduate program can receive a master's degree in nursing. The graduate degree provides the advanced clinician with strong skills in nursing science and theory, with emphasis on the basic sciences and research-based clinical practice. A master's degree in nursing is important for the roles of nurse educator and nurse administrator, and it is required for an advanced practice registered nurse (APRN).
- Professional doctoral programs in nursing (DSN or DNSc) prepare graduates to apply research findings to clinical nursing. Other doctoral programs emphasize more basic research and theory and award the research-oriented Doctor of Philosophy (PhD) in nursing. Recently the AACN recommended the Doctor of Nursing Practice (DNP) as the terminal practice degree and required preparation for all APRNs by 2015 (Chase and Pruitt, 2006). The DNP is a practice-focused doctorate. It provides skills in obtaining expanded knowledge through the formulation and interpretations of evidence-based practice (Chism, 2010).
- The need for nurses with doctoral degrees is increasing. Expanding clinical roles and continuing demand for well-educated nursing faculty, nurse administrators, and APRNs in the clinical settings and new areas of nursing specialties such as nursing informatics are just a few reasons for increasing the number of doctorally prepared nurses.
Continuing and In-Service Education
- Nursing is a knowledge-based profession, and technological expertise and clinical decision making are qualities that our health care consumers demand and expect. Continuing education programs are one way to promote and maintain current nursing skills, gain new knowledge and theory, and obtain new skills reflecting the changes in the health care delivery system (Hale et al., 2010). Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. An example is a program on caring for older adults with dementia offered by a university or a program on safe medication practices offered by a hospital. Continuing education updates your knowledge about the latest research and practice developments, helps you to specialize in a particular area of practice, and teaches you new skills and techniques (Hale et al., 2010).
- In-service education programs are instruction or training provided by a health care agency or institution. An in-service program is held in the institution and is designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Often in-service programs are focused on new technologies such as how to correctly use the newest safety syringes. Many in-service programs are designed to fulfill required competencies of an organization. For example, a hospital might offer an in-service program on safe principles for administering chemotherapy or a program on cultural sensitivity
You will have an opportunity to practice in a variety of settings, in many roles within those settings, and with caregivers in other related health professions. Administrators in health care agencies and institutions guide the practice of nursing only in part. State and provincial Nurse Practice Acts (NPAs) establish specific legal regulations for practice, and professional organizations establish standards of practice as criteria for nursing care. The ANA is concerned with legal aspects of nursing practice, public recognition of the significance of nursing practice to health care, and implications for nursing practice regarding trends in health care. The ANA definition of nursing illustrates the consistent orientation of nurses to providing care to promote the well-being of their patients individually or in groups and communities
Nurse Practice Acts
In the United States the State Boards of Nursing oversee NPAs. NPAs regulate the scope of nursing practice and protect public health, safety, and welfare. This protection includes shielding the public from unqualified and unsafe nurses. Although each state defines for itself the scope of nursing practice, most have similar NPAs. The definition of nursing practice published by the ANA is representative of the scope of nursing practice as defined in most states. However, in the last decade many states have revised their NPAs to reflect the growing autonomy of nursing and the expanded roles of nurses in practice. For example, NPAs expanded their scope to include minimum education requirements, required certifications, and practice guidelines for APRNs such as nurse practitioners and certified RN anesthetists. The expansion of scope of practice includes skills unique to the advanced practice role (e.g., advanced assessment, prescriptive authority for certain medications and diagnostic procedures, and some invasive procedures).
Licensure and Certification
- In the United States RN candidates must pass the NCLEX-RN® examination administered by the individual State Boards of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States. This provides a standardized minimum knowledge base for nurses.
- Beyond the NCLEX-RN®, the nurse may choose to work toward certification in a specific area of nursing practice. Minimum practice requirements are set, based on the certification the nurse seeks. National nursing organizations such as the ANA have many types of certification to enhance your career such as certification in medical surgical or geriatric nursing. After passing the initial examination, you maintain your certification by ongoing continuing education and clinical or administrative practice.
Science and Art of Nursing Practice
Because nursing is both an art and a science, nursing practice requires a blend of the most current knowledge and practice standards with an insightful and compassionate approach to patient care. Your patients’ health care needs are multidimensional. Thus your care will reflect the needs and values of society and professional standards of care and performance, meet the needs of each patient, and integrate evidence-based findings to provide the highest level of care. Nursing has a specific body of knowledge; however, it is essential that you socialize within the profession and practice to fully understand and apply the nursing knowledge base and develop professional expertise. Clinical expertise takes time and commitment. According to Benner et al. (2010), an expert nurse passes through five levels of proficiency when acquiring and developing generalist or specialized nursing skills
Autonomy and Accountability
Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. For example, you independently implement coughing and deep-breathing exercises for a patient who recently had surgery. You actively collaborate with other health professionals to pursue the best treatment plan for a patient. With increased autonomy comes greater responsibility and accountability. Accountability means that you are responsible, professionally and legally, for the type and quality of nursing care provided. You need to keep current and competent in nursing and scientific knowledge and technical skills. The nursing profession also regulates accountability through nursing audits and standards of practice.
As caregiver, you help patients maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process. You provide healing through both physical and interpersonal skills. Healing involves more than achieving improved physical well-being. You need to meet all health care needs of the patient by providing measures that restore a patient's emotional, spiritual, and social well-being. As a caregiver, you help the patient and family set goals and assist them with meeting these goals with minimal financial cost, time, and energy.
As a patient advocate, you protect your patient's human and legal rights and provide assistance in asserting these rights if the need arises. As an advocate you act on behalf of your patient and secure your patient's health care rights and stand up for them (Hanks, 2010). For example, you provide additional information to help a patient decide whether or not to accept a treatment, or you find an interpreter to help family members communicate their concerns. You sometimes need to defend patients’ rights in a general way by speaking out against policies or actions that put patients in danger or conflict with their rights.
As an educator you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patient's progress in learning. Some of your patient teaching is unplanned and informal. For example, during a casual conversation you respond to questions about the reason for an intravenous infusion, a health issue such as smoking cessation, or necessary lifestyle changes. Other teaching activities are planned and more formal such as when you teach your patient to self-administer insulin injections. Always use teaching methods that match your patient's capabilities and needs and incorporate other resources such as the family in teaching plans
Your effectiveness as a communicator is central to the nurse-patient relationship. It allows you to know your patients, including their strengths and weaknesses, and their needs. Communication is essential for all nursing roles and activities. You will routinely communicate with patients and families, other nurses and health care professionals, resource persons, and the community. Without clear communication, it is impossible to give comfort and emotional support, give care effectively, make decisions with patients and families, protect patients from threats to well-being, coordinate and manage patient care, assist the patient in rehabilitation, or provide patient education. The quality of communication is a critical factor in meeting the needs of individuals, families, and communities
- Today's health care environment is fast paced and complex. Nurse managers need to establish an environment for collaborative patient-centered care to provide safe, quality care with positive patient outcomes. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. The manager uses appropriate leadership styles to create a nursing environment for the patients and staff that reflect the mission and values of the health care organization
Advanced Practice Registered Nurses
The advanced practice registered nurse (APRN) is the most independently functioning nurse. An APRN has a master's degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice (APRN, 2008). There are four core roles for the APRN: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified nurse midwife (CNM), and certified RN anesthetist (CRNA). The educational preparation for the four roles is in at least one of the following six populations: adult-gerontology, pediatrics, neonatology, women's health/gender related, family/individual across life span, and psychiatric mental health
Clinical nurse Specialist
The clinical nurse specialist (CNS) is an APRN who is an expert clinician in a specialized area of practice (Fig. 1-1). The specialty may be identified by a population (e.g., geriatrics), a setting (e.g., critical care), a disease specialty (e.g., diabetes), a type of care (e.g., rehabilitation), or a type of problem (e.g., pain) (National CNS Competency Task Force, 2010). The CNS practice is in all health care settings.
The nurse practitioner (NP) is an APRN who provides health care to a group of patients, usually in an outpatient, ambulatory care, or community-based setting. NPs provide care for patients with complex problems and a more holistic approach than physicians. The NP provides comprehensive care, directly managing the medical care of patients who are healthy or who have chronic conditions. A significant percentage of primary care visits by patients result from health-related problems that extend beyond the boundaries of medicine and demand the expertise of a nurse. The NP is able to establish a collaborative provider-patient relationship, working with a specific group of patients or with patients of all ages and health care needs. The major NP categories are acute care, adult, family, pediatric, women's, psychiatric mental health, and geriatric. An NP has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions such as asthma, diabetes mellitus, and hypertension.
A certified nurse-midwife (CNM) is an APRN who is also educated in midwifery and is certified by the American College of Nurse-Midwives. The practice of nurse-midwifery involves providing independent care for women during normal pregnancy, labor, and delivery and care for the newborn. It includes some gynecological services such as routine Papanicolaou (Pap) smears, family planning, and treatment for minor vaginal infections. A CNM practices with a health care agency that provides medical consultation, collaborative management, and referral.
Certified Registered Nurse Anesthetist
A certified registered nurse anesthetist (CRNA) is an APRN with advanced education in a nurse anesthesia accredited program. Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician with advanced knowledge of surgical anesthesia.
Professional Nursing Organizations
- A professional organization deals with issues of concern to those practicing in the profession. In North America the major professional nursing organizations are the National League for Nursing (NLN) and the ANA. The NLN advances excellence in nursing education to prepare nurses to meet the needs of a diverse population in a changing health care environment. The NLN (2008) sets standards for excellence and innovation in nursing education.
- The purpose of the ANA is to improve standards of health and the availability of health care, to foster high standards for nursing, and to promote the professional development and general and economic welfare of nurses. The ANA is part of the International Council of Nurses (ICN). The objectives of the ICN parallel those of the ANA: promoting national associations of nurses, improving standards of nursing practice, seeking a higher status for nurses, and providing an international power base for nurses.
- The ANA is active in political, professional, and financial issues affecting health care and the nursing profession. It is a strong lobbyist in professional practice issues such as limits of overtime hours. For example, ANA extensively lobbied state legislatures to restrict the length of overtime any one nurse's shift can be extended. When nurses’ shifts last longer than 12 to 16 hours, both the patient's and nurse's safety is at risk. The risk for treatment errors and nurse injury is increased when the nurse's workday is extended.
- Nursing students take part in organizations such as the National Student Nurses Association (NSNA) in the United States and the Canadian Student Nurses Association (CSNA) in Canada. These organizations consider issues of importance to nursing students such as career development and preparation for licensing. The NSNA often cooperates in activities and programs with the professional organizations.
- Some professional organizations focus on specific areas such as critical care, nursing administration, nursing research, or nurse-midwifery. These organizations seek to improve the standards of practice, expand nursing roles, and foster the welfare of nurses within the specialty areas. In addition, professional organizations present educational programs and publish journals.
Quality and Safety Education for Nurses
The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the IOM (Barton et al., 2009). QSEN addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments (Table 1-1). The QSEN initiative encompasses the competencies of: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). For each competency there are targeted knowledge, skills, and attitudes (KSAs). The KSAs are elements that are integrated in a nursing prelicensure program (Jarzemsky et al., 2010). As you gain experience in clinical practice, you will encounter situations in which your education helps you to make a difference in improving patient care
Application to Nursing Practice
- • Communicate with clarity and precision when designing multidisciplinary plans of care (Robinson et al., 2010).
- • Seek out the skills and expertise of other disciplines.
- • Develop a culture of mutual respect for all disciplines and professionals within the discipline (Manojilovich and DeCicco, 2007).
- • Recognize that electronic communication may be quick, but in some situations it may not be effective (Robinson et al., 2010). When patient care issues are at stake, a focused, well-organized interdisciplinary meeting is more effective than a series of “round-robin” e-mails.
- • It usually takes the same amount of time to communicate and collaborate ineffectively as it does to do it effectively.
Key points in nursing
- • Nursing responds to the health care needs of society, which are influenced by economic, social, and cultural variables of a specific era.
- • Changes in society such as increased technology, new demographic patterns, consumerism, health promotion, and the women's and human rights movements lead to changes in nursing.
- • Nursing definitions reflect changes in the practice of nursing and help bring about changes by identifying the domain of nursing practice and guiding research, practice, and education.
- • Nursing standards provide the guidelines for implementing and evaluating nursing care.
- • Professional nursing organizations deal with issues of concern to specialist groups within the nursing profession.
- • Nurses are becoming more politically sophisticated and, as a result, are able to increase the influence of nursing on health care policy and practice.
PICOT critical thinking question
- P = Patient population of interest
- Identify patients by age, gender, ethnicity, and disease or health problem.
- I = Intervention of interest
- Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)?
- C = Comparison of interest
- What is the usual standard of care or current intervention used now in practice?
- O = Outcome
- What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)?
- T = Time
- What amount of time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient behavior)?
Nurses are in a unique position to help patients achieve and maintain optimal levels of health.
In an era of cost containment and advanced technology, nurses are a vital link to the improved health of individuals and society. They identify actual and potential risk factors that predispose a person or a group to illness. In addition, the nurse uses risk factor modification strategies to promote health and wellness and prevent illness.
Healthy People documents
Healthy People provides science-based, 10-year national objectives for promoting health and preventing disease. In 1979 an influential document, Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention, was published; it introduced a goal for improving the health of Americans by 1990. The report outlined priority objectives for preventive services, health protection, and health promotion that addressed improvements in health status, risk reduction, public and professional awareness of prevention, health services and protective measures, and surveillance and evaluation. The report served as a framework for the 1990s as the United States increased the focus on health promotion and disease prevention instead of illness care. The strategy announced by the Secretary of Health and Human Services required a cooperative effort by government, voluntary and professional organizations, businesses, and individuals. Widely cited by popular media, in professional journals, and at health conferences, it has inspired health promotion programs throughout the country.
Healthy People 2010
Healthy People 2010, published in 2000, served as a road map for improving the health of all people in the United States for the first decade of the twenty-first century (USDHHS, 2000). This edition emphasized the link between individual health and community health and the premise that the health of communities determines the overall health status of the nation.
Healthy People 2020
Healthy People 2020 was approved in December 2010. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages
- Defining health is difficult. The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity”
- Pender explains that "all people free of disease are not equally healthy"
- Health beliefs are a person's ideas, convictions, and attitudes about health and illness.
- Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness.
The health promotion model (HPM) proposed by Pender (1982; revised, 1996) was designed to be a “complementary counterpart to models of health protection” (Fig. 6-2). It defines health as a positive, dynamic state, not merely the absence of disease (Pender, Murdaugh, and Parsons, 2011). Health promotion is directed at increasing a patient's level of well-being. The HPM describes the multidimensional nature of persons as they interact within their environment to pursue health
Health belief model
Physical stressors such as a poor living environment, exposure to air pollutants, and an unsafe environment also affect health. Hereditary and psychological stressors such as emotional, intellectual, social, developmental, and spiritual factors influence one's level of health.
Primary prevention is true prevention; it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Primary prevention includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities (Edelman and Mandle, 2010). Primary prevention includes specific protection such as immunization for influenza and hearing protection in occupational settings
Secondary prevention focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible (Edelman and Mandle, 2010). A large portion of nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. It includes screening techniques and treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease. Screening activities also become a key opportunity for health teaching as a primary prevention intervention
Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration (Edelman and Mandle, 2010). Activities are directed at rehabilitation rather than diagnosis and treatment. Care at this level helps patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning.
- Illness is a state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired.
- Although nurses need to be familiar with different types of diseases and their treatments, they often are concerned more with illness, which may include disease but also includes the effects on functioning and well-being in all dimensions.
acute vs. chronic illness
An acute illness is usually reversible, has a short duration, and is often severe. The symptoms appear abruptly, are intense, and often subside after a relatively short period. An acute illness may affect functioning in any dimension. A chronic illness persists, usually longer than 6 months, is irreversible, and affects functioning in one or more systems.
People who are ill generally act in a way that medical sociologists call illness behavior. It involves how people monitor their bodies, define and interpret their symptoms, take remedial actions, and use the resources in the health care system (Mechanic, 1995). Personal history, social situations, social norms, and past experiences affect illness behavior
Technical personel vs professional nurse
Clinical decision making separates professional nurses from technical personnel. For example, a professional nurse observes for changes in patients, recognizes potential problems, identifies new problems as they arise, and takes immediate action when a patient's clinical condition worsens. Technical personnel simply follow direction in completing aspects of care that the professional nurse has identified as necessary.
clinical decision making
Benner (1984) describes clinical decision making as judgment that includes critical and reflective thinking and action and application of scientific and practical logic. Most patients have health care problems for which there are no clear textbook solutions. Each patient's problems are unique, a product of the patient's physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Thus as a nurse you do not always have a clear picture of a patient's needs and the appropriate actions to take when first meeting a patient. Instead you must learn to question, wonder, and explore different perspectives and interpretations to find a solution that benefits the patient.
critical thinking requirements
Critical thinking requires cognitive skills and the habit of asking questions, remaining well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues
levels of critical thinking in nursing
Your ability to think critically grows as you gain new knowledge in nursing practice. Kataoka-Yahiro and Saylor (1994) developed a critical thinking model (Fig. 15-1) that includes three levels: basic, complex, and commitment. An expert nurse thinks critically almost automatically. As a beginning student you make a more conscious effort to apply critical thinking because initially you are more task oriented and trying to learn how to organize nursing care activities. At first you apply the critical thinking model at the basic level. As you advance in practice, you adopt complex critical thinking and commitment.
Basic critical thinking
- At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. For example, as a nursing student you use a hospital procedure manual to confirm how to insert a Foley catheter. You likely follow the procedure step by step without adjusting it to meet a patient's unique needs (e.g., positioning to minimize the patient's pain or mobility restrictions). You do not have enough experience to anticipate how to individualize the procedure. At this level answers to complex problems are either right or wrong (e.g., when no urine drains from the catheter, the catheter tip must not be in the bladder), and one right answer usually exists for each problem.
- A basic critical thinker learns to accept the diverse opinions and values of experts (e.g., instructors and staff nurse role models). However, inexperience, weak competencies, and inflexible attitudes can restrict a person's ability to move to the next level of critical thinking.
Complex critical thinkers
- Complex critical thinkers begin to separate themselves from experts. They analyze and examine choices more independently. The person's thinking abilities and initiative to look beyond expert opinion begin to change. A nurse learns that alternative and perhaps conflicting solutions exist.
- In complex critical thinking each solution has benefits and risks that you weigh before making a final decision. There are options. Thinking becomes more creative and innovative. The complex critical thinker is willing to consider different options from routine procedures when complex situations develop. You learn a variety of different approaches for the same therapy.
commitment (critical thinking)
As a nurse you do more than just consider the complex alternatives that a problem poses. At the commitment level you choose an action or belief based on the available alternatives and support it. Sometimes an action is to not act or to delay an action until a later time. You choose to delay as a result of your experience and knowledge. Because you take accountability for the decision, you consider the results of the decision and determine whether it was appropriate.
- 1 Identifying the problem
- 2 Collecting data
- 3 Formulating a question or hypothesis
- 4 Testing the question or hypothesis
- 5 Evaluating results of the test or study
- Decision making is a product of critical thinking that focuses on problem resolution. Following a set of criteria helps to make a thorough and thoughtful decision. The criteria may be personal; based on an organizational policy; or, frequently in the case of nursing, a professional standard.
- Examples of decision making in the clinical area include determining which patient care priority requires the first response, choosing a type of dressing for a patient with a surgical wound, or selecting the best teaching approach for a family caregiver who will assist a patient who is returning home after a stroke.
In diagnostic reasoning use patient data that you gather or collect to logically recognize the problem. For example, after turning a patient you see an area of redness on the right hip. You palpate the area and note that it is warm to the touch and the patient complains of tenderness. You press over the area with your finger; after you release pressure, the area does not blanch or turn white. After thinking about what you know about normal skin integrity and the effects of pressure, you form the diagnostic conclusion that the patient has a pressure ulcer. As a student, confirm your judgments with experienced nurses. At times you possibly will be wrong, but consulting with nurse experts gives you feedback to build on future clinical situations.
clinical decision making
As in the case of general decision making, clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. In clinical decision making a nurse identifies a patient's problem and selects a nursing intervention. When you approach a clinical problem such as a patient who is less mobile and develops an area of redness over the hip, you make a decision that identifies the problem (impaired skin integrity in the form of a pressure ulcer) and choose the best nursing interventions (skin care and a turning schedule).
Nurses apply the nursing process as a competency when delivering patient care (Kataoka-Yahiro and Saylor, 1994). The nursing process is a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation. The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems (American Nurses Association, 2010). Human responses include patient symptoms and physiological reactions to treatment, the need for knowledge when health care providers make a new diagnosis or treatment plan, and a patient's ability to cope with loss.
5 components of critical thinking
there are five components of critical thinking: knowledge base, experience, critical thinking competencies (with emphasis on the nursing process), attitudes, and standards. The elements of the model combine to explain how nurses make clinical judgments that are necessary for safe, effective nursing care
- The first component of the critical thinking model is a nurse's specific knowledge base.
- A nurse's knowledge base is continually changing as science progresses (Swinny, 2010). As a nurse your knowledge base includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Nurses use their knowledge base in a different way than other health care disciplines because they think holistically about patient problems. For example, a nurse's broad knowledge base offers a physical, psychological, social, moral, ethical, and cultural view of patients and their health care needs. The depth and extent of knowledge influence your ability to think critically about nursing problems.
- Nursing is a practice discipline. Clinical learning experiences are necessary to acquire clinical decision-making skills.
- Your practice improves from what you learn personally. The opportunities you have to experience different emotions, crises, and successes in your lives and relationships with others build your experience as a nurse.
Competency, specifically the nursing process, is the third component of the critical thinking model. In your practice you apply critical thinking components during each step of the nursing process. Throughout the clinical chapters of this text, the relationship of critical thinking to the nursing process is emphasized.
The fourth component of the critical thinking model is attitudes. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem (Paul, 1993) (Box 15-3). For example, when a patient complains of anxiety before a diagnostic procedure, the curious nurse explores possible reasons for the patient's concerns. The nurse shows discipline in collecting a thorough assessment to find the source of the patient's anxiety. Attitudes of inquiry involve an ability to recognize that problems exist and that there is a need for evidence to support the truth in what you think is true. Critical thinking attitudes are guidelines for how to approach a problem or decision-making situation. An important part of critical thinking is interpreting, evaluating, and making judgments about the adequacy of various arguments and available data. Knowing when you need more information, knowing when information is misleading, and recognizing your own knowledge limits are examples of how critical thinking attitudes guide decision making.
- Confidence grows with experience in recognizing your strengths and limitations. You shift your focus from your own needs (e.g., remembering how to perform a procedure) to the patient's needs.
- Never attempt anything on your patient unless you have the knowledge base and feel confident. Patient safety is of the upmost importance. When you show confidence, your patients recognize it by how you communicate and the way you perform nursing care. Confidence builds trust between you and your patients.
Bias and critical thinking
So, as human beings, we pre-judge situations. It saves time.
It is unrealistic to think that we will enter into a situation "without bias".
What is important and realistic is to allow yourself to discover your biases and prejudices so that you have insight into what otherwise may be a blind spot for you.
The best we can do is to explore situations with an open mind and to be prepared to re-evaluate the positions that we feel most natural when the evidence suggests that we do. It can be painful to recognize that our previous position on something was ill-informed, but this is how we learn and grow.
- We are not perfect, but must always strive to do our best. If we do, our best becomes better and better.
- A critical thinker deals with situations justly. This means that bias or prejudice does not enter into a decision. For example, regardless of how you feel about obesity, you do not allow personal attitudes to influence the way you care for a patient who is overweight.
Standards of practice
- When caring for patients you are responsible for correctly performing nursing care activities based on standards of practice. Standards of practice are the minimum level of performance accepted to ensure high-quality care.
- As a nurse you are answerable or accountable for your decisions and the outcomes of your actions. This means that you are accountable for recognizing when nursing care is ineffective and you know the limits and scope of your practice
A critical thinker is willing to take risks in trying different ways to solve problems. The willingness to take risks comes from experience with similar problems. Risk taking often leads to advances in patient care. Nurses in the past have taken risks in trying different approaches to skin and wound care and pain management, to name a few. When taking a risk, consider all options; follow safety guidelines; analyze any potential dangers to a patient; and act in a well-reasoned, logical, and thoughtful manner.
A disciplined thinker misses few details and follows an orderly or systematic approach when collecting information, making decisions, or taking action. For example, you have a patient who is in pain. Instead of only asking the patient, “How severe is your pain on a scale of 0 to 10?” you also ask more specific questions about the character of pain. For example, “What makes the pain worse? Where does it hurt? How long have you noticed it?” Being disciplined helps you identify problems more accurately and select the most appropriate interventions.
A critical thinker is determined to find effective solutions to patient care problems. This is especially important when problems remain unresolved or recur. Learn as much as possible about a problem and try various approaches to care. Persevering means to keep looking for more resources until you find a successful approach. For example, a patient who is unable to speak following throat surgery poses challenges for the nurse to be able to communicate effectively. Perseverance leads the nurse to try different communication approaches (e.g., message boards or alarm bells) until he or she finds a method that the patient is able to use. A critical thinker who perseveres is not satisfied with minimal effort but works to achieve the highest level of quality care.
Creativity involves original thinking. This means that you find solutions outside of the standard routines of care while still keeping standards of practice. Creativity motivates you to think of options and unique approaches. A patient's clinical problems, social support systems, and living environment are just a few examples of factors that make the simplest nursing procedure more complicated. For example, a home care nurse has to find a way to help an older patient with arthritis have greater mobility in the home. The patient has difficulty lowering and raising herself in a chair because of pain and limited range of motion in her knees. The nurse uses wooden blocks to elevate the chair legs so the patient is able to sit and stand with little discomfort while making sure the chair is safe to use.
A critical thinker's favorite question is “Why?” In any clinical situation you learn a great deal of information about a patient. As you analyze patient information, data patterns appear that are not always clear. Having a sense of curiosity motivates you to inquire further (e.g., question family, consult with a physician, or review the scientific literature) and investigate a clinical situation so you get all the information you need to make a decision.
Critical thinkers question and test their own knowledge and beliefs. Your personal integrity as a nurse builds trust from your co-workers. Nurses face many dilemmas or problems in everyday clinical practice, and everyone makes mistakes at times. A person of integrity is honest and willing to admit to mistakes or inconsistencies in his or her own behavior, ideas, and beliefs. In addition, the professional nurse always tries to follow the highest standards of practice.
It is important for you to admit to any limitations in your knowledge and skill. Critical thinkers admit what they do not know and try to find the knowledge needed to make proper decisions. It is common for a nurse to be an expert in one area of clinical practice but a novice in another. That is because the knowledge in all areas of nursing is unlimited. A patient's safety and welfare are at risk if you do not admit your inability to deal with a practice problem. You have to rethink a situation; learn more; and use the new information to form opinions, draw conclusions, and take action.
When you consider a patient problem, apply the intellectual standards such as preciseness, accuracy, and consistency to make sure that all clinical decisions are sound. A thorough use of the intellectual standards in clinical practice makes certain that you do not perform critical thinking haphazardly.
- Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility (Paul, 1993). Application of professional standards requires you to use critical thinking for the good of individuals or groups (Kataoka-Yahiro and Saylor, 1994). Professional standards promote the highest level of quality nursing care.
- Excellent nursing practice is a reflection of ethical standards (Chapter 22). Patient care requires more than just the application of scientific knowledge. Being able to focus on a patient's values and beliefs helps you make clinical decisions that are just, faithful to the patient's choices, and beneficial to the patient's well-being. Critical thinkers maintain a sense of self-awareness through conscious awareness of their beliefs; values; feelings; and the multiple perspectives that patients, family members, and peers present in clinical situations. Critical thinking also requires the use of evidence-based criteria for making clinical judgments.
To develop critical thinking skills, it is important to learn how to connect knowledge and theory with practice. Your ability to make sense of what you learn in the classroom, from reading, or from having dialogue with other students and then to apply it during patient care is always challenging.
How often do you think back on a situation to consider the following: Why did that occur? How did I act? What could I have done differently? What knowledge could I have applied? Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. It is like rewinding a videotape. Reflection involves playing back a situation in your head and taking time to honestly review everything you remember about it. Reflective practice is a conscious process of thinking, analyzing, and learning from your work situations by way of journaling or regularly meeting with colleagues to explore work situations and self-evaluate (Cirocco, 2007). Critical thinking becomes more deliberate through reflection because it allows you to think about your previous thinking to make your future thinking better
As a nurse you care for patients who have multiple nursing diagnoses or collaborative problems. A concept map is a visual representation of patient problems and interventions that shows their relationships to one another. It offers a nonlinear picture of a patient that can then be used for comprehensive care planning (Taylor and Wros, 2007). The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures (Hill, 2006). Through drawing a concept map, you learn to organize or connect information in a unique way so the diverse information that you have about a patient begins to form meaningful patterns and concepts. You begin to see a more holistic view of a patient. When you see the relationship between the various patient diagnoses and the data that support them, you better understand a patient's clinical situation. Concept maps become more detailed, integrated, and comprehensive as you learn more about the care of a patient and the care you provide similar patients (Ferrario, 2004). The similarities and differences that you see among patients build your decision-making skills. Unit 3 includes chapters that provide diagrams of actual concept maps and more detail on their development. Concept maps can also be found in Units 5 and 6.
- A diagnosis is a clinical judgment based on information.
- You review information collected about a patient, see cues and patterns in the data, and identify the patient's specific health care problems. Some of the conclusions lead to identifying nursing diagnoses, whereas others do not. Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems). Together nursing diagnoses and collaborative problems represent the range of patient conditions that require nursing care
define medical diagnosis
A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures. Physicians are licensed to treat diseases and conditions described in medical diagnostic statements.
- Nursing has a similar diagnostic language. Nursing diagnosis, the second step of the nursing process (Fig. 17-1), classifies health problems within the domain of nursing. A nursing diagnosis such as acute pain or nausea is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat (NANDA International, 2012). What makes the nursing diagnostic process unique is having patients involved, when possible, in the process.
- The diagnostic process flows from the assessment process and includes decision-making steps (Fig. 17-2). These steps include data clustering, identifying patient health problems, and formulating the diagnosis.
A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status (Carpenito-Moyet, 2009). When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines. Nurses manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions.
A data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way.
Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion. Each NANDA-I–approved nursing diagnosis has an identified set of defining characteristics that support identification of a nursing diagnosis (NANDA International, 2012). You learn to recognize patterns of defining characteristics from your patient assessments and then readily select the corresponding diagnosis. Working with similar patients over a period of time helps you recognize clusters of defining characteristics, but remember that each patient is unique and requires an individualized diagnostic approach.
Interpretation-Identifying Health Problems
- While analyzing clusters of data, you begin to consider the patient's health problems. Your interpretation of the information allows you to select among various diagnoses the ones that apply to your patient. It is critical to select the correct diagnostic label for a patient's need. Usually from assessment to diagnosis you move from general information to specific. It helps to think of the problem identification phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem. For example, after analyzing Mr. Jacob's problem with comfort, Tonya begins to identify data needed for a specific pain diagnosis.
- Often a patient has defining characteristics that apply to more than one diagnosis. For example, Mr. Jacobs provided a verbal report of pain and showed protective behavior in minimizing movement while lying in bed. Both of these defining characteristics possibly indicates that the patient has either acute pain or chronic pain as nursing diagnoses. Knowing that there are similar diagnoses directs you to gather more information to clarify your interpretation. For example, Tonya checks Mr. Jacobs’ blood pressure after he rates his discomfort a 7 on a 10-point rating scale. She notes that his blood pressure is elevated, a defining characteristic unique to the diagnosis of acute pain. When interpreting data to form a diagnosis, remember that the absence of certain defining characteristics suggests that you reject a diagnosis under consideration. Thus in the same example, if Tonya's assessment eliminates the signs of fatigue, fear of reinjury, and depression, it is less likely Mr. Jacobs’ is having chronic pain. In addition, Tonya recognizes that the pain source is the patient's incision and not some underlying chronic problem. The correct diagnosis for Mr. Jacobs is acute pain. Always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. To be more accurate, review all characteristics, eliminate irrelevant ones, and confirm the relevant ones.
Formulating a Nursing Diagnoses
- To individualize a nursing diagnosis further, you identify the associated related factor. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis (NANDA International, 2012). A related factor allows you to individualize a nursing diagnosis for a specific patient.
- While focusing on patterns of defining characteristics, you also compare a patient's pattern of data with data that are consistent with normal, healthful patterns. Use accepted norms as the basis for comparison and judgment. This includes using laboratory and diagnostic test values, professional standards, and normal anatomical or physiological limits. When comparing patterns, judge whether the grouped signs and symptoms are expected for the patient and whether they are within the range of healthful responses. Isolate any defining characteristics not within healthy norms to allow you to identify a specific problem.
- Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which you, as a nurse, are accountable
- Collaborative problems occur or probably will occur in association with a specific disease, trauma, or treatment (Carpenito-Moyet, 2009). You need nursing knowledge to assess a patient's specific risk for these problems, identify the problems early, and take preventive action (Fig. 17-3). Critical thinking is necessary in identifying nursing diagnoses and collaborative problems so you appropriately individualize care for your patients.
Risk nursing diagnosis
A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community (NANDA International, 2012). These diagnoses do not have related factors or defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
Health promote nursing diagnosis
- A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Health promotion diagnoses can be used in any health state and do not require current levels of wellness (NANDA International, 2012). A person's readiness is supported by defining characteristics. Examples of health promotion nursing diagnoses include:
- • Readiness for enhanced family coping
- • Readiness for enhanced nutrition
The diagnostic label is the name of the nursing diagnosis as approved by NANDA International (see Box 17-2). It describes the essence of a patient's response to health conditions in as few words as possible. All NANDA-I approved diagnoses also have a definition. The definition describes the characteristics of the human response identified.
The related factor is identified from the patient's assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patient's actual or potential response to the health problem and can change by using specific nursing interventions. Related factors for NANDA-I diagnoses include four categories: pathophysiological (biological or psychological), treatment-related, situational (environmental or personal), and maturational
The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions. Sometimes health care providers record medical diagnoses as the etiology of the nursing diagnosis. This is incorrect. Nursing interventions do not change a medical diagnosis. However, you direct nursing interventions at behaviors or conditions that you are able to treat or manage. For example, the nursing diagnosis acute pain related to prostatectomy is incorrect. Nursing actions do not affect the medical diagnosis of the surgical removal of the prostate gland. Rewording the diagnosis to read acute pain related to trauma of incision results in nursing interventions directed at appropriate wound care, using turning techniques to reduce stress on the suture line and offering nonpharmacological comfort measures
the PES format
This is the format we use at Dominican. In practice it looks like this:
Nursing diagnosis RELATED TO etiology AS EVIDENCED BY symptoms or defining characteristics
- Ex: Impaired Physical Mobility R/T incisional pain AEB guarding, pt. report of pain 9/10 when moving
- • P (problem)—NANDA-I label—Example: impaired physical mobility
- • E (etiology or related factor)—Example: incisional pain
- • S (symptoms or defining characteristics)—briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning
What makes concept map special?
The advantage of a concept map is its central focus on the patient rather than the patient's disease or health alteration. This encourages nursing students to concentrate on patients’ specific health problems and nursing diagnoses. The focus also promotes patient participation with the eventual plan of care.
Errors in diagnostic statements
- To reduce errors, follow these guidelines:
- 1 Identify the patient's response, not the medical diagnosis (Carpenito-Moyet, 2009). Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Change the diagnosis acute pain related to prostatectomy to acute pain related to trauma of an incision.
- 2 Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. One symptom is insufficient for problem identification. For example, dyspnea alone does not definitively lead you to a diagnosis. However, the pattern of dyspnea, shortness of breath, pain on inspiration, and productive cough with thick secretions are defining characteristics that lead you to the diagnosis of ineffective breathing pattern related to increased airway secretions.
- 3 Identify a treatable etiology or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. An accurate etiology allows you to select nursing interventions directed toward correcting the etiology of the problem or minimizing the patient's risk. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A patient with fractured ribs likely has pain when inhaling; impaired chest excursion; and slower, shallow respirations. An x-ray film may show atelectasis (collapse of alveolar air sacs) in the area affected. The nursing diagnosis of ineffective breathing pattern related to shallow respirations is an incorrect diagnostic statement. Ineffective breathing pattern related to pain in chest is more accurate.
- 4 Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. Patients experience many responses to diagnostic tests and medical treatments. These responses are the area of nursing concern. The patient who has angina and is scheduled for a cardiac catheterization possibly has a nursing diagnosis of anxiety related to lack of knowledge about cardiac catheterization. An incorrect diagnosis is anxiety related to cardiac catheterization.
- 5 Identify the patient response to the equipment rather than the equipment itself. Patients are often unfamiliar with medical technology. The diagnosis of deficient knowledge regarding the need for cardiac monitoring is accurate compared with the statement anxiety related to cardiac monitor.
- 6 Identify the patient's problems rather than your problems with nursing care. Nursing diagnoses are always patient centered and form the basis for goal-directed care. Potential intravenous complications related to poor vascular access indicates a nursing problem in initiating and maintaining intravenous therapy. The diagnosis risk for infection properly centers attention on patient needs.
- 7 Identify the patient problem rather than the nursing intervention. You plan nursing interventions after identifying a nursing diagnosis. The statement, “offer bedpan frequently because of altered elimination patterns,” changes to the correct diagnostic statement, diarrhea related to food intolerance. This corrects the misstatement and allows proper implementation of the nursing process. More appropriate interventions are selected rather than a single intervention that will not solve the problem.
- 8 Identify the patient problem rather than the goal of care. You establish goals during the planning step of the nursing process (see Chapter 18). Goals based on accurate identification of a patient's problems serve as a basis to determine problem resolution. Change the diagnostic statement, “Patient needs high-protein diet related to potential alteration in nutrition,” to imbalanced nutrition: less than body requirements related to inadequate protein intake.
- 9 Make professional rather than prejudicial judgments. Base nursing diagnoses on subjective and objective patient data and do not include your personal beliefs and values. Remove your judgment from impaired skin integrity related to poor hygiene habits by changing the nursing diagnosis to read impaired skin integrity related to inadequate knowledge about perineal care.
- 10 Avoid legally inadvisable statements (Carpenito-Moyet, 2009). Statements that imply blame, negligence, or malpractice have the potential to result in a lawsuit. The statement, “recurrent angina related to insufficient medication,” implies an inadequate prescription by the health care provider. Correct problem identification is chronic pain related to improper use of medications.
- 11 Identify the problem and etiology to avoid a circular statement. Circular statements are vague and give no direction to nursing care. Change the statement, “impaired breathing pattern related to shallow breathing,” to identify the patient problem and cause, ineffective breathing pattern related to incisional pain.
- 12 Identify only one patient problem in the diagnostic statement. Every problem has different specific expected outcomes. Confusion during the planning step occurs when you include multiple problems in a nursing diagnosis. Restate pain and anxiety related to difficulty in ambulating as two nursing diagnoses such as impaired physical mobility related to pain in right knee and anxiety related to difficulty in ambulating. It is permissible to include multiple etiologies contributing to one patient problem, as in complicated grieving related to diagnosed terminal illness and change in family role.
Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. Ultimately during implementation your interventions resolve the patient's problems and achieve the expected goals and outcomes
- Remember that a single patient often has multiple nursing diagnoses and collaborative problems. In addition, once you enter into nursing practice, you do not care for just a single patient. Eventually you care for groups of patients. Being able to carefully and wisely set priorities for a single patient or group of patients ensures the timeliest, relevant, and appropriate care.
- Priority setting is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions
- Nursing diagnoses that, if untreated, result in harm to a patient or others (e.g., those related to airway status, circulation, safety, and pain) have the highest priorities.
- Intermediate priority nursing diagnoses involve nonemergent, nonlife-threatening needs of patients.
- Low-priority nursing diagnoses are not always directly related to a specific illness or prognosis but affect the patient's future well-being.
- The order of priorities changes as a patient's condition changes, sometimes within a matter of minutes.
- Involve patients in priority setting whenever possible. Patient-centered care requires you to know a patient's preferences, values, and expressed needs.
goals and planning
During planning you select goals and outcomes for each nursing diagnosis to provide a clear focus for the type of interventions needed to care for your patient and to then evaluate the effectiveness of these interventions. A goal is a broad statement that describes a desired change in a patient's condition or behavior.
An expected outcome is a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved. Sometimes several expected outcomes must be met for a single goal.
- A patient-centered goal reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources.
- Each goal is time limited so the health care team has a common time frame for problem resolution.
A short-term goal is an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours. A long-term goal is an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (e.g., “Patient will be tobacco free within 60 days”Always partner with patients when setting their individualized goals. Mutual goal setting includes the patient and family (when appropriate) in prioritizing the goals of care and developing a plan of action. For patients to participate in goal setting, they need to be alert and have some degree of independence in completing activities of daily living, problem solving, and decision making. Unless goals are mutually set and there is a clear plan of action, patients fail to fully participate in the plan of care. Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse. When setting goals, act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible.
Nursing-sensitive patient outcome
A nursing-sensitive patient outcome is a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
It published the Nursing Outcomes Classification (NOC) and linked the outcomes to NANDA International nursing diagnoses (Moorhead et al., 2008). For each NANDA International nursing diagnosis there are multiple NOC suggested outcomes. These outcomes have labels for describing the focus of nursing care and include indicators to use in evaluating the success with nursing interventions (Table 18-2). NOC contains outcomes for individuals, family caregivers, the family, and the community in all health care settings. Efforts to measure outcomes and capture the changes in the status of patients over time allow nurses to improve patient care quality and add to nursing knowledge
Each goal and outcome should address only one behavior or response.
time limited plans
The time frame for each goal and expected outcome indicates when you expect the response to occur. It is very important to collaborate with patients to set realistic and reasonable time frames. Time frames help you and the patient to determine if the patient is making progress at a reasonable rate. If not, you must revise the plan of care. Time frames also promote accountability in delivering and managing nursing care.
Part of the planning process is to select nursing interventions for meeting the patient's goals and outcomes. Once nursing diagnoses have been identified and goals and outcomes are selected, you choose interventions individualized for the patient's situation. Nursing interventions are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes (Bulechek et al., 2008). During planning you select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes. The actual implementation of these interventions occurs during the implementation phase of the nursing process
Independent Nursing interventions
Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates. These do not require an order from another health care professional. As a nurse you act independently on a patient's behalf. Nurse-initiated interventions are autonomous actions based on scientific rationale. Examples include elevating an edematous extremity, instructing patients in side effects of medications, or repositioning a patient to achieve pain relief. Such interventions benefit a patient in a predicted way related to nursing diagnoses and patient goals (Bulechek et al., 2008). Nurse-initiated interventions require no supervision or direction from others.
dependent nursing interventions
Physician-initiated interventions are dependent nursing interventions, or actions that require an order from a physician or another health care professional. The interventions are based on the physician's or health care provider's response to treat or manage a medical diagnosis.
Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Typically when you plan care for a patient, you review the necessary interventions and determine if the collaboration of other health care disciplines is necessary.
The NIC model includes three levels: domains, classes, and interventions for ease of use. The domains are the highest level (level 1) of the model, using broad terms (e.g., safety and basic physiological) to organize the more specific classes and interventions (Table 18-3). The second level of the model includes 30 classes, which offer useful clinical categories to reference when selecting interventions. The third level of the model includes the 542 interventions, defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes (Bulechek et al., 2008) (Box 18-2). Each intervention then includes a variety of nursing activities from which to choose (Box 18-3) and which a nurse commonly uses in a plan of care. NIC interventions are also linked with NANDA International nursing diagnoses for ease of use (NANDA International, 2012). For example, if a patient has a nursing diagnosis of acute pain, there are 21 recommended interventions, including pain management, cutaneous stimulation, and anxiety reduction. Each of the recommended interventions has a variety of activities for nursing care.
Nursing care plan
Generally a nursing care plan includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation. Nurses revise a plan when a patient's status changes. Electronic care plans often follow a standardized format, but you can individualize each plan to a unique patient's needs (see Chapter 26). The standardized format is usually based on nursing diagnoses or select problem areas, which nurses are able to individualize for a specific patient. In hospitals and community-based settings, patients receive care from more than one nurse, physician, or allied health professional. Thus more institutions are developing interdisciplinary care plans, which include contributions from all disciplines involved in patient care. The interdisciplinary plan is designed to improve the coordination of all patient therapies and communication among all disciplines.
Consultation occurs when you identify a problem that you are unable to solve using personal knowledge, skills, and resources. The process requires good intrapersonal and interprofessional collaboration. Consultation with other care providers increases your knowledge about the patient's problems and helps you learn skills and obtain resources. A good time to consult with another health care professional is when the exact problem remains unclear.
Implementation, the fourth step of the nursing process, formally begins after the nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, the nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes (Bulechek et al., 2008). Ideally the interventions a nurse uses are evidenced based (see Chapter 5), providing the most current, up-to-date, and effective approaches for managing patient problems. Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.
direct care vs indirect care
Direct care interventions are treatments performed through interactions with patients (Bulechek et al., 2008). For example, a patient receives direct intervention in the form of medication administration, insertion of an intravenous (IV) infusion, or counseling during a time of grief. Indirect care interventions are treatments performed away from the patient but on behalf of the patient or group of patients (Bulechek et al., 2008). For example, indirect care measures include actions for managing the patient's environment (e.g., safety and infection control), documentation, and interdisciplinary collaboration. Both direct and indirect care measures fall under the intervention categories described in Chapter 18: nurse-initiated, physician-initiated, and collaborative.
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. A standing order directs the conduct of patient care in a specific clinical setting. Licensed prescribing health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where patients’ needs change rapidly and require immediate attention.
ANA Standards of Professional Nursing Practice
The ANA Standards of Professional Nursing Practice (ANA, 2010) are to be used as evidence of the standard of care that registered nurses provide their patients (see Chapter 1). The standards are formally reviewed on a regular basis. The newest standards include competencies for establishing professional and caring relationships, using evidence-based interventions and technologies, providing holistic care across the life span to diverse groups, and using community resources and systems. In addition, the standards emphasize implementing a timely plan following patient safety goals
Psychomotor skills require the integration of cognitive and motor activities. For example, when giving an injection you need to understand anatomy and pharmacology (cognitive) and use good coordination and precision to administer the injection correctly (motor). With time and practice you learn to perform skills correctly, smoothly, and confidently.
To protect consumers, commercially processed and packaged foods are subject to Food and Drug Administration (FDA) regulations. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Although food supply in the United States is one of the safest in the world, each year about 76 million illnesses occur, more than 300,000 persons are hospitalized, and 5,000 die from foodborne illness (Centers for Disease Control and Prevention, 2009). Groups at the highest risk are children, pregnant women, older adults, and people with compromised immune systems. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient's risk for infections and food poisoning.
Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia. Exposure to extreme heat changes the electrolyte balance of the body and raises the core body temperature, resulting in heatstroke or heat exhaustion. Chronically ill patients, older adults, and infants are at greatest risk for injury from extreme heat. These patients need to avoid extremely hot, humid environments
Physical hazards in the environment threaten a person's safety and often result in physical or psychological injury or death. Unintentional injuries are the fifth leading cause of death for Americans of all ages (National Center for Injury Prevention, 2010a). Motor vehicle accidents are the leading cause, followed by poisonings and falls. Additional hazards consist of fire and disasters. A nurse plays a role in educating patients about common safety hazards and how to prevent injury while placing emphasis on hazards to which patients are more vulnerable.
Among adults 64 years and older, falls are the leading cause of unintentional death (Centers for Disease Control and Prevention, 2010a). Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics) (Deandrea et al., 2010). Common physical hazards that lead to falls include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices in the home. Often a fall leads to serious injury such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis. Injuries frequently result from accidental contact with objects on stairs, floors, bedside tables, closet shelves, refrigerator tops, and bookshelves. Children fall from anywhere (i.e., trees, wall/fences, playground equipment, furniture, and moving objects such as skateboards and bicycles). Forces from falls lead to injury with variable severity, depending on the height of the fall, body position on impact, and impact surface.
The leading cause of fire-related death is careless smoking, especially when people smoke in bed at home. The improper use of cooking equipment and appliances, particularly stoves, is the main source for in-home fires and fire injuries. Smoke detectors and carbon monoxide detectors need to be placed strategically throughout a home. Multipurpose fire extinguishers need to be near the kitchen and any workshop areas.
When they strike, natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are a major cause of death and injury. These types of disasters result in death and leave many people homeless. Every year millions of Americans face disaster and its terrifying consequences (FEMA, 2010). Bioterrorism is another cause of disaster. Threats of this type come in the form of biological, chemical, and radiological attacks. Bioterrorism, or the use of biological agents to create fear and threat, is the most likely form of a terrorist attack to occur. Although terrorists could use any agent, health officials are most concerned with biological agents such as anthrax, smallpox, pneumonic plague, botulism, tularemia, and viral hemorrhagic fevers
A pathogen is any microorganism capable of producing an illness. The most common means of transmission of pathogens is by the hands. For example, if an individual infected with hepatitis A does not wash his or her hands thoroughly after having a bowel movement, the risk for transmitting the disease during food preparation is great. One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene
define healthy environment
free of pollution
Risks for infection
Patients in all health care settings are at risk for acquiring infections because of lower resistance to pathogens; increased exposure to pathogens, some of which may be resistant to most antibiotics; and invasive procedures. Health care workers are at risk for exposure to infections as a result of contact with patient blood, body fluids, and contaminated equipment and surfaces. By practicing basic infection prevention and control techniques, you avoid spreading pathogens to patients and sustaining an exposure when providing direct care.
Chain of Infection
- Infection occurs in a cycle that depends on the presence of all of the following elements:
- • An infectious agent or pathogen
- • A reservoir or source for pathogen growth
- • A port of exit from the reservoir
- • A mode of transmission
- • A port of entry to a host
- • A susceptible host
- Infection can develop if this chain remains uninterrupted
A reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. Common reservoirs are humans and animals (hosts), insects, food, water, and organic matter on inanimate surfaces (fomites)
- Microorganisms thrive in dark environments
- The acidity of an environment determines the viability of microorganisms. Most microorganisms prefer an environment within a pH range of 5.0 to 7.0. Bacteria in particular thrive in urine with an alkaline pH.
- After microorganisms find a site to grow and multiply, they need to find a port of exit if they are to enter another host and cause disease. Ports of exit include sites such as blood, skin and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
If an infection is localized (e.g., a wound infection), the patient usually experiences localized symptoms such as pain, tenderness, and redness at the wound site.
An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated.
Normal floras of the large intestine exist in large numbers without causing illness. They also secrete antibacterial substances within the walls of the intestine. The normal floras of the skin exert a protective, bactericidal action that kills organisms landing on the skin. The mouth and pharynx are also protected by floras that impair growth of invading microbes. Normal floras maintain a sensitive balance with other microorganisms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquiring a disease. For example, the use of broad-spectrum antibiotics for the treatment of infection can lead to suprainfection. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. When normal bacterial floras are eliminated, body defenses are reduced, which allows for disease-producing microorganisms to multiply, causing illness
body system defenses
The skin, respiratory tract, and gastrointestinal tract are easily accessible to microorganisms.
- The cellular response of the body to injury, infection, or irritation is termed inflammation. Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure.
- Physical agents, chemical agents, or microorganisms trigger the inflammatory response.
Health care-associated infections (HAIs)
Patients in health care settings, especially hospitals and long-term care facilities, have an increased risk of acquiring infections. Health care–associated infections (HAIs), formerly called nosocomial or health care–acquired infections, result from the delivery of health services in a health care facility. They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities.
Iatrogenic infections are a type of HAI (health care-associated infections) from a diagnostic or therapeutic procedure.
Age and infection
- Throughout life, susceptibility to infection changes. For example, an infant has immature defenses against infection. Born with only the antibodies provided by the mother, the infant's immune system is incapable of producing the necessary immunoglobulins and WBCs to adequately fight some infections. However, breastfed infants often have greater immunity than bottle-fed infants because they receive their mother's antibodies through the breast milk. As the child grows, the immune system matures; but the child is still susceptible to organisms that cause the common cold, intestinal infections, and infectious diseases such as mumps, measles, and chickenpox (if not vaccinated).
- The young or middle-age adult has refined defenses against infection. Viruses are the most common cause of communicable illness in young or middle-age adults. Since 2000 there has been a major effort to vaccinate all children against all infectious diseases for which vaccines are available. Vaccine-preventable disease levels are at or near record lows (CDC, 2011). For example; hepatitis B infection in children and adolescents decreased by 89% in 2005 (CDC, 2005b).
- Defenses against infection change with aging (Lesser, Paiusi, and Leips, 2006). The immune response, particularly cell-mediated immunity, declines. Older adults also undergo alterations in the structure and function of the skin, urinary tract, and lungs. For example, the skin loses its turgor, and the epithelium thins. As a result it is easier to tear or abrade the skin, which increases the potential for invasion by pathogens. In addition, older adults who are hospitalized or reside in an assisted-living or residential care facility are at risk for airborne infections. Ensuring that health care workers are vaccinated against influenza reduces the transmission of this illness in older adults
A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing (see Chapter 48). Patients with illnesses or problems that increase protein requirements, such as extensive burns and conditions causing fever, are at further risk. Patients who have undergone surgery, for example, require increased protein. A thorough diet history is necessary. Determine a patient's normal daily nutrient intake and whether preexisting problems such as nausea, impaired swallowing, or oral pain alter food intake. Confer with a dietitian to assist in calculating the calorie count of foods ingested.
The body responds to emotional or physical stress by the general adaptation syndrome (see Chapter 37). During the alarm stage the basal metabolic rate increases as the body uses energy stores. Adrenocorticotropic hormone increases serum glucose levels and decreases unnecessary antiinflammatory responses through the release of cortisone. If stress continues or becomes intense, elevated cortisone levels result in decreased resistance to infection. Continued stress leads to exhaustion, which causes depletion in energy stores, and the body has no resistance to invading organisms. The same conditions that increase nutritional requirements such as surgery or trauma also increase physiological stress.
- Patients with diseases of the immune system are at particular risk for infection. Leukemia, AIDS, lymphoma, and aplastic anemia are conditions that compromise a host by weakening defenses against infectious organisms. For example, patients with leukemia are unable to produce enough WBCs to ward off infection. Patients with HIV are often unable to ward off simple infections and are prone to opportunistic infections.
- Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Diseases that impair body system defenses such as emphysema and bronchitis (which impair ciliary action and thicken mucus), cancer (which alters the immune response), and peripheral vascular disease (which reduces blood flow to injured tissues) increase susceptibility to infection. Patients with burns have a high susceptibility to infection because of the damage to skin surfaces. The greater the depth and extent of the burns, the higher the risk for infection.
- Cleaning is the removal of all soil (e.g., organic and inorganic material) from objects and surfaces (Rutala and Weber, 2008, 2009). Generally cleaning involves use of water and mechanical action with detergents or enzymatic products. When an object comes in contact with an infectious or potentially infectious material, it is contaminated. If the object is disposable, it is discarded. Reusable objects need to be cleaned thoroughly before reuse and then either disinfected or sterilized according to manufacturer recommendations. Failure to follow manufacturer recommendations transfers liability from the manufacturer to the health care facility or agency if an infection results from improper processing.
- Apply protective eyewear (or a face shield) and utility (dishwashing style) gloves when cleaning equipment that is soiled by organic material such as blood, fecal matter, mucus, or pus. Protective barriers provide protection from potentially infectious organisms. A brush and detergent or soap are necessary for cleaning. The following steps ensure that an object is clean:
- 1 Rinse contaminated object or article with cold running water to remove organic material. Hot water causes the protein in organic material to coagulate and stick to objects, making removal difficult.
- 2 After rinsing, wash the object with soap and warm water. Soap or detergent reduces the surface tension of water and emulsifies dirt or remaining material. Rinse the object thoroughly.
- 3 Use a brush to remove dirt or material in grooves or seams. Friction dislodges contaminated material for easy removal. Open hinged items for cleaning.
- 4 Rinse the object in warm water.
- 5 Dry the object and prepare it for disinfection or sterilization if indicated by classification of the item—critical, semicritical, or noncritical.
- 6 The brush, gloves, and sink used to clean the equipment are considered contaminated and are cleaned and dried according to policy.
Disinfection and sterilization
- Disinfection describes a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects
- Sterilization is the complete elimination or destruction of all microorganisms, including spores.
Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and handling of contaminated body fluids. An example includes blood or other body fluids from an infected patient that enter the health care worker's body through direct contact with compromised skin or mucous membranes. Indirect contact involves the transfer of an infectious agent through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if hand hygiene is not performed between patients
Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. An example is a patient with influenza.
Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. This requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. All health care personnel wear an N95 respirator every time they enter the room.
Focuses on a very limited patient population. This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms
Negative pressure air flow
Private rooms used for isolation sometimes provide negative-pressure airflow to prevent infectious particles from flowing out of a room to other rooms and the air handling system. Special rooms with positive-pressure airflow are also used for highly susceptible immunocompromised patients such as recipients of transplanted organs. On the door or wall outside the room the nurse posts a card listing precautions for the isolation category in use according to health care facility policy. The card is a handy reference for health care personnel and visitors and alerts anyone who might enter the room accidentally that special precautions must be followed.
Body balance occurs when a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support. When the vertical line from the center of gravity does not fall through the base of support, the body loses balance. Proper posture or a body position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones enhances body balance (Patton and Thibodeau, 2010). Nurses use balance to maintain proper body alignment and posture through two simple techniques. First widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support. For example, you raise the height of the bed when performing a procedure such as changing a dressing to prevent bending too far at the waist and shifting the base of support.
coordinated body movement
Coordinated body movement is a result of weight, center of gravity, and balance.
- Friction is a force that occurs in a direction to oppose movement. Reduce friction by following some basic principles. When you move objects, those with a greater surface area create more friction. To reduce friction, you need to decrease the object's surface area. For example, when helping patients move up in bed, place their arms across the chest. This decreases surface area and reduces friction.
- A patient who is passive or immobilized produces greater friction to movement (see Chapter 47). When possible, use some of your patients’ strength and mobility when positioning and transferring them. Explain the procedure and tell your patients when to move. You decrease friction when your patients bend their knees as you help them move up in the bed.
- You can also reduce friction by using an air-assisted device when performing lateral patient transfers (Baptiste et al., 2006). Air-assisted devices are commercially available transfer devices that are effective solutions to reducing injury to health care employees and patients.
- The best program of physical activity includes a combination of exercises that produces different physiological and psychological benefits. Three categories of exercise are isotonic, isometric, and resistive isometric. The type of muscle contraction involved determines the classification of the exercise. Isotonic exercises cause muscle contraction and change in muscle length (isotonic contraction). Examples are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isotonic exercises enhance circulatory and respiratory functioning; increase muscle mass, tone, and strength; and promote osteoblastic activity (activity by bone-forming cells), thus combating osteoporosis.
- Isometric exercises involve tightening or tensing muscles without moving body parts (isometric contraction). Examples are quadriceps set exercises and contraction of the gluteal muscles. This form of exercise is ideal for patients who do not tolerate increased activity. A patient who is immobilized in bed can perform isometric exercises. The benefits are increased muscle mass, tone, and strength, thus decreasing the potential for muscle wasting; increased circulation to the involved body part; and increased osteoblastic activity.
- Resistive isometric exercises are those in which the individual contracts the muscle while pushing against a stationary object or resisting the movement of an object (Hoeman, 2006). A gradual increase in the amount of resistance and length of time that the muscle contraction is held increases muscle strength and endurance. Examples of resistive isometric exercises are push-ups and hip lifting, in which a patient in a sitting position pushes with the hands against a surface such as a chair seat and raises the hips. In some long-term care settings, footboards are placed on the end of beds; patients push against them to move up in bed. Resistive isometric exercises help promote muscle strength and provide sufficient stress against bone to promote osteoblastic activity.
- The U.S. Occupational Safety and Health Administration released federal ergonomic guidelines to prevent musculoskeletal injuries in the workplace (OSHA, 2009). Half of all back pain is associated with manual lifting tasks (Box 38-10). Coordinated musculoskeletal activity is necessary when positioning and transferring patients. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Injury to these areas affects the ability to bend forward, backward, and from side to side. The ability to rotate the hips and lower back is also decreased (Nelson and Hughes, 2009). Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients (Table 38-1).
- Before lifting, assess the weight to be lifted, determine the assistance needed, and evaluate available resources. Use safe patient-handling equipment when the patient is unable to assist in transfer. Lift teams, consisting of two physically fit people competent in lifting techniques, reduce the risk of injury to the patient and members of the health care team (Baptiste et al., 2006; Pelczarski, 2007). Use manual lifting only as a last resort when you need to lift a small portion of the patient's weight (Nelson and Baptiste, 2004; Nelson et al., 2008; Tullar et al., 2010). Teaching health care workers about patient-handling equipment, proper body mechanics, and the use of lift teams is most effective in preventing injury
Assitive devices for walking
Walker, Cane, crutches
Inserting and Maintaining a Nasogastric Tube
- A patient's condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery (see Chapter 50), infections of the GI tract, trauma to the GI tract, and conditions in which peristalsis is absent.
- A nasogastric (NG) tube is a pliable hollow tube that is inserted through the patient's nasopharynx into the stomach. NG intubation has several purposes (Table 46-6). There are two main categories of NG tubes: Fine- or small-bore tubes and large-bore tubes. Large-bore tubes, 12-Fr and above, are usually used for gastric decompression or removal of gastric secretions. Small-bore tubes are frequently used for medication administration and enteral feedings (see Chapter 44 for enteral feedings). The Levin and Salem sump tubes are the most common for stomach decompression. The Levin tube is a single-lumen tube with holes near the tip. You connect it to a drainage bag or to an intermittent suction device to drain stomach secretions.
- Stimulation comes from many sources in and outside the body, particularly through the senses of sight (visual), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory). The body also has a kinesthetic sense that enables a person to be aware of the position and movement of body parts without seeing them.
- Many patients seeking health care have preexisting sensory alterations. Others develop them as a result of medical treatment (e.g., hearing loss from antibiotic use or hearing or visual loss from brain tumor removal) or hospitalization. The health care environment is a place of unfamiliar sights, sounds, and smells and minimal contact with family and friends. If patients feel depersonalized and are unable to receive meaningful stimuli, serious sensory alterations sometimes develop.
a sense that allows a person to recognize the size, shape, and texture of an object.
Normally the nervous system continually receives thousands of bits of information from sensory nerve organs, relays the information through appropriate channels, and integrates the information into a meaningful response. Sensory stimuli reach the sensory organs to elicit an immediate reaction or present information to the brain to be stored for future use. The nervous system must be intact for sensory stimuli to reach appropriate brain centers and for an individual to perceive the sensation. After interpreting the significance of a sensation, the person is then able to react to the stimulus.
- Reception, perception, and reaction are the three components of any sensory experience (see Chapter 43). Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, or sound. In the case of special senses, the receptors are grouped close together or located in specialized organs such as the taste buds of the tongue or the retina of the eye. When a nerve impulse is created, it travels along pathways to the spinal cord or directly to the brain. For example, sound waves stimulate hair cell receptors within the organ of Corti in the ear, which causes impulses to travel along the eighth cranial nerve to the acoustic area of the temporal lobe. Sensory nerve pathways usually cross over to send stimuli to opposite sides of the brain.
- The actual perception or awareness of unique sensations depends on the receiving region of the cerebral cortex, where specialized brain cells interpret the quality and nature of sensory stimuli. When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. A person's level of consciousness influences perception and interpretation of stimuli. Any factors lowering consciousness impair sensory perception. If sensation is incomplete such as blurred vision or if past experience is inadequate for understanding stimuli such as pain, the person can react inappropriately to the sensory stimulus.
- It is impossible to react to all stimuli entering the nervous system. The brain prevents sensory bombardment by discarding or storing sensory information. A person usually reacts to stimuli that are most meaningful or significant at the time. However, after continued reception of the same stimulus, a person stops responding, and the sensory experience goes unnoticed. For example, a person concentrating on reading a good book is not aware of background music. This adaptability phenomenon occurs with most sensory stimuli except for those of pain.
The most common types of sensory alterations are sensory deficits, sensory deprivation, and sensory overload. When a patient suffers from more than one sensory alteration, the ability to function and relate effectively within the environment is seriously impaired.
- A deficit in the normal function of sensory reception and perception is a sensory deficit. A person loses a sense of self with impaired senses. Initially he or she withdraws by avoiding communication or socialization with others in an attempt to cope with the sensory loss. It becomes difficult for the person to interact safely with the environment until he or she learns new skills. When a deficit develops gradually or when considerable time has passed since the onset of an acute sensory loss, a person learns to rely on unaffected senses. Some senses may even become more acute to compensate for an alteration. For example, a blind patient develops an acute sense of hearing to compensate for visual loss.
- Patients with sensory deficits often change behavior in adaptive or maladaptive ways. For example, a patient with a hearing impairment turns the unaffected ear toward the speaker to hear better, whereas another patient avoids people because he or she is embarrassed about not being able to understand what other people say. Box 49-1 summarizes common sensory deficits and their influence on those affected.
The reticular activating system in the brainstem mediates all sensory stimuli to the cerebral cortex; thus patients are able to receive stimuli even while sleeping deeply. Sensory stimulation must be of sufficient quality and quantity to maintain a person's awareness. Three types of sensory deprivation are reduced sensory input (sensory deficit from visual or hearing loss), the elimination of patterns or meaning from input (e.g., exposure to strange environments), and restrictive environments (e.g., bed rest) that produce monotony and boredom
- When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from responding appropriately to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, a person no longer perceives the environment in a way that makes sense. Overload prevents meaningful response by the brain; the patient's thoughts race, attention scatters in many directions, and anxiety and restlessness occur. As a result, overload causes a state similar to that produced by sensory deprivation. However, in contrast to deprivation, overload is individualized. The amount of stimuli necessary for healthy function varies with each individual. People are often subject to environmental overload more at one time than another. A person's tolerance to sensory overload varies with level of fatigue, attitude, and emotional and physical well-being.
- The acutely ill patient easily experiences sensory overload. The patient in constant pain or who undergoes frequent monitoring of vital signs is at risk. Multiple stimuli combine to cause overload even if the nurse offers a comforting word or provides a gentle back rub. Some patients do not benefit from nursing intervention because their attention and energy are focused on more stressful stimuli. Another example is a patient who is hospitalized in an intensive care unit (ICU), where the activity is constant. Lights are always on. Patients can hear sounds from monitoring equipment, staff conversations, equipment alarms, and the activities of people entering the unit. Even at night an ICU is very noisy.
- It is easy to confuse the behavioral changes associated with sensory overload with mood swings or simple disorientation. Look for symptoms such as racing thoughts, scattered attention, restlessness, and anxiety. Patients in ICUs sometimes resort to constantly fingering tubes and dressings. Constant reorientation and control of excessive stimuli become an important part of a patient's care.
- One example of this is called "ICU psychosis'.
People hospitalized in the ICU are subjected to numerous painful procedures, surrounded by an 24/7 environment filled with beeps and buzzes…
Age and sensory function
- Infants and children are at risk for visual and hearing impairment because of a number of genetic, prenatal, and postnatal conditions. A concern with high-risk neonates is that early, intense visual and auditory stimulation can adversely affect visual and auditory pathways and alter the developmental course of other sensory organs (Hockenberry and Wilson, 2011). Visual changes during adulthood include presbyopia and the need for glasses for reading. These changes usually occur from ages 40 to 50. In addition, the cornea, which assists with light refraction to the retina, becomes flatter and thicker. These aging changes lead to astigmatism. Pigment is lost from the iris, and collagen fibers build up in the anterior chamber, which increases the risk of glaucoma by decreasing the resorption of intraocular fluid. Other normal visual changes associated with aging include reduced visual fields, increased glare sensitivity, impaired night vision, reduced depth perception, and reduced color discrimination.
- Hearing changes begin at the age of 30. Changes associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination. Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over background noise. It is also difficult to discriminate the consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k). Vowels that have a low pitch are easiest to hear. Speech sounds are distorted, and there is a delayed reception and reaction to speech. A concern with normal age-related sensory changes is that older adults with a deficit are sometimes inappropriately diagnosed with dementia (Ebersole et al., 2008).
- Gustatory and olfactory changes begin around age 50 and include a decrease in the number of taste buds and sensory cells in the nasal lining. Reduced taste discrimination and sensitivity to odors are common.
- Proprioceptive changes common after age 60 include increased difficulty with balance, spatial orientation, and coordination. Older adults cannot avoid obstacles as quickly, and the automatic response to protect and brace oneself when falling is slower. Older adults experience tactile changes, including declining sensitivity to pain, pressure, and temperature secondary to peripheral vascular disease and neuropathies.
Meaningful stimuli reduce the incidence of sensory deprivation. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Note whether patients have roommates or visitors. The presence of others offers positive stimulation. However, a roommate who constantly watches television, persistently tries to talk, or continuously keeps lights on contributes to sensory overload. The presence or absence of meaningful stimuli influences alertness and the ability to participate in care.
Amount of stimuli
Excessive stimuli in an environment causes sensory overload. The frequency of observations and procedures performed in an acute health care setting are often stressful. If a patient is in pain or restricted by a cast or traction, overstimulation frequently is a problem. In addition, a room that is near repetitive or loud noises (e.g., an elevator, stairwell, or nurses’ station) contributes to sensory overload.
The amount and quality of social contact with supportive family members and significant others influence sensory function. The absence of visitors during hospitalization or residency in an extended care facility influences the degree of isolation a patient feels. This is a common problem in hospital intensive care settings, where visitation is often restricted. The ability to discuss concerns with loved ones is an important coping mechanism for most people. Therefore the absence of meaningful conversation results in feelings of isolation, loneliness, anxiety, and depression for a patient. Often this is not apparent until behavioral changes occur.
- A person's occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Individuals who have occupations involving exposure to high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing loss and need to be screened for hearing impairments. Hazardous noise is common in work settings and recreational activities. Noisy recreational activities that weaken hearing ability include target shooting and hunting, woodworking, and listening to loud music. Individuals who have occupations involving risk of exposure to chemicals or flying objects (e.g., welders) are at risk for eye injuries and need to be screened for visual impairments. Sports activities and consumer fireworks also place individuals at risk for visual alterations. Occupations that involve repetitive wrist or finger movements (e.g., heavy assembly line work) cause pressure on the median nerve, resulting in carpal tunnel syndrome. Carpal tunnel syndrome alters tactile sensation and is one of the most common industrial or work-related injuries. Patients at risk for carpal tunnel need to be carefully assessed for numbness, tingling, weakness, and pain.
- A hospitalized patient is sometimes at risk for sensory alterations as a result of exposure to environmental stimuli or a change in sensory input. Patients who are immobilized by bed rest or who have a chronic disability are unable to experience all of the normal sensations of free movement. Another group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis (see Chapter 28). These patients stay in private rooms and are often unable to enjoy normal interactions with visitors.
To understand the nature of a communication problem, you need to know whether a patient has trouble speaking, understanding, naming, reading, or writing. Patients with existing sensory deficits often develop alternate ways of communicating. To interact with the patient and promote interaction with others, understand his or her method of communication (Fig. 49-2). Vision becomes almost a primary sense for people with hearing impairments.
use of assistive devices
Assess the use of assistive devices (e.g., use of a hearing aid or glasses) and the sensory effects for the patient. This includes learning how often the patient uses the devices daily, the patient's or family caregiver's method of cleaning, and the patient's knowledge of what to do when a problem develops. When you identify that the patient has an assistive device, it is important to remember that, just because the individual has the assistive device, it does not mean that it works or that the patient uses it or benefits from it.
- Trauma is a common cause of blindness in children. Penetrating injury from propulsive objects such as firecrackers or slingshots or from penetrating wounds from sticks, scissors, or toy weapons are just a few examples. Parents and children require counseling on ways to avoid eye trauma such as avoiding use of toys with long, pointed projections and instructing children not to walk or run while carrying pointed objects. Instruct patients that they can find safety equipment in most sports shops and large department stores.
- Adults are at risk for eye injury while playing sports and working in jobs involving exposure to chemicals or flying objects. The Occupational Safety and Health Administration (OSHA, 2010) has guidelines for workplace safety. Employers are required to have eye wash stations and to have employees wear eye goggles and/or use equipment such as HPDs to reduce the risk of injury. Healthy People 2020 (USDHHS, 2009) identifies goals that include reducing new cases of work-related, noise-induced hearing loss. Occupational health nurses reinforce the use of protective devices. In addition, nurses need to routinely assess patients for noise exposure and participate in providing hearing conservation classes for teachers, students, and patients.
- Another means of prevention involves regular immunization of children against diseases capable of causing hearing loss (e.g., rubella, mumps, and measles). Nurses who work in health care providers’ offices, schools, and community clinics instruct patients about the importance of early and timely immunization. In all populations use caution when administering ototoxic drugs.
Use of assistive devices
- Patients who wear corrective contact lenses, eyeglasses, or hearing aids need to make sure that they are clean, accessible, and functional (see Chapter 39). It is helpful to have a family member or friend who also knows how to care for and clean an assistive aid (Box 49-7). A contact lens wearer must frequently clean lenses (see Chapter 39) and use the appropriate solutions for cleaning and disinfection. Contact lens wearers are subject to serious eye infections caused by infrequent lens disinfection, contamination of lens storage cases or contact lens solutions, and use of homemade saline. Swimming while wearing lenses also creates a serious risk of infection. Reinforce proper lens care in any health maintenance discussion.
- Older adults are often reluctant to use hearing aids. Reasons cited most often include cost, appearance, insufficient knowledge about hearing aids, amplification of competing noise, and unrealistic expectations. Neuromuscular changes in the older adult such as stiff fingers, enlarged joints, and decreased sensory perception also make the handling and care of a hearing aid difficult. Fortunately today there are a wide variety of aids that not only enhance a person's hearing but also are cosmetically acceptable and useful for persons with manual dexterity issues. Chapter 39 summarizes the types of hearing aids available and tips for proper care and use.
- Acknowledging a need to improve hearing is a person's first step. Give patients useful information on the benefits of hearing aid use. A person who understands the need for good hearing will likely be influenced to wear hearing aids. It is also important to have a significant other available to assist with hearing aid adjustment. Federal regulations require medical clearance from a health care provider before an individual can purchase a hearing aid. Hearing aids are contraindicated for the following conditions: visible congenital or traumatic deformity of the ear, active drainage in the last 90 days, sudden or progressive hearing loss within the last 90 days, acute or chronic dizziness, unilateral sudden hearing loss within the last 90 days, visible cerumen accumulation or a foreign body in the ear canal, pain or discomfort in the ear, or an audiometric air-bone gap of 15 decibels or greater. A nursing assessment detects the first seven of these conditions during a physical examination. Refer the patient to an otolaryngologist for further counseling
- To maximize residual hearing function, work closely with the patient to suggest ways to modify the environment. Patients can amplify the sound of telephones and televisions. An innovative way to enrich the lives of the hearing impaired is recorded music. Some patients with severe hearing loss are able to hear music recorded in the low-frequency sound cycles.
- One way to help an individual with a hearing loss is to ensure that the problem is not impacted cerumen. With aging, cerumen thickens and builds up in the ear canal. Excessive cerumen occluding the ear canal causes conductive hearing loss. Instilling a softening agent such as 0.5 to 1 mL of warm mineral oil into the ear canal followed by irrigation of a solution of 3% hydrogen peroxide in a quart of warmed water removes cerumen and significantly improves the patient's hearing ability
taste and smell
- Promote the sense of taste by using measures to enhance remaining taste perception. Good oral hygiene keeps the taste buds well hydrated. Well seasoned, differently textured food eaten separately heightens taste perception. Flavored vinegar or lemon juice adds tartness to food. Always ask the patient which foods are most appealing. Improving taste perception improves food intake and appetite as well.
- Stimulation of the sense of smell with aromas such as brewed coffee, cooked garlic, and baked bread heightens taste sensation. The patient needs to avoid blending or mixing foods because these actions make it difficult to identify tastes. Older persons need to chew food thoroughly to allow more food to contact remaining taste buds.
- Improve smell by strengthening pleasant olfactory stimulation. Make a patient's environment more pleasant with smells such as cologne, mild room deodorizers, fragrant flowers, and sachets. Consult with patients to find out which scents they can tolerate. The removal of unpleasant odors (e.g., bedpans or soiled dressings) also improves the quality of a patient's environment.
- Patients with reduced tactile sensation usually have the impairment over a limited portion of their bodies. Providing touch therapy stimulates existing function. If a patient is willing to be touched, hair brushing and combing, a back rub, and touching the arms or shoulders are ways of increasing tactile contact. When sensation is reduced, a firm pressure is often necessary for a patient to feel a nurse's hand. Turning and repositioning also improves the quality of tactile sensation.
- If a patient is overly sensitive to tactile stimuli (hyperesthesia), minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with a patient and protecting the skin from exposure to irritants are helpful measures. Physical therapists can recommend special wrist splints for patients to wear to dorsiflex their wrists and relieve nerve pressure when they have numbness and tingling or pain in the hands, as with carpal tunnel syndrome. For patients who use computers, special keyboards and wrist pads are available to decrease the pressure on the median nerve, aid in pain relief, and promote healing.
- A sensory deficit often causes a person to feel isolated because of an inability to communicate with others. It is important for individuals to be able to interact with people around them. The nature of the sensory loss influences the methods and styles of communication that nurses use during interactions with patients (Box 49-8). You also teach communication methods to family members and significant others. For patients with visual deficits or blindness, speak normally, not from a distance, and be sure to have sufficient lighting.
- The patient with a hearing impairment is often able to speak normally. To more clearly hear what a person communicates, family and friends need to learn to move away from background noise, rephrase rather than repeat sentences, be positive, and have patience. In a group setting it is better to form a semicircle in front of the patient so he or she can see who is speaking next; this helps foster group involvement. On the other hand, some patients who are deaf have serious speech alterations. Some use sign language or lip reading, wear special hearing aids, write with a pad and pencil, or learn to use a computer for communication. Special communication boards that contain common terms (e.g., pain, bathroom, dizzy, or walk) help patients express their needs.
- The patient with recent visual impairment often requires help with walking. The presence of an eye patch, frequently instilled eyedrops, and the swelling of eyelid structures following surgery are just a few factors that cause a patient to need more assistance than usual. A sighted guide gives confidence to patients with visual impairments and ensures safe mobility. Ebersole et al. (2008) list three suggestions for a sighted guide:
- 1 Ask the patient if he or she wants a “sighted guide.” If assistance is accepted, offer an elbow or arm. Instruct the patient to grasp your arm just above the elbow (Fig. 49-5). If necessary, physically help the person by guiding his or her hand to your arm or elbow.
- 2 Go one-half step ahead and slightly to the side of the person. The shoulder of the person needs to be directly behind your shoulder. If the person is frail, place the hand on your forearm.
- 3 Relax and walk at a comfortable pace. Warn the patient when you approach doorways or narrow spaces.
- While walking with the patient, describe the surroundings and ensure that obstacles have been removed. Never leave a patient with a visual impairment standing alone in an unfamiliar area. It is important to teach family members techniques for assisting with ambulation. Nursing staff also need to ensure that the patient knows where the call light is before leaving the patient alone. Place necessary objects in front of the patient to prevent falls caused by reaching over the bedside. Appropriate use of side rails is also an option
Communication and Nursing Practice
- Communication is a lifelong learning process. Nurses make the intimate journey with patients and their families from the miracle of birth to the mystery of death. As a nurse you communicate with patients and families to collect meaningful assessment data, provide education, and interact using therapeutic communication to promote personal growth and attainment of health-related goals. Despite the complexity of technology and the multiple demands on nurses’ time, it is the intimate moment of connection that makes all the difference in the quality of care and meaning for a patient and a nurse.
- Communication is an essential part of patient-centered nursing care. Patient safety also requires effective communication among members of the health care team as patients move from one caregiver to another or from one care setting to another. Breakdown in communication among the health care team is a major cause of errors in the workplace and threatens professional credibility (World Health Organization, 2007). Effective team communication and collaboration skills are essential to ensure patient safety and high-quality patient care (Cronenwett et al., 2007). Competency in communication helps maintain effective relationships within the entire sphere of professional practice and meets legal, ethical, and clinical standards of care.
- The qualities, behaviors, and therapeutic communication techniques described in this chapter characterize professionalism in helping relationships. Although the term patient is often used, the same principles apply when communicating with any person in any nursing situation.
Communication and interpersonal relationships
- Caring relationships formed among a nurse and those affected by a nurse's practice are at the core of nursing (see Chapter 7). Communication is the means of establishing these helping-healing relationships. All behavior communicates, and all communication influences behavior. For these reasons communication is essential to the nurse-patient relationship.
- A nurse's ability to relate to others is important for interpersonal communication. This includes the ability to take initiative in establishing and maintaining communication, to be authentic (one's self), and to respond appropriately to the other person. Effective interpersonal communication also requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership and that both are equal participants. Nurses honor the fact that people are very complex and ambiguous. Often more is communicated than first meets the eye, and patient responses are not always what you expect. By giving all of your attention to a patient, you attend to the patient's needs and aid the healing process (Tavernier, 2006). Most nurses embrace the profession's view of the holistic nature of people and experience synergy in human interaction. When patients and nurses work together, much can be accomplished.
- Therapeutic communication occurs within a healing relationship between a nurse and patient (Arnold and Boggs, 2011). Like any powerful therapeutic agent, the nurse's communication can result in both harm and good. Every nuance of posture, every small expression and gesture, every word chosen, every attitude held—all have the potential to hurt or heal, affecting others through the transmission of human energy. Knowing that intention and behavior directly influence health gives nurses tremendous ethical responsibility to do no harm to those entrusted to their care. Respect the potential power of communication and do not carelessly misuse communication to hurt, manipulate, or coerce others. Skilled communication empowers others and enables people to know themselves and make their own choices, an essential aspect of the healing process. Nurses have wonderful opportunities to bring about good things for themselves, their patients, and their colleagues through this kind of therapeutic communication.
levels of communication
- Nurses use different levels of communication in their professional role. A competent nurse uses a variety of techniques in each level.
- Intrapersonal communication is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk, self-verbalization, or inner thought. People's thoughts strongly influence perceptions, feelings, behavior, and self-concept. You need to be aware of the nature and content of your own thinking. Self-talk provides a mental rehearsal for difficult tasks or situations so individuals deal with them more effectively and with increased confidence (Gibson and Foster, 2007; White, 2008). Nurses and patients use intrapersonal communication to develop self-awareness and a positive self-concept that enhances appropriate self-expression. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions.
- Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart of nursing practice. It takes place within a social context and includes all the symbols and cues used to give and receive meaning. Because meaning resides in persons and not in words, messages received are sometimes different from intended messages. Nurses work with people who have different opinions, experiences, values, and belief systems; thus it is important to validate meaning or mutually negotiate it between participants. For example, use interaction to assess understanding and clarify misinterpretations when teaching a patient about a health concern. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth.
- Transpersonal communication is interaction that occurs within a person's spiritual domain. Study of the influence of religion and spirituality has increased dramatically in recent years, and ongoing research helps us understand the role of nurses in addressing a patient's spiritual needs (Pesut et al., 2008). Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their “higher power.” Nurses have a responsibility to assess a patient's spiritual needs and intervene to meet those needs (see Chapter 35).
- Small-group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small-group communication process. Small groups are most effective when they are cohesive and committed and have an appropriate meeting place with suitable seating arrangements (Arnold and Boggs, 2011). A nurse's role varies with the function of a group. He or she frequently coordinates the group, provides recognition and acceptance of the contributions of each group member, and provides encouragement and motivation to help the group meet its goals (Townsend, 2009).
- Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Public communication requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate messages effectively. Effective public communication increases audience knowledge about health-related topics, health issues, and other issues important to the nursing profession.
The referent motivates one person to communicate with another. In a health care setting sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, and other cues initiate communication. Knowing which stimulus initiates communication enables you to develop and organize messages more efficiently and better perceive meaning in another's message. A patient request for help prompted by difficulty breathing brings a different nursing response than a request prompted by hunger.
sender and receiver
The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The sender puts ideas or feelings into a form that is transmitted and is responsible for the accuracy of its content and emotional tone. The sender's message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the sender's message. Sender and receiver roles are fluid and change back and forth as two persons interact; sometimes sending and receiving occurs simultaneously. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly.
- The message is the content of the communication. It contains verbal, nonverbal, and symbolic language. Personal perceptions sometimes distort the receiver's interpretation of the message. Two nurses can provide the same information yet convey very different messages because of their personal communication styles. Two persons understand the same message differently. You send effective messages by expressing clearly, directly, and in a manner familiar to the receiver. You determine the need for clarification by watching the listener for nonverbal cues that suggest confusion or misunderstanding. Communication is difficult when participants have different levels of education and experience. “Your incision is well approximated without purulent drainage” means the same as “Your wound edges are close together, and there are no signs of infection,” but the latter is easier to understand. You can also send messages in writing, but make sure that patients are able to read.
- So when you are talking with another nurser with the surgeon, you would use the first way of phrasing things. When you are talking with a non-professional (patient or family member) you would use the second.
Channels are means of conveying and receiving messages through visual, auditory, and tactile senses. Facial expressions send visual messages, spoken words travel through auditory channels, and touch uses tactile channels. Individuals usually understand a message more clearly when the sender uses more channels to convey it. For example, when teaching about insulin self-injection, the nurse talks about and demonstrates the technique, gives the patient printed information, and encourages hands-on practice with the vial and syringe. Nurses use verbal, nonverbal, and mediated (technological) communication channels. They send and receive information in person, by informal or formal writing, over the telephone or pager, by audiotape and videotape, through fax and electronic mail, and through interactive and informational websites.
Feedback is the message the receiver returns. It indicates whether the receiver understood the meaning of the sender's message. Senders seek verbal and nonverbal feedback to evaluate the effectiveness of communication. The sender and receiver need to be sensitive and open to one another's messages, clarify the messages, and modify behavior accordingly. In a social relationship both persons assume equal responsibility for seeking openness and clarification, but the nurse assumes primary responsibility in the nurse-patient relationship.
Interpersonal variables are factors within both the sender and receiver that influence communication. Perception is one such variable that provides a uniquely personal view of reality formed by an individual's expectations and experiences. Each person senses, interprets, and understands events differently. A nurse says, “You have been very quiet since your family left. Is there something on your mind?” One patient may perceive the nurse's question as caring and concerned; another perceives the nurse as invading privacy and is less willing to talk. Other interpersonal variables include educational and developmental levels, sociocultural backgrounds, values and beliefs, emotions, gender, physical health status, and roles and relationships. Variables associated with illness such as pain, anxiety, and medication effects also affect nurse-patient communication.
The environment is the setting for sender-receiver interaction. For effective communication the environment needs to meet participant needs for physical and emotional comfort and safety. Noise, temperature extremes, distractions, and lack of privacy or space create confusion, tension, and discomfort. Environmental distractions are common in health care settings and interfere with messages sent between people. You control the environment as much as possible to create favorable conditions for effective communication.
Forms of communication
Messages are conveyed verbally and nonverbally, concretely and symbolically. As people communicate, they express themselves through words, movements, voice inflection, facial expressions, and use of space. These elements work in harmony to enhance a message or conflict with one another to contradict and confuse it
Communication is unsuccessful if senders and receivers cannot translate one another's words and phrases. When a nurse cares for a patient who speaks another language, an interpreter is often necessary. Even those who speak the same language use subcultural variations of certain words (e.g., dinner means a noon meal to one person and the last meal of the day to another). Medical jargon (technical terminology used by health care providers) sounds like a foreign language to patients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health care team members improves communication. Children have a more limited vocabulary than adults. They may use special words to describe bodily functions or a favorite blanket or toy. Teenagers often use words in unique ways that are unfamiliar to adults.
Denotative and connotative meaning
Some words have several meanings. Individuals who use a common language share the denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The connotative meaning is the shade or interpretation of the meaning of a word influenced by the thoughts, feelings, or ideas people have about the word. For example, health care providers tell a family that a loved one is in serious condition, and they believe that death is near; but to nurses serious simply describes the nature of the illness. You need to carefully select words, avoiding easily misinterpreted words, especially when explaining a patient's medical condition or therapy. Even a much-used phrase such as “I'm going to take your vital signs” may be unfamiliar to an adult or frightening to a child.
Tone of voice dramatically affects the meaning of a message. Depending on intonation, even a simple question or statement expresses enthusiasm, anger, concern, or indifference. Be aware of voice tone to avoid sending unintended messages. For example, a patient interprets a nurse's patronizing tone of voice as condescending, and this inhibits further communication. A patient's tone of voice often provides information about his or her emotional state or energy level.
Clarity and Brevity
Effective communication is simple, brief, and direct. Fewer words result in less confusion. Speaking slowly, enunciating clearly, and using examples to make explanations easier to understand improve clarity. Repeating important parts of a message also clarifies communication. Phrases such as “you know” or “OK?” at the end of every sentence detract from clarity. Use short sentences and words that express an idea simply and directly. “Where is your pain?” is much better than “I would like you to describe for me the location of your discomfort.”
Timing and relevance
Timing is critical in communication. Even though a message is clear, poor timing prevents it from being effective. For example, you do not begin routine teaching when a patient is in severe pain or emotional distress. Often the best time for interaction is when a patient expresses an interest in communicating. If messages are relevant or important to the situation at hand, they are more effective. When a patient is facing emergency surgery, discussing the risks of smoking is less relevant than explaining presurgical procedures.
People signal readiness to communicate through eye contact. Maintaining eye contact during conversation shows respect and willingness to listen. Eye contact also allows people to closely observe one another. Lack of eye contact may indicate anxiety, defensiveness, discomfort, or lack of confidence in communicating. However, persons from some cultures consider eye contact intrusive, threatening, or harmful and minimize or avoid its use (see Chapter 9). Always consider a person's culture when interpreting the meaning of eye contact. Eye movements communicate feelings and emotions. Looking down on a person establishes authority, whereas interacting at the same eye level indicates equality in the relationship. Rising to the same eye level as an angry person helps establish autonomy.
territoriality and personal space
Territoriality is the need to gain, maintain, and defend one's right to space. Territory is important because it provides people with a sense of identity, security, and control. It is sometimes separated and made visible to others such as a fence around a yard or a bed in a hospital room. Personal space is invisible, individual, and travels with the person. During interpersonal interaction, people maintain varying distances between each other, depending on their culture, the nature of their relationship, and the situation. When personal space becomes threatened, people respond defensively and communicate less effectively. Situations dictate whether the interpersonal distance between nurse and patient is appropriate. Box 24-3 provides examples of nursing actions within zones of personal space and touch (Kneisl and Trigoboff, 2009; Stuart, 2009). Nurses frequently move into patients’ territory and personal space because of the nature of caregiving. You need to convey confidence, gentleness, and respect for privacy, especially when your actions require intimate contact or involve a patient's vulnerable zone.
Zones of personal space
- Zones of Personal Space Intimate Zone (0 to 18 Inches)
- • Holding a crying infant
- • Performing physical assessment
- • Bathing, grooming, dressing, feeding, and toileting a patient
- • Changing a patient's dressing
- Personal Zone (18 Inches to 4 Feet)
- • Sitting at a patient's bedside
- • Taking a patient's nursing history
- • Teaching an individual patient
- • Exchanging information at change of shift
- Social Zone (4 to 12 Feet)
- • Making rounds with a physician
- • Sitting at the head of a conference table
- • Teaching a class for patients with diabetes
- • Conducting a family support group
- Public Zone (12 Feet and Greater)
- • Speaking at a community forum
- • Testifying at a legislative hearing
- • Lecturing to a class of students
zones of touch
- Social Zone (Permission not Needed)
- • Hands, arms, shoulders, back
- Consent Zone (Permission Needed)
- • Mouth, wrists, feet
- Vulnerable Zone (Special Care Needed)
- • Face, neck, front of body
- Intimate Zone (Great Sensitivity Needed)
- • Genitalia, rectum
Nurse-patient helping relationships
- Helping relationships are the foundation of clinical nursing practice. In such relationships you assume the role of professional helper and come to know a patient as an individual who has unique health needs, human responses, and patterns of living. Therapeutic relationships promote a psychological climate that facilitates positive change and growth. Therapeutic communication between you and your patients allows the attainment of health-related goals (Arnold and Boggs, 2011). The goals of a therapeutic relationship focus on a patient achieving optimal personal growth related to personal identity, ability to form relationships, and ability to satisfy needs and achieve personal goals (Stuart, 2009). There is an explicit time frame, a goal-directed approach, and a high expectation of confidentiality. A nurse establishes, directs, and takes responsibility for the interaction; and a patient's needs take priority over a nurse's needs. Your nonjudgmental acceptance of a patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings. It does not mean that you always agree with the other person or approve of the patient's decisions or actions. A helping relationship between you and a patient does not just happen—you create it with care, skill, and trust.
- Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal; whereas therapeutic interactions are often more intense, difficult, and uncomfortable.
- The skillful nurse uses judgment about what to share and provides minimal information or deflects such questions with gentle humor and refocuses conversation back to the patient.
- Through narrative interactions you begin to understand the context of others’ lives and learn what is meaningful for them from their perspective.
Phases of the Helping Relationship
- Preinteraction Phase
- Before meeting a patient:
- • Review available data, including the medical and nursing history.
- • Talk to other caregivers who have information about the patient.
- • Anticipate health concerns or issues that arise.
- • Identify a location and setting that fosters comfortable, private interaction.
- • Plan enough time for the initial interaction.
- Orientation Phase
- When the nurse and patient meet and get to know one another:
- • Set the tone for the relationship by adopting a warm, empathetic, caring manner.
- • Recognize that the initial relationship is often superficial, uncertain, and tentative.
- • Expect the patient to test your competence and commitment.
- • Closely observe the patient and expect to be closely observed by the patient.
- • Begin to make inferences and form judgments about patient messages and behaviors.
- • Assess the patient's health status.
- • Prioritize the patient's problems and identify his or her goals.
- • Clarify the patient's and your roles.
- • Form contracts with the patient that specify who will do what.
- • Let the patient know when to expect the relationship to be terminated.
- Working Phase
- When the nurse and patient work together to solve problems and accomplish goals:
- • Encourage and help the patient express feelings about his or her health.
- • Encourage and help the patient with self-exploration.
- • Provide information needed to understand and change behavior.
- • Encourage and help the patient set goals.
- • Take action to meet the goals set with the patient.
- • Use therapeutic communication skills to facilitate successful interactions.
- • Use appropriate self-disclosure and confrontation.
- Termination Phase
- During the ending of the relationship:
- • Remind the patient that termination is near.
- • Evaluate goal achievement with the patient.
- • Reminisce about the relationship with the patient.
- • Separate from the patient by relinquishing responsibility for his or her care.
- • Achieve a smooth transition for the patient to other caregivers as needed.
Nurse family relationships
Many nursing situations, especially those in community and home care settings, require you to form helping relationships with entire families. The same principles that guide one-on-one helping relationships also apply when the patient is a family unit, although communication within families requires additional understanding of the complexities of family dynamics, needs, and relationships
nurse-health care team relationships
- Communication with other members of the health care team affects patient safety and the work environment. Breakdown in communication is a frequent cause of serious injuries in health care settings (World Health Organization, 2007). When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, there is a risk for miscommunication. Accurate communication is essential to prevent errors (Cronenwett et al., 2007).
- Use of common language when communicating critical information helps prevent misunderstandings. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation
- Professional nursing care requires nurses to interact with members of the nursing team and interdisciplinary health care providers. Effective communication leads to a healthy work environment (Triola, 2006). Communication focuses on team building, facilitating group processes, collaborating, consulting, delegating, supervising, leading, and managing (see Chapter 21). Social, informational, and therapeutic interactions help team members build morale, accomplish goals, and strengthen working relationships. Lateral violence between colleagues sometimes occurs and includes behaviors such as withholding information, backbiting, making snide remarks, and nonverbal expressions of disapproval such as raising eyebrows or making faces. Lateral violence has an adverse effect on the work environment, leading to job dissatisfaction, poor retention of qualified nurses, nurses leaving the profession, and poor teamwork
Common courtesy is part of professional communication. To practice courtesy, say hello and goodbye to patients and knock on doors before entering. State your purpose, address people by name, and say “‘please” and “thank you” to team members. When a nurse is discourteous, others perceive him or her as rude or insensitive. It sets up barriers between nurse and patient and causes friction among team members.
Use of names
Always introduce yourself. Failure to give your name and status (e.g., nursing student, registered nurse, or licensed practical nurse) or acknowledge a patient creates uncertainty about the interaction and conveys an impersonal lack of commitment or caring. Making eye contact and smiling recognizes others. Addressing people by name conveys respect for human dignity and uniqueness. Because using last names is respectful in most cultures, nurses usually use a patient's last name in an initial interaction and then use the first name if the patient requests it. Ask how your patients and co-workers prefer to be addressed and honor their personal preferences. Using first names is appropriate for infants, young children, patients who are confused or unconscious, and close team members. Avoid terms of endearment such as “honey,” “dear,” “grandma,” or “sweetheart.” Avoid referring to patients by diagnosis, room number, or other attribute, which is demeaning and sends the message that you do not care enough to know the person as an individual.
autonomy and responsibility
Autonomy is being self-directed and independent in accomplishing goals and advocating for others. Professional nurses make choices and accept responsibility for the outcomes of their actions (Townsend, 2009). They take initiative in problem solving and communicate in a way that reflects the importance and purpose of the therapeutic conversation
communication with non-english speaking patients
- Patients who speak little or no English present challenges for nurse-patient communication. Federal and state laws require that consumers of health care have access to interpreter services, but these services are costly; thus use is often limited to crucial interactions. Sometimes there is a delay in interpreter services, yet some patients require urgent care. Use of family members, children, or auxiliary personnel poses legal liabilities. Language is not the only barrier. Cultural differences also lead to misunderstanding. Developing cultural competence increases understanding (Regenstein et al., 2009; Cobb, 2010).
- Implications for Practice
- • Understand your own cultural values and biases.
- • Assess the patient's primary language and level of fluency in English.
- • Provide an interpreter for the patient and health care providers to communicate with each other.
- • Speak directly to the patient even if an interpreter is present.
- • Nodding or statements such as “OK” do not necessarily mean that the patient understands.
- • Provide written information in English and primary language.
- • Learn about other cultures, especially those commonly encountered in your work area.
- Culture influences thinking, feeling, behaving, and communicating. Be aware of the typical patterns of interaction that characterize various cultures. For example, European Americans are more open and willing to discuss private family matters; whereas Hispanics, African Americans, and Asian Americans are sometimes reluctant to reveal personal or family information to strangers. Hispanics and Asian Americans value a quiet demeanor and self-restraint; to be open or argumentative reflects negatively on family honor. Native Americans also value silence and are comfortable with it.
- Foreign-born persons do not always speak or understand English. Those who speak English as a second language often experience difficulty with self-expression or language comprehension. To practice cultural sensitivity in communication, understand that persons of different cultures use different degrees of eye contact, personal space, gestures, loudness of voice, pace of speech, touch, silence, and meaning of language. Make a conscious effort not to interpret messages through your cultural perspective, but consider the communication within the context of the other individual's background. Avoid stereotyping, patronizing, or making fun of other cultures. Language and cultural barriers are not only frustrating but also dangerous, causing delay in care
Therapeutic communication techniques
Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. Learning these techniques helps you develop awareness of the variety of nursing responses available for use in different situations. Although some of the techniques seem artificial at first, skill and comfort increase with practice. Tremendous satisfaction results from developing therapeutic relationships and achieving desired patient outcomes.
- Active listening means being attentive to what a patient is saying both verbally and nonverbally. Active listening facilitates patient communication. Inexperienced nurses sometimes feel the need to talk to prove they know what they are doing or to decrease anxiety (Stuart, 2009). It is often difficult at first to be quiet and really listen. Active listening enhances trust because you communicate acceptance and respect for a patient. Several nonverbal skills facilitate attentive listening. You identify them by the acronym SOLER (Townsend, 2009):
- S—Sit facing the patient. This posture conveys the message that you are there to listen and are interested in what the patient is saying.
- O—Observe an open posture (i.e., keep arms and legs uncrossed). This posture suggests that you are “open” to what the patient says. A “closed” position conveys a defensive attitude, possibly provoking a similar response in the patient.
- L—Lean toward the patient. This posture conveys that you are involved and interested in the interaction.
- E—Establish and maintain intermittent eye contact. This behavior conveys your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying.
- R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates a lack of interest and a feeling of discomfort to the patient.
- Nurses make observations by commenting on how the other person looks, sounds, or acts. Stating observations often helps a patient communicate without the need for extensive questioning, focusing, or clarification. This technique helps start a conversation with quiet or withdrawn persons. Do not state observations that will embarrass or anger a patient, such as telling someone, “You look a mess!” Even if you make such an observation with humor, the patient can become resentful.
- Sharing observations differs from making assumptions, which means drawing unnecessary conclusions about the other person without validating them. Making assumptions puts a patient in the position of having to contradict the nurse. Examples include the nurse interpreting fatigue as depression or assuming that untouched food indicates lack of interest in meeting nutritional goals. Making observations is a gentler and safer technique: “You look tired …,” “You seem different today …,” or “I see you haven't eaten anything.”
Nurses recognize that hope is essential for healing and learn to communicate a “sense of possibility” to others. Appropriate encouragement and positive feedback are important in fostering hope and self-confidence and for helping people achieve their potential and reach their goals. You give hope by commenting on the positive aspects of the other person's behavior, performance, or response. Sharing a vision of the future and reminding others of their resources and strengths also strengthen hope. Reassure patients that there are many kinds of hope and that meaning and personal growth can come from illness experiences. For example, the nurse says to a patient discouraged about a poor prognosis, “I believe that you'll find a way to face your situation because I've seen your courage and creativity.”
- Dean and Major (2008) found that humor enhances teamwork, relieves tension, and helps nurses reframe difficult situations, allowing them to gain perspective. It also increases emotional flexibility, allowing nurses to shift rapidly from one situation to another. Huntley (2009) noted that humor helps nurses cope with serious situations and improves the work environment. Laughter provides a diversion from stress-related tension.
- Health care professionals sometimes use a kind of dark, negative humor after difficult or traumatic situations as a way to deal with unbearable tension and stress. This coping humor has a high potential for misinterpretation as uncaring by persons not involved in the situation. For example, nursing students are sometimes offended and wonder how staff are able to laugh and joke after unsuccessful resuscitation efforts. When nurses use coping humor within earshot of patients or their loved ones, great emotional distress results.
- Because of modern fast-paced technical environments, nurses are required more than ever to bring the sense of caring and human connection to their patients (see Chapter 7). Touch is one of the most potent forms of communication. Historically physical touch played a central role in healing (Leder and Krucoff, 2008). Nurses are privileged to experience more of this intimate form of personal contact than almost any other professional. Touch is used during procedures and assessment or to convey emotion (Playfair, 2010). It conveys many messages such as affection, emotional support, encouragement, tenderness, and personal attention. Comfort touch such as holding a hand is especially important for vulnerable patients who are experiencing severe illness with its accompanying physical and emotional losses (Fig. 24-2). When people are ill, they may feel detached from their body and become isolated from others. Touch helps them increase awareness of their body and gain connection with another person (Leder and Krucoff, 2008).
- Students often initially find giving intimate care to be stressful, especially when caring for patients of the opposite gender. They learn to cope with intimate contact by changing their perception of the situation. Since much of what nurses do involves touching, you need to learn to be sensitive to others’ reactions to touch and use it wisely. It should be as gentle or as firm as needed and delivered in a comforting, nonthreatening manner. Sometimes you withhold touch (e.g., highly suspicious or angry persons respond negatively or even violently to a nurse's touch).
Silence is particularly useful when people are confronted with decisions that require much thought. For example, it helps a patient gain the necessary confidence to share the decision to refuse medical treatment. It also allows the nurse to pay particular attention to nonverbal messages such as worried expressions or loss of eye contact. Remaining silent demonstrates patience and a willingness to wait for a response when the other person is unable to reply quickly. Silence is especially therapeutic during times of profound sadness or grief.
asking relevant questions
Asking too many questions is sometimes dehumanizing. Seeking factual information does not allow a nurse or patient to establish a meaningful relationship or deal with important emotional issues. It is a way for a nurse to ignore uncomfortable areas in favor of more comfortable, neutral topics. A useful exercise is to try conversing without asking the other person a single question. By using techniques such as giving general leads (“tell me about it …”), making observations, paraphrasing, focusing, and providing information, you discover important information that would have remained hidden if you limited the communication process to questions alone.
Self-disclosures are subjectively true personal experiences about the self that are intentionally revealed to another person. This is not therapy for a nurse; rather it shows patients that the nurse understands their experiences and their experiences are not unique. You choose to share experiences or feelings that are similar to those of the patient and emphasize both the similarities and differences. This kind of self-disclosure is indicative of the closeness of the nurse-patient relationship and involves a particular kind of respect for the patient. You offer it as an expression of sincerity and honesty, and it is an aspect of empathy (Stuart, 2009). Self-disclosures need to be relevant and appropriate and made to benefit the patient rather than yourself. Use them sparingly so the patient is the focus of the interaction: “That happened to me once, too. It was devastating, and I had to face some things about myself that I didn't like. I went for counseling, and it really helped…. What are your thoughts about seeing a counselor?”
When you confront someone in a therapeutic way, you help the other person become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors (Stuart, 2009). This technique improves patient self-awareness and helps him or her recognize growth and deal with important issues. Use confrontation only after you have established trust, and do it gently with sensitivity: “You say you've already decided what to do, yet you're still talking a lot about your options.”
Nontherapeutic communication techniques
- Certain communication techniques hinder or damage professional relationships. These specific techniques are referred to as nontherapeutic or blocking and often cause recipients to activate defenses to avoid being hurt or negatively affected. Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses or behaviors in others.
- Ex: asking personal questions, giving personal opinions, changing the subject, automatic responses, false reassurance, sympathy, asking for explanations, approval or disapproval, defensive responses, passive or aggressive responses, arguing,
adapting communication techniques for the patient with special needs
- With our aging population more patients have difficulty communicating. Hearing loss increases with age; 47% of Americans age 75 or older have a hearing impairment (NIDCD, 2010). Vision loss affects communication and presents a challenge for the 6.5 million Americans age 65 and older who report significant vision loss (AFB, 2010). Interacting with people who have conditions that impair communication requires special thought and sensitivity. Such patients benefit greatly when you adapt communication techniques to their unique circumstances or developmental level. For example, a nurse caring for a patient with impaired verbal communication related to cultural differences provides a table of simple words in the patient's language. The nurse and patient use the table to help communicate about basic needs such as food, water, toileting, pain relief, and sleep. Environmental considerations and adaptive equipment improve communication with hearing-impaired individuals (Swann, 2007). Research findings suggest that many of the difficulties in communicating with patients with severe communication impairment come from the lack of an understandable nurse-patient communication system (Hemsley et al., 2001). Further research in care of adults with cerebral palsy found that successful communication between nurses and patients with complex communication needs requires the nurse's knowledge of communication assistive devices and collaboration with the patient and family (Balandin et al., 2007).
- A nurse directs actions toward meeting the goals and expected outcomes identified in the plan of care, addressing both the communication impairment and its contributing factors. Box 24-9 lists many methods available to encourage, enhance, restore, or substitute for verbal communication. Be sure that a patient is physically able to use the chosen method and that it does not cause frustration by being too complicated or difficult.
- Documentation is anything written or printed on which you rely as record or proof of patient actions and activities. Documentation in a patient's medical record is a vital aspect of nursing practice.
- The health care environment creates many challenges for accurately documenting and reporting the care delivered to patients. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important responsibility of a nurse. Whether the transfer of patient information occurs through verbal reports, written documents, or electronically, you need to follow basic principles to maintain confidentiality of information.
- Sometimes nurses use health care records for data gathering, research, or continuing education. As long as a nurse uses a record as specified and permission is granted, this is permitted. When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice.
- To protect patient confidentiality, ensure that written or electronic materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information) and never print material from an electronic health record for personal use.
Reports are oral, written, or audiotaped exchanges of information among caregivers. Common reports given by nurses include change-of-shift reports, telephone reports, hand-off reports, and incident reports. A health care provider calls a nursing unit to receive a verbal report on a patient's condition. The laboratory submits a written report providing the results of diagnostic tests and often notifies the nurse by telephone if results are critical.
Purposes of records
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring.
The patient's record is one way that health care team members communicate patient needs and progress, individual therapies, content of consultations, patient education, and discharge planning. The plan of care needs to be clear to anyone reading the chart (see Unit 3). The record is the most current and accurate continuous source of information about a patient's health care status. Information communicated in the patient's record allows health care providers to know a patient thoroughly, facilitating safe, effective, and timely patient-centered decisions. To enhance communication and promote safe patient care, you base communication on assessment findings and document patient information as you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment).
- Accurate documentation is one of the best defenses for legal claims associated with nursing care (see Chapter 23). To limit nursing liability nursing documentation must indicate clearly that a patient received individualized, goal-directed nursing care based on the nursing assessment. The record must describe exactly what happened to a patient and follow agency standards. This is best achieved when you chart immediately after providing care. Even though nursing care may have been excellent, in a court of law “care not documented is care not provided.”
- Common charting mistakes that result in malpractice include: (1) failing to record pertinent health or drug information, (2) failing to record nursing actions, (3) failing to record that medications have been given, (4) failing to record drug reactions or changes in patients' conditions, (5) writing illegible or incomplete records, and (6) failing to document discontinued medications. Table 26-1 provides guidelines for legally sound documentation.
- Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care. A DRG is a classification based on patients’ medical diagnoses. Hospitals are reimbursed a predetermined dollar amount by Medicare for each DRG. Detailed recording establishes diagnoses for determining a DRG. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency.
- A medical record audit reviews financial charges used in the patient's care. Private insurance carriers and auditors from federal agencies review records to determine the reimbursement that a patient or a health care agency receives. Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement.
A patient's record contains a variety of information, including diagnoses, signs and symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviors. One way to learn the nature of an illness and the individual patient's response to it is to read the patient care record. No two patients have identical records, but you can identify patterns of information in records of patients who have similar health problems. With this information you learn to anticipate the type of care required for a patient.
After obtaining appropriate agency approvals, nurse researchers often use patients’ records for research studies to gather statistical data on the frequency of clinical disorders, complications, use of specific medical and nursing therapies, recovery from illness, and deaths. Researchers also use this information to investigate nursing interventions or health problems. For example, a nurse wants to compare a new method of pain control with a standard pain protocol using two groups of patients. The records provide data on the two types of interventions: the new method and the standard pain control. The nurse researcher collects data from the records that describe the type and dose of analgesic medications used, objective assessment data, and patients’ subjective reports of pain relief. The researcher then compares the findings to determine if the new method was more effective than the standard pain control protocol. Analysis of the data contributes to evidence-based nursing practice and quality health care
auditing and monitoring
Hospitals establish quality improvement programs for conducting objective, ongoing reviews of patient care. Quality improvement programs keep nurses informed of standards of nursing practice to maintain excellence in nursing care. Accrediting agencies such as TJC (2011) require quality improvement programs and set standards for the information located in a patient's record, including indications that a plan of care is developed with the patient as a participant and that discharge planning and patient education have occurred. Institutions and accrediting groups establish standards for quality care. Nurses audit records throughout the year to determine the degree to which standards of care are met and identify areas needing improvement and staff development (see Chapter 5). Nurses share deficiencies identified during monitoring with all members of the nursing staff to make changes in policy or practice.
guidelines for quality documentation and reporting
- High-quality documentation and reporting are necessary to enhance efficient, individualized patient care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current, and organized.
- A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of the details regarding the behaviors exhibited by a patient. Objective documentation includes observations of a patient's behaviors. For example, instead of documenting “the patient seems anxious,” provide objective signs of anxiety and document “the patient's pulse rate is elevated at 110 beats/min, respiratory rate is slightly labored at 22 breaths/min, and the patient reports increased restlessness.”
- The only subjective data included in the record are what the patient says. When recording subjective data, document the patient's exact words within quotation marks whenever possible. For example, when he or she exhibits anxiety, you record, “Patient states, ‘I feel very nervous.’” Include objective data to support subjective data so your charting is as descriptive as possible.
- Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care. To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected from a patient. Document the following activities or findings at the time of occurrence:
- • Vital signs
- • Pain assessment
- • Administration of medications and treatments
- • Preparation for diagnostic tests or surgery, including preoperative checklist
The database section contains all available assessment information pertaining to a patient (e.g., history and physical examination, the nurse's admission history and ongoing assessment, the dietitian's assessment, laboratory reports, and radiological test results). It is the foundation for identifying patient problems and planning care. As new data become available, you revise the database. It accompanies patients through successive hospitalizations or clinic visits.
After analyzing data, health care team members identify problems and make a single problem list. The problem list includes the patient's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs. Team members list the problems in chronological order and file the list in the front of the patient's record to serve as an organizing guide for his or her care. Add new problems as you identify them. When a problem is resolved, record the date and highlight it or draw a line through the problem and its number.
Disciplines involved in the patient's care develop a care plan or plan of care for each problem (see Chapter 18). Nurses document the plan of care in a variety of formats. Generally these plans of care include nursing diagnoses, expected outcomes, and interventions.
- Health care team members monitor and record the progress of a patient's problems. Progress notes come in various formats or structured notes. One method is SOAP charting (see Box 26-1). The acronym SOAP stands for:
- S—Subjective data (verbalizations of the patient)
- O—Objective data (that which is measured and observed)
- A—Assessment (diagnosis based on the data)
- P—Plan (what the caregiver plans to do).
- A second progress note method is the PIE format. It is similar to SOAP charting in its problem-oriented nature. However, PIE charting differs from the SOAP method in that it has a nursing origin, whereas SOAP originated from medical records. The format simplifies documentation by unifying the care plan and progress notes. PIE differs from SOAP notes because the narrative does not include assessment information. A nurse's daily assessment data appear on flow sheets, preventing duplication of data. The narrative note includes P—Problem, I—Intervention, and E—Evaluation. The PIE notes are numbered or labeled according to the patient's problems. Resolved problems are dropped from daily documentation after the nurse's review. Continuing problems are documented daily.
- A third narrative format is focus charting. It involves use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness). A DAR note addresses patient concerns: a sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in a patient's condition (see Box 26-1). Documentation follows the nursing process. Nurses broaden their thinking to include any patient concerns, not just problem areas. Focus charting incorporates all aspects of the nursing process, highlights a patient's concerns, and can be integrated into any clinical setting
In a source record a patient's chart has a separate section for each discipline (e.g., nursing, medicine, social work, or respiratory therapy) to record data.
charting by exception
Charting by exception (CBE) focuses on documenting deviations from established norms. This approach reduces documentation time and highlights trends or changes in a patient's condition (Mosby, 2006). It is a shorthand method for documenting normal findings and routine care based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. With standards integrated into documentation forms such as predefined normal assessment findings or predetermined interventions, a nurse then only documents significant findings or exceptions to the predefined norms. The nurse writes a progress note only when the standardized statement on the form is not met. Assessments are standardized on forms so all caregivers evaluate and document findings consistently
Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame. All health care team members use the same critical pathway to monitor a patient's progress during each shift or, in the case of home care, every visit.
Flow sheets allow you to quickly and easily enter assessment data about a patient, including vital signs and routine repetitive care such as hygiene measures, ambulation, meals, weights, and safety and restraint checks. They provide current patient information that is accessible to all members of the health care team. Because there is a coding system for data entry, flow sheets help team members quickly see patient trends over time and decrease time spent on writing narrative notes. If an occurrence on a flow sheet is unusual or changes significantly, enter a focus note. For example, if a patient's blood pressure becomes dangerously high, first complete a focus assessment. You record your assessment and the action taken in the progress notes. Critical and acute care units commonly use flow sheets for all types of physiological data.
Patient Care Summary or Kardex
- This is the way you find out quickly and easily what's going on with the patient and who's involved. You will want to check this at the beginning of your shift and any time you need to clarify something. It will need frequent updating, as well.
- Many hospitals now have computerized systems that provide information in the form of a patient care summary that is often printed for each patient during each shift. The summary automatically updates as nurses make decisions and data (e.g., orders) are entered into the computer. In some settings a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. Most Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.
Standardized care plans
- Some institutions use standardized care plans to make documentation more efficient. The plans, based on the institution's standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. After completing a nursing assessment, the nurse identifies the standard care plans that are appropriate for the patient and places the plans in his or her medical record. The nurse modifies the plans to individualize the therapies. Most standardized care plans also allow a nurse to add specific goals or desired outcomes of care and the dates by which these outcomes should be achieved.
- Standardized care plans are useful when conducting quality improvement audits. They also improve continuity of care among professional nurses. When they are used in a health care facility, the nurse remains responsible for providing individualized care to each patient. Standardized care plans cannot replace a nurse's professional judgment and decision making. Update care plans on a regular basis to ensure that they are current and appropriate.
discharge summary forms
- To save costs and ensure appropriate reimbursement, it is important to prepare patients for an effective, timely discharge from a health care institution. A patient's discharge also needs to result in desirable outcomes. Interdisciplinary discharge planning ensures that a patient leaves the hospital in a timely manner with the necessary resources (Box 26-3).
- Ideally discharge planning begins at admission. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home. Nurses revise a plan of care as a patient's condition changes. Involve the patient and family in the discharge planning process so they have the necessary information and resources to return home. Discharge documentation includes medications, diet, community resources, follow-up care, and who to contact in case of an emergency or for questions.
home care documentation
Documentation in the home care system is different from other areas of nursing. Medicare has specific guidelines to establish eligibility for home care reimbursement. Information used for reimbursement comes from a patient's medical record. In addition, home care documentation systems provide the entire health care team with the information needed to enhance teamwork. Documentation is both the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies. Nurses must document all their services for payment (e.g., direct skilled care, patient instructions, skilled observation, and evaluation visits) (TJC, 2011). Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers.
hand off report
- Hand-off reports happen any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient (Table 26-4). Examples of hand-off reports include change-of-shift reports and transfer reports.
- An effective hand-off report is quick and efficient. A good report provides a baseline for comparisons and indicates the kind of care anticipated for the next nurse who will be caring for the patient. An organized and concise approach helps you set goals and anticipate patient needs and lessens the chance of overlooking important information.
- A registered nurse makes a telephone report when significant events or changes in a patient's condition have occurred. A telephone report needs to include clear, accurate, and concise information. About 60% of the worst type of medical errors, called sentinel events, relate to communication problems that often arise during telephone reports (Hemmila, 2006). Thus some institutions use SBAR, an acronym that stands for Situation-Background-Assessment-Recommendation. SBAR standardizes telephone communication of significant events or changes in a patient's condition and is a communication strategy designed to improve patient safety. For example, when describing the situation, you include both the admitting and secondary diagnoses and the problem your patient is having as the current issue. Background information includes pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. For assessment data include significant findings in your head-to-toe physical assessment, recent vital signs, current treatment measures, restrictions, recent laboratory results and diagnostics, and pain status. Then provide your recommendation, in which you suggest a plan of care and what needs to be addressed (Hemmila, 2006).
- Document every phone call you make to a health care provider. Documentation includes when the call was made, who made it (if you did not make the call), who was called, to whom information was given, what information was given, what information was received, and verification of the information with the provider.
A telephone order (TO) occurs when a health care provider gives an order over the phone to a registered nurse. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. TOs and VOs usually occur at night or during emergencies and frequently cause medical errors (Bombard, 2008). The nurse receiving a TO or VO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct (Bombard, 2008). An example follows: “10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back.” The health care provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy. TOs and VOs are used only when absolutely necessary and not for the sake of convenience. In some situations it is prudent to have a second person listen to TOs. Check agency policy. Box 26-4 provides guidelines that promote accuracy when receiving TOs.
Incident or Occurrence Reports
- An incident or occurrence is any event that is not consistent with the routine operation of a health care unit or routine care of a patient. Examples of incidents include patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or a risk for patient injury. Analysis of incident reports helps with the identification of trends in systems and unit operations that provide justification for changes in policies and procedures or for in-service seminars. Incident (or occurrence) reports are an important part of the quality improvement program of a unit (see Chapter 5).
- Always contact the patient's health care provider whenever an incident happens. Note that you do not mention the incident report in the patient's medical record. Instead you document an objective description of what happened, what you observed, and the follow-up actions taken in the patient's medical record. It is important to evaluate and document the patient's response to the error or incident.
- Follow agency policy when making an incident report.
Health informatics is defined by the American Medical Informatics Association (AMIA) as, “The application of computer and information science in all basic and applied biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and communication of health-related data. The focus is the patient and the process of care, and the goal is to enhance the quality and efficiency of care provided” (Hebda et al., 2009). Nursing competence in health care informatics is becoming a priority as health care facilities adopt EMRs/EHRs and other technologies. A recent survey found that only 28% of primary care physicians in the United States used EMRs in practice (Davis et al., 2009). Another survey of 2952 hospitals in the United States reported that only 1.5% of U.S. hospitals have a comprehensive EHR system in place and 10.9% were using a basic EHR (Jha et al., 2009). Use of EMRs/EHRs is increasing as a result of the creation of the federal Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009. The government will make incentive payments totaling over $27 billion over a 10-year period to health care agencies and provider's offices that adopt EHRs and use data meaningfully from the EHR to promote safe, high-quality patient care resulting in positive patient outcomes (Blumenthal, 2010). In addition, penalties will be assessed to health care facilities that do not adopt EHRs or show meaningful use of data generated from EHRs.
information technology (IT)
refers to the management and processing of information, generally with the assistance of computers
Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice (American Nurses Association, 2008). It facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings. The application of nursing informatics results in an efficient and effective NIS.
clinical decision support system
Clinical decision support systems (CDSSs) are computerized programs used within the health care setting to support decision making (Lyerla, 2008). When used to support nursing decisions it is called a nursing CDSS (Fig. 26-2). A CDSS is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information to the user. The information within a CDSS is current, is evidence based, and has the ability to be updated. Information provided by a CDSS is given to the right person at the right time. For example, an effective CDSS notifies health care providers of patient allergies before ordering a medication. This enhances patient safety during the medication ordering process. CDSSs also improve nursing care. When patient assessment data are combined with patient care guidelines, nurses are better able to implement evidence-based nursing care, resulting in improved patient outcomes
Definitions of health
- Dictionary: hale, sound, whole. "The state of being hale, sound, or whole in body, mind, and soul" Websters
- Wholeness of body, parts functioning properly, mental balance
- In harmony with nature, balance, yin and yang
- Multidimensional: WHO, 1947: "A state of complete physical, mental and social well-being, not merely the absence of disease or infirmity"
- Biological: absence of diagnosable disease, "normal", physical findings
- Not necessarily synonymous with disease
- A state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished compared with a previous experience.”
- Illness impacts individual and family self concept, roles and interpersonal dynamics
risk factors for disease
- genetic and physiological factors
- any situation, habit, social or environmental condition, physiological or physiological condition, or spiritual or other variable that increases the vulnerability of an individual or group to an illness or accident
- the process of enabling people to increase control over and to improve their health (WHO)
- That which supports health and healthy growth and development:
- -Strong and healthy relationships
- Scope of concept includes the individual, family, community, population and environment
definitions of evidence
- Evidence is a testimony of facts tending to prove or disprove a conclusion
- -the legal system is an essential element in judging a situation; establishes guilt
- -evidence from the field of health sciences establishes benefit or harm, best practices in the context of health care, evidence supports or disputes the efficacy of treatment, use of diagnostic tool, transmission of a disease and so on
- -evidence-based nursing is an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served
- -has it been systemically examined utilizing research methods and published in a peer reviewed journal?
levels of evidence
- quality of evidence varies
- level or grade of evidence is often provided in practice guidelines, for example:
- -Grade A: strongly recommends
- Grade B: recommends
- Grade C: no recommendation
- Grade D: recommends against
- Grade I: insufficient evidence to recommend for or against
Individual-focused health promotion models
- Most health promotion models that focus on individuals share these common themes:
- -decision making
community-focused health promotion models
- Most health promotion models that focus on communities share these common themes:
- -focus on community values and norms
- -legitimization of desirable behavior and environmental changes
- -participation of community leadership
- -planned change in which community members have control
critical thinking defined
- Involves recognizing that a problem exists
- Analyzing information about the issue
- Evaluation and synthesizing the information
- Drawing conclusions
- Timeframe included
safety in nursing practice
- Definition: the prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors
- Estimated that between 44,000 and 98,000 people in the US die of medical error each year
- The estimated cost of medical errors was between $17 billion and $29 billion at hospitals across the country
- 180,000 patients die in medicare alone in a given year
- Between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death
- Medical errors are the third-leading cause of death in America, behind heart disease and cancer being the second
- Quality and Safety Education for Nurses definition of safety: minimizes risk of harm to patients and providers through both system effectiveness and individual performance
- Levels of error:
- -Adverse event
- -near miss
- -Sentinel event (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof)
- Estimated 99,000 deaths each year
- over 2 million patients infected
- cost to health care system=$4.5 billion/year
- Preventable with use of aseptic principles/techniques
examples of spread by droplet
rubella, mumps, whopping cough, menigococcal pneumonia, influenza
examples of airborne pathogens
TB, chicken pox, measles
a sense that allows a person to recognize the size, shape and texture of an object
Three primary categories of communication
- Linguistic: spoken words or written symbols
- Paralinguistic: nonverbal messages (gestures, eye contact, facial expressions)
- Metacommunication: context of the message
levels of communication
- Intrapersonal: occurs within an individual
- Interpersonal: one-to-one interaction between two people
- Transpersonal: interaction within a person's spiritual domain
- Small group: interactions with a small number of people
- Public: interaction with an audience
inability to speak
- Situation: what is going on with the patient?
- Background: what is the clinical background or context?
- Assessment: what do I think the problem is?
- Recommendation: what do I recommend?
Nursing Information Systems (NIS)
- -Nursing process design: most traditional. It organizes documentation within well-established formats such as admission and postoperative assessment problem lists, care plans, discharge
- planning instructions, and intervention lists or notes.
-protocol or critical pathway design
-Clinical decision support systems (CDSSs): used to support decision makin