Chapter 9: Communication & Collaboration in Nursing

1. Chapter 9: Communication & Collaboration in Nursing Bonnie M. Wivell, MS, RN, CNS

2. 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

3. 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)

4. 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)

5. 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

6. 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

7. Professional vs Social Relationship

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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.

22. 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

23. 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

24. 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

25. 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

26. 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

27. Chapter 10: Illness, Culture, & Caring: Impact on Patients, Families, & Nurses Bonnie M. Wivell, MS, RN, CNS

28. 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

29. 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

30. 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

31. 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”.

32. 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

33. 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.”

34. 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

35. 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

36. 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

37. 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.”

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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?

44. 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)

45. 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

46. 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

47. 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

48. 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

49. Self-Learning • Please read The Introduction and Chapter 1 of Relationship Based Care • A Caring and Healing Environment