Transcript Communication & Collaboration in Nursing

Chapter 9:
Communication &
Collaboration in Nursing
Bonnie M. Wivell, MS, RN,
CNS
Therapeutic Use of Self
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Hildegard Peplau was first to focus on nursepatient 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
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Orientation phase
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“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
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Admit what you don’t know, but find out the answers
Develop an initial understanding of patient problem/needs
Tasks of this phase
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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
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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
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Termination phase
End relationship
 Feelings of loss for both discussed
 Gifts & continued contact should be avoided (not a
social relationship)
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Role of Self-awareness
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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
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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
Professional
Social
Focuses on the patient’s needs;
relationship purposeful for patient
needs and goals to be met
Focuses on both individual’s needs
Needs of both met
Time limited with termination date
Not time-limited
Goals predetermined
No predetermined goals set
Nurse uses therapeutic
communication with intention
Therapeutic communication may or
may not be used
Nurses uses empathy
Sympathy & empathy may be used in
social relationships
Nonjudgmental acceptance
May or may not include nonjudgmental
acceptance
Principles for Determining
Professional Boundaries
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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
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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 NursePatient Relationship
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Assumptions of the Nurse-Patient relationship
which no longer hold true
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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
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Approach each nurse-patient contact as an
opportunity for connection and goal achievement
rather than as one step in a lengthy relationshipbuilding 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
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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
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Infants use SOMATIC language = crying; reddening of
the skin; fast, shallow breathing; facial expressions; and
jerking of the limbs
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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
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Decreases with maturity
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
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Feedback: giving back information to sender
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Appropriateness: reply fits circumstances
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Efficiency: simple, clear words paced
suitably
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Flexibility: base message on immediate
situation rather than on preconceived notion
Becoming a Better Communicator
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Active listening: communicating interest and
attention
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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
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3 faults: interrupting, finishing sentences for others,
lack of interest
You can become a better communicator with
conscious practice and awareness
Helpful Response Techniques
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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
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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
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“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
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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
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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
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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
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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
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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
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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
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Important to Patient Care
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Positive relationships have a positive impact on
patient care
Relationship based care includes relationships
with:
 Patient/family
 Self
 Colleagues
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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
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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
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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
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The Sick Role
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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
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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
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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
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Disposition: personality, health, cognition
Family factors: warmth, support, organization
Outside support: supportive network and success at
school or work
 Spirituality:
power
inner strength related to belief in a higher
Spirituality
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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
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External influences:
 Past
experiences
 Culture: pattern of learned behavior and values that
are reinforced
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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
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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
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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.
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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
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Impact of Illness on Family
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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
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 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
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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
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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
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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?
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Barriers to Learning
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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
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Teaching Tips
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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
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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
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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
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Please read The Introduction and Chapter
1 of Relationship Based Care
A
Caring and Healing Environment