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Chapter 9: Communication & Collaboration in Nursing. Bonnie M. Wivell, MS, RN, CNS. Therapeutic Use of Self. Hildegard Peplau was first to focus on nurse-patient relationships, Interpersonal Relations in Nursing (1952)

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Chapter 9: Communication & Collaboration in Nursing

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Chapter 9: Communication & Collaboration in Nursing

Bonnie M. Wivell, MS, RN, CNS


Therapeutic Use of Self

Hildegard Peplau was first to focus on nurse-patient relationships, Interpersonal Relations in Nursing (1952)

Therapeutic use of self: forming a trusting relationship that provides comfort, safety, and nonjudgmental acceptance of patients to help them improve their health status.

It calls for self-awareness & use of effective communication techniques.

Communication skills can be developed


Traditional Nurse-Patient Relationship

  • Orientation phase

    • “Getting to know you”

    • Nurse and patient assess one another

    • Early impressions are important

    • Pt. should learn RN name, credentials, responsibility

    • Beginning development of trust

      • Admit what you don’t know, but find out the answers

      • Develop an initial understanding of patient problem/needs

  • Tasks of this phase

    • Pt. will have enough trust to participate in relationship

    • RN and pt. see each other as unique individuals & worthy of respect,

    • Set goals and identify problems (contract – formal/informal)


Traditional Nurse-Patient Relationship

  • Working phase

    • Tasks/goals worked on

    • Pt. may alternate with periods of intense effort and resistance to change

    • Nurse must be patient, listen to patient’s feelings/needs

  • Termination phase

    • End relationship

    • Feelings of loss for both discussed

    • Gifts & continued contact should be avoided (not a social relationship)


Role of Self-awareness

Important to be aware of own feelings, stereotypes, blind spots, & biases—may interfere with nonjudgmental acceptance

Guard against nurse need to be liked/needed—get own emotional needs met outside of nurse-patient relationship.

Not all patients like their nurse & not all nurses like their patients

Not all patients share nurse’s beliefs, values, ethics

Self-awareness keeps nurse non-judgmental , avoid stereotyping, build a therapeutic relationship


Professional Boundaries

Professional boundaries: “the space between the nurse’s power and the client’s vulnerability.”

Nurse responsible for delineating & maintaining boundaries; nurse-client relationship does not meet needs of nurse; no post-termination relationships; no social relationships


Professional vs Social Relationship


Principles for DeterminingProfessional Boundaries

Nurse responsible to delineate boundaries

Nurse work within “zone of helpfulness”

Nurse examine any boundary crossing, aware of implications; avoid repeated crossing

Variables that impact: setting; community; client needs; nature of therapy

Actions that meet nurse’s needs overstep boundaries and are boundary violations

Avoid dual relationships of both personal & business

Post-termination relationships complex as client may need additional services & difficult to determine when relationship terminated


Reflective Practice

  • Patients’ values, beliefs and lifestyles may challenge the nurses’ own

  • Can produce discomfort as nurses become aware of the tensions and anxieties

  • Are your personal values challenged by the realities of practice?

  • Time to reflect on experiences and interactions allows us the ability to develop insight into self


Re-conceptualizing the Nurse-Patient Relationship

  • Assumptions of the Nurse-Patient relationship which no longer hold true

    • It is linear and proceeds through several phases, each building on the preceding one

    • Building trust is essential during early phases of the relationship

    • Time and repeated contacts are required to establish an effective relationship

    • Patients desire relationships with nurses, wish to receive services from them, and will cooperate and comply with those nurses.


Theory of Human Relatedness

  • Approach each nurse-patient contact as an opportunity for connection and goal achievement rather than as one step in a lengthy relationship-building process

  • Approach the patients with a sense of the patient’s autonomy, choice and participation

  • Put relationship on equitable ground – nurse doesn’t need to have the power


Communication

Exchange of thoughts, ideas, or information and is basis of relationships—dynamic

Verbal (speech) and nonverbal (gestures, tone & volume of voice, posture, actions, facial expressions) Do these match—congruent?

Ruesch’s major elements: sender, message, receiver, feedback, context.

Operations: Perception (interpretation of incoming signal into meaning), evaluation (analysis of information ), transmission (expression of information—verbal/nonverbal)

Influences: gender, culture, interests & mood, clarity, length


How Communication Develops

  • Infants use SOMATIC language = crying; reddening of the skin; fast, shallow breathing; facial expressions; and jerking of the limbs

    • Decreases with maturity

  • ACTION language consists of reaching out, pointing, crawling toward a desired object, or closing the lips and turning the head when an undesired food is offered

  • VERBAL language is last to develop

    • Amount of stimuli can enhance or retard development of language skills

  • Development of communication is determined by inborn and environmental factors

  • Nonverbal communication development is influenced by environment


Successful Communication

Feedback: giving back information to sender

Appropriateness: reply fits circumstances

Efficiency: simple, clear words paced suitably

Flexibility: base message on immediate situation rather than on preconceived notion


Becoming a Better Communicator

  • Active listening: communicating interest and attention

    • Eye contact

    • Nod, mumble, encourage continuation

    • Open posture

    • Pay attention, focus on patient not the task

    • Reflect feelings, meaning

    • Allow patients to vent concerns or frustrations

  • 3 faults: interrupting, finishing sentences for others, lack of interest

  • You can become a better communicator with conscious practice and awareness


Helpful Response Techniques

Empathy: awareness, sensitivity to, and identify with feelings of another (Sympathy shares feelings of another)

Open-ended questions: require more than yes or no answers. “Tell me about…..”

Giving information: sharing knowledge recipient not expected to know; don’t share your opinion

Reflection: encourages patient to think through problems for themselves

Silence: allows time for reflection & thinking; be with your patient


Blocks to Communication

Failing to see each individual as unique: stereotyping; preconceived ideas; prejudices

Failing to recognize levels of meaning: verbal cues

Using value statements and clichés

Using false reassurance: “It will be alright.”

Failing to clarify


Holistic Communication

  • “The art of sharing emotional and factual information. It involves letting go of judgments and appreciating the patient’s point of view.”

  • Speeds healing

  • Decreases anxiety

  • Pts complain less

  • Call for attention less often

  • Feel understood and valued

  • More likely to comply with treatment plan


Communication in Workplace

Use same communication skills with colleague

Face to face communication best, important

Use of e-mail lacks facial expression, tone of voice, and contextual cues—no non-verbal

Be courteous, give full attention, no cell phone use while speaking with others

Avoid jargon, acronyms, abbreviations

Keep short & purposeful: SBAR

Receiving messages—read, listen, and evaluate entire message before responding.


Multicultural Workplace

  • Diversity in age, race, gender, ethnicity, country of origin, sexual orientation, and disability is present

  • Culture is the lens through which all other aspects of life are viewed

  • Culture determines one’s health beliefs and practices

  • Strategies on page 229 of text

  • Use clear, simple messages and clarify intent

  • TRUST must exist for communication to be effective


Collaboration

  • Implies working jointly with other professionals, all of whom are respected for their unique knowledge and abilities, to improve a patient’s health status or to solve an organizational problem.


Collaboration with Co-workers

Acknowledgement of cultural diversity

Respect for each other & difference in opinion

Emotional maturity

Confidence in own knowledge; know limits

Willingness to learn

Cooperative spirit

Belief in common purpose

Willingness to negotiate

Acknowledge conflict and solve problems


Organizational Collaboration

  • Flat organizational structure

  • Encouragement and support of individuals to act autonomously

  • Recognition of team accomplishments

  • Cooperation

  • Valuing of knowledge and expertise

  • Support equality and interdependence

  • Creativity and shared vision are valued


RN-MD Collaboration

  • Gender differences

  • Care-cure conflict

  • Emotionally-based conflicts are attributable to relationships

  • Task-based conflicts are a result of differences of opinion over how to approach a task or achieve a mutual goal


Collaboration with Assistive Personnel

  • Assistive personnel need to feel welcome, appreciated, and respected

  • RNs need to feel competent as managers of pt. care and have unlicensed personnel comply with requests and give feedback about assigned activities

  • Mutual respect and understanding


Important to Patient Care

Positive relationships have a positive impact on patient care

Relationship based care includes relationships with:

Patient/family

Self

Colleagues

Effective communication skills practiced and intentionally used, and communication blocks avoided, improve relationships


Chapter 10: Illness, Culture, & Caring: Impact on Patients, Families, & Nurses

Bonnie M. Wivell, MS, RN, CNS


Illness

  • Illness is a highly personal experience

  • Disease is an alteration at the tissue/organ level causing reduced capacities or reduction of normal life span

  • One may feel ill in the absence of disease

  • Patient’s perceptions of change in body image or loss of function/body part play a role in whether they see themselves as ill

  • Illness is experienced differently by individuals and their families

  • Culture determines how individuals and families react to illness


Acute vs Chronic Illness

  • Acute: characterized by severe symptoms that are relatively short-lived, appear suddenly, progress steadily & subside; may not require medical attention; acute illness can lead to chronic illness, i.e. MI → CHF

  • Chronic: usually develops gradually, requires ongoing medical attention, and may continue for duration of person’s life. Are caused by permanent changes that leave residual disability.

  • Remission: when symptoms subside

  • Exacerbation: when symptoms reappear or worsen


Stages of Adjustment to Illness

  • Stage I: Disbelief & Denial

  • Stage II: Irritability & Anger

  • Stage III: Attempting to gain control

  • Stage IV: Depression & Despair

  • Stage V: Acceptance & Participation

  • Not all go through every stage and may not go through them at same rate or in same order


The Sick Role

  • Children learn sick role through parental modeling

  • Culture determines certain criteria for “sick”

  • Sick role for Anglo-Americans (Parsons, 1964)

    • Exempt from social responsibilities

    • Cannot expect to care for self

    • Should want to get well

    • Should seek medical advice

    • Should cooperate with medical experts

  • Current expectation is person accepts responsibility for their own care & want to get well; Healthy behavior encouraged. If don’t cooperate labeled ”noncompliant”.


Illness Behaviors

  • Internal influences: personality

    • Dependence/independence needs

    • Coping: ability to assess and manage demands

    • Hardiness: resistance to stressful life events

    • Learned resourcefulness: promoting adaptive, healthy lifestyles

    • Resilience: pattern of successful adaptation despite challenging or threatening circumstances

      • Disposition: personality, health, cognition

      • Family factors: warmth, support, organization

      • Outside support: supportive network and success at school or work

    • Spirituality: inner strength related to belief in a higher power


Spirituality

  • Occurs over lifetime & internal process

  • Role in health care being researched

  • Benson & Stark(1996) Prayer for relaxation

  • Spiritual nursing goes beyond chaplain

  • Holistic nursing: physical, psychological, social, & spiritual

  • NANDA nursing diagnosis of spiritual distress: “disturbance in belief or value system that provides strength, hope, & meaning to life.”


Illness Behaviors

  • External influences:

    • Past experiences

    • Culture: pattern of learned behavior and values that are reinforced

      • Communication patterns strongly influenced by culture (i.e. nodding head to be polite not in understanding)

      • Personal space norms depend on cultural experience (i.e. touching can be major form of communication or be considered disrespectful)

      • Role expectations: nurse being passive vs authoritarian

      • Values of nurse may conflict with pt’s cultural values (ex. pain management)

      • Ethnocentrism: to view one’s own cultural group as superior to others


History of Cultural Competence

  • Early 1970s: SONs began including cultural concepts

  • 1981: Transcultural Nursing Society incorporated

  • 1988: Certification began

  • 1989: Journal of Transcultural Nursing published

  • Dr. Madeleine Leininger, Founder of Transcultural Nursing


Cultural Considerations

  • Cultural competence: nurse’s knowledge of cultural influences that affect a pt’s response to healthcare and interventions

  • Consider culture including health and religious beliefs in providing culturally sensitive care

  • Avoid stereotyping—one size does not fit all

  • Cultural conditioning: Culture-bound; unconscious of own innate values/beliefs and assume all are alike

    • Personal Space

    • Role Expectations


Cultural Considerations Cont’d.

  • Ethnopharmacology = understanding responses to prescribed meds and genetic variations in responses to drugs

  • Ethnocentrism = the inclination to view one’s own cultural groups as superior to others and to view differences negatively

  • Cultural assessment: “merely asking people their preferences, what they think, who we should talk to in making a decision.”


Impact of Illness on Patient

  • Behavioral & emotional changes

  • Changes in patient role within family

  • Disturbance of family dynamics

  • Severe illness may affect physical appearance & functioning

  • Emotions of guilt, anger, anxiety


Impact of Illness on Family

  • Acute and chronic illness changes family functioning

  • Feelings experienced go up & down

  • Sometimes family members withdraw from each other—fear feelings may not be okay

  • Family members uncertain how to treat & relate to sick member

  • Shift of responsibilities within family


Anxiety

  • Definition: Response to some real or perceived threat

  • Symptoms:

    • Physical: Increase HR, BP, Respirations, insomnia, N/V, fatigue, sweaty, tremors

    • Emotional: restlessness, irritable, feelings of helplessness, crying & depression

    • Cognitive: inability to concentrate, forgetfulness, inattention to surroundings & preoccupation


Anxiety Levels

  • Mild: Increased alertness & ability to focus, improved concentration, expanded learning

  • Moderate: Concentration limited to one thing, including body movements, rapid speech, subjective awareness of discomfort

  • Severe Anxiety: Thoughts scattered, verbal communication difficult, discomfort, purposeless movements

  • Panic: Disorganized, difficulty distinguishing real from unreal, random movements, unable to function without assistance


Stress

  • Definition: response of interaction between the individual and environment—includes all responses body makes to maintain equilibrium & deal with demands

  • Plays a major role in the development of illness

    • PUD

    • HTN

    • Autoimmune disorders

    • Reduces immune response resulting in delayed healing and greater susceptibility to infection such as cold or flu

  • Evaluate lifestyles—triggers; individual perception; capable of handling/coping?

  • Relaxation techniques


Impact of Anxiety & Stress

  • Nurse should consider impact of client’s anxiety/stress levels when providing care.

  • What other emotions may be involved?

  • Today’s reduced hospital stays increases need for client/family to learn needed care

  • How will anxiety/stress impact learning?

  • These & what other things reduce the client/family’s ability to learn that impacts the client’s hospitalization and outcome?


Barriers to Learning

  • High Anxiety

  • Sensory deficits (vision, hearing)

  • Pain

  • Fatigue

  • Hunger/thirst

  • Language differences

  • Differing health values

  • Low literacy

  • Lack of motivation

  • Environmental factors (noise, lack of privacy)


Principles of Adult Learning

  • Prior experiences resources for learning

  • Readiness to learn r/t social or dev. task

  • Motivation to learn greater if immediately useful—what does client want/need to learn?

  • Arrange learning environment to facilitate

    learning

  • Meet physical needs before teaching session


Teaching Tips

  • Identify and remove barriers to learning

  • Evaluate what already know

  • Short frequent sessions better than long

  • Realistic goals set with patient

  • Respect cultural implications

  • Avoid medical jargon

  • Move from simple to complex

  • Actively engage patient in learning

  • Use multiple senses: see, hear, tell, watch, do

  • Give feedback: positive and what to do better

  • Written materials at 5th grade level & in patient language

  • Evaluate pt understanding & clarify misunderstanding


Compassion Fatigue

  • Nurses often report that the needs of patients and families, as well as their own spouses and children, take priority over their own needs

  • The nurse is then left feeling stretched, overwhelmed, frustrated, unappreciated, and resentful

  • Negative feelings interfere with the ability to maintain a caring attitude and drain caring out of our interactions with others


Nurse Caring for Self

  • Jean Watson: “caring the essence of nursing practice”

  • “Caregivers who are filled with stress & negativity cannot provide an atmosphere conducive to healing.”

  • Choose a facility that supports caring and professional nursing practice – Magnet facilities

  • Important to develop a balanced life

  • Create a balanced life care plan for yourself – see page 266 of text


Self-Learning

  • Please read The Introduction and Chapter 1 of Relationship Based Care

    • A Caring and Healing Environment


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