N302 Test 1 Slides Outline

7/29/2019 N302 Test 1 Slides Outline

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Introduction

(*A lot of slides do not have text, if a mac user can outline any relevant information thatd be awesome)

World Health Organization (WHO) defined Health as a state of complete physical, mental,

and social well-being and not merely the absence of disease or infirmity."

Working as a Team

A nurse is only as good as the team around her, and a nurse who cannot ask questions of her co-

workers is extremely hampered. Nursing is so complex it must be discussed and talked about, shared

and delegated.

That is why teamwork in nursing is so important. It is vital not only to the nurse, but to the patient as

well. Nurses who work together make the best outcomes for their patients.

Essentials of Successful Team Building:

1. Clear Expectations-you need to know why the team was created.

2. Context-understand why you are participating on the team (you are assigned).

3. Commitment-do you want to participate on the team, you must feel this assignment is

important.

4. Competence-utilize the members as your resource.

5. Control-the have the freedom and empowerment to be creative to complete the task.

6. Collaboration-all members must participate and must problem solve and met the expectedoutcomes.

7. COMMUNICATION- Give feedback and receive honest performance feedback. Do the

team members communicate clearly and honestly with each other? Do they bring diverse

opinions to the table? Are conflicts addressed?

8. Creative Innovation-unique solutions and new ideas.

9. Consequences-members must feel responsible and accountable for team achievements.

*Working as a team cannot be mandated or required

*Working on a team is not easy thus a multifactorial approach is needed.

Stages of Group Development:

1. Forming, or coming together.

2. Storming, or conflict.

3. Norming, or working out the rules.


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4. Performing, or getting the job done.

5. Mourning, or breaking up.

*The First three stages must be passed through in order to achieve high team

performance.

How to create a win/win situation:

1. Define tasks and roles.

2. Need a clear work plan.

3. Everyone needs to be responsible.

4. Try to be excited!

5. Become attached to the group.

Four types of roles on a TEAM:

Task Roles (getting the power point done)

Functional Roles (ways to interact, coordinator)

Maintenance Roles (insure all participate and work within the timeframe)

Dysfunctional Roles (being aggressive, blocking, competing, clowning and dominating)

TEAM Members MAY become HOSTILE or OVERZEALOUS:

Members may want to express their individuality and resist group efforts.

You may find:

infighting, defensiveness and competition

doubts about success

low morale

polarization of group members

How do you deal with the following? :

The person who is resisting task demands.

The person who criticizes everyone and everything.

Final Keys for Success:

Attempt to achieve the maximum harmony by avoiding conflict.

Develop a high level of trust and respect for others in the group.


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Attempt to achieve maximum harmony by avoiding conflict

Develop a high level of trust and respect for others in the group.

Develop a sense of team cohesion with a common spirit and goal.

Understand members strengths and weaknesses.

It is only when the contributions of all team members are valued that the team will functionefficiently.

Process Recording

A Useful Tool for Professional Nursing Practice

Process Recording

Process recording is one of the most important skills to develop in nursing practice skill of self-

reflection. The process recording is a TOOL that helps guide the acquisition of this skill, as

self-reflection helps focus on ones thoughts, beliefs, actions and reactions in relation topractice.

A Good Process Recording:

Captures the various facets of a practice moment, and allows for the identification of what

one did well and where improvement is need.

A Process Recording:

Addresses and examines both the content and the process of the interaction with the

patient/client system.

The process part denotes ACTION!

The Objectives of a Process Recording are:

To structure thinking about professional practice.

To conceptualize what happens in the transactions between the nurse and the client system.

To heighten awareness of oneself in action as part of a transaction.

To distinguish fact from judgments and impressions.

A Practice Moment:

Practice moment A moment in time of practice in the health care setting.

A good process recording will capture the various facets of a practice moment, and allow for

identification of what one did well and where improvement is needed.

Select a setting or practice moment that will provide insight and feedback on your practice.


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What does a process recording do?

The process recording addresses and examines both the content and the process of the

interaction with the patient or client system.

It is a useful as a teaching tool to:

Learn about yourself

Learn how you relate to other people

Understand your feelings and behaviors

What do you learn?

To pay attention.

To be aware of your own experience

To describe behavior, affect, content, and recognize its significance.

To analyze your responses and the responses of your patients.

To recognize the consequences of an intervention.

To develop the ability to intervene purposefully if needed.

Guidelines: Confidentiality

In accordance with HIPPA regulations care should be taken to disguise the identifying

information of the patient.

The reality of process recording:

Process recordings should be done as soon as possible after the interview so that the

recording will be as accurate and complete as possible.

Process recording is a very time consuming task.

Process recording provides an opportunity for evaluation.

Process recordings do not become part of the permanent record of the patient.

Practical Concerns

How do I remember all that stuff?

The process recording is based on your best recollection


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Remembering the information from a process recording will improve with practice and

you should write notes immediately following the session.

How much should I recollect? The more you are willing to provide, the more opportunity you

will have to learn.

Should I type or hand-write? That is up to you, the legibility of your handwriting is a factor to

consider.

Recommended Format

Cover page

Process Recording Table

The interaction

Reflections

Analysis

Identification of a theme or concept

Summary

Cover Page:

Identification data: Name, Course name and number, instructor and date of interview.

Setting: describe the place where this interaction occurred

Why you selected the interaction.Client background (follow HIPPA guidelines)

Purpose of the interaction: You are seeing this client for a professional reason-what is that?

Tuning in: What do you think the client is expecting from the interaction? What are you

expecting or anticipating (describe thoughts and feelings prior to the interaction).

The Interaction:

You will recreate all or part of the actual interaction (should be at least 15 minutes time period)

You should write this as soon as possible after the actual interaction.

Be precise as you can in terms of verbal and nonverbal communication.

You cannot tape record for these assignments.

Follow the defined format.

Defined Format:


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This Section of the Process Recording is in a table format with the following cells of the table:

Narrative

Reflections

Analysis

The Narrative:

Include all verbal and non-verbal interactions including interruptions or other unplanned

events.

Nurse said ...

Patient said ...

Reflections:

Describe your subjective thoughts, feelings, reactions during the exchange.

Analysis:

Identify the knowledge and skills, if any, that you used.

Objectively evaluate your interaction and the skills, knowledge you used.

It is the opportunity to integrate the content developed in your classes and from the text.

Communication today!

The way we are taught to communicate in our society seems to be harmful to be harmful to

esteem and destroys intimacy. (Melanie Sears, 1996)

An Example of non-therapeutic communication:

A woman was in the emergency room with her baby who had been injured when the car

overturned.

Woman: I only took her out of her car seat because she was choking.

Nurse: you should never take a baby out of a car seat while the car is moving.

Woman: When your baby is choking you just dont stop and think.

Nurse: You should pull the car over and stop first.

Woman: (crying and sobbing): But she was choking.

Nurse: Now, you need to calm down, you need to be calm for your baby because babies can

sense when their mothers are upset.

An example of therapeutic communication using the same incident:


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Woman: I only took her out of her car seat because she was choking.

Nurse: Are you feeling scared that you are being judged for what you did?

Women: Ever since this happened people have been acting like the whole thing is my fault.

Nurse: Are you angry about that and need some understanding about all the factors involved

in making this happen?

Women: (sobbing) Yes, I feel so guilty already that when everyone is putting all the blame on

me and I just feel horrible.

Nurse: When you see what happened to your baby and hear peoples reaction to it, I wonder

if you feel ashamed?.

Women: Yes, Im scared Im not a good mother. It was so stupid of me to take her out of her

car seat.

Analysis:

In the first example, the woman remained defensive and scared throughout the

communication. She would not be receptive to nursing intervention.

In the second example, the nurse was not being judgmental and giving advice. The nurse

was empathetic and utilized therapeutic communication.

Identification of a theme or concept:

Themes or concepts are underlying issues or problems experienced by the patient that emerge

repeatedly during the course of the nurse-patient relationship. (Ex: anxiety or depression)

Summary

The process recording:

Contains the students questions, reflections, and evaluations of the nurse-patient relationship.

It answers the questions: Did this do what I wanted it to do? and What would I have done

different.

*Other Lecture 1 stuff:

Nursing Practice Acts: http://www.rn.ca.gov/pdfs/regulations/npr-b-03.pdf

ANA Definitions:

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf
http://www.rn.ca.gov/pdfs/regulations/npr-b-03.pdfhttp://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdfhttp://www.rn.ca.gov/pdfs/regulations/npr-b-03.pdfhttp://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf


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What is a Concept?

Relevance to Nursing

Nursing has an interest to clarify and develop its knowledge base.

In nursing we must communicate in a clear, concise way.

Aspects of nursing can be abstract.

All nurses are psychiatric and mental health nurses because we have to take into account

all of the psychosocial and mental issues in every patient.

What is this all about?

The goal is to strengthen and integrate social behavioral and mental health content into

nursing practice.

Some concepts in nursing are stated too broadly and general to have meaning.

A Concept defined:

Concept An abstraction that is expressed in some form.

It exists through socialization and repeat public interaction.

Other definitions: Concept Something conceived in the mind. Concept An abstract

or generic idea generalized from particular instances.

A concept is...

Generally expressed in statements that indicate what are considered to be attributes.

Concepts are labels, categories or selected properties of objects.

Concepts are...

The dimensions, aspects, and attributes of reality.

Expected to be useful in dealing with reality.

A defined unit of knowledge built from characteristics.

A concept...

Is a common feature or characteristic.

Chair Example

What is a chair?

We cannot explain that a chair is something we sit on because we can sit on many

objects. The chair is a concept. Think of the image and abstractions in your mind that

you construct when you think of a chair


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Concepts are bearers of meaning

A concept can be expressed by any number of languages:

A dog can be verbally expressed as hund, chien, or perro.

But, we all think of the same concept (a dog).

We dont think of a cat, cow, or anything else because we understand theconcept of a dog

What image do you see when I say SENILE?

Old, forgetful, incontinent, etc.

The image in your mind is a concept of the word senile.

Some words we frequently use to define concepts cannot translate into other

languages: senile is an example of this.

What is E=MC2?

What you construct in your mind from this equation is a concept. The actual formula is a

collection of concepts that have been logically put together and tested through science,

But the concept is your thoughts that originate when you see the equation.

Professionalism

Back in John Lantzs day, dress and etiquette of the nurse emphasized professionalism.

Today, nursing is complex and far more autonomous, but contemporary behavior and dress tend todownplay professionalism, and blur the identity of nurses.

It becomes unclear to many: a nurse, is a nurse, is a nurse

Objectives

Discuss professional guides to action in the nurse-client relationship.

List elements of being a professional.

Describe the role and function of the BRN.

Locate and familiarize yourself with the nurse practice act.

What is a Profession?

A profession is: a calling that requires: special knowledge, skill and preparation, and that

grows because of societys needs for special services.

Is Nursing a Profession? Yes

Criteria of a Profession:


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To provide a needed service to society.

To advance knowledge in its field.

To protect its members and make it possible to practice effectively.

Being a Professional

Being a professional is much more than wearing a uniform, and possessing a college degreeor a noted title

The Elements of a Profession:

Appearance, demeanor, reliability, competence, ethics, etiquette and poise, communication

skills, organizational skills, accountability, and specialized knowledge base.

Appearance and Demeanor

Exceed the dress code requirements.

You should exude confidence but not cockiness.

Be polite and keep calm, even during tense situations.

Stay calm.

Specialized knowledge base

Being a professional requires many hours of study and preparation.

You are expected to maintain a high knowledge level and expertise.

Committed to continued training and development.

Reliability

You can be counted on to get the job done.

You should respond to people promptly and follow up on your promises in a timely manner.

Competence

Strive to be an expert in your field.

You must become a life-long learner.

Professionals are expected to produce results.

Ethical

You adhere to a strict code of ethics and maintain ethical behavior at all times.

Have a strong sense of what is right and wrong.

Key elements: Integrity and Trust.


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Collective networking spirit

Work is not limited to their organization.

Professional relationships are key.

Expands beyond nursing.

Appreciate and support those you work with.Etiquette and Poise

Manners! Be classy. Say thank you! No attitude!

Communication Skills

Focus your communication so the person feels they are important.

Think before speaking.

Deliver on promises made.

Verbal or written communication should be clear, concise and accurate.

Organizational Skills

A professional can quickly and easily find what is needed.

You should be organized.

Accountability

Professionals are accountable for their actions at all times.

Recognize your mistakes.

Dont try to place blame.

Be honest and fair in all of your dealings with others.

Licensure

Licensure is governed by each state. You must be licensed in the state you wish to practice.

You cannot practice as a Registered Nurse unless licensed by the state.

State Board of Nursing grants the RN license

License has to be renewed every 2 years

Why is Licensure important?

It protects the public


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It protects clinical agencies

And, tracks your practice

How do I get Licensed?

http://www.rn.ca.gov/

Must apply, pay fees, take NCLEX, and get fingerprinted (back-ground check).Have to have completed a Board Approved Nursing Education Program

DEPARTMENT OF CONSUMER AFFAIRS

State agency that protects the public by regulating practice of registered nurses

Responsible for enforcement of the Nurse Practice Act

9-member Board-5 RNs, 4 Public Members (7 appointed by the governor)

Part of the Department of Consumer Affairs

Nurse Practice Act

CA, STATE law that sets out scope of practice for RNs

Can be found in the California Business and Professions Code

http://www.rn.ca.gov/regulations/bpc.shtml

Nurse practice acts differ slightly from state to state

California Nurse Practice Act

Business and Professions code

Article 2:2725

The practice of nursing means:

1. Direct and indirect patient care services

2. Administration of medications prescribed by a physician

3. Performance of skin tests, immunizations, withdrawal of blood from veins and arteries

4. Observation-determine normal from abnormal

5. Standardized procedures

Unlicensed personnel shall NOT do any of the following:

Administer medication


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Venipuncture or intravenous therapy

Parenteral or tube feedings

Invasive procedures (insert NG tubes, catheters, tracheal suctioning)

Assess patient condition

Patient educationModerately complex lab tests

NCLEX

https://www.ncsbn.org/index.htm

NCLEX-National Council Licensure Examination

$200.00 fee

You must apply to the state board of nursing for licensure to receive permission to take thisexam

Administered on a computer

75-265 multiple choice application questions, that increase in difficulty with correct answers.

Designed to test knowledge for the safe and effective practice of nursing at an entry level

Negligence

In addition to adhering to our scope of practice, nursing practice is held to a reasonable

standard of care.

Criteria to judge this is based on what a reasonable and prudent nurse would do in the same

situation.

Court cases involve testimony from nurses as expert witnesses.

Abandonment of Patients

In order for abandonment to have occurred the nurse must first have accepted the assignment

and then severed the relationship without giving notice to the appropriate person so that

arrangements can be made for continuation of care by others.

Advanced Directives

Patient Self Determination Act

Written statement telling others the extent of medical care to be given if the patient

loses their decision-making ability. (DNR, etc.)

Professional Organizations


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Set standards for practice

Advocate for nurses

Advocate for patients

And, are advanced bodies of knowledge

American Nurses Associationwww.nursingworld.org

Started over 100 years ago

The only organization that represents interests of the nearly 3 million nurses

Collective bargaining

Political activity

Legislative activity

http://www.youtube.com/watch?v=PRwPhOjeqL4 (Meaningless)

Specialty Nursing Organizations

The ANA and affiliates of the ANA.

Other specialty groups - not all are affiliates of ANA

Specialty organizations address certain areas of practice or certain patient conditions.

Respect

This presentation will explore the concept of respect and its impact in on nursing process from patient

and nurses perspective.

Objectives:

At the end of to this presentation the learner will have the opportunity to:

Define the elements of the concept respect

List three behaviors that show lack of respect

List three strategies to enhance respect.

Mutual respect is an essential for nursing practice:

Respect for others may be perceived to be an innate trait of all, but the reality is that societal

changes have shown that individuals have less respect for others.

Theme:
http://www.youtube.com/watch?v=PRwPhOjeqL4http://www.youtube.com/watch?v=PRwPhOjeqL4


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Why do most take off their hats for the national anthem?

Why do most stand up for the flag?

Why do they salute in the Military?

Why do most give up their seats in a bus to an elder?

Why do most stop when the Policeman blows his whistle?

Has reality TV eroded respect for us?

The problem

Some have said that our relentless pursuit of leisure time has made us too selfish to value age

and experience and too lazy to act civilly towards others.

Behaviors have become: Crude, rude, and socially unacceptable.

No one is immune to disrespect!

Working and Playing WELL with others begins early!

Manner Illiteracy

Whatever happened to manners? U.S. News and world reports 89% a growing problem (?)

ABC NEWS/World News Tonight

In a 1999 poll, 73% of Americans thought manners were worse than 20 to 30 years ago.

These respondents place the blame on inadequate parenting.

They also cited movies and television as contributing to the problem.

Adults set the molds for the future.

Work on one skill at a time.

Give immediate positive feedback for manners success.

Be tolerant of mistakes, but do not overlook them.

Set a good example-manners are not a one-way street. (Rosemond, Better Home andGardens)

Its a Matter of Respect!

Respect for People

Respect for Institutions

Respect for Wisdom


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Respect for Values

Respect for Human Dignity

Respect and Responsibility dont just happen. Its not luck, magic, or coincidence.

As a nurse you should treat others as you would like to be treated

Build on peoples strengths, not their weaknesses.Be consistent in how you treat patients and peers.

Loss of respect for elderly (Perez, 2011)

Cases of elderly who do not receive food or water for days or who are neglected in their room

without receiving the minimum hygienic care over weeks.

Things the nurse can do:

Dont rush when meeting with patients.

Try to interact at eye level.

Beware of you non-verbal clues

Prepare for your patient care.

Listen, listen and listen.

Give both positive as well as constructive comments.

Sometimes its just what you say!

The teacher said she could teach a monkey to learn what she was trying to teach me. That hurt!

BITE YOUR TONGUE!

How can the nurse gain the respect of patients?

Exhibit good nursing skills. (Organization is key)

Learn some behavior management. (Create the environment)

Be professional and evenhanded.

Treat everyone equally.

Dress slightly formal at the least-look like a nurse.

(Moormans Parent Teacher Talk, 2002)

Why would patient be disrespectful?

She doesnt even know me.


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Brief comments.

Humiliating

Prejudicial judgments (Asian are not assertive enough)

Most of all underestimating the patients abilities and intelligence.

RESPECT is a Component Critical in ANY Nursing Interaction!

One way to teach respect is through example:

Higher education is a place for thinking people to think, and for the learner to gain knowledge.

It is also a place where the respect for all people can be fostered.

Respect is not something one can imitate, but something one must embody.

Do as I say, not as I do does not work when it comes to respect.

Maintaining professional boundaries is essential

Mutual respect does not eliminate the power relationship.

Respect must be earned! (no)

I believe this is an excuse. Giving respect should not need to be earned. We should give respect for

some of the following reasons/people:

Position, Authority, Parents, Elderly, and most of all Being a human being!

Respect is due to parents not because they are super moms and dads but because of their position,

they are parents!

We live in a culture of Consumption.

We are constantly being told we need more.

The New York Times estimated that the average American is exposed to 35 hundred

commercial messages each day.

We are told we dont have enough, keep striving to achieve more and acquire more.

The patient is our customer!

And, the customer is egocentric. (Concerned for their own interests and welfare)

How can we address disrespect?

Confront it. Do not tolerate disrespectful behavior. Get support as needed.

The heart of courtesy is respect for persons!


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Treating one another with dignity, it is infectious:

Say thank you

Open doors

Listen when someone is talking to you

Speak the right truth at the right time in the right way for the right reasonCurb violence in a violent time

Dont show up at a wedding in a baseball cap.

Dont be late.

How we demand it is important!

Some behaviors are not CUTE (Baby flipping of the bird.gif)

Behaviors are learned!

ETHICS

Objectives

Describe Ethical Principles that guide Care.

Formulate implications for nursing practice based on the 2001 ANA Code of Ethics for Nurses

with Interpretive statements.

Analyze a clinical scenario from an ethical perspective.

NURSING is the best of Science and the noblest of HUMAN Arts.

As a nurse you enter a social compact, which requires a commitment in clinical practice which

requires: moral, ethical, and social behaviors.

Key concepts:

Respect, dignity, worth, uniqueness (of every individual), human rights, and values.

It is not always easy to do what is right!

What would you do, if you didnt want to do what you were told? (Nazi Germany, nurses were

the first to send Jews to the gas chambers)

Most often when we think of ethical decision making, we think of cloning or technological

miracles, but as nurses, our practices are filled with more mundane ethical dilemmas.

Think about these questions:

1. When, if ever, is it permissible to take a gift or gratuity from a patient?


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2. When is it legitimate and perhaps mandatory to break a patients confidence?

3. Is it permissible to lie to a patient if it is for his or her own good?

4. What must I do if I make a medication error that no one else knows about and it appears

harmless to my patient?

5. What obligations do I have as a colleague to report a peer, with whom I am working, who

appears to be abusing alcohol and appears chemically impaired?

6. What if I come upon a practice that is legal, but appears to be unethical?

Health Care Ethics reside in the realm of:

1. human values

2. morals

3. individual culture

4. intense personal beliefs

5. faith

The very fabric of our common humanity!

Ethical Issues:

Will continue to be a major challenge to the profession of nursing and the health care delivery

system

For this class, you will even see that sometimes we try to legislate ethical decisions.Different People view the World and Humanity in Different Ways:

Must know the language!

Some of these ways are:

1. Egoism

2. Utilitarianism

3. Relativism

4. Deontology

5. Hedonistic

6. Nihilism

It is important to note: Common Decisions that Shape our Values

Independence - Freedom from constraint


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Autonomy - Self-determination

Privacy/confidentiality - Fear of invasion

Self-esteem - Need to value oneself

Well-being - Freedom from pain & suffering

Security - Control of fear & anxietySense of belonging - Group Identification

Sexual and spiritual support - Fulfillment

Freedom from Disability - Physical/Mental capacity

Accomplishment - Personal Fulfillment

As humans, we are born with a series of undifferentiated potentials.

Example: All are born with a capacity to learn a language-what language is determined by...

CULTURAL FRAMEWORK

Piaget (1935) in Moral Development of a Child defined four STAGES:

1. AMORAL

2. EGOCENTRIC

3. HETERONOMOUS

4. AUTONOMOUS

Amoral Stage

Occurs up to age two

Child is totally self-centered

Egocentric Stage

Occurs age two years to seven years.

Not particularly interested or concerned about rules.

IT IS ABOUT HAVING FUN!

Heteronomous Stage


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Occurs from age 7 years to 12 years.

Children view behavior as right or wrong.

Autonomous Stage

Occurs after 12 years of age.

Actively engages in rule making.KEY Ethical Principles to Consider When Exploring Health Care:

Autonomy

Freedom

Beneficence

Fidelity This principle requires loyalty, fairness, truthfulness, advocacy, and dedication to

our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of

keeping a commitment and is based upon the virtue of caring.

Veracity

Privacy

*These are in that definitions document:

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf

Autonomy

The right of a person to take individual actions.

Basic to all bioethics (Bioethics Ethics of medical/bio research)

Individuals are unique. It is the right of the individual to be what s/he is.

Individual has desires, values, and purposes peculiar to herself.

Freedom

The right of a person to determine for himself the meaning and importance of a context.

Nothing should be done to a patient without the patients consent.

Individual has a right to act.

Freedom is freedom to be autonomous.

Beneficence

Continuum from do no harm and to do good
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdfhttp://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethics-Definitions.pdf


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Based on good will of the other.

Actions motivated by benevolence.

Fidelity

Keeping ones promises both explicit and implied.

Veracity

Truth telling

Requires one to accept the truth concerning the unique nature of the patient.

Cannot have real freedom of choice without truth.

Privacy

The right to be protected from any form of intrusive contact from others.

News: MD may be fired because she posted on social media that she is upset because herpatients are late for appointments. (OB)

Justice

No good definition

Not synonymous with fairness.

Distribution of the harms and benefits of society.

Historical Evolution in Professional Code of Ethics

1893- Nightingale Pledge

1899- International Council of Nurses

1900-Robbs Nursing Ethics: For Hospital and Private Use

1950-ANAs first Ethical Code

1953- ICN Code of Ethics

1985- ANAs first Ethical Code using the word ethics

2001-ANA Code of Ethics with Interpretive Statements

ANA Code of Ethics review-respond by March 15, 2013 (???)

Critical Thinking and Ethical Reasoning

Method of thinking about thinking

Involves self-reflection about ones own values and beliefs


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Requires open-mindedness

In clinical practice there isnt always a clear right choice- nurse needs to reason out what

should be done when there is no right way.

Choice - nurse needs to reason out what should be done when there is no right way.

Historical Evolution in Professional Code of Ethics

1893- Nightingale Pledge

1899- International Council of Nurses

1900-Robbs Nursing Ethics: For Hospital and Private Use

1950-ANAs first Ethical Code

1953- ICN Code of Ethics

1985- ANAs first Ethical Code using the word ethics

2001-ANA Code of Ethics with Interpretive Statements

ANA Code of Ethics review-respond by March 15, 2013

The "Nightingale Pledge"

The Nightingale Pledge was composed by Lystra Gretter, an instructor of nursing at the old

Harper Hospital in Detroit, Michigan, and was first used by its graduating class in the spring of

1893. It is an adaptation of the Hippocratic Oath taken by physicians.

I solemnly pledge myself before God and in the presence of this assembly, to pass my life inpurity and to practice my profession faithfully. I will abstain from whatever is deleterious and

mischievous, and will not take or knowingly administer any harmful drug. I will do all in my

power to maintain and elevate the standard of my profession, and will hold in confidence all

personal matters committed to my keeping and all family affairs coming to my knowledge in the

practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote

myself to the welfare of those committed to my care.

ANA Code of Ethics

Published 2001Call for input!

Nine Provisions

First three address fundamental values of a nurse

Next three address boundaries of duty and loyalty

Last three address aspects of duty beyond individual patients


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Whats important in the new code?

Non-negotiable ethical standard with respect to nursing practice

Patient focused

Loyalties are to the patient, not hospitals, not insurers, not to employers

Compassionate care to alleviate sufferingSupport patient self determination

ANA Code of Ethics

Treat all patients equally

1. The nurse, in all professional relationships, practices with compassion and respect

for 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 patient is your employer

2. The nurses primary commitment is to the patient, whether an individual, family,

group or community.

Do nurses who run clinical trials represent the interests of the study or the interests of

the patient?

If you are working for a private physician, who is your primary commitment to?

Confidentiality, protection

3. The nurse promotes, advocates for; and strives to protect the health, safety, and

rights of the patient.

Personal accountability

4. The nurse is responsible and accountable for individual nursing practice and

determines the appropriate delegation of tasks consistent with the nurses obligation to

provide optimum patient care.

As a new graduate, still on probation, you are assigned a patient who is receivingchemotherapy yet you have not yet given chemo

Lifelong learning, self-care

5. 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.

What are your plans for maintaining your competence after you graduate?


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Moral character with colleagues

6. 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.

How do you respond when a colleague tells a racist, sexist, you-fill-in-the-blank, joke?

Advancement of the Profession

7. The nurse participates in the advancement of the profession through contributions to

practice, education, administration, and knowledge development.

Need to be engaged in current events!

8. The nurse collaborates with other health professionals and the public in promoting

community, national, and international efforts to meet health needs.

Do you read a daily newspaper?

Society trusts nurses

9. 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.

Ethical Theories

Human Rights-based Model

Each person has certain rights

Example: Informed Consent, product labeling

Principalism Rule based criteria to determine obligations or duties

Beneficence Compassion; taking positive action to help others; desire to do good; core

principle of our patient advocacy.

Nonmaleficence Avoidance of harm or hurt; core of medical oath and nursing ethics.

Autonomy --Agreement to respect another's right to self-determine a course of action;support of independent decision making.

Justice -- An equal and fair distribution of resources, based on analysis of benefits and

burdens of decision.

Veracity Conformity to facts; habitual truthfulness.

Three Categories of Ethical Dilemmas common in clinical practice

Moral uncertainty Unsure about which moral rule(s) apply


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Moral dilemma Two or more moral principles are in conflict

Moral distress Nurse knows what is right but is forced to do otherwise by legal or

institutional constraints

Ethics impacts you not only as a professional, but also YOU as a member of SOCIETY!

Closing Thought:

If all the animals are running in the same direction, follow them!

Communication

Communication The process of transmitting messages and interpreting meaning (Wilson 1995)

In Therapeutic Communication

The sender, or nurse seeks to illicit a response from the receiver, the patient that is beneficial

to the patients mental and physical health.

Therapeutic Communication

Could this be you?

I constantly sacrificed my own need to meet the needs of patients and administration, and I

was efficient, tireless, strong, and had excellent skills. I worked much of the time in intensive

care units where I was free to apply my skills and knowledge to patients alive, and where I

didnt have to communicate much because the patients were intubated. I often was distressed

because I wanted respect and acknowledgement, but no matter how hard I tried these needs

remained unfulfilled.

Melanie Sears, MBA, RN

Perceptions are important in the Process of therapeutic communication:

Perceptions are an essential element in communicating.

It is highly personal and an internal act.

It refers to the experience of sensing, interpreting, and comprehending the world.


Therapeutic Communication is listening to and understand client while promoting clarificationand insight.

The Goals of Therapeutic Communication:

1. To understand the clients message.

2. To facilitate verbalization of feelings.

3. To communicate understanding and acceptance.


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4. To identify problems, goals, and objectives.

Effective Therapeutic Communication Depends on:

You as a nurse must be aware how you appear to the client.

Often on a busy unit we are rushed and harried. We speak fast and do not listen to the client.

WHATS DOES THE CLIENT SEE...

PHASES OF THE NURSE-PATIENT INTERACTION:

Pre-interaction Phase

Introductory/Orientation Phase

Working Phase

Termination Phase

Pre-interaction phase:

Obtain available information about the patient from their chart, significant others and members

of the health care team.

Examine your feelings, fears and anxieties about working with the particular patient.

Establish a goal or outcome the nurses wishes to accomplish.

Introductory/Orientation Phase:

Begins when the nurse goes to the patient location and begins introduction.

Build trust and rapport by demonstrating acceptance.

Establish a therapeutic environment.

Working Phase:

During this phase the nurse and patient actively work on meeting the objectives and goals.

Nurses anxiety and patient fears decrease.

Help patient express feelings.

Termination Phase:


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During this phase progress is summarized.

Separation is the outcome.

It began when you started.

Therapeutic Responses

Using Silence (non verbal)Using general leads or broad openings

Clarification

Reflecting

Using Silence

Using Silence:

Allows the patient time to think and reflect.

It conveys acceptance, support and understanding.

Allows the patient to take the lead in the conversation.

The nurse should maintain eye contact and be receptive to non-verbal communication

Examples of Using Silence

(Nothing)

Use proper nonverbal communication, remain seated, maintain eye contact, sit quiet and wait.

Using General Lead or Broad Openings

Encourages the patient to talk.

Indicates interest in the patient.

Allows the patient to choose subject.

It helps seek relevance and depth.

Communication with warmth and respect.

Examples of Using General Lead or Broad Openings

What would you like to talk about? Then what? Go on...

What brought you to the hospital?

What can you tell me about that?

What are you thinking about?


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Clarification

Encourages recall and details of a particular experience.

Encourages description of feelings.

Seeks clarification, pinpoints specifics.

Makes sure nurse understands patient.Examples of Clarification

Give me an Example.

Tell me more.

And how do you feel when youre angry?

Who are they?

Reflecting

Paraphrases what patient says.

Reflects what the patient says, especially feelings conveyed.

Reflection is directing back the patients ideas, feelings, questions or content.

Lets the patient know he is being heard.

Examples of Reflection

It sounds like youre feeling angry.

In other words, you really felt abandoned.

Are you saying...?

Non-therapeutic Responses

Closed-ended questions that can be answered with a yes or no.

How many children do you have?

Who do you live with?

Are you sad?

Advise giving.

Why dont you...?

You really should cut your hair and wear makeup.

You should stop smoking, its going to kill you.


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Arguing or responding in a hostile way.

If you do not take your mediation, there is really nothing we can do to help you.

If you dont eat, we will have to give you an IV or stick a tube down your throat.

False Reassurance

You will start feeling much better any day.Dont worry, your doctors will do everything necessary for your care.

Asking Why questions

Why didnt you take your medicine?

Why dont you contact your family and ask them to visit you?

Judgmental responses

You should never have had a abortion, they may be why your are sad.

You were wrong to do that.

Responding from a personal perspective or experience

Yes, I understand, I had the same surgery in 1999. and it...

When I get sad...I take a walk.

Two parts of Communication:

Face to Face (verbal expression of thoughts and feelings)

Nonverbal expression

Non-verbal communication constitutes two-thirds of all communication and it give the

most accurate reflection of attitudes and feelings.

A Wide Variety of Nonverbal Indicators:

Body Movements

Facial Expression

Hand Gestures

Body Position

Eye Contact

Voice Quality Pitch, range, etc.

Non-language Sounds i.e. Sobbing, grunts. Etc.


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Non-verbal communication can be seen in anger, stress, feeling ill, feeling sad, etc. These emotions

may not be communicated by words, but by gestures and facial expressions.

Powerful nonverbal messages can stand alone.

Nonverbal Communication may:

Contradict verbal behavior

Emphasize an emotional tone or mood

Complement verbal behavior

Control the environment

Be the communication of choice

Touch:

It helps personalize communication.

Guidelines control, who, when, why and where people touch

Mindful Listening!

Translates into ACTIVE listening.

It means you give your undivided attention to the interaction.

Assertiveness

The assertive nurse appears warm, confident and comfortable.

Assertive behavior is an active behavior.

Three Essential Criteria of Assertive Communication

Timing

Content

Receptivity

There is a fine-line between assertiveness and aggressiveness

Aggressiveness is that loud, forceful communication often in a confrontational way.

Getting what you want even at the expense of others.

Caring

A concept that will be developed in a later class. Some believe it is the essence of nursing.

Things in chapter 2 pay attention to:

1. The clients rights in a helping relationship.


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2. Characteristics of the helping relationship.

3. Dos and Donts in a helping relationship.

Bridges and Barriers in Therapeutic Communication Techniques

Objectives

1. Define therapeutic communication.

2. Compare and contrast selected strategies to facilitate therapeutic communication.

3. Describe 6 bridges and 4 barriers to therapeutic communication.

Barriers

Recognizing barriers to effective communication is a first step in improving communication

style.

A barrieris anything that interferes with or stands in the way of effective communication.

OBSTACLES BETWEEN THE PATIENT AND NURSE

A number of obstacles can interfere with an effective message.

The Nurse is the Sender.

The Patient is the Receiver.

Lack of Sensitivity to the Receiver

A breakdown in communication may result when a message is not adapted to its receiver.

Recognize the patients needs, status, knowledge of the subject, and language skills assists

the nurse in preparing a successful message. If a patient is angry, for example, an effective

response may be just to listen to the person vent for a while.

Lack of Basic Communication Skills

The patient is less likely to understand the message if the nurse has trouble choosing the

precise words needed and arranging those words in a grammatically-correct sentence.

Insufficient Knowledge of the Subject

If the nurse lacks specific information about something, the patient will likely receive an unclear

or mixed message.

Information Overload


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If you receive a message with too much information, you may tend to put up a barrier because

the amount of information is coming so fast that you may have difficulty comfortably

interpreting that information.

Emotional Interference

An emotional individual may not be able to communicate well. If someone is angry, hostile,

resentful, joyful, or fearful, that person may be too preoccupied with emotions to receive the

information.

TRANSMITTING BARRIERS

Things that get in the way of message transmission are sometimes called NOISE.

In addition to noise, some other problems can impact with the transmission of a message.

Physical Distractions

Check YouTube for noise in hospital setting.

Communication in a noisy hospital room can destroy communication; its like a bad cellular

phone connection.

Physical distractions may make it difficult for the nurse to concentrate.

Conflicting Messages

Messages that cause a conflict in perception for the receiver may result in incomplete

communication.

Using jargon, slang or medical terms may cause a mixed message.

Detailed instructions presented may be confusing and may be difficult to understand.

With a long communication chain, the message may be lost.

STRATEGIES TO EFFECTIVE LISTENING

Stop

Focus on the patient, their thoughts and feelings.

Consciously focus on quieting your own internal commentary and step away from your

own concerns to think about those of the speaker.

Give your full attention to the speaker.

Look

Pay attention to non-verbal messages without letting yourself be distracted.

Notice body language and non-verbal use to allow, for a richer understanding of the

speakers point.


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Avoid getting distracted from the verbal message.

Listen

Listen for the essence of the speakers thoughts: details, major ideas and their

meanings.

Seek an overall understanding of what the speaker is trying to communicate, rather than

reacting to the individual words or terms that they use to express themselves.

Be Empathetic

Imagine how you would feel in their circumstances.

Be empathetic to the feelings of the patient, while maintaining a calm center within

yourself.

You need not be drawn into all of their problems or issues, as long as you acknowledge

what they are experiencing.

Ask questions

Use questions to clarify your understanding, as well as to demonstrate interest in what

is being said.

BARRIERS TO ACCURATE PERCEPTION

Perception is at the heart of the communication process. It is how we make sense of and

understand ourselves and others.

Stereotyping and generalizing

Be careful not to hold on to preconceptions about people or things.

We have a tendency to see what we want to see, forming an impression from a sample

amount of information or one experience, and assuming that to be highly representative

of the whole person or situation.

Not investing time

Making assumptions and ignoring details or circumstances can lead to misconceptions.

When we fail to look in-depth for causes or circumstances, we miss important details,and do not allow for the complexity of the situation.

Having a distorted focus

Focusing on the negative aspects of a conversation or a situation is a habit common to

many people.

Even though we may recognize the positive things, we often give more weight to the

negative.


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Assuming similar interpretations

Not everyone will draw the same conclusions from a given situation or set of

information.

Everybody interprets things differently.

Validate your perceptions with others.

Strategies

Be flexible towards others and remember diversity brings creativity and innovation.

Present yourself as an equal rather than a superior even when you are in a position of

authority.

Use affirming responses.


Therapeutic Communication A specialized form of communication used in health care tosupport, educate, and empower people to cope with health care issues.

A purposeful form of communication to help a patient achieve health care goals.

Reinforces a persons self-esteem.

Therapeutic communication, like caring, is called the essence of nursing.

You will spend your entire career learning techniques of therapeutic communication. This is

the essence of nursing and the hardest skill to teach and learn because what works in one

situation may not work in another. It is highly individualized.

Ultimately it comes back to why you are even in this field.

There are skills to be learned, but underlying therapeutic communication is a good knowledge

of oneself.

Bridges of Therapeutic Communication

Respect, Caring, Empowerment, Trust, Empathy, and Mutuality

Respect is the foundation of the professional relationship

What does it look like when you dont show respect?

What are some techniques to enhance respect?

In order to respect anothers values and beliefs you first have to take the time to learn

what those are.

Mirroring A technique to convey respect

Follow the patients lead on level of formality (Mrs. Jones vs Betty).


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Use similar vocabulary. Use repeat-back method to ensure understanding.

Match the response to the clients tone.

Observe non-verbal messages your patient is sending before you engage in conversation.

Active Listening

An interactive processInterested not just in what is said, but also in how it is said.

Allows the nurse to see the situation from clients perspective.

Maintain eye contact but not staring.

Techniques to enhance active listening

Sitting at eye level

Providing private space for conversation (limit distracters)

Head nod, acknowledging grunt

Smiling

Leaning forward

Hmmgo on..

Barriers to Active Listening

Preoccupation with other tasks by nurse

Feeling insecure or intimidated

Client Rambling

Too much information

Check yourself- are you interrupting the patient, trying to steer the conversation, indifferent to

what is being said?

Silence A powerful technique

Allows time to take a deep breath and react to what has been said.

Emphasizes to patient that you are really listening.

Body Language Facial expression, gestures, body position, touch, personal space, etc.

Much of what we communicate to others is non-verbal.

Nurses need to consciously observe patients body language and be aware about how our

body language speaks to them


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This may be the only way a patient is able or willing to communicate

Caring Moral and knowledge component

What does it look like when it is present?

Active, engaged process

Curiosity about the patients conditionEnthusiasm for the work of nursing

What does it look like when care is provided without caring?

Apathetic

Perfunctory (done with little interest)

Caring:

Caring is an ethical responsibility that guides a health care provider to advocate for the client.

Caring is demonstrated professionally in the therapeutic relationship.

It is intentional action that is learned.

A person who has received caring is more likely to be able to offer it to others.

Touch

Can be very effective for sensory deprived.

Can convey caring to patients who feel isolated or grotesque. (Obese, homeless, disfigured,disabled)

Sometimes there are no words that can help.

Can also be tricky between males/females.

Empowerment-assisting patients to take charge of their own life

What does it sound like when it is present?

Coaching

Suggesting

Affirming

What does it sound like when communication is not empowering?

Paternalistic You dont need to worry about that.

Telling patients what they should do or should not do


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Trust Key to establishing working relationship

Allow the patient to make choices

Be honest/give complete information

Provide consistency

Plan scheduleFollow through on promises

Trust

Establishing trust is the foundation in all relationships.

The development of a sense of interpersonal trust, a sense of feeling safe, is the keystone in

the nurse-client relationship.

Empathy The ability to put oneself into the clients position

1. Recognize message and feelings

2. Willingness to understand

3. Full acknowledgement of hidden message and meaning

4. Empathy is used by the nurse after trust is established.

COMMUNICATION TECHNIQUES

Questioning

Open-ended:

How, what,

Closed ended-can be answered as yes or no or with simple answer:

Often starts with Why, When, Who, Where, etc.

Focused Questions More appropriate when time is limited

Clarification

Asks client to expand on a point

Oh when I get out of here I am calling my lawyer.

Im not quite sure I understand what you meant. Can you tell me more about that?

Paraphrasing

Different from restating in that the nurse re-states what the client said in her own words.


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Dr. Jones just keeps ordering the same pain medication for my pain and I told him it

isnt working!

So, in other words, you feel that you arent being listened to by your doctor.

Reflection

I am sick of being a guinea pig for every student who has to practice starting an IV. Im not

letting anyone else use me as a pincushion!

It sounds like you are really frustrated with how difficult it has been to get an IV started.

Physical characteristics that convey meaning:

Degree of Cleanliness

Hairstyle

Style of clothing

Piercing, tattoos, fetishes

Posture

Proxemics The branch of knowledge that deals with the amount of space that people feel it

necessary to set between themselves and others. (About 3 feet for casual communication)

Modulating Tone and Posture

High pitched loud voice conveys alarmBest to sit at eye level; looking down at patient sets up power differential

Moving in closer or stepping back

Restatement Useful when patient is exaggerating or overgeneralizing

I need to get out of this hospital. Nothing you are doing is helping and I feel worse than when

I got here!

Let me see if I have this right- you think the medications arent helping you at all?

Use of space

Amount of preferred space varies by culture. Individual preference

Increase intensity by moving closer

Decrease intensity by moving apart

Eye contact enters into persons personal space


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Need to respect the hospitalized patients space, belongings, etc.

Facial expression Usually reflects underlying emotional state

Look for congruence between what is said verbally and what the facial expression conveys.

Eyebrows: raised or squeezed together

Eyes: making direct eye contact or not; sad eyes, happy eyes, squintingLips: biting or curling lip pursed

Jaw: clenched

Facial Color and muscles

Barriers to Therapeutic Communication: Anxiety

Non-verbal Behaviors patients use to reduce anxiety:

Nervous movements

Shifting position

Hands constantly moving

Vibrating leg, foot movements

Grunting, giggling

Playing with hair

Grinding teeth

Non-pharmacological Strategies to Reduce Patient Anxiety

Close curtains to avoid extra stimuli.

Lower lights, close shades.

Assess Technology.

Warm compresses/blanket *cocoon*

Foot massage

Comfortable temperature

Decaffeinated Tea

Eliminate Clutter

Troubleshoot alarms (IV, Tube feeding, Bed, Telemetry, etc.)

Nurse Anxiety


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Before you can be therapeutic you have to manage your own anxiety.

Deep breathing

Body scan

Mental rehearsals

N302 Test 1 Slides Outline

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