FNP Transes

exchange of ideas or thoughts. This kind of Because the intent of communication is to elicit a
 Module 8: THERAPEUTIC communication uses methods such as talking and response, the process is ongoing; the receiver of the
COMMUNICATION listening or writing and reading. message then becomes the sender of a response, and
the original sender then becomes the receiver.
TOPIC 1 : COMMUNICATION Nursing as a health care science, focuses on serving
the needs of human as a biopsychosocial and spiritual  SENDER
Effective communication between the nurse and the being. Its practice requires not only scientific
patient is important for the successful outcome of any knowledge, but also interpersonal, intellectual and The sender, a person or group who wishes to
care to each patient. It requires an understanding of the technical abilities and skills. This means a communicate a message to another, can be considered
patient and the experiences they express. It requires composition of knowledge, clinical work and the source-encoder. This term suggests that the person
skills and simultaneously the sincere intention of the interpersonal communication. Communication is a or group sending the message must have an idea or
nurse to understand what concerns the patient. vital element in Nursing in all areas of activity and in reason for communicating (source) and must put the
all its interventions such as prevention, treatment, idea or feeling into a form that can be transmitted.
Communication is a critical skill for nursing. It is the therapy, rehabilitation, education and health
process by which humans meet their survival needs, promotion. Encoding involves the selection of specific signs or
build relationships, and experience emotions. In symbols (codes) to transmit the message, such as
nursing, communication is a dynamic process used to Nurses who communicate effectively are better able to which language and words to use, how to arrange the
gather assessment data, to teach and persuade, and to collect assessment data, initiate interventions, evaluate words, and what tone of voice and gestures to use.
express caring and comfort. outcomes of interventions, initiate change that
promotes health, and prevent the safety and legal  MESSAGE
The term communication has various meanings, problems associated with nursing practice. The
depending on the context in which it is used. To some, communication process is built on a trusting The second component of the communication process
communication is the interchange of information relationship with a client and support people. Effective is the message itself—what is actually said or written,
between two or more people; in other words, the communication is essential for the establishment of a the body language that accompanies the words, and
exchange of ideas or thoughts. This kind of nurse–client relationship. how the message is transmitted. The method used to
communication uses methods such as talking and convey the message can target any of the receiver’s
listening or writing and reading.  The Communication Process senses. It is important for the method to be appropriate
for the message, and it should help make the intent of
The term communication has various meanings, Face-to-face communication involves a sender, a the message clearer.
depending on the context in which it is used. To some, message, a receiver, and a response, or feedback. In its
communication is the interchange of information simplest form, communication is a two-way process  RECEIVER
between two or more people; in other words, the involving the sending and the receiving of a message.
The receiver, the third component of the Communication is generally carried out in two  PACE AND INTONATION - The manner of
communication process, is the listener, who must different modes: verbal and nonverbal. speech, as in the rate or rhythm and tone, will
listen, observe, and attend. This person is the decoder, modify the feeling and impact of a message. The
who must perceive what the sender intended Verbal communication uses the spoken or written tone of words can express enthusiasm, sadness,
(interpretation). word; nonverbal communication uses other forms, anger, or amusement. The rate of speech may
such as gestures or facial expressions, and touch. indicate interest, anxiety, boredom, or fear.
Perception uses all the senses to receive verbal and  SIMPLICITY - includes the use of commonly
nonverbal messages. To decode means to relate the Although both kinds of communication occur understood words, brevity, and completeness.
message perceived to the receiver’s storehouse of concurrently, the majority of communication Nurses need to learn to select appropriate,
knowledge and experience and to sort out the meaning is nonverbal. Learning about nonverbal understandable, and simple terms based on the
of the message. communication is important for nurses in developing age, knowledge, culture, and education of the
effective communication patterns and relationships client.
Whether the message is decoded accurately by the with clients.  CLARITY AND BREVITY A message that is
receiver, according to the sender’s intent, depends direct and simple will be effective. Clarity is
largely on their similarities in knowledge and Another form of communication has evolved with saying precisely what is meant, and brevity is
experience and sociocultural background. If the technology—electronic communication. A common using the fewest words necessary.
meaning of the decoded message matches the intent of form of electronic communication is e-mail, in which  TIMING AND RELEVANCE No matter how
the sender, then the communication has been effective. an individual can send a message, by computer, to clearly or simply words are stated or written, the
another person or group of people. timing needs to be appropriate to ensure that
Ineffective communication occurs when the receiver words are heard. Moreover, the messages need to
misinterprets the sent message.  VERBAL COMMUNICATION
relate to the person or to the person’s interests
and concerns.
 RESPONSE Verbal communication is largely conscious because
 ADAPTABILITY The nurse needs to alter
people choose the words they use. The words used
spoken messages in accordance with behavioral
The fourth component of the communication process, vary among individuals according to culture,
cues from the client. This adjustment is referred
the response, is the message that the receiver returns to socioeconomic background, age, and education.
to as adaptability. What the nurse says and how it
the sender. It is also called feedback. Feedback can be
is said must be individualized and carefully
either verbal, nonverbal, or both. Nonverbal examples Nurses need to consider the following when choosing
considered. This requires astute assessment and
are a nod of the head or a yawn. Either way, feedback words to say or write: pace and intonation, simplicity,
sensitivity on the part of the nurse.
allows the sender to correct or reword a message. clarity and brevity, timing and relevance, adaptability,
 CREDIBILITY means worthiness of belief,
credibility, and humor.
trustworthiness, and reliability. Credibility may
 MODES OF COMMUNICATION
be the most important criterion of effective
communication. Nurses foster credibility by being
 consistent, dependable, and honest. The nurse Computers are playing an increasing role in nursing experiences, each will perceive and interpret
needs to be knowledgeable about what is being practice. Many health care agencies are moving messages and experiences differently.
discussed and to have accurate information. toward electronic medical records where nurses 4. Personal Space - the distance people preferini
 HUMOR The use of humor can be a positive and document their assessments and nursing care. nteractions with others. Proxemics is the study of
powerful tool in the nurse–client relationship, but Electronic mail (e-mail) can be used in health care distance between people in their interactions.
it must be used with care. Humor can be used to facilities for many purposes: to schedule and confirm Communication thus alters in accordance with
help clients adjust to difficult and painful appointments, report normal lab results, conduct client four distances, each with a close and a far phase.
situations. The physical act of laughter can be an education, and for follow-up with discharged clients. Beebe, Beebe, and Redmond (2014, p. 202) list
emotional and physical release, reducing tension the following examples:
by providing a different perspective and  FACTORS INFLUENCING THE 1. Intimate: 0 to 1.5 feet
promoting a sense of well-being. When using COMMUNICATION PROCESS 2. Personal: 1.5 to 4 feet
humor, it is important to consider the client’s
perception of what is considered humorous. Many factors influence the communication process. 3. Social: 4 to 12 feet
Timing is also important to consider. Though Some of these are development, gender, values and 4. Public: 12 feet and beyond.
humor and laughter can help reduce stress and perceptions, personal space, territoriality, roles and
anxiety, the feelings of the client need to be relationships, environment, congruence, interpersonal 5.Territoriality is a concept of the space and things
considered. attitudes, and boundaries. that an individual considers as belonging to the self.
Territories marked off by people may be visible to
 NONVERBAL COMMUNICATION 1. Development - Knowledge of a client’s others.
developmental stages will allow the nurse to
Nonverbal communication, sometimes called body modify the message accordingly. 6. The roles and the relationships between sender and
language, includes gestures, body movements, use of 2. Gender - From an early age, females and male receiver affect the communication process. Roles such
touch, and physical appearance, including adornment. communicate differently. Girls tend to use as nursing student and instructor, client and primary
Nonverbal communication often tells others more language and seek confirmation, minimize care provider, or parent and child affect the content
about what a person is feeling than what is actually differences, and establish intimacy. Boys uses and responses in the communication process.
being said, because nonverbal behavior is controlled language to establish independence and negotiate
less consciously than verbal behaviour. status within a group. These difference can 7. Environment- People usually communicate most
continue into adulthood. effectively in a comfortable environment. Temperature
Example: Posture and Gait, Facial Expression and 3. Values and Perception - Values are the standards extremes, excessive noise, and a poorly ventilated
Gestures that influence behavior,and perceptions are the environment can all interfere with communication.
personal view of an event. Because each person
 ELECTRONIC COMMUNICATION has unique personality traits, values, and life 8. In congruent communication, the verbal and
nonverbal aspects of the message match. Clients more
readily trust the nurse when they perceive the nurse’s ON and tentative “Are you in
communication as congruent. USING Accepting Sitting quietly rather than pain?” (general
SILENCE pauses or (or walking with absolute. statement)
9. Interpersonal Attitudes- Attitudes convey beliefs, silences that the client) and
thoughts, and feelings about people and events. may extend waiting “You seem
Attitudes are communicated convincingly and rapidly for several attentively until unconcerned
to others. Attitudes such as caring, warmth, respect, seconds or the client is able about your
and acceptance facilitate communication, whereas minutes to put thoughts diabetes.”
condescension, lack of interest, and coldness inhibit without and feelings into (tentative
communication. interjecting words. statement)”
any verbal
10. Boundaries- For nurses, professional boundaries response.
are crucial in the context of the nurse– client PROVIDING Using “Can you tell me USING OPEN Asking broad “I’d like to hear
relationship. To keep clear boundaries, the nurse keeps GENERAL statements or how it is for ENDED questions that more about
the focus on the client and avoid sharing personal LEADS questions that you?” QUESTIONS lead or invite that.” “Tell me
information or meeting his or her own need through (a) encourage “Perhaps you the client to more. . . .”
the nurse– client relationship. the client to would like to explore “How have you
verbalize, (b) talk about. . . .” (elaborate, been feeling
TOPIC 2 THERAPEUTIC COMMUNICATION clarify, lately?”
choose a topic
of “Would it help describe,
Therapeutic communication promotes understanding compare, or “What brought
conversation, to discuss your
and can help establish a constructive relationship illustrate) you to the
and (c) feelings?”
between the nurse and the client. Unlike a social thoughts or hospital?”
facilitate “Where would
relationship, where there may not be a specific feelings. “What is your
continued you like to
purpose or direction, the therapeutic helping Open-ended opinion?”
verbalization. begin?”
relationship is client and goal directed. Nurses need to questions “You said you
respond not only to the content of a client’s verbal “And then specify only were frightened
message but also to the feelings expressed. what?” the topic to be yesterday. How
BEING Making “Rate your pain discussed and do you
THERAPEUTIC COMMUNICATION
SENSITIVE statements on a scale of invite answers
TECHNIQUES feel now?”
AND that are zero to ten.” that are longer
TENTATIVE specific rather (specific than one or
TECHNIQUES DESCRIPTI EXAMPLES
than general, statement)
 two words. those thoughts Nurse: “You had or garbled. To another way.”
and/or difficulty eating clarify the
feelings in yesterday.” message, the
USING TOUCH Providing Putting an arm similar words. nurse can
appropriate over the client’s This conveys Client: “Yes, I restate the
forms of shoulder. that the nurse was very upset basic message
touch to Placing your has listened after my family or confess
reinforce hand over the and left.” confusion and
caring client’s hand. understood ask the client
feelings. the client’s to repeat or
Because basic message restate the
tactile and also message.
contacts vary offers clients
considerably a clearer idea Nurses can
among of what they also clarify
individuals, have said. their own
families, message with
and cultures, statements.
the nurse must SEEKING A method of “I’m puzzled.”
be sensitive to CLARIFICATIO making the “I’m not sure I
the NS client’s broad understand PERCEPTION A method Client: “My
differences in overall that.” “Would CHECKING OR similar to husband never
attitudes and meaning of you please say CONSENSUAL clarifying that gives me any
practices of the message that again?” VALIDATION verifies the presents.”
clients and more “Would you tell meaning of Nurse: “You
self. understandabl me more?” specific words mean he has
RESTATING OR Actively Client: “I e. It is used “I meant this rather than the never given you
PARAPHRASIN listening for couldn’t manage when rather than that.” overall a present for
G the client’s to eat any dinner paraphrasing “I’m sorry that meaning of a your birthday or
basic message last night—not is difficult or wasn’t very message. Christmas?”
and then even the when the clear. Let me try
repeating dessert.” communicatio to explain Client: “Well—
n is rambling not never. He
 INFORMATION a simple and scheduled for 11 ment may be
does get me direct manner, am tomorrow.” with or walker.”
something for specific “You will feel a without
my factual pulling sensation understanding
information when the tube is , verbal or
birthday and the client may re- nonverbal.
Christmas, but or may not
he never thinks request. When moved from
of giving me information is your abdomen.” CLARIFYING Helping the Client: “I
anything at any not known, “I do not know TIME AND client clarify vomited this
other time.” the nurse the answer to SEQUENCE an event, morning.”
states this and that, but I will situation, or Nurse: “Was
indicates who find out from happening in that after
OFFERING Suggesting “I’ll stay with has it or when Mrs. King, the relationship to breakfast?”
SELF one’s you until your the nurse will nurse in charge.” time. Client: “I feel
presence, daughter obtain it. that I have been
interest, or arrives.” asleep for
wish to “We can sit here weeks.”
understand the quietly for a ACKNOWLEDG Giving “You trimmed
client without while; we don’t ING recognition, in your beard and Nurse: “You had
making any need to talk a mustache and your operation
demands or unless you nonjudgmenta washed Monday, and
attaching would like to.” l way, of a your hair.” today is
conditions “I’ll help you to change in “I notice you Tuesday.”
that the client dress to go behavior, an keep squinting
must comply home, if you effort the your eyes. Are
with to like. client has you having PRESENTING Helping the “That telephone
receive the made, or a REALITY client to ring came from
nurse’s contribution difficulty differentiate the program on
attention. to a seeing?” the real from television.”
communicatio “You walked the unreal. “Your magazine
n. twice as far is here in the
GIVING Providing, in “Your surgery is Acknowledg today with your drawer. It has
 not been stolen.” REFLECTING Directing Client: “What an
ideas, can I do?” introduction “Tomorrow, I
feelings, Nurse: “What do to future care will look at your
FOCUSING Helping the Client: “My questions, or you think would planning. feeling journal.”
client expand wife says she content back be helpful?”
on and will look after to clients to Client: “Do you
develop a me, but I don’t enable them think I should
topic of think she can, to explore tell my BARRIERS TO COMMUNICATION
importance. It what with the their own husband?”
is important children to take ideas and Nurses need to recognize barriers or nontherapeutic
for the nurse care of, feelings about Nurse: “You responses to effective communication. Failing to
to wait until a situation. seem unsure listen, improperly decoding the client’s intended
the client and they’re about telling message, and placing the nurse’s needs above the
finishes always after her your husband.” client’s needs are major barriers to communication.
stating the about something
main concerns —clothes, TECHNIQUE DESCRIPTION EXAMPLES
before homework, SUMMARIZING Stating the “During the past Offering
attempting to what’s for AND main points of half hour we generalized and
focus. The dinner that PLANNING a discussion have talked oversimplified
“Two-year-olds
focus may be night.” to clarify the about. . . .” beliefs about
are brats.”
an idea or a relevant “Tomorrow groups of people
“Women are
feeling; Nurse: “Sounds points afternoon we that are based on
complainers.”
however, the like you are discussed. may explore this experiences too
“Men don’t
nurse often worried about This further.” STEREOTYPING
cry.”
emphasizes a how well she technique is limited to be
“Most people
feeling to help can manage.” useful at the “In a few days valid. These
don’t have any
the client end of an I’ll review what responses
pain after this
recognize an interview or you have categorize clients
type of surgery.”
emotion to review a learned about and negate their
disguised health the actions and uniqueness as
behind words. teaching effects of your individuals.
session. It insulin.” AGREEING AND Similar to Client: “I don’t
often acts as DISAGREEING judgmental think Dr. Broad
 responses, the nurse from
agreeing and admitting why, he visits
is a very good
disagreeing weaknesses in you every
doctor.
imply that the the health care day.”
He doesn’t seem
client is either services, know.” Asking for
interested in his Client: “I was
right or wrong including information
clients.” speeding along
and that the nurse personal chiefly out of
the street and
is in a position to weaknesses. curiosity rather
Nurse: “Dr. didn’t see
judge this. Giving a than with the
Broad is head of the stop sign.”
These responses response that Client: “I felt intent to assist the
the department Nurse: “Why
deter clients from makes clients nauseated after client. These
of surgery were you
thinking through prove their that red pill.” responses are
and is an PROBING speeding?”
their position and statement or Nurse: “Surely considered prying
excellent
may cause a CHALLENGHING point of view. you don’t think and violate the
surgeon.” Client: “I
client to become These responses I gave you the client’s privacy.
didn’t ask the
defensive. indicate that the wrong pill?” Asking “why” is
doctor when he
BEING Attempting to Client: “Those nurse is failing to Client: “I feel as often probing and
was here.”
DEFENSIVE protect a person night nurses consider the if I am dying.” places the client in
Nurse: “Why
or health care must just sit client’s feelings, a defensive
didn’t you?”
services from around and talk making the client Nurse: “How position.
negative all night. They feel it necessary to can you feel TESTING Asking questions “Who do you
comments. These didn’t answer defend a position. that way when that make the think you are?”
responses my light for your pulse client admit to (forces people
prevent the client over an hour.” is 60?” something. These to admit
from expressing Client: “I responses permit their status is
true concerns. Nurse: “I’ll have believe my the client only only that of
The nurse is you know we husband limited answers client) “Do you
saying, “You literally run doesn’t love and often meet the think I am not
have no right to around on me.” nurse’s need busy?” (forces
complain.” nights. You’re rather than the the client to
Defensive not the only Nurse: “You client’s. admit
responses protect client, you can’t say that;
 my home to a
that the nurse This sunshine ADVICE responses deny the nursing
really is busy) clients should not is good for my home?”
Refusing to discuss certain roses. I have a Nurse: “If I
“I don’t want
discuss certain topics. beautiful rose client’s right to be an were you, I’d
to discuss that.
topics with the garden.” equal partner. Note that go to a nursing
Let’s talk
client. Using clichés or giving expert rather than home, where
about. . . .”
These responses comforting common advice is you’ll get your
“Let’s discuss “You’ll feel
often make clients statements of therapeutic. meals cooked
REJECTING other areas of better soon.”
feel that the nurse advice as a means for you.”
interest to you “I’m sure
is rejecting not UNWARRANTED to reassure the
rather than the everything will
only their REASSURANCE client. These TOPIC 3 : COMMUNICATION AND THE
two problems turn out all
communication responses block NURSING PROCESS
you keep right.”
but also the clients the fears, feelings,
mentioning.” “Don’t worry.”
themselves. and other thoughts Communication is an integral part of the nursing
CHANGING Directing the “I can’t talk of the client. process. Nurses use communication skills in each
TOPICS AND communication now. I’m on Giving opinions phase of the nursing process. Communication is also
SUBJECTS into areas of self- my way for and approving or important when caring for clients who have
interest rather than coffee break.” disapproving communication problems. Communication skills are
“That’s good
considering the Client: “I’m responses, even more important when the client has sensory,
(bad).”
client’s concerns separated from moralizing, or language, or cognitive deficits.
“You shouldn’t
is often my wife. Do implying one’s
do that.” NURSING MANAGEMENT
you think I PASSING own values.
“That’s not
a self-protective should have JUDGEMENT
good enough.” Assessing
response to a topic sexual relations These responses
“What you did
that causes with another imply that the
was wrong To assess the client’s communication abilities, the
anxiety. These woman?” client must think
(right).” nurse determines communication impairments or
responses imply as the nurse
that what the nurse Nurse: “I see thinks, fostering barriers and communication style. Culture may
considers that you’re 36 client dependence. influence when and how a client speaks. Obviously,
important will be and that you language varies according to age and development.
GIVING Telling the client Client: “Should
discussed and that like gardening. With children, the nurse observes sounds, gestures,
COMMON what to do. These I move from
and vocabulary.
Impairments to Communication If the communication issue is due to the client having communication, and educating the client and support
a problem coping, the diagnoses of Fear or Anxiety person.
Various barriers may alter a client’s ability to send, may be more appropriate. Other NANDA nursing
receive, or comprehend messages. These include diagnoses (Herdman & Kamitsuru, 2014) used for Evaluating
language deficits, sensory deficits, cognitive clients experiencing communication problems that
impairments, structural deficits, and paralysis. The involve impaired verbal communication as the Evaluation is useful for both client and nurse
nurse must assess each client to determine the etiology could include the following: communication. To establish whether client outcomes
presence of barriers. have been met in relation to communication, the nurse
• Anxiety related to impaired verbal communication must listen actively, observe nonverbal cues, and use
Style of Communication • Powerlessness related to impaired verbal therapeutic communication skills to determine that
communication communication was effective.
In assessing communication style, the nurse considers • Situational Low Self-Esteem related to impaired
both verbal and nonverbal communication. In addition verbal communication • Social Isolation related to  Module 9 :
to physical barriers, some psychological illnesses (e.g., impaired verbal communication GUIDELINES/PROTOCOL/TOOL FOR
depression or psychosis) influence the ability to • Impaired Social Interaction related to impaired DOCUMENTATION RELATED TO CLIENT
communicate. verbal communication. CARE

Diagnosing Planning TOPIC 1 : INTORDUCTION

Impaired Verbal Communication may be used as a When a nursing diagnosis related to impaired verbal Effective communication among health professionals
nursing diagnosis when an individual experiences a communication has been made, the nurse and client is vital to the quality of client care. Generally, health
“decreased, delayed, or absent ability to receive, determine outcomes and begin planning ways to personnel communicate through discussion, reports,
process, transmit, and/or use a system of symbols” promote effective communication. The overall client and records. A discussion is an informal oral
(Herdman & Kamitsuru, 2014, p. 261). outcome for individuals with Impaired Verbal consideration of a subject by two or more health care
Communication is to reduce or resolve the factors personnel to identify a problem or establish strategies
Communication problems may be receptive (e.g., impairing the communication. to resolve a problem. A report is oral, written, or
difficulty hearing) or expressive (e.g., difficulty computer-based communication intended to convey
speaking). The nursing diagnosis Impaired Verbal Implementing information to others. For instance, nurses always
Communication may not be useful when an report on clients at the end of a hospital work shift. A
individual’s communication problems are caused by a Nursing interventions to facilitate communication with record, also called a chart or client record, is a formal,
psychiatric illness. clients who have problems with speech or language legal document that provides evidence of a client’s
include manipulating the environment, providing care and can be written or computer based. Although
support, employing measures to enhance health care organizations use different systems and
forms for documentation, all client records have reveal the presence of a certain microorganism. Nurses 7. Legal Documentation - The client’s record is a legal
similar information. The process of making an entry use baseline and ongoing data to evaluate the document and is usually admissible in court as
on a client record is called recording, charting, or effectiveness of the nursing care plan. evidence. It may be used as evidence in court
documenting. Each health care organization has proceedings, and therefore play an important role in
policies about recording and reporting client data, and 3. Quality Review/Auditing Health Agencies - An implicating or absolving health practitioners charged
each nurse is accountable for practicing according to audit is a review of client records for quality- with improper care. In some jurisdictions, however,
these standards. Agencies also indicate which nursing assurance purposes. Charts may be reviewed to the record is considered inadmissible as evidence
assessments and interventions can be recorded by evaluate the quality of care patients have received and when the client objects, because information the client
registered nurse and which can be charted by the competence of the nurses providing that care. gives to the physician is confidential.
unlicensed personnel. In addition, The Joint Accrediting agencies may review client records to
Commission requires client record documentation to determine if a particular health agency is meeting its - It can also be used in accident or injury claims made
be timely, complete, accurate, confidential, and stated standards. by the patient.
specific to the client.
2 8. Reimbursement - used to demonstrate to payers that
Client records are kept for a number of purposes patients received the care for which reimbursement is
including communication, planning client care, 4. Research - The information contained in a record being sought.
auditing health agencies, research, education, can be valuable source of data for research. Patient
reimbursement, legal documentation, and health care records may be studied by researchers who hope to 9. Historical Documentation - Because the dates of
analysis. learn from the study of similar cases how best to entries on records are specified, the record has value
recognize or treat identified health problems. as a historical document. Information concerning a
TOPIC 2: PURPOSES OF PATIENT RECORDS patient’s past health care may be pertinent.
5. Health Care Analysis - record review may reveal
1. Communication - It helps healthcare professionals both underutilized and overutilized services, patients TOPIC 3: GUIDELINES FOR EFFECTIVE
from different departments who interact with the with prolonged stays who require special assistance, DOCUMENTATION
patient at different times to communicate with one and financial information about which services
another. This prevents fragmentation, repetition and generate revenue compared with those that cost the 1. Content
delays in client care. institution or agency money.
✓  enter information in a complete, accurate
2. Planning Client Care - Each health professional uses 6. Education - healthcare professionals and students
data from the client’s record to plan care for that reading a patient’s chart can learn a great deal about relevant (concise) and factual manner
client. A primary provider, for example, may order a the clinical manifestations of particular health
problems, effective treatment modalities, and factors ✓  record patient findings (observations of behavior)
specific antibiotic after establishing that the client’s
that affect patient goal achievement. rather than your interpretation of these
temperature is steadily rising and that laboratory tests
findings. 3. Format 5. Confidentiality
- chart on the proper form as designated by agency - patients have a moral and legal rights to expect that
✓  Avoid words such as good, average, normal or policy the information contained in their patient
sufficient
- print or write legibly in dark ink to ensure health record will be kept private.
✓  Avoid generalizations permanence - most agencies allows students access to patient
- use correct grammar and spelling records for educational reasons.
✓  Note problems as they occur in an orderly, - use standard terminology only commonly accepted - keep in strict confidence all the information they
sequential manner, record the nursing intervention and terms, abbreviations and symbols learn by reading patient records.
the patient’s response; update problems or delete as - date and time each entry - actual patient names and other identities should not
appropriate - chart nursing interventions chronologically on be used in written or oral student reports
consecutive lines. Never skip lines. Draw a single line
✓  Document all medical visits and consultations through blank spaces. TOPIC 4: Subjective informant, Objective
informant, Assessment, Plan, Implement and
✓  Document in a legally prudent manner 4. Accountability Evaluate (SOAPIE)
- sign your initial, last name and title to each entry. Do
✓  Document the nursing response to questionable Kozier & Erb, (2018) Fundamentals of Nursing in
not sign notes describing interventions
medical orders or treatment Practice
NOT performed by you that you have no way of
2. Timing  The Nursing Process is a systematic, rational
verifying.
- indicate each entry the date and both the time the method of planning and providing individualized
- do not use dittos, erasures or correcting fluids. A
entry was written and the time of pertinent nursing care. Its purpose is to identify a client’s
single line should be drawn through an incorrect entry
observations and interventions. health status and actual or potential health care
and word “ERROR” should be printed above or beside
- document nursing interventions as closely as possible problems or needs, to establish plans to meet the
the entry and sign the entry should then be rewritten
to the time of their execution. As a rule, documenting identified needs, and to deliver specific nursing
correctly.
should be done as soon as possible after an assessment interventions to meet those needs. The client may
or intervention. - identify each page of the record with the patient’s be an individual, a family, a community, or a
- never leave the unit for a break when caring for a name and identification number group.
seriously ill patient until all significant data was - recognize that the patient record is permanent.
recorded. Follow agency policy pertaining to the color of Phases of Nursing Process
- never document interventions before carrying them
out. No recording should be done before providing ink and the type of pen or ink to be used complete 1. Assessment – focus on a client’s responses to a
nursing care. patient record before sending it to medical records. health problem. A nursing assessment should include
the client’s perceived needs, health problems, related 2. Health promotion - relates to clients’ preparedness ■ Compromised (to make vulnerable to threat).
experience, health practices, values, and lifestyles. To to implement behaviors to improve their health
be most useful, the data collected should be relevant to condition.
a particular health problem. Therefore, nurses should 3. Risk - is a clinical judgment that a problem does not
think critically about what to assess. The Joint exist, but the presence of risk factors indicates that a
Commission (2008) requires that each client have an problem is likely to develop unless nurses intervene.
initial nursing assessment consisting of a history and 4. Wellness - describes human responses to levels of  Formulating Diagnostic Statements
physical examination performed and documented wellness.
Most nursing diagnoses are written as two-part or
within 24 hours of admission as an inpatient.
 Components of a NANDA Nursing Diagnosis three-part statements, but there are variations of these.
The basic two-part statements
a nursing diagnosis has three components: 1. Problem (P): statement of the client’s response
2. Diagnosis – the nurses use critical thinking skills to (NANDA label)
interpret assessment data and identify client strengths (1) the problem and its definition – diagnostic label –
and problems. The standardized NANDA names for describe the client’s health problem. 2. Etiology (E): factors contributing to or probable
the diagnoses are called diagnostic labels; and the (2) the etiology – the cause. causes of the responses.
client’s problem statement, consisting of the (3) the defining characteristics – signs and symptoms.
For example:
diagnostic label plus etiology (causal relationship
between a problem and its related or risk factors), is  Qualifiers
Problem related to Etiology
called a nursing diagnosis that provides the basis for
selection of nursing interventions to achieve outcomes are words that have been added to some NANDA
labels to give additional meaning to the diagnostic Constipation related to prolonged laxative use
for which the nurse is accountable.
statement, for example: Severe Anxiety related to threat to physiological
integrity: possible cancer diagnosis The basic three-
 The diagnostic process has three steps:
■ Deficient (inadequate in amount, quality, or degree; part statements

■ Analyzing data not sufficient; incomplete)

■ Impaired (made worse, weakened, damaged, 1. Problem (P): statement of the client’s response
■ Identifying health problems, risks, and strengths ■
reduced, deteriorated) (NANDA label)
Formulating diagnostic statements.
2. Etiology (E): factors contributing to or probable
■ Decreased (lesser in size, amount, or degree) causes of the response
 The Kinds of Nursing Diagnoses
3. Signs and symptoms (S): defining characteristics
1. Actual - is a client problem that is present at the ■ Ineffective (not producing the desired effect) manifested by the client.
time of the nursing assessment.
For example:
Problem related to Etiology as manifested by Signs Initial Planning - the nurse who performs the ■ Selecting nursing interventions and activities
and Symptoms admission assessment usually develops the initial ■ Writing individualized nursing interventions on care
comprehensive plan of care. plans.
Situational Low Self-Esteem related to feelings of
rejection by husband as manifested by hypersensitivity Ongoing Planning - the nurses obtain new The nurse must consider a variety of factors when
to criticism; states “I don’t know if I can manage by information and evaluate the client’s responses to care; assigning priorities, including the following: 1.
myself” and rejects positive feedback. they can individualize the initial care plan further. Client’s health values and beliefs.
2. Client’s priorities.
TOPIC 5: Guidelines for writing Nursing Discharge Planning - anticipating and planning for 3. Resources available to the nurse and client.
Diagnosis Statement needs after discharge, is a crucial part of a
comprehensive health care and should be addressed in 4. Urgency of the health problem. 5. Medical
each client’s care plan. Because the average stay of treatment plan.
clients in acute care hospitals has become shorter,
people are sometimes discharged still needing care.  Purpose of Desired Goals/Outcomes

 Purpose of Ongoing Plan 1. Provide direction for planning nursing

interventions.
1. To determine whether the client’s health status has 2. Serve as criteria for evaluating client progress.
changed 3. Enable the client and nurse to determine when the
2. To set priorities for the client’s care during the shift problem has been resolved. 4. Help motivate the client
3. To decide which problems to focus on during the and nurse by providing a sense of achievement.
shift
4. To coordinate the nurse’s activities so that more ❖ As goals are met, both client and nurse can see that
than one problem can be addressed. their efforts have been worthwhile. This provides
motivation to continue following the plan, especially
Planning - the nurse refers to the client’s assessment The Planning Process In the process of developing when difficult lifestyle changes need to be made.
data and diagnostic statements for direction in client care plans, the nurse engages in the following
formulating client goals and designing the nursing activities:  Guidelines in writing desired outcomes
interventions required to prevent, reduce, or eliminate ■ Setting priorities
the client’s health problems. ■ Establishing client goals/desired outcomes 1. Write goals and outcomes in terms of client
responses, not nursing activities. Beginning each
 Types of Planning goal statement with the client will may help focus the
goal on client behaviors and responses. Avoid
statements that start with enable, facilitate, allow, let, knowledge of nutrition can mean different things to Nursing interventions may be written for the purpose
permit, or similar verbs followed by the word client. different people. of individualizing the medical order based on the
These verbs indicate what the nurse hopes to 6. Make sure the client goals/desired outcomes are client’s status.
accomplish, not what the client will do. Correct: The important and values them. Some outcomes, such as
client will drink 100 mL of water per hour (client those for problems related to self-esteem, parenting, c)  Collaborative interventions are actioning the
behavior). Incorrect: Maintain client hydration and communication, involve choices that are best nurse carries out in collaboration with other health
(nursing action). made by the client or in collaboration with the client. team members, such as physical therapists, social
2. Be sure that desired outcomes are realistic for workers, dietitians, and primary care providers.
the client’s capabilities, limitations, and designated 4. Intervention - are the actions that a nurse performs Collaborative nursing activities reflect the overlapping
time span, if it is indicated. Limitations refers to to achieve client goals. The specific interventions responsibilities of, and collegial relationships among,
finances, equipment, family support, social services, chosen should focus on eliminating or reducing the health personnel.
physical and mental condition, and time. For example, etiology of the nursing diagnosis.
For example, the primary care provider might order
the outcome “Measures insulin accurately” may be
 Types of Nursing Interventions physical therapy to teach the client crutch-walking.
unrealistic for a client who has poor vision due to
The nurse may assist with crutch-walking and
cataracts.
a)  Independent interventions are those activities that collaborate with the physical therapist to evaluate the
3. Ensure that the goals and desired outcomes are
nurses are licensed to initiate on the basis of their client’s progress.
compatible with the other professionals. For
knowledge and skills. They include physical care,
example, the outcome “The client will increase the
ongoing assessment, emotional support and comfort,  Criteria for Choosing Nursing Intervention
time spent out of bed by 15 minutes each day” is not
teaching, counseling, environmental management, and
compatible with a primary care provider’s prescribed ■ Safe and appropriate for the individual’s age, health,
making referrals to other health care professionals.
therapy of bed rest. and condition.
4. Make sure that each goal is derived from only
For example, providing special mouth care for a client
one nursing diagnosis. For example, the goal “The ■ Achievable with the resources available.
after diagnosing impaired oral mucous membranes.
client will increase amount of nutrients ingested and ■ Congruent with the client’s values, beliefs, and
show progress in the ability to feed self” is derived b)  Dependent interventions are activities carried out culture.
from two nursing diagnoses: Feeding Self-Care Deficit under the orders or supervision of a licensed physician ■ Congruent with other therapies.
and Imbalanced Nutrition: Less than Body provider authorized to write orders to nurses. Primary
Requirements. care providers’ orders commonly direct the nurse to ■ Based on nursing knowledge and experience.
5. Use observable, measurable terms for outcomes. provide medications, intravenous therapy, diagnostic ■ Established standards of care as determined by state
Avoid words that are vague and require interpretation tests, treatments, diet, and activity. With the client, the laws, professional organizations, accrediting
or judgment by the observer. For example, phrases nurse is responsible for assessing the need for, organizations and the policies of the institution.
such as increase daily exercise and improve explaining, and administering the medical orders.
 Guidelines for Implementing Intervention 5. Provide teaching, support, and comfort. The the nursing process because conclusions drawn from
nurse should always explain the purpose of the evaluation determine whether the nursing
1. The nurse must be aware of the scientific interventions, what the client will experience, and how interventions should be terminated, continued, or
rationale, as well as possible side effects or the client can participate. The client must have changed.
complications, of all interventions. sufficient knowledge to agree to the plan of care and
For example, a client has been taking an oral to be able to assume responsibility for as much self- The Evaluation Phase has Five Components
medication after meals; however, this medication is care as desirable.
not absorbed well in the presence of food. Therefore, ■ Collecting data related to the desired outcomes ■
6. Be holistic. The nurse must always view the client
the nurse will need to explain why this practice needs Comparing the data with desired outcomes
as a whole and consider the client’s responses in that
to be altered. ■ Relating nursing activities to outcomes
context.
■ Drawing conclusions about problem status
For example, whenever possible, the nurse honors the
2. The nurse is responsible for intelligent client’s expressed preference that interventions be
implementation of medical and nursing plans of care. ■ Continuing, modifying, or terminating the nursing
planned for times that fit with the client’s usual
For example, a nurse requires knowledge of each care plan.
schedule of visitors, work, sleep, or eating.
intervention, its purpose in the client’s plan of care,
7. Respect the dignity of the client and enhance the When determining whether a goal has been achieved,
any contraindications (allergies), and changes in the
client’s self - esteem. Providing privacy and the nurse can draw one of three possible conclusions:
client’s condition that may affect the order.
encouraging clients to make their own decisions are 1. The goal was met; that is, the client response is the
3. Adapt activities to the individual client. A client’s ways of respecting dignity and enhancing self-esteem. same as the desired outcome.
beliefs, values, age, health status, & environment are
8. Encourage clients to participate actively in
factors that can affect the success of a nursing action.
implementing the nursing interventions. Active 2. The goal was partially met; that is, either a short-
For example, the nurse determines that a client chokes
participation enhances the client’s sense of term outcome was achieved but the long- term goal
when swallowing pills, so consults with the primary
independence and control. The amount of desired was not, or the desired goal was incompletely attained.
care provider to change the order to a liquid form of
involvement may be related to the severity of the 3. The goal was not met.
the medication. Or, the nurse recognizes that many
illness; the client’s culture; or the client’s fear,
Asian persons prefer to drink hot water rather than ice
understanding of the illness, and understanding of the  Guidelines for Writing Nursing Care Plans
water and, after confirming it with a specific client,
intervention.
supplies this at the bedside.
1. Date of plan is written and sign by the nurse. The
4. Implement safe care. Evaluation –is a planned, ongoing, purposeful activity date of plan is essential for evaluation, review, and
For example, when changing a sterile dressing, the in which clients and health care professionals future planning. The nurse’s signature demonstrates
nurse practices sterile technique to prevent infection; determine (a) the client’s progress toward achievement accountability to the client care.
when giving a medication, the nurse administers the of goals/outcomes and (b) the effectiveness of the 2. Use category headings. “Nursing Diagnoses,”
correct dosage by the ordered route. nursing care plan. Evaluation is an important aspect of “Goals/ Desired Outcomes,” “Nursing Interventions,”
and “Evaluation” are the common headings. the goal of preventing joint contractures and ✓  The action category reflects planning and
3. Use standardized/approved medical or English maintaining muscle strength and joint mobility. implementation and includes immediate and future
symbols rather than complete sentences to 8. Ensure that the plan contains ongoing nursing actions. It may also include any changes to the
communicate your ideas unless the agency policy assessment of the client. For example, “Inspect plan of care.
dictates otherwise. For example, write “Turn and incision q8h”).
reposition q2h” rather than “Turn and reposition the ✓  The response category reflects the evaluation
9. Include collaborative and coordination activities
client every two hours.” Or, write “Clean wound c H ̄ phase of the nursing process and describes the client’s
in the plan. For example, the nurse may write
2O2 bid” rather than “Clean the client’s wound with response to any nursing and medical care.
interventions to ask a nutritionist or physical therapist
hydrogen peroxide twice a day, morning and evening.” about specific aspects of the client’s care.
✓  The focus charting system provides a holistic
4. Be specific. Because nurses are now working shifts 10. Include plans for the client’s discharge and
perspective of the client and the client’s needs. It also
of different lengths, with some working 12-hour shifts home care needs. The nurse begins discharge
provides a nursing process framework for the progress
and some working 8-hour shifts, it is even more planning as soon as the client has been admitted. It is
notes (DAR).
important to be specific about expected timing of an often necessary to consult and make arrangements
intervention. If the intervention reads “change with the community health nurse, social worker, and
Date/hours Focus Progress Notes
incisional dressing q shift,” it could mean either twice specific agencies that supply client information and
Data - guarding abdominal
in 24 hours, or three times in 24 hours, depending on needed equipment.
11/23/2020 incision. facial grimacing
the shift time. Pain
9:00am
5. Refer to procedure books or other sources of
rates pain at 8 on scale of 0 – 10.
information rather than including all the steps on a
Action -Administered Morphine
written plan. For example, write “See unit procedure TOPIC 6: Focus, Data, Action, Response (FDAR)
Sulfate 4mg IV.
book for tracheostomy care,” or attach a standard
Focus charting is intended to make the client and Response – Rate pain at 1 on the
nursing plan about such procedures as radiation-
client concerns and strengths the focus of care. 9:30am scale of 0-10. Patient state
implantation care and preoperative or postoperative
“willing to ambulate”.
care.
✓  Three columns for recording are usually used: (1)
6. Ensuring the client’s preference about the time
date and time, (2) focus, and (3) progress notes.
of care and method used. This reinforces the client’s
individuality and sense of control.
✓  The data category reflects the assessment phase of Topic 7: Electronic Health Record (HER)
7. Ensure that the nursing plan incorporates the nursing process and consists of observations of
preventive and health maintenance aspects as well client status and behaviors, including data from flow Computers are used for educating nursing students and
as restorative ones. For example, carrying out the sheets (e.g., vital signs, pupil reactivity). clients; assessing, documenting, and testing clients’
intervention “Provide active assistance ROM (range- health conditions; managing medical records;
of-motion) exercises to affected limbs q2h” addresses communicating among health care providers and with
clients; and conducting nursing research. All nurses data used to manage an organization or department. information (referred to as protected health
must have a basic level of computer literacy to ❖ The system provides analyses used for strategic information or PHI). Because PHI is now stored
perform their jobs. In hospitals, data terminals are planning, decision making, and electronically, HIPAA regulations have mandated
commonly used to order supplies, tests, meals, and strict control over access and communication of HIS
services from other departments. Tracking of these evaluation of management activities. data.
orders allows the nursing service to determine the Hospital Information Systems (HIS) - is focuses on
most frequent or most costly items used by a particular the types of data needed to manage client care Technology in Nursing Practice involve collecting,
nursing unit. This information may lead to decisions to activities and health care organizations. recording, and using data. Specifically, the nurse
modify a budget, provide different staffing, move records client information in computer records, can
supplies to a different location, or make other changes ❖  The goal is to provide people with the data they accesses by other departments to manage client
for more efficient and higher quality care. Computers need to determine appropriate actions and allow nurses scheduling, and uses programs for unique applications
are used extensively for scheduling and client to communicate care plans across the health care such as home health nursing and case management.
appointments can be easily entered or changed. continuum without needing to regather or repeat
Staffing patterns must also be coordinated. Each information. Computer-Based Client Records – was established
practice needs to keep track of procedures health care in 1992, identified four ways the Electronic Medical
workers perform, client diagnoses, and time spent with ❖  The subsystems provide areas of admissions, Record could improve health care:
clients so that billing can be accurate. Medicare, and medical records, clinical laboratory, pharmacy, order (a) constant availability of client health information
most other insurance companies prefer electronic entry, and finance. across the life span,
submission of health care billing. In electronic data (b) ability to monitor quality,
The National Library of Medicine (NLM) has
interchange protocols are used to maximize privacy
created the Unified Medical Language System (c) access to warehoused (stored) data,
and minimize the chances of inappropriate sharing of
(UMLS) to facilitate the development of computer (d) ability for clients to share in knowledge and
confidential client data.
systems that recognize the language of health. activities influencing their own health.
Computer Systems is a network of computers, users,
The Unified Medical Language System (databases) Electronic Medical Records – providers easily
programs, and procedures in an organization assisting
and associated software programs are available to retrieve specific data such as trends in vital signs
the health care team with decision making and
system developers of electronic health information immunization records, and current problems. The
communication.
systems. systems allow replay of audio, graphic, or video data
 The two most common types of computer for comparison with status.
The Health Insurance Portability and
systems used by nurses are:
Accountability Act of 1996 (HIPAA) established ❖  Electronic access to client data designed for record
Management Information Systems (MIS) – is legal requirements for the protection, security, and keeping, other computers are used extensively in
designed to facilitate the structure and application of appropriate sharing of client personal health health care to assess and monitor clients’ conditions.
❖  Electronic records take up much less space than ✓  Multiple flow sheets are not needed in Although most of these monitors are applied
paper records and may be stored more securely. computerized record systems because information can externally, implanted electronic.
be easily retrieved in a variety of formats.
❖  Copies can be made easily on various types of  The Policies and Procedure to Ensure the
electronic media that tend to be more compact and ✓  Computers make care planning and documentation Privacy and Confidentiality of Computer
durable than paper. relatively easy. To record nursing actions and client Records
responses, the nurse either chooses from standardized
❖  Data can also be transmitted electronically to a lists of terms or types narrative information into the 1. A personal password is required to enter and sign
consulting specialist in another location. computer. off computer files. Do not share this password with
anyone, including other health team members.
 There are Several Areas of Concern with For example, the nurse can obtain results of a client’s 2. After logging on, never leave a computer terminal
EMRs. blood test, a schedule of all clients on the unit who are unattended.
to have surgery during the day, a suggested list of 3. Do not leave client information displayed on the
1. Maintaining the privacy and security of data is a interventions for a nursing diagnosis, a graphic chart monitor where others may see it.
significant issue. One way in which computers can of a client’s vital signs, or a printout of all progress
protect data is by user authentication via passwords or notes for a client. 4. Shred all unneeded computer-generated worksheets.
biometric identifiers (e.g., fingerprint or retinal scans) 5. Know the facility’s policy and procedure for
—only those persons who have a legitimate need to Telemedicine – uses technology to transmit electronic correcting an entry error.
access the data receive the password. data about clients to persons at distant locations. In 6. Follow agency procedures for documenting
2. Policies and procedures for protecting the one example, two-way audiovisual communication sensitive material.
confidentiality of EMRs are evolving as the use of allows an international expert to examine and consult 7. Information technology (IT) personnel must install
computer systems becomes more widespread. on a client’s case from thousands of miles away. X- a firewall to protect the server from unauthorized
3. Maintaining confidentiality of medical records, and rays, scans, stored computer data, and almost anything access.
the nurse’s role. One role of the nurse informaticist, an imaginable
expert who combines computer, information, and Topic 4. Problem Oriented Medical Record
nursing. ✓ Client Monitoring and Computerized Diagnostics (PROM) or Problem Oriented Record (POR)
Nursing has benefited greatly from the myriad of
Electronic Health Records (EHRs) are used to client monitors. In everyday practice, nurses use ➢  established by Lawrence Weed in the 1960s. ➢  the
manage the huge volume of information required in digital or tympanic thermometers, digital scales, pulse data are arranged according to the client’s problems
contemporary health care. Nurses use computers to oximetry, ECG/telemetry/hemodynamic monitoring, rather than the source of the information. Members of
store the client’s database, add new data, create and apnea monitors, fetal heart monitors, blood glucose the health care team contribute to the problem list,
revise care plans, and document client progress. analyzers, ventilators, and intravenous (IV) pumps. plan of care, and progress notes.
➢  Plans for each active or potential problem are baseline diagnostic tests. R—Revision reflects care plan modifications
drawn up, and progress notes are recorded for each derived from the database. It is usually kept suggested by the evaluation. Changes may be made in
problem. 2. desired outcomes, interventions, or target dates
at the front of the chart and serves as an
Problem
index to the numbered entries in the
Problem Oriented Medical Record (PROM) list  MODULE 11: CONCEPT OF LEADERSHIP
progress notes.
AND MANAGEMENT
3. Plan of a written plan of care done by the health
Advantage Disadvantage
care care provider.
1. Caregivers differ in TOPIC 1 : CONCEPT LEADING
1. It encourages is a chart entry made by all health
their ability to use the
collaboration. professionals involved in a client’s care; Nurses function within health care systems, working
required charting format. 4.
they all use the same type of sheet for notes. with multiple clients and other health
2. The problem list in the Progress
Progress notes are numbered to correspond care providers. As a part of multidisciplinary teams,
front of the chart alerts notes
2. It takes constant to the problems on the problem list and may the nurse is often in a leadership
caregivers to the client’s be lettered for the type of data.
vigilance to maintain an position and frequently delegates aspects of care to
needs and makes it easier
up-to-date problem list. others. There are opportunities in
to track the status of each For example, the SOAP format is frequently used. nursing to become leaders at various levels and also
problem. S—Subjective data consist of information obtained many situations in which the nurse
3. It is somewhat from what the client says. functions as a manager and as a change agent.
inefficient because O—Objective data consist of information that is
assessments and measured or observed by the healthcare provider.  THE NURSE AS LEADER AND MANAGER
interventions that apply to A—Assessment is the interpretation or conclusions The professional nurse frequently assumes the roles of
more than one problem drawn about the subjective and objective data. The leader and manager. These two
must be repeated. “A” entry should be a statement of the problem. roles are linked; that is, managers must have
P—Plan of care designed to resolve the stated leadership abilities, and leaders often
 Four Basic Components of Problem Oriented problem. manage, but the two roles differ.
Medical Record (PROM) The SOAP format has been modified. The acronyms
SOAPIE and SOAPIER refer to formats that add  Leader
1. consist of all updated information about the interventions, evaluation, and revision. Influences others to work together to accomplish a
Database client’s health status changes when enters I—Interventions refer to the specific interventions specific goal.
health care agency. It includes the nursing that have actually been performed by the caregiver. -are often visionary; they are informed, articulate,
assessment, the primary care provider’s E—Evaluation includes client responses to nursing confident, and self-aware.
history, social and family data, and the interventions and medical treatments. This is primarily -usually have outstanding interpersonal skills and are
results of the physical examination and reassessment data. excellent listeners and
communicators. They have initiative and the ability (b) efficiently using the organization’s resources,
and confidence to innovate (c) ensuring effective client care, and
change, motivate, facilitate, and mentor others. (d) ensuring compliance with institutional,
- participate in and guide teams that assess the professional, regulatory, and governmental
effectiveness of care, implement standards.
evidence-based practice, and construct process Managers are also responsible for development of
improvement strategies licensed and unlicensed personnel
.They may be employed in a variety of positions—from within their work group.
shift team leader to
institutional presidents may also hold volunteer  LEADERSHIP
positions such as chairperson of a Leadership may be formal or informal. The formal
professional organization or a community board of leader, or appointed leader, is selected
directors. by an organization and given official authority to
make decisions and act. An informal
A manager is an employee of an organization who is leader is not officially appointed to direct the activities
given authority, power, and of others, but because of seniority,
responsibility for planning, organizing, coordinating, age, or special abilities is recognized by the group as Leadership Theory
and directing the work of its leader, and plays an important A. CLASSIC LEADERSHIP THEORIES
others, and for establishing and evaluating standards. role in influencing colleagues, coworkers, or other The trait theorists found that leaders often possess
- understand organizational structure and culture. group members to achieve the group’s specific qualities and abilities including good
They control human, financial, goals. judgment, decisiveness, knowledge, adaptability,
and material resources. integrity, tact, self-confidence, and cooperativeness.
- set goals, make decisions, and solve problems. They The behaviorists believed that through education,
initiate and implement training, and life experiences, leaders develop a
change. Nurses are responsible for managing client particular leadership style.
care. Some nurses These styles have been characterized as
assume a position within the organization as unit 1. autocratic,
manager, supervisor, or 2. democratic,
executive. 3. laissez-faire,
4. and bureaucratic.
As a manager, the nurse is responsible for 1. An autocratic (authoritarian) leader makes
(a) efficiently accomplishing the goals of the decisions for the group.
organization,
◆ The leader believes individuals are externally ◆ This type of leader acts as a catalyst or facilitator, ◆ A laissez-faire style is most effective for groups
motivated (their driving force is extrinsic, they desire actively guiding a group toward achieving the group’s whose members have both personal and professional
rewards from others) and are incapable of independent goals. Group productivity and satisfaction are high as maturity. When the group has made a decision, the
decision making. group members contribute to the work effort. members become committed to it. Individual group
members then perform tasks in their area of expertise
◆ Likened to a dictator, the autocratic leader ◆ The democratic leader assumes individuals are while the leader acts as resource person.
determines policies, giving orders and internally motivated (their driving force is intrinsic,
directions to the group. they desire self-satisfaction), are capable of making 5. Bureaucratic leader does not trust self or others to
decisions, and value independence. Providing make decisions.
◆ Under this leadership style, the group may feel constructive feedback, offering information, making ◆ This type of leader relies on the organization’s
secure because procedures are well suggestions, and asking questions become the focus of rules, policies, and procedures to direct the group’s
defined and activities are predictable. Productivity the democratic leader. work efforts. Group members are usually dissatisfied
may also be high. with the leader’s inflexibility and impersonal relations
◆ This leadership style demands that the leader have with them.
◆ However, the group’s needs for creativity, faith in the group members to accomplish the goals. ◆ Table 28–2 compares the autocratic, democratic,
autonomy, and self-motivation are not met, Although democratic leadership has been shown to be laissez-faire, and bureaucratic
and the degree of openness and trust between the less efficient and more cumbersome than authoritarian leadership styles.
leader and the group members is minimal or absent. leadership, it allows for more self-10 motivation and
more creativity among group members. It also calls for
◆ Members are often dissatisfied with this leadership a great deal of cooperation and coordination among
style; however, at times an autocratic style is the most group members.
effective When urgent decisions are necessary (e.g., a
cardiac arrest, a unit fire, or a terrorist attack), one ◆ This leadership style can be extremely effective in
person must assume the responsibility for making the health care setting.
decisions without being challenged by other team
members. When group members are unable to or do 3. Laissez-faire (permissive) leader recognizes the
not wish to participate in making a decision, the group’s need for autonomand selfRegulation.
authoritarian style solves the problem and enables the ◆ The leader assumes a “hands off” approach. The
SITUATIONAL LEADERSHIP THEORY.
individual or group to move on. This style can also be leader presupposes the group is internally motivated.
◆ According to contingency theorists, effective
effective when a project must be completed quickly However, group members may act independently and
leaders adapt their leadership style to the situation. A
and efficiently. at opposing purposes because of a lack of cooperation
popular contingency theory describes the situational
2. Democratic leader -encourages group discussion and coordination.
leader.
and decision making.
 Contemporary theorists have described charismatic The group is empowered because members and leader
The situational leader leaders, transactional leaders, transformational leaders, share values, honesty, trust, and continual learning.
(a) flexes task and relationship behaviors and shared leadership. Independence, individual growth, and change are
(b) considers the staff members’ abilities facilitated. For example, the nurses working with this
(c) knows the nature of the task to be done ▪ Charismatic leader is rare and is characterized by type of leader to implement a major change in the
(d) is sensitive to the context or environment in which having an emotional relationship with the group model of nursing care delivered to a group of clients
the task takes place. members. The charming personality of the leader will each accept responsibility for a segment of the
evokes strong feelings of commitment to both the project, keep all members informed of their progress,
The task-orientation focuses the leader on activities leader and the leader’s cause and beliefs. When this and consider the impact of their actions on the larger
that encourage group productivity to get the work type of nurse leader speaks to a group, nurses feel group.
done. The relationship-orientation style is concerned inspired and motivated to do whatever they can to
with interpersonal relationships and focuses on meet the leader’s expectations. The followers of a One subtype of transformational leadership is servant
activities that meet group members’ needs. charismatic leader often overcome extreme hardship to leadership, based on the concept that leaders serve
achieve the group’s goals because of faith in the their constituencies. Members of an organization
Situational leaders adapt their leadership style to the leader. act as both servants and leaders within a work
readiness and willingness of the individual or group to environment of mutual respect, trust, and
perform the assigned task. When employees are ▪ Transactional leader has a relationship with collaboration. As is true in many situations, servant
insecure, or unable or unwilling to perform the task, followers based on an exchange for some resource leadership can be effectively demonstrated by both
the leader uses a highly directive style, providing valued by the follower. These incentives are used to formal and informal leaders (Mahon, 2011). In
specific instructions and close supervision. If the promote loyalty and performance. nursing, this concept is
group is motivated and willing but unable to perform For example, to ensure adequate staffing on the night internally consistent with a focus on caring.
the task, the leader again uses a highly directive style, shift, the nurse manager entices a staff nurse to work
but in this case, explains decisions and provides the the night shift in exchange for a weekend shift off. Evidence-Based Practice What Does It Take To Be
opportunity for clarification. When the group is able The transactional leader represents the traditional an Authentic Nurse
but unwilling or lacking in confidence, the leader manager, focused on the day to-day tasks of achieving Leader?
shares ideas and facilitates decision making. For a organizational goals, and understanding and meeting The purpose of this qualitative study by Murphy
group that is willing, able, and confident to perform the needs of the group. (2012) was to explore the experiences of hospital chief
the task, the leader delegates, turning responsibility for ▪ Transformational leader fosters creativity, risk nurse executives in becoming and remaining authentic
decision making and implementation over to the taking, commitment, and collaboration by empowering nurse leaders. The research question was “What can
group. the group to share in the organization’s vision. The the life stories of hospital nurse executives tell us
leader inspires others with a clear, attractive, and about the development of authentic nurse leaders and
 CONTEMPORARY LEADERSHIP attainable goal and enlists the group to participate in the challenges to sustained authenticity?” Two themes
THEORIES attaining the goal. emerged about how the study
participants maintained their authenticity and authentic Shared governance is a method that aims to distribute • Facilitate personal relationships.
leadership: decision making among a group of people. It provides • Plan and organize activities of the group.
(1) the importance of values and structure by articulating a mechanism for advocacy • Are consistent in behavior toward group members.
(2) having the moral courage to do the right thing. and influence of the staff nurse through all levels of • Delegate tasks and responsibilities to develop
Both themes included emphasis on keeping the client nursing. It empowers ownership of quality nursing members’ abilities, not merely to
at the center of the nurse leaders’ concerns. This practice and influences the work environment and get tasks performed.
helped them to stay the course as authentic leaders administrative functions (Rheingans, 2012) • Involve members in all decisions.
despite pressures to take an easier path. This is • Value and use group members’ contributions.
sometimes referred to as having a clear Effective Leadership • Encourage creativity.
moral compass guiding them to their “true north.” Much has been written about effective leadership and • Encourage feedback about their leadership style.
style; some descriptive statements about effective • Assess for and promote use of current technology.
IMPLICATIONS leaders are listed in Box 28–1. Leadership is a learned
The small sample size in this study (three) does not process. To be an effective leader requires an Vision is a mental image of a possible and desirable
negate the value of the findings. A major implication understanding of factors such as the needs, goals, and future state. Leaders transform visions into realistic
of this research for nurse leaders is the critical rewards that motivate people; knowledge of leadership goals and communicate their visions to others who
importance of not allowing decisions about cost skills and of the group’s activities; and possession of accept them as
containment and efficiency to cause a loss of the interpersonal skills to influence others. Principles their own.
focus on core values of quality client care. Nurses who of effective leadership include vision, influence, and Influence is an informal strategy used to gain the
can keep their balance in making these decisions and acting as a role model. cooperation of others without exercising
stay focused on key priorities and core values are the formal authority. Influence is exercised through
ones most likely to become and remain authentic nurse BOX 28–1 Characteristics of Effective Leaders persuasion and excellent communication skills; it is
leaders They are the ones who can be trusted to act Effective leaders: based on a trusting relationship with the followers.
with courage and integrity when the tough decisions • Use a leadership style that is natural to them.
must be made. • Use a leadership style appropriate to the task and the An effective leader needs to show sensitivity to being
members. a positive role model, someone who sets the example
Shared leadership recognizes that a professional • Assess the effects of their behavior on others and the for others to follow. As is appropriate for any health
workforce is made up of many leaders. No one person effects of others’ behavior and caring profession, leadership should also be
is considered to have knowledge or ability beyond that on themselves. humanistic; that is, leaders should act in ways that
of other members of the work group. Appropriate • Are sensitive to forces acting for and against change. stress individuals’ dignity and worth. Being a good
leadership is thought to emerge in relation to the • Express an optimistic view about human nature. leader takes thought, care, insight, commitment, and
challenges that confront the work group. Examples of • Are energetic. energy. The leader demonstrates caring toward
shared leadership in nursing are self-directed work • Are open and encourage openness, so that real issues coworkers and clients.
teams, coleadership, and shared governance. are confronted.
TOPIC 2: CONCEPT OF MANAGING establishing goals and developing strategic plans. equipment, and physical space are included in the
Nurse executives are registered nurses who are planning for resource allocation. An upper-level
MANAGEMENT responsible for the management of nursing within the manager spends considerable time planning goals and
The manager’s job is to accomplish the work of the organization and the practice of nursing. Some nurse services, determining numbers and types of nurses and
organization. To this end, managers perform roles and executives are also responsible for auxiliary units such other personnel needed to provide these services.
functions that vary with the type of organization and as the pharmacy, laboratory, and dietary departments.
the level of management. Nurses in these positions may be called vice president • On the other hand, a first-level manager such as a
for client care services, vice president for nursing, staff nurse spends less time planning but manages
Levels of Management director of nursing, or chief nurse. individual clients by use of the nursing process. An
Traditional management is divided into three levels of example of the planning function is risk
responsibility. The reporting relationship among staff CLINICAL ALERT! management, having in place a system to reduce
and managers is often referred to as the chain of Nurses generally move from first- to middle- to upper- danger to clients and staff. The steps of risk
command. level management positions through promotion. In management include anticipating and seeking sources
addition, nursing administration graduate academic of risk; analyzing, classifying, and prioritizing risks;
First-level managers are responsible for managing programs are available at some nursing schools. developing a plan to
the work of non managerial personnel and the day-to- avoid and manage risk; gathering data that indicate
day activities of a specific work group or groups. Management Functions success at avoiding or minimizing risk; and evaluating
Their primary responsibility is to motivate staff to Four management functions are planning, organizing, and modifying risk reduction programs. Central to the
achieve the organization’s goals. This level of directing, and coordinating. process of risk management is communication among
manager communicates staff issues to upper These four functions help to achieve the broad goal of all involved individuals.
administration and reports administrative messages quality client care.
back to staff. Titles may include primary care nurse, Planning is an ongoing process that involves Organizing is also an ongoing process of coordinating
team leader, or charge nurse. (a) assessing a situation, work. After identifying the work and evaluating
(b) establishing goals and objectives based on human and material resources, the manager arranges
Middle-level managers supervise a number of first- assessment of a situation or future the work into smaller
level managers and are responsible for the activities in trends Units
the departments they supervise. Middle-level (c) developing a plan of action that identifies
managers serve as liaisons between first-level priorities, delineates who is responsible, determines • Organizing involves determining responsibilities,
managers and upper-level managers. They may be deadlines, and describes how the intended outcome is communicating expectations, and establishing the
called supervisors, nurse managers, or head nurses. to be achieved and evaluated. chain of command for authority and communication.
• In short, it involves deciding what, when, Although upper-level managers delegate much of the
Upper-level (top-level) managers are organizational where, and how to do it, by whom, and with what work and responsibility and accountability for the
executives who are primarily responsible for resources. Distribution of money, personnel, work to others, they need to ensure that department
objectives, priorities, job descriptions, lines of staff nurse determines whether nursing interventions Responsibility is an obligation to perform a task.
communication, nursing standards, procedures, and have helped the client achieve desired outcomes. Managers are responsible for effective utilization of
policies clearly describe the expectations. resources, communication to subordinates, and
Principles of Management implementation of organizational goals and objectives.
Directing is the process of getting the organization’s A manager has authority, accountability, and • Responsibility for nursing actions can be transferred
work accomplished. responsibility. to another practitioner but accountability is always
shared (Sullivan, 2013).
• Directing involves assigning and communicating Authority is defined as the legitimate right to direct
expectations about the task to be completed, providing the work of others. It is an integral component of Skills and Competencies of Nurse Managers
instruction and guidance, and ongoing decision managing. To be effective managers, nurses need to think
making. Upper-level managers devote less time to • is conveyed through leadership actions; it is critically, communicate well, manage resources
directing than to planning, organizing, and controlling. determined largely by the situation, and it is always effectively and efficiently, enhance employee
associated with responsibility and accountability. The performance, build and manage teams, manage
• Directing at this level of management generally manager must accept the authority granted. conflict, manage time, and initiate and manage
involves supervision of the next level of managers change.
such as those in middle management. Unit managers Accountability is the ability and willingness to
(charge nurses) and staff nurses devote more time to assume ownership for one’s actions and to accept the CRITICAL THINKING
directing. For example, charge nurses direct shift work consequences of one’s behavior. Critical thinking is a creative cognitive process that
by assigning clients and scheduling meal and break includes problem solving and decision making. The
times. Staff nurses direct the care of clients by • This can be viewed as hierarchic, starting at the nurse manager reasons with logic and explores
ordering nursing care, communicating care in written individual level, then the institutional or professional assumptions, alternatives, and the consequences of
care plans and shift reports, and supervising care that level, and finally the societal level. actions.
is given by others. • At the individual or client level,accountability is COMMUNICATING
reflected in the nurse’s ethical integrity. Managers’ report spending much of their day
Coordinating is the process of ensuring that plans are • At the institutional level, it is reflected in the communicating. Good communication is essential and
carried out and evaluating outcomes. The manager statement of philosophy and objectives of the nursing often determines the manager’s success. Managers use
measures results or actions against standards or department and nursing audits. both verbal and written communication. Effective
desired outcomes and then reinforces effective actions • At the professional level, it is reflected in standards managers communicate assertively, expressing their
or changes ineffective ones For example, an upper- of practice developed by national nursing associations. ideas clearly, accurately, and honestly.
level manager evaluates the effectiveness of At the societal level, it is reflected in legislated nurse Managers use networking, a process whereby
recruitment, staff turnover, and budget performance. practice acts. professional links are established through which
The charge nurse appraises staff performance. The people can share ideas, knowledge, and information;
offer support and direction to each other; a facilitate preceptor also instills understanding of the routines, Nurse managers are frequently in a position to manage
accomplishment of professional goals. policies, and procedures of the institution and the unit. conflict among people, groups, or teams. The conflict
may arise from differing values, philosophies, or
MANAGING RESOURCES BUILDING AND MANAGING TEAMS personalities. For example, employees may have
One of the greatest responsibilities of managers is In addition to personnel development, managers are strong disagreements about whether each member of
their accountability for human, fiscal, and material responsible for building and managing work teams. the nursing team is doing a fair share of the work. In
resources. Budgeting and determining variances Familiarity with group processes facilitates a health care, conflict can also arise due to competition
between the actual and budgeted expenses are crucial manager’s ability to lead a group and enhances for resources, especially funding for staff positions or
skills for any manager. development of that group into a work team. Groups equipment. There are many methods the nurse can use
develop in stages, during which roles and relationships to manage conflict and each has itsadvantages and
ENHANCING EMPLOYEE PERFORMANCE are established. The purposes of the team as a whole disadvantages. Among the most common are
Several ways of enhancing employee performance are and the role of each member must be clear. Each compromise, negotiation, and collaboration. The new
available to managers. Managers are responsible for member must feel that the manager and the other nurse manager may require training to become
ensuring that employees develop by providing members recognize his or her contributions. In health proficient in the use of these methods. Basic principles
appropriate learning opportunities, such as in-service care, the team may consist of any health care for all types of conflict management include
education; by facilitating attendance at professional providers: nurses, therapists, unlicensed personnel, demonstrating respect for all parties, avoiding blame,
workshops and conventions; and by encouraging clergy, and so on. All members of the team need to use allowing full discussion, using ground rules during
achievement of advanced education such as higher effective meetings to promote fairness, encouraging active
degrees or certifications. The nurse manager who communication skills. Evaluating the group’s work is listening, identifying the themes in the discussion, and
empowers the staff by providing information, support, another responsibility of the manager. Effectiveness, exploring alternative solutions. An effective manager
resources, and opportunities to participate will find efficiency, and productivity are three outcome recognizes that, if the problem is significant to any of
that employees have greater commitment to the measures that are frequently used. In health care, the individuals involved, avoiding or failing to handle
institution, are more effective in their role, have effectiveness is a measure of the quality or quantity of the conflict is likely to result in the problem becoming
increased self-esteem, and are better able to meet their services provided. Efficiency is a measure of the larger and more difficult (Pfendt & Anderson, 2012).
goals. In addition, the manager may provide day-to- resources used in the provision of nursing services. In
day coaching or serve as a mentor or preceptor. A nursing, productivity is a performance measure of MANAGING TIME
mentor “is a wiser and more experienced person who both the effectiveness and efficiency of nursing care. The effective nurse manager uses time effectively and
guides, supports, and nurtures a less experienced Productivity is frequently measured by the amount of assists others to do the same. Many factors inhibit
person” (Sullivan, 2013, p. 233). Having a mentor is nursing resources used per client or in terms of good use of time such as preference for doing things
recognized as important for career development. In the required versus actual hours of care provided. the nurse likes to do before things the nurse prefers not
clinical area, the term preceptor is used to describe an to have to do, emergencies or crises that divert one’s
experienced nurse who assists the “new” nurse in MANAGING CONFLICT attention, and unrealistic demands from others.
improving clinical nursing skill and judgment. The Strategies that the manager—and all nurses—can use
in order to use time well involve setting goals and continued evaluation of the client’s care. These “nurse effectiveness of the delegation and whether the desired
priorities, delegating appropriately, examining how extenders” may be identified by a variety of titles client outcome was attained”
time is used, minimizing paperwork (automating including certified nursing aides/assistants, home (NCSBN, 2005, p. 1).
whenever possible), and using regular schedules that health aides, medication assistants, patient care It is not possible to generate an exhaustive list of
avoid interruptions and set time limits on activities. technicians, orderlies, or surgical technicians. They exactly which actions can be delegatedto UAP.
have had diverse degrees of training and experience. Examples of tasks that may and may not be delegated
TOPIC 3: CONCEPT OF DELEGATING They are employees and do not include family are given in Box 28–2. A statement regarding
members or friends who provide some client care. delegation to UAP is included with the steps for each
THE NURSE AS DELEGATOR Each state nurse practice act specifies which actions skill in this text. The unlicensed person may not
Delegation is the act of transferring to a competent constitute the legal practice of nursing, which actions delegate tasks to another person. Principles guiding
individual the authority to perform a selected nursing are the purview only of nurses, and which may be the nurse’s decision to delegate ensure the safety and
task in a selected situation (National Council of State delegated to others. The model state nursing practice quality of outcomes.
Boards of Nursing act authored by the NCSBN (2012) states that both the
[NCSBN], 2012). The delegate assumes responsibility registered nurse (including advanced practice nurses) These principles are listed in Box 28–3. Even if the
for the actual performance of the task or procedure. and the licensed vocational/practical nurse task is one that may legally be delegated, the
The delegator retains accountability for the outcome. (LVN/LPN) may delegating nursing interventions to individual nurse must still determine if the task can be
Delegation is a tool that allows the delegator to devote implement the plan of care. delegated to a particular UAP for a specific
more time to tasks that cannot be delegated. It also client. The NCSBN has created decision trees to assist
enhances the skills and abilities of the delegate, which The NCSBN (1997) published five “rights” of the nurse in determining if delegation is safe (Figure
builds self-esteem, promotes morale, and enhances delegation: 28–2 •). Once the decision has been made to delegate,
teamwork and attainment of the organization’s goals. 1. The nurse delegates the right task, the nurse must communicate clearly to the UAP and
In nursing, delegation refers to indirect care—the 2. under the right circumstances, verify that the UAP understands:
intended outcome is achieved through the work of 3. to the right person, • The specific tasks to be done for each client
someone supervised by the nurse—and involves 4. with the right direction and communication, • When each task is to be done
defining the task, determining who can perform the 5. and the right supervision and evaluation. • The expected outcomes for each task, including
task, describing the expectation, seeking agreement, “The steps of the delegation process include parameters outside of which the
monitoring performance, and providing feedback to assessment of the client, the staff and the context of unlicensed person must immediately report to the
the delegate regarding performance. Registered nurses the situation; communication to provide direction and nurse (and any action that must urgently
increasingly delegate components of nursing care to opportunity for interaction during the completion of be taken)
other health care workers, especially unlicensed the delegated task; surveillance and monitoring to • Who is available to serve as a resource if needed
assistive personnel (UAP). An RN who delegates a assure compliance with standards of practice, policies • When and in what format (written or verbal) a report
task to another health care worker is accountable for and procedures; and evaluation to consider the on the tasks is expected.
selecting an appropriately skilled caregiver and for
A specific task that can be delegated to one UAP may TASKS THAT MAY NOT BE DELEGATED TO and may not be capable of performing every task cited
not be appropriate for another UAP, UNLICENSED ASSISTIVE PERSONNEL in the job description.
depending on each UAP’s experience and individual • Assessment 10. When unsure about an assistant’s abilities to
skill sets. Also, a task that is appropriate for the UAP • Interpretation of data perform a task, observe while the person performs it,
to perform with one client may not be appropriate with • Making a nursing diagnosis or demonstrate it to the person and get a return
a different client or the same client under altered • Creation of a nursing care plan demonstration before allowing the person to
circumstances. For example, the taking of routine vital • Evaluation of care effectiveness perform it independently.
signs may be delegated to the UAP for a client in • Care of invasive lines 11. Clarify reporting expectations to ensure the task is
stable condition but would not be delegated for the • Administering parenteral medications accomplished.
same client who has become unstable. It is important • Insertion of nasogastric tubes 12. Create an atmosphere that fosters communication,
to note that the nurse is not held legally responsible for • Client education teaching, and learning. For example,
the acts of the unlicensed person, but is accountable • Performing triage encourage staff to ask questions listen carefully to
for the quality of the act of delegation and has the • Giving telephone advice their concerns, and make use of every opportunity
ultimate responsibility for ensuring that proper care is BOX 28–3 Principles Used by the Nurse to to teach.
provided.22 Determine Delegation to Unlicensed Assistive
Personnel SAFETY ALERT!
BOX 28–2 Examples of Tasks That May and May 1. The nurse must assess the individual client prior to Each nurse or other licensed or unlicensed health care
Not Be Delegated to Unlicensed Assistive Personnel delegating tasks. provider is responsible for his or her own actions.
TASKS THAT MAY BE DELEGATED TO 2. The client must be medically stable or in a chronic Anyone who feels unqualified to perform a delegated
UNLICENSED ASSISTIVE PERSONNEL condition and not fragile. task must decline to perform it. In addition to
• Taking of vital signs 3. The task must be considered routine for this client. delegating to UAP, the RN also delegates to
• Measuring and recording intake and output 4. The task must not require a substantial amount of LVN/LPNs and other RNs. Because LVN/LPNs are
• Client transfers and ambulation scientific knowledge or technical skill. licensed, the nurse must know their state-specific
• Postmortem care 5. The task must be considered safe for this client. scope of practice in order to delegate effectively.
• Bathing 6. The task must have a predictable outcome. LVN/LPNs require less direct supervision than UAPs.
• Feeding 7. Learn the agency’s procedures and policies about In some regions and some agencies, LVN/LPNs may
• Gastrostomy feedings in established systems delegation. perform tasks generally considered the role of the
• Attending to safety 8. Know the scope of practice and the customary registered nurse if they have received special training.
• Weighing knowledge, skills, and job description for each health For example, in most U.S. states they may assess
• Performing simple dressing changes care discipline represented on your team. intravenous (IV) infusion sites, but in only some states
• Suctioning of chronic tracheostomies 9. Be aware of individual variations in work abilities. can LVN/ LPNs administer IV fluids or medications,
• Performing basic life support (CPR) Each individual caregiver has different experiences initiate IVs, administer parenteral nutrition, or
delegate to others. The process of delegating to these
nurses is the same as it is in delegating to UAP. For promoting change are influenced by the culture of the behavioral changes that are in conflict with the
example, LVN/LPNs may be authorized to provide caregivers. Specific examples include: person’s needs or goals.
client teaching from a standard teaching plan but the • Communication: Volume, tone, and choice of words
RN must still confirm that the particular LVN/LPN’s plus nonverbal behavior used in communicating ideas Unplanned change is an alteration imposed by
job description, education, and competency meet the and instructions may be interpreted differently in external events or individuals. It occurs when
needs of the specific situation (Kelly & Marthaler, different cultures. unexpected events force a reaction. It is usually
2011). When delegating to this nurse, the RN retains • Space: The distance between two individuals or the haphazard, and the results can be
primary responsibility and accountability for seating arrangement in a group may either promote or unpredictable. Drift is a type of unplanned change in
implementation of the nursing process. The RN also impede effective teamwork. which change occurs without effort on anyone’s part.
delegates to other RNs. This is part of the daily routine • Time: There are culturally defined perspectives on Situational, or natural, change also may be considered
of determining which of the available nurses should what situations are considered emergencies as well as unplanned and occurs without any control by the
care for which clients or when specific additional how much time is meant by words such as now, soon, person or group impacted. An example is the change
assistance is required for one client. When delegating or immediately. Also, a specific culture may be more that occurs because of a war or a natural disaster. Not
to RNs who are new to a particular setting— such as focused on the present, past, or future than on the all situational changes are negative. For example, as
when the nurse from one unit in a hospital is other time frames. agencies open or close units, the nurse may have the
temporarily assigned to a different unit (called • Power/control: Cultures vary in their views of opportunity to change to a new workplace.
“floating”)—the delegating nurse must confirm that whether events are internally or externally controlled
the five rights are still met. Delegation can be an and this may influence personnel’s initiative. Some SELF-CARE ALERT
extremely useful strategy in providing thorough and individuals may always wait to be told when to Change that is viewed as a threat by one nurse may be
effective nursing care. Skill in delegation, however, perform activities, whereas others may do so viewed as an opportunity by another nurse.
must be learned and developed over time. The nurse independently. Beliefs also vary related to luck, fate,
should not hesitate to consult with others regarding the destiny, and personal choice. The Nurse’s Role in Change
appropriateness of delegation. In his classic work, Lewin (1951) described change as
Change may be considered covert or overt. A covert involving three stages: unfreezing, moving, and
PATIENT-CENTERED CARE | Culturally change is hidden or occurs without the individual’s refreezing. During the unfreezing stage, the need for
Responsive Care awareness. An example is the gradual, subtle increase change is recognized, driving and restraining forces
Cultural Considerations in Leadership, in the severity of the clients on a nursing unit. Overt are identified, alternative solutions are generated, and
Management, and Delegation change is change of which a person is aware. An participants are motivated to change. In the second
example might be that a piece of equipment will no stage, moving, participants agree the status quo is
In the same way that nurses consider how care is longer be available since the agency has changed undesirable and the actual change is planned in detail
influenced by the client’s culture, the nurse must suppliers. People who experience overt change may and implemented. In the final stage, refreezing, the
consider how leading, managing, delegating, and experience anxiety. Overt change often necessitates change is integrated and stabilized.
An important aspect of planning change is establishing • Low tolerance for change related to intellectual or 8. Divert attention by creating a different disturbance.
the likelihood of the acceptance of the change and then emotional insecurity Energy can shift to a more important problem inside
determining the criteria by which that acceptance can • Perception that the change will not achieve goals; the system, thereby redirecting resistance. Alternately,
be identified. Accepting change often takes time, failure to see the big picture attention can be brought to an external threat to create
particularly when it does not fit into a person’s • Lack of time or energy a bully phenomenon. When members perceive a
attitudinal framework. The course of acceptance is • Perceived loss of freedom to engage in particular greater environmental threat (such as competition or
easier for people if they are involved in the process. If behaviors restrictive governmental policies), they tend to unify
possible, change should be instituted on a small or BOX 28–5 Guidelines for Dealing with Resistance internally. From Effective Leadership and
pilot scale before full implementation. To facilitate to Change Management in Nursing (8th ed., pp. 63–64), by E. J.
acceptance of the change, the change agent needs to 1. Talk with those who oppose the change. Get to the Sullivan, 2013, Upper Saddle River, NJ: Prentice Hall.
identify common driving and restraining forces (Box root of their reasons for Reprinted with permission.27
28–4). Guidelines for dealing with resistance to opposition. 2. Identify key persons who will be affected by the
change are found in Box 28–5. 2. Clarify information, and provide accurate change. Pay attention to those immediately above and
information. below the point of change.
Change requires energy, much of which comes from 3. Be open to revisions but clear about what must 3. Find out as much as possible about these key
those who have power. To access optimal power, use remain. people. What are their “tickle points”?
the following strategies: 4. Present the negative consequences of resistance What interests them, gets them excited, turns them
1. Analyze the organizational chart; know the formal (e.g., threats to organizational off? What is on their personal and organizational
lines of authority. Identify informal lines as well. survival, compromised client care). agendas? Who typically aligns with whom on
BOX 28–4 Common Driving and Restraining 5. Emphasize the positive consequences of the change important decisions?
Forces for Change and how the individual or group will benefit. 4. Begin to build a coalition of support before you start
DRIVING FORCES However, do not spend too much energy on rational the change process. Identify the key people who will
• Perception that the change is challenging analysis of most likely support your idea and those who are most
• Economic gain why the change is good and why the arguments likely to be persuaded easily. Talk informally with
• Perception that the change will improve the situation against it do not hold up. People’s resistance them to flush out possible objections to your idea
• Visualization of the future impact of change frequently flows from feelings that are not rational. and potential opponents. What will the costs and
• Potential for self-growth, recognition, achievement, 6. Keep resisters involved in face-to-face contact with benefits be to them—especially in political
and improved relationships supporters. Encourage proponents to empathize with terms? Can your idea be modified in ways that retain
RESTRAINING FORCES opponents, recognize valid objections, and relieve your objectives but appeal to more key people?
• Fear that something of personal value will be lost unnecessary fears. 5. Follow the organizational chain of command in
(e.g., threat to job security or self-esteem) 7. Maintain a climate of trust, support, and confidence. communicating with administrators. Do not bypass
• Misunderstanding of the change and its implications anyone to avoid having an excellent proposal
undermined. (Sullivan, 2013, pp. 64–65)
All nurses are affected by change; nobody can avoid a) Belief System. Filipinos are believers of religion.
it. Nurses knowledgeable about the historical and They believe so much on supernatural powers and
current trends in nursing and current political, social, viewed themselves as only a speck in this wide
technologic, and economic issues make rational plans universe. Success is considered a blessing from above,
to deal with opportunities to initiate and guide needed as a result of good luck and faith Good is considered
change and to respond to change that affects them in relative. Happiness and success differ from one person
the workplace, government, 0rganizations, and the to another. Hospitality is practice.
community.
b) Value System. Cultural values are shared
 MODULE 12 : FILIPINO CULTURE, assumptions of what is right, good or important. Guide Filipino word/s depicting cultural beliefs and their
VALUES AND PRACTICE IN RELATION man's behavior and action as he relates himself in English translation
TO HEALTH CARE most situations in LIfe. Can best be seen from the (Abad and Tan et.al, 2014)
aspects of personal and social relationships. Majority
Topic 1. Filipino Cultural Values and Beliefs in of Filipinos value more their honor (karangalan) rather The Filipino Cultural Perspectives
Relation to healthcare than wealth. 1. The Traditional Concept hold that Filipino culture
was developed due to the conglomeration of the
Culture is defined as the “totality of socially In Revisiting usog, pasma, and kulam, Tan explains physical, intellectual, moral and spiritual aspects.
transmitted pattern of thoughts, values, meanings, that “culture is inscribed in our bodies and in our
and beliefs” (Purnell 2005). It is not limited to any minds” (Tan 2008). As such, the relationship of
specific ethnic group, geographical area, language, culture and health is important to understand as it 2. The Nationalistic View regards culture as the
religious belief, manner of clothing, sexual orientation, impacts an individual’s worldview and decision- summation of the needs of people, the description of
and socioeconomic status (Fisher 1996). making process (Purnell 2005). Like in other fields of their past and present condition, an expression of their
medicine, the impact of cultural beliefs is increasingly values, thoughts and emotions, and the depiction of
Filipino culture is the summation of indigenous being recognized as an essential component in the their historic struggles too liberate themselves.
forces and foreign influences that had come to bear genetic counseling process (Cohen et al. 1998;
upon the people in varying degrees during the last Edwards et al. 2008; Penn et al. 2010). 3. Cultural Dualism the Philippines is a transitional
centuries. Contributory factors to Filipino Culture society dominated on one side by the
Malays Chinese Indian Hindu Spanish Americans Seven common Filipino cultural beliefs are traditional culture and on the other side by the modern
presented in the paper of Abad and Tan et.al culture.
The Filipino culture involves two important influential (2014) and these are: namamana, lihi, sumpa, gaba,
factors: pasma, namaligno, and The Common Filipino Values
kaloob ng Diyos. 1. Utang-na -loob. it is a technique of reciprocity of
debt of gratitude to others within the family circle or
primary group, sometimes unlimited in nature, threatened or questioned and to retaliate. Common - an abstract biological-medical conception of
emotional rather than financial or rational. It is sign of forms of this are 6 “hele hele bago quiere” or pakipot pathological abnormalities in people’s bodies
marginal economy where no place is available in which shows at aperson initially refusing an offer  Sakit
bargaining, formal agreements, written contracts, even if he wants very much to accept it. - In Philippine society, only one word exists to
specific rights and responsibilities. 8. Health Decision. In decision- making, the Filipinos describe such phenomena – “Sakit”
2. Pakikisama. Closely to utang-na-loob It is the value usually consult and take into consideration the - The term “sakit” is closer to the meaning of illness
of belongingness and loyalty to the snall in-group consensus of the family members as the feelings of than to disease
with sensitivity to the feelings of others on the those who are to be affected. That is why in health - In many cases, ailments or illnesses are culture-
principle of “give and take.” Is a folk concept of good decision making the familial values and influence specific.
public relations and avoidance of conflict with the is taken into consideration - Ex. Usug, Bangungot (Western: nightmare death
leader or majority of the groups. syndrome
3. Hiya. Controls a large extent the behavior of the Topic 2. Filipino Health Beliefs and Behaviors: Sakit = Pain
individual. Dependent on others will think, say and do. Theories of Illness - Western medicine – pain as a symptom
Because of hiya, a Filipino cannot say “NO” even it is Health in the Filipino setting is a combination of - Filipino medicine – sakit = pain in several contexts
against his will to do what is being requested. maturative processes or development in (ex. sakit ng ulo, sakit ng tiyan)
4. Bahala na. Common expression among Filipinos correspondence to the ability to function properly or to - Sakit also has different degrees (ex. hapdi for a
and this rest on the fatalistic outlook and strong be active. Being either Thin (Payat) or Mataba/taba stinging type; kirot for a sharp,
dependence on the “spirits” who will take care of (Fat) are not considered as healthy, but not necessarily recurrent type; antak for internal, continuous stinging
everything if they are really meant for a person ill. Health = Kalusugan = “Able-bodied” type)
5. Authoritarianism. It is the dependence of the Full development, progressiveness (in terms of  LUSOG
Filipinos in a paternalistic rather than in a stern way vigorous physical development, Panganiban, 1998). Sakit = illness
upon the elders of the family, upon their boss, if Malusog vs. Payat (Not necessarily ill) - Diagnosis involves the culmination of a process of
employed, and upon people in authority as their father observing signs and eliciting symptoms that are graded
figure. Commonly practice in the Filipino family to Illness vs. Disease in terms of seriousness (often associated with level of
which basically patriarchal in nature. The father is  Illness physical activity one can still exert)
seen as the head that makes major decisions affecting - a single instance of “being sick”  May Sakit
the family. - the human experiencing of disease - A normally strong person who suddenly feels weak
6. Individualism. Pattern of behavior which  Disease is said to be have the beginnings of an illness. This
characterizes the Filipino as self-centered. The desire - a diagnostic category, a conceptual entity which weakness is close to the English term lethargic.
to make the name for himself becomes the primary classifies particular illnesses, symptoms or - Persistence of lethargy, accompanied by other
motivation for success. pathological components of illnesses or stages of symptoms are monitored by family and friends but the
7. Amor-propio. Individual's highly emotional reaction illnesses term MAY SAKIT will only be used when the person
to protect his honor and dignity when they are
is unable to perform physical tasks (common criterion: o Ex. A person pondering on the meaning of his/her cast out these evil forces through the use of prayers,
bed-ridden) life = depressive order = need for anti-depressants incantations, medicinal herbs and plants. For
Filipino ways to manage illness: - Few health professionals have the ability to see that protection the healer may recommend using holy oils,
1. No matter what ailment, it is considered as some “problems” may actually =be part of a healthy or wearing religious objects, amulets or talismans
mild/slight at first notice. Patient is rarely given process of an individual’s mental, emotional, and (anting anting).
treatment during this stage. social development
2. The gravity of the sickness will only be taken into - Therefore, immediately attaching medical labels and  Naturalistic Causes
notice when patient starts to suffer more and more. treatment on such conditions may be detrimental as it Naturalistic causes include a host of factors ranging
3. If one complains of pain or great itching, this is the medicalizes life’s processes from natural forces (thunder, lightning, drafts, etc.) to
first stage of malaise. If symptom excessive stress, food and drug incompatibility,
continues over a considerable period of time Theories of illness causation in the Philippines infection, or familial susceptibility.
accompanied by the intensifying of the symptom, the Physical and mental health and illness are viewed
patient and the family sees the sickness as serious. holistically as an equilibrium model. In contrast, other Indigenous Health Beliefs
4. If patient starts to stay in bed than continuing with explanatory models may include mystical,
his daily routine, this is considered as another stage of personalistic and naturalistic causes of illness or  Concept of Balance (Timbang)
severity. disease (Anderson, 1983; Tan, 1987; Tompar-Tiu & This concept is central to Filipino self-care practices
5. Filipinos consider CRYING as the surest indicator Sustento-Seneriches, 1995). and is applied to all social relationships and
of severity encounters. According to this principle, health is
 Mystical Causes thought to be a result of balance, while illness due to
Medicalization by Western Countries Mystical causes are often attributed to experiences or humoral pathology and stress is usually the result of
- Some illnesses are more than just physical o More behaviors such as ancestral retribution for unfinished some imbalance. Rapid shifts from “hot” to “cold”
health professionals are starting to recognize the tasks or obligations. Some believe that the soul goes cause illness and disorder. Illustrated below are a
important role of social relationships in determining out from the body and wanders, a phenomenon known range of humoral balances that influence Filipino
health and disease as Bangungot, or that having nightmares after a heavy health perceptions:
- “Syndrome” – slowly becoming a popular term in meal may result in death. • Rapid shifts from “hot” to “cold” lead to illness
medical literature but still reflects the need to delimit • “Warm” environment is essential for maintaining
the qualifiers used by the western-oriented medical  Personalistic Causes optimal health
system Personalistic causes are associated with social • Cold drinks or cooling foods should be avoided in
- Some illnesses/ailments cannot and should not be punishment or retribution from supernatural forces the morning
immediately appropriated into biomedical or such as evil spirit, witch (Manga ga mud) or sorcerer • An overheated body is vulnerable to disease; a
psychiatric pathology o Some physicians quickly label (mangkukulam). The forces cast these spells on people heated body can get “shocked”
some problems as medical, when some are if they are jealous or feel disliked. Witch doctors • When cooled quickly, it can cause illness
actually more philosophical in nature. (Herbularyo) or priests are asked to counteract and
• A layer of fat maintains warmth, protecting the the nurse encounters clients who may be experiencing Actual loss - can be arising in response to or in
body’s vital energy grief related to decreasing health, loss of a body part anticipation of a situation. For example, a woman
• Imbalance from worry and overwork create stress or terminal illness, or the impending death of self or a whose husband is dying may experience actual loss in
and illness significant other. anticipation of his death.
• Emotional restraint is a key element in restoring  
balance In the community setting Perceived loss - is experienced by one person but
• A sense of balance imparts increased body awareness the nurse may encounter grieving losses to personal cannot be verified by others. For example, a woman
(Adapted from Becker, 2003). crisis (e.g. divorce, separation) or natural disaster who leaves her employment to care for her children at
(earthquakes, floods, or hurricanes). home may perceive a loss of independence and
 MODULE 15 : NURSING INTERVENTIONS Therefore, it is important that the nurse understand the freedom.
TO PROMOTE HEALTHY significance of loss and develop the ability to assist
PSYCHOSOCIAL RESPONSES TO clients as they work through the grieving process. Maturational loss - is experienced because of natural
HEALTH/ ILLNESS developmental processes. It is a loss resulting from
Loss normal life transitions.
 Concept of Death and Dying/ Grief and It occurs when a valued person or object, or situation  
Grieving is changed or made inaccessible so that its value is Situational loss - is occur in response to specific
diminished or removed. People can experience the loss external event. It is experienced because of an
The nurse is often the key person in providing support of body image, a significant other, a sense of well- unpredictable event, including traumatic injury,
and care when loss or death occurs. being, a job, personal possessions, or beliefs. Illness disease, death, or national disaster.
and hospitalization often produce losses.  
To provide effective care, the nurse must have Anticipatory loss - in which a person displays loss and
accepted her own feelings about death and understand Death grief behaviors for a loss that has yet to take place. It
the stages of grieving and dying. Is unavoidable, it can stimulate people to grow in their is often seen in the families of patients with serious
understanding of themselves and others.The dying and life-threatening illnesses and serves to lessen the
The Nursing Goal Focus on person’s experience life in ways that bring impact of the actual loss of family member.
1.Health maintenance and restoration. significance and fulfillment. People experiencing loss
2.Maintaining maximum potential wellness. often search for the meaning of the event, and it is Categories of Loss
3.Promote good dying through compassionate generally accepted that finding meaning is needed for
palliative care. healing to occur. However, persons can be well 1. Loss of an Aspect of Self - may include a body part,
4. Facilitate coping with disability and death. adjusted without searching for meaning, and even physiological or psychological function.
those who find meaning may not see it as an end point 2. Loss of External Objects - involves any possession
In the clinical setting but rather an ongoing process. that is worn out, misplaced, stolen, or ruined by
disaster.
3. Loss of a Known Environment - includes leaving a Nurses interact with clients responding to many losses with oneself or with others. Client or family express
familiar setting. along the continuum of health and illness. Regardless anger sometimes at nurse and staff members, about
4. Loss of a Significant Other - this includes parents, of the type of loss, nurses must have a basic things that normally would upset them.
spouses, children, siblings, teachers, clergy, friends, understanding of what is involved to meet the “Why me? I didn’t do anything to deserve this.”
neighbors, and work associates. challenge that grief brings to clients. May pick out “scapegoats” on which to vent anger e.g.
5. Loss of life - person who face death live, feel, think, By understanding the phenomena that clients doctors, friends, and others.
and respond to events and people around them until experience as they deal with the discomfort of loss,  
the moment of death. nurses may promote the expression and release of May begin to use:
emotional as well as physical pain during grieving. Self-blaming
Grief - refers to the subjective emotions and affect that Supporting this process means ministering to Switching blame
are a normal response to the experience of loss. psychological and physical needs. Blaming the victim
Grieving, also known as bereavement. Aggressive anger: believing to have the right to vent
The therapeutic relationship and therapeutic blame and rage aggressively to the closest target.
Bereavement refers to the process by which a person communication skills such as active listening is
experiences the grief. It involves not only the content paramount when assisting grieving clients. Bargaining: "Just let me live to see my son graduate."
(what a person thinks, says, and feels) but also the Recognizing the verbal and nonverbal communication Bargain or strike a deal with God to make the loss go
process (how a person thinks, says, and feels). All content of the various stages of grieving can help away.Promise to do anything to make the loss go
people grieve when they experience life’s changes and nurses to select interventions that meet the client’s away.Seeks to bargain to avoid loss.May begin putting
losses. Often, grieving is one of the most difficult and psychological and physical needs. affairs in order, for example making wills and giving
challenging processes of human existence; rarely it is away personal items.Guilt for real or imagined past
comfortable or pleasant.  5 stages of grief by Elisabeth Kubler – Ross, sins may be expressed.
MD.  
Anticipatory grieving - is when people facing an May begin to:
imminent loss begin to struggle with the very real Denial: The initial stage: "It can't be happening." Shop around: believing to look for the “right” agent
possibility of the loss. Refuse to believe that a loss is happening. with the “cure” for the loss.
  Isolates self from reality and represses what is Gamble: believing that taking chances on “cures” for
Mourning - is the outward expression of grief. Rituals discussed. the loss
of mourning include having a wake, holding religious Ignore the signs of the loss. Take risks: believing to put oneself in jeopardy
ceremonies, and arranging funerals. Artificial cheerful to prolong the denial. financially, emotionally, and physically to get to an
answer or “cure” for the loss
Grieving Progress Anger: "Why ME? It's not fair?!" (either referring to Sacrifice: believing that ignoring the real needs in
God, oneself, or anybody perceived, rightly or pursuit of the “cure” can change the loss.
wrongly, as "responsible") Become angry with God,
Depression: "I'm so sad, why bother with anything?" gives oneself time to “deal” with it. Sets realistic time Cultural and religious differences can create
Grieves over what has happened and what cannot be. frame. Self- confidence: gains confidence needed for misunderstanding of death-related behaviors.
May cry and talk freely about the loss or may personal growth.
withdraw. Medical point of view
Physical Symptoms dying begins when the person has an untreatable and
May begin to experience: Feelings of tightness in the throat fatal disease.
Guilt: believing oneself is responsible for the loss Choking When death is inevitable, a “do not resuscitate” (DNR)
Remorse: believing that should feel sorry for the real Empty feeling in abdomen order is appropriate.
or perceived “bad past”, deeds for which the loss is Lack of muscular strength Advance directives should be sought regarding life-
some form of retribution or punishment. Subjective distress such as mental pain or distress sustaining measures and organ donation after death.
Loss of hope: believing that no hope of being able to Sleep disturbances
return to the calm and order of life prior to loss. Signs of death are the result of
Loss of faith and trust: believing that because of the Preoccupation with Image of the Deceased or Loss cell destruction
loss, can no longer trust in the goodness and mercy of Hears, sees, or imagines the deceased person. loss of body heat
God and mankind. Feeling of emotional distance from others. stagnation of blood
Feeling of loss of emotional control. rigor mortis.
Acceptance: "It's going to be OK."
Comes to terms with loss. Feelings of Guilt Criteria to determine irreversible coma used to make
May have decreased interest in surroundings and Searches for ways that loss could have been prevented. decisions about continuing life-support systems and
significant others.May wish to begin making plans. Accuses others of negligence or fault. procuring viable organ donors.
Can now: Loss of response to external stimuli, no pupillary
Describe the terms and conditions involved in the loss. Loss of Usual Behavior response to light, no corneal reflex, no normal
Cope with the loss.Test the concepts and alternatives Restlessness, inability to sit still, aimless movement. reflexive eye movement, and no gag or cough reflex
available in dealing with the loss. Impaired concentration. and no relationship of these losses to drugs or
May begin to use: Lack of capacity to initiate usual interests or activities. hypothermia.Cessation of spontaneous movement and
Rational thinking: refute irrational beliefs or fantasy Inability to experience pleasure. breathing.Two electroencephalograms 24 hours apart
thinking to address loss. Changes in eating habits. are flat decree that the patient has died, even when the
Adaptive behavior: can incorporate changes necessary respiration and circulation are being maintained by
after the loss.Appropriate emotion: expresses Death is an event, a state. chemicals and equipment.Loss of respiration and heart
emotional responses freely and are better able to It does not have the same meaning for everyone. beat with inability to reestablish them is death.
verbalize pain, hurt and suffering that has been Dying is subjective and private experience.
experienced.Patience and self-understanding: It is a dynamic process, a stage of life. In the case of terminal illness, an illness in which
recognize that it takes time to adjust to the loss and death is expected within a limited space of time, the
physician is usually responsible for deciding what, sustaining treatment-and should be made aware of this Fears Experienced by the Dying Person
when, and how the patient should be told. right. Fear of the unknown.
The nurse, along with members of the clergy and other Fear of abandonment and loneliness.
healthcare professionals, may be involved with these Impact on Family Fear of loss of relationships and experiences in the
decisions and in discussing the patient’s condition The family and significant others of terminally ill future.
with him or her. patients should be encouraged to participate in Fear of dependency and loss of independence.
Most patients want to know their diagnosis and planning the patient’s care. Fear of pain.
prognosis as soon as possible so that they can begin Healthcare personnel should be available to discuss
appropriate planning and take care of business and the patient’s condition with family members and The Major Nursing Responsibility for Clients who are
personal affairs. should offer support and care as the family begins the Dying is to assist the client to a peaceful death. More
grieving process. specific responsibilities are the following:
It is critical for terminally ill patients and their families The family may want to make arrangements with the To provide relief from loneliness, fear, and depression.
to have some sense of how the disease is most likely to patient for funeral or memorial services, depending on To maintain the client’s sense of security, self-
progress and what this will mean for the patient. which stage of grief both the patient and the family confidence, dignity, and self-worth.
All who are involved with the patient’s care should members are in. To maintain hope.
know exactly what the patient and the family have Palliative Care To help the client accept losses.
been told; members of the patient’s healthcare team means taking care of the whole person-body, mind, To provide physical comfort.
need to communicate among themselves. and spirit, heart and soul. It looks at dying as
Cultural differences may dictate how much something natural and personal. Dignity - defined as the ability to function as a
information is desired and which family members are The goal of palliative care is to give patients with life- significant and integrated person. True dignity comes
to be informed. threatening illnesses the best quality of life they can from within.
have by the aggressive management of symptoms. Generally, dependence on others and loss of control
Impact on Patient Palliative acre is sometimes called hospice care. over oneself and interactions with the environment are
Many patients realize without being told that they are associated with loss of dignity.
suffering from a terminal illness; they often pick up Caring for the dying and the bereaved is one of the Nurses need to ensure that the client is treated with
this knowledge from nonverbal communication by nurse’s most complex and challenging responsibilities, dignity, that is, with honor and respect. Dying clients
their families and by healthcare professionals. bringing into play all the skills needed for holistic often feel that they have lost control over their lives
Patients must be allowed to go through the stages of physiologic and psychosocial care. and over life itself.
grieving process and to make decisions about their To be effective, nurses must come to grips with their By introducing options available to the client and
care. own attitudes toward loss, death, and dying, because significant others, nurses can restore and support
Competent patients have the right to consent and these attitudes will directly affect their ability to feelings of control.
refuse all indicated medical treatment-even life- provide care. Some choices that clients can make are the location of
care (e.g. hospital, home, or hospice); times of
appointments with health professionals; activity stage of illness, at the time of death, and during the Prayer and religious services, such as sacraments or
schedule; use of health resources; and times of visits bereavement period of survivors. blessings
from relatives and friends. Spiritual assistance at the time of death from clergy,
Most clients interviewed about dying indicate that they The principles of hospice care can be carried out in a family, or health care providers
want to be able to manage the events preceding death variety of settings, the most common being the Peace and tranquility of spirit
so they can die peacefully. autonomous hospice and the hospital-based palliative
Nurses can help clients to find meaning and care unit. The nurse has a responsibility to ensure that the
completeness and to determine their own physical, Palliative care is special care that is challenging and client’s spiritual needs are attended to, either through
psychological, and social priorities. requires skillful interpersonal relationships and direct intervention or by arranging access to
Dying people often strive for self-fulfillment more compassion. individuals who can provide spiritual care.
than self-preservation, and they need to find meaning Nurses need to be aware of their own comfort and
in continuing to live while suffering. Meeting Physiologic Needs of the Dying Client spiritual issues and be clear about their ability to
Part of the nurse’s challenge, then, is to help maintain, The physiologic needs of the dying are related to a interact supportively with the client
day to day, the client’s will and hope. slowing of the body processes and to homeostatic
imbalances. Nurses have the a responsibility to not impose their
Hospice and Home Care Interventions include providing personal hygiene own religious/spiritual beliefs on a client, but to
Hospice care, palliative care, and home care focus on measures; controlling pain; relieving respiratory respond to the client in relation to the client’s own
support and care of the dying person and family, with difficulties; assisting with movement, nutrition, background and needs.
the goal of facilitating a peaceful and dignified death. hydration, and elimination; and providing measures Communication skills are most important in helping
Hospice care is based on holistic concepts that related to sensory changes. the client articulate needs and in developing a sense of
emphasize care to improve the quality of life rather caring and trust.
than cure. Spiritual Support
The hospice movement was founded by Dr. Cecily Spiritual support is of great importance in dealing with Specific interventions may include facilitating
Saunders in London, England, in 1967 and was later death. expressions of feeling, prayer, meditation, reading,
extended to the United States by Dr. Sylvia Lack Although not all clients identify with a specific and discussion with appropriate clergy/spiritual
religious faith or belief, the majority have a need for advisor.
Its goals are: meaning in their lives, particularly as they experience It is important for nurses to establish an effective
To control and relieve pain and symptoms of the a terminal illness. interdisciplinary relationship with spiritual support
illness. Jacik (1989, pp. 271-273) describes the spiritual needs specialists.
To provide physical comfort for the terminally ill. as follows:
To provide social, emotional, and spiritual comfort for Sensory Functioning
the client, family, and friends throughout the final Forgiveness from and reconciliation with God and past Sensory stimuli give meaning to events in the
human relationships environment.
Any alteration in people’s sensory functions can affect For an individual to be aware of the surroundings. reticular faciltatory area of the upper brain stem and
their ability to function within the environment. thereby reduce the tonic nerve signals transmitted by
For example, many clients have impaired sensory 1. Stimulus - an act that stimulates a nerve receptor. way of the spinal cord to the antigravity muscles.
functions that put them at risk in the health care 2. Receptor - nerve cell acts as a receptor by
setting; nurses can help them find ways to function converting the stimulus to a nerve impulse.
safely in this often-confusing environment. Most receptors are specific, that is, sensitive to only
one type of stimulus, such as visual, auditory, or
The sensory process involves two components: touch.
1. Sensory Reception - is the process of receiving 3. Impulse conduction - impulse travels along nerve
stimuli or data. These stimuli are either external or pathways either to the spinal cord or directly to the
internal to the body. brain
For example, auditory impulses travel to the organ of
External stimuli - are visual (sight), auditory (hearing), Corti in the inner ear. From there the impulses travel
olfactory (smell), tactile (touch), and gustatory (taste). along the eighth cranial nerve to the temporal lobe of
Internal stimuli - are gustatory stimuli (taste) can be the brain.  
internal as well. Other types of internal stimuli are 4. Perception - awareness and interpretation of stimuli
kinesthetic, stereognosis and visceral. takes place in the brain, where specialized brain cells
Kinesthetic - refers to awareness of the position and interpret the nature and quality of the sensory stimuli.
movement of body parts.
For example, a person walking is aware of which leg The client’s level of consciousness affects the
is forward. perception of the stimuli. Arousal Mechanism For the
Stereognosis - the ability to perceive and understand person to receive and interpret stimuli, the brain must
an object through touch by its size, shape, and texture. be alert, also referred to as arousal
For example, a person holding a tennis ball is aware of
its size, round shape, and soft surface without seeing Reticular Activating System (RAS) in the brainstem is
it. thought to mediate the arousal mechanism. The RAS
Visceral - refers to any large organ within the body. has two components:
Visceral organs may produce stimuli that make a Reticular excitatory area (REA) - is responsible for
person aware of them (e.g., a full stomach). arousal and wakefulness. People have their own zone
of optimum arousal, the level at which the person feels
Sensory Perception - involves the conscious comfortable. Sensoristasis is the term
organization and translation of the data or stimuli into Reticular inhibitory area (RIA) – located medially and
meaningful information. ventrally in the medulla. This area can inhibit the