2. 1. Medication Administration SAL 2.Ethical and Legal Dimensions at EOL – lecture #4

3. Ethical and Legal Dimensions End-of-Life Chapter 43, pp. 1551-1555

4. Ethical and Legal Dimensions Advance directives Do-not-resuscitate or No-code orders Comfort measures only and other special orders Terminal weaning Active and passive euthanasia (euthanasia = good dying) Active – doing something to end a patient’s life Assisted suicide – provides the patient with the means to end life Passive – not doing something to preserve a patient’s life

5. Communicator Chapter 21 Joann M. Doherty NU 101

7. Communication is Key http://www.youtube.com/watch?v=QiwbeFu-iskptx

8. The Process of Communication Communication Source (encoder) Message Channel Auditory – hearing, listening Visual – sight, observation, perception Kinesthetic – procedural touch, caring touch Receiver (decoder) Feedback Noise

10. Forms of Communication Verbal Exchange of information using words, including both spoken & written

11. Forms of Communication Nonverbal Communication The exchange of information without the use of words “body language” Nonverbal communication expresses more of the true meaning of a message than verbal Be aware of culture variations in nonverbal communication

12. Various Forms of Nonverbal Communication Touch Eye contact Facial expressions Posture Gait Gestures General physical appearance Mode of dress and grooming Sounds Silence

14. Levels of Communication Intrapersonal Communication Interpersonal Communication Group Communication Small-Group Organizational Group Dynamics Task-oriented roles Group-building or maintenance roles Self-serving roles

15. Characteristics of Effective and Ineffective Groups Group identity Cohesiveness Patterns of interaction Decision making Responsibility Leadership Power

16. Factors Influencing Communication Developmental level Child – explain in simple terms Adolescent – more detailed and abstract explanations; be familiar with commonly-used slang Adults – find out what they already know, attitude toward health Older patients – assess for any problems w/ hearing or sight, confusion, depression Gender Women – seek confirmation, minimize differences, establish or reinforce intimacy Men – establish their independence and to negotiate status activities in large groups Sociocultural differences Culture – (def.) the common lifestyles, languages, behavior patterns, traditions, and beliefs that are learned from one generation to the next Identify your own personal cultural beliefs and identify “prejudices or attitudes that could be a barrier to good communication” Helps understand/recognize nonverbal behaviors Understand that healthcare is a culture of its own A patients language proficiency should be evaluated on admission, and interpreters made available prn

17. Factors Influencing Communication Roles and responsibilities Space and territoriality Physical distance Usually 18 in. To 4 ft. for intake interview Generally, European Americans and African Americans require more personal space Generally Mediterranean, Hispanic, Asian, Middle Eastern, East Indian are more comfortable closer Note whether patient moves closer or farther when you are in proximity Generally hands, arms, shoulders, back w/in social zone; increasing levels of privacy are face, neck, and front of body, and then genitalia

18. Factors Influencing Communication Physical, mental, and emotional state Note box – Cognitive Stimulation Activities and Cognitive Orientation – p.443 Values Environment

19. Using Therapeutic Communication in the Nursing Process Assessment Diagnosing Outcome Identification and Planning Implementing Evaluating Documenting Communication Hand-off Communication: SBAR Technique

20. SBAR JCAHO has mandated a National Patient Safety Goal – “implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions” Situation - objective Background - objective Assessment - subjective Recommendations - subjective

21. Using Therapeutic Communication in the Helping Relationship Helping relationship (also called nurse-patient relationship) exists among people who provide and receive assistance in meeting human needs goal-oriented need gratification occurs as the result of a successful helping relationship The quality of this relationship is the most significant element in determining helping effectiveness

22. Helping Relationship v. a Social Relationship The helping relationship: Does not occur spontaneously Characterized by an unequal sharing of information Built on the patient’s needs They are professional relationships – the nurse needs to communicate professionalism, confidence, expertise

23. Characteristics of the Helping Relationship Dynamic Purposeful and time limited The person providing the assistance is professionally accountable for the outcomes

24. Goals of Helping Relationship Should be established cooperatively Defined in terms of the patient’s needs The nurse may have needs to be met; but the patient’s needs are the focus

25. Phases of the Helping Relationship 1. orientation – the development of a trusting relationship is crucial patient calls the nurse by name (nurse writes name); roles clarified; an agreement is made; the patient is oriented to the facility 2. working – the longest phase; purposeful interactions; designed to achieve goals the patient will actively participate, cooperate, express feelings and concerns 3. termination – the patient will participate in identifying the goals accomplished or the progress made; patient will verbalize feelings about the termination

26. Factors Promoting Effective Communication w/in the Helping Relationship Dispositional traits – warmth and friendliness; openness and respect; empathy; honesty, authenticity, and trust; caring; competence Rapport builders – Rapport – a feeling of mutual trust experienced by people in a satisfactory relationship Specific objectives; comfortable environment; privacy; confidentiality; patient v. task focus; using nursing observations; optimal pacing; respecting personal space

27. Developing Therapeutic Communication Skills Conversation Skills Listening Skills Silence Touch Therapeutic touch Humor

28. Conversation Skills Control the tone of your voice Be knowledgeable about the topic/have accurate information Be flexible Be clear and concise; make statements simple Avoid words that might have different interpretations Be truthful Keep an open mind Take advantage of available opportunities

29. Listening Skills Listening involves both hearing and interpreting Requires attention and concentration When communicating w/ patient: Sit if possible; do not cross your arms or legs Be alert and relaxed Keep conversation natural Maintain eye contact (if culturally appropriate) Indicate that you are paying attention Think before you respond Do not pretend to listen Listen for themes in comments

30. Interviewing Techniques Open-ended Closed Validating Clarifying Reflective Sequencing Directing

31. Assertiveness Skills Assertive v. aggressive Assertive – open, honest, and direct use clear, concise “I” statements nurse’s self-presentation include a confident, open body posture, eye contact The assertive nurse is able to work to capacity w/ or w/out supervision, able to remain calm under supervision, feels free to ask for help prn, able to give and accept compliments, is honest, and responsible Aggressive – harsh, injurious, or destructive

32. Blocks to Communication Failure to perceive the patient as a human being Failure to listen Inappropriate comments and questions (see next slide) Changing the subject Giving false assurance Gossip and rumor Aggressive interpersonal behavior (see future slide)

34. Inappropriate comments and questions Using clichés Using questions requiring only a yes/no answer Using questions containing the words why/how Using questions that probe for information Using leading questions Using comments that give advice Using judgmental comments

35. Aggressive Interpersonal Behavior Disruptive behavior has a negative effect Adverse events occur when communication is ineffective, abusive, or negative JCAHO (2009) – requires hospitals to establish a code of conduct defining acceptable and unacceptable behavior; and a means to address these incidents

36. Aggressive Interpersonal Behavior w/ physicians Do not allow negative behavior by a MD to discourage future communication Stay focused and professional and approach in a collegial manner Follow hospital policies and procedures to deal with situation w/ other nurses – horizontal violence Nurses who refuse to be a victim can break the cycle Pro-active behaviors Documentation and reporting Insist abuse be addressed w/ patients Use a calm, assertive approach Stay w/ anxious patient unless your safety is at risk Remove yourself from a dangerous situation Physical restraints are a last resort

37. Focus on the Older Adult Impaired Verbal Communication Voice problems Dysarthria Aphasia Hearing problems Other communication problems

38. Communicating with Patients who have Special Needs Patients who are visually impaired Patients who are hearing impaired Patient with a physical barrier (laryngectomy or ET) Patient who are cognitively impaired Patients who are unconscious Patients who do not speak english

40. Counselor Chapter 22 Taylor, pp. 486-490

41. Counseling – the interpersonal process of helping patients to make decisions that promote their overall well-being Requires IPR skills of warmth, friendliness, openness, and empathy Counseling requires listening carefully to the patient’s or family’s questions, concerns, demands, and complaints and then responding in an effective manner Do not tell the patient what to do to solve the problem but assist and guide them to solve problems and make decisions

42. References Taylor, C. R., Lillis, C., LeMone, P. & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care. (7 th ed.). Philadelphia: Lippincott Williams & Wilkens.