therapeutic comm. & teaching

COMMUNICATION

CLIENT TEACHING & DOCUMENTATION

COMMUNICATION: What is it?

• Exchange of information, ideas, feelings

• Very important to nursing

• Failure to communicate causes serious difficulties, increases liability, threatens professional credibility

• Is a skill learned. Takes many years to master

Levels of Communication

• Intrapersonal:

• Interpersonal:

• Transpersonal:

Basic Elements of the Process

Communication leads to Interpersonal Relationships

• The nurses ability includes:– Taking initiative in establishing and

maintaining communication– To be authentic (one’s self, sincere)– To respond appropriately to the other person– Develop mutuality (pt./nurse relationship is a

partnership, both are equal)– Respect and honor the differences

Zones of personal space

• Intimate: 0-18 inches

Zones of Personal SpacePersonal :18 inches to 4 feet

Zones of touch

• Social Zone (permission not needed)– Hands, arms, shoulders, back

• Consent Zone (permission needed)– Mouth, wrists, feet

• Vulnerable zone (special care needed)– Face, neck, front of body

• Intimate Zone (great sensitivity needed)– Genitalia, rectum

Zones of Personal Space:Social Zone: 4-12 feet

Zones of Personal Space:Public Zone: 12 feet +

Thoughts on Communication

• All communication contains stimuli with the potential to influence others (Curtis,et al l997)

Levels, continued

• Small group: – goal directed, understands group dynamics. – Task forces, client support groups,– workable size, suitable seating, commitment.

• Public: – interaction with an audience, use of eye contact,

gestures, voice inflections, media materials, – for teaching, increasing public knowledge

Nurse as a small group leader

Forms of Communication

• Verbal: spoken or written words – Vocabulary (7%), connotative meaning,

pacing, intonation (38%) clarity, and brevity, timing and relevance

• Non-verbal: 55%– personal appearance, posture and gait, facial

expression, eye contact, gestures, sounds, territoriality and personal space, symbolic, most accurate

Nurse-Client Helping Relationships

• Therapeutic• Promotes a climate that facilitates positive

change and growth. • The nurse establishes, directs, and takes

responsibility for the interaction. • Time-frame, goal-oriented approach • Highly confidential. • The client needs take priority over nurse’s

needs. • Built on trust and ability to comfort.

Phases of the Helping Relationship

• Pre-interaction phase

• Orientation phase

• Working phase

• Termination phase

Elements of Professional Communication

• Courtesy

• Use of names

• Privacy and Confidentiality

• Trustworthiness

• Autonomy and Responsibility

• Assertiveness

Therapeutic CommunicationTechniques

• Active listening

• Sharing Observations

• Sharing Empathy

• Sharing Hope

• Sharing Humor

• Sharing Feelings

• Using Touch

Therapeutic, continued

• Using Silence• Asking Relevant Questions: open-ended,

general leads, paraphrasing, focusing, making observation

• Providing Information: health teaching• Clarifying, summarizing, confronting• Self-disclosure: intent to help the other

person, not the nurse

Non-therapeutic Communication Techniques

• Asking personal questions• Giving personal opinions• Changing the subject• Automatic responses: stereotyping or cliché`• False Reassurance• Sympathy• Asking for Explanations: Why? Questions

Non-therapeutic, continued

• Approval or Disapproval: judgmental

• Defensive Responses

• Passive or Aggressive Responses

• Arguing or Challenging

Blocks to Effective Communication

• Language barriers, different perceptions

• Unresponsive, comatose persons

• Elderly, or loss of senses, dementia

• Persons in extreme pain, or grieving

• Persons with behavioral problems

• Depression, or other psychiatric disorders

Exercise #1

• Mrs. Maria Ramirez, an American of Puerto Rican descent, is faced with the difficult decision of whether to continue chemotherapy in the face of a rapidly spreading malignancy. What communication techniques could the nurse use to help her at this point, and what traps must the nurse avoid in such situations?

Exercise #2

• Jan, a nurse colleague, is having difficulty standing up to a physician who has an abrupt, intimidating communication style. She often ends up with a lot of unspoken anger, developing tension headaches, and easily becoming tearful. What could the nurse do to help.

Exercise #3

• Mr. Hess, a client with Parkinson’s disease living at an extended care facility, has a stiff, expressionless face. He sits slumped in a recliner chair all day and seems lost in his own world, rarely looking at or interacting with anyone. When he does talk, he mumbles in a soft voice, and his words are difficult to understand. What kinds of things could the nurse do to establish a helping/healing relationship with Mr. Hess?

Exercise #4

• Jennifer Hughes, a new graduate, is very discouraged. In school, she had felt a great deal of anxiety about her own performance, and even now she finds it difficult to be positive about herself or her job. What knowledge about communication could she use to help improve her situation?

Exercise #5

• Mrs. Esther Larson, a client who has been recently admitted to a hospice program, confides in the nurse that she feels overwhelmed with the number of things she must attend to now that she’s facing the possibility of death. She says, “My thoughts are all over the place. I don’t know where to start.” What communication techniques, based on the critical thinking model, could the nurse use to help her at this point?

Teaching

Teaching & Learning: What is it?

• Interactive • Conscious, deliberate actions that help

individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

• Learning is the purposeful acquisition of new knowledge, attitudes, behaviors and skills

• Usually involves demonstration• Learning objective: “will be able to…..”

The Teaching Role of the Nurse

• Teaching plan important because:– Short stays, impact client outcomes– Need knowledge concerning their illness,

condition or prevention– Need to make informed decisions – Improve overall health and wellness– Coping with impaired functioning, restoration

of health

Standards for Client Education

• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• “Goal 2000 of client and family education is to promote healthy behaviors and encourage the client’s involvement both in the delivery of health care and in health care decisions; to improve outcomes.”

Domains of Learning

• Cognitive (understand)

• Affective (attitudes)

• Psychomotor (Motor skills)

How do we learn?

• Attentional set: – (pain, anxiety, environment, distractions etc.)

• Motivation: – may result from a social,(connection, self-esteem)

task,(achieve, competence) or physical motive,(survival) from within

• Compliance is the client’s adherence to the prescribed plan of therapy

Ability to Learn

• Developmental capability, cognitive function– Learning in Children – Adult learning, can identify own learning needs, draws

on prior experiences, set mutual goals

• Physical capabilities, size, strength, coordination, sensory acuity, energy, illness, pain

• Learning Environment

Adult/Adolescent Learning

Child Learning

Teaching incorporates what client already knows

• Children

Learn by

Exploration,

Touch, trust,

imitation

Case Study• Mrs. S has a 10-year-history of HTN and a 5-year-

history of DM. Recently her HTN has become uncontrolled, and she has been diagnosed with depression. Her medications, which have recently been changed, include captopril (Capoten), 25 mg 3 times a day; diltiazem (Cardizem), 240 mg. every morning; metformin (Glucophage XR), 1500 mg before the evening meal; and sertraline (Zoloft), 100 mg. at bedtime. The nurse identifies the priority nursing diagnosis as “Deficient knowledge R/T change in medications”. The nurse wants to develop a plan of care that uses the three domains of learning. What are the client’s teaching priorities? Which learning needs would require a cognitive method? Which need would be more appropriate to satisfy through affective or psychomotor methods?

DOCUMENTATION

What it must be…….

• Documentation is a vital aspect of nursing practice.

• It must be comprehensive, a legal record• flexible enough to retrieve critical data,• Maintain quality and continuity of care• Track client outcomes, for reimbursement• Reflect current standards

Multidisciplinary team

Guidelines for Charting

• Factual: – descriptive – objective information about what the nurse sees,

hears, feels, and smells, direct observation and measurement

– do not use words like, appears, seems, apparently, (they suggest the nurse did not know the facts).

– Subjective data needs to be in quotation marks.

Guidelines for Charting, cont.

• Accurate: – exact TPR B/P, I&O, measurements of all

types – Dated and timed – Use of standardized abbreviations, symbols,

system of measures– Spelling, complete, current, organized

Charting

• Chart according to hospital policy

• JCAHO guidelines: client outcomes, response to treatment, teaching, or preventive care

• Reflects the nursing process

• Expects a multidisciplinary care plan

Chart Record

• Contains admission sheet• Physician’s orders sheets• Nurse’s admission assessment• Graphic sheet and flow sheets• Medical history and examination (H&P)• Nurses’ notes• Health card discipline's records• Discharge summary

Charting by Exception

• Used to streamline documentation• Check-off method• Standards integrated into forms• Predefined assessment findings, interventions

for normal recovery, expected outcomes, provides consistency

• If goals not met, variance documentation needed

Critical Pathways

• Standardized by disease or condition• Multidisciplinary: PT, OT, RT, Dietary,

Psychosocial, discharge planning, medicine, nursing, etc.

• Reduce duplication, amount of charting• Generally cover 24 hours or more of care• Easily defined variances, negative (or

complications) unexpected outcome: (positive), would be an early outcome, before average time

Other types of records• Acuity recording systems• Standardized care plans• Discharge summary forms • Home health care (medicare guidelines)• Long-term health care documentation: weekly

summaries, resident activity notebooks• Computerized documentation: RTs and discharge

planners, others• Change of shift report: for communication• Telephone orders/Incident reports

Telephone Orders

Doctors’ orders

Exercise

• You have just followed an order that stated “Insert a 16 Fr. Foley catheter”

• Following insertion, what does your charting state???

Exercise

• You just followed an order that stated, “Give Demerol 75 mg IM q4h and prn”

• What will your charting state?

The End