LECTURE 4

• Therapeutic Communication


  Promotes understanding and can help establish a constructive relationship between the nurse and the client
• Therapeutic helping relationship


  Client and goal-oriented
• Attentive listening


  • Most important technique in nursing
  • Listening actively and with mindfulness, using all senses, and paying attention to what the client says, does and feels
  • Conveys an attitude of caring and interest
• Blocks in attentive listening

  • Rehearsing —being too busy thinking about what you want to say
  • Being concerned with yourself —the focus should be on the client
  • Assuming —thinking that you know what the client "really means" without validation
  • Judging —framing what you hear or see in terms of your judgment about the client as being immature, depressed, etc.
  • Identifying —focusing on your own similar experiences, feelings, or beliefs
  • Getting off track —changing the subject if you become uncomfortable, bored, or tired
  • Filtering —tuning out or only hearing certain things
• Visibly tuning in to clients

  • Emphatic presence
• The helping relationship

  The nurse-client relationship (interpersonal relationship)
• Professional helping relationships


  • Nurse— client
  • Nurse— family
  • Nurse— health team
  • Nurse— community
• Elements of professional communication

  • Courtesy
  • Autonomy and responsibility
  • Privacy and confidentiality
  • Assertiveness
  • Trustworthiness
• Three basic goals of therapeutic communication

  Help clients manage their problems in living more effectively and develop unused or underused opportunities more fully<|>Help clients develop an action-oriented prevention mentality in their lives
• Key to the helping relationship

  • Trust and acceptance
  • Underlying belief that nurse cares and wants to help client
• Phases of the helping relationship

  • Pre-interaction
  • Introductory
  • Working
  • Termination
• Skills in the working phase

  • Exploring and understanding thoughts and feelings
  • Empathetic listening and responding
  • Respect
  • Genuineness
  • Concreteness
  • Confrontation
  • Facilitating and taking action
• Incivility


  Rude or disruptive behavior that may result in psychological or physiological distress for the people involved and, if left unaddressed, may progress into threatening situations
• Lateral violence


  Also known as horizontal violence and horizontal hostility, are terms that describe physical, verbal, or emotional abuse or aggression directed at RN coworkers at the same organizational level
• Needed actions to stop disruptive behaviors and promote an emotionally safe work environment

  • Communication styles- Nurse: descriptive in verbal and written communication; MD: concise, to the point, and focused on a problem
  • Emotional intelligence - the ability to form work relationships with colleagues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others
  • Assertive communication- promotes client safety by minimizing miscommunication with colleagues
• Health personnel communication

  • Discussion- an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
  • Reports- oral, written, or computer-based communication intended to convey information to others
  • Records- chart or client record, is a formal, legal document that provides evidence of a client's care and can be written or computer based
• Purpose of records


  • Communication
  • Legal documentation
  • Planning client care
  • Auditing/ monitoring
  • Research
  • Education
  • Financial billing
  • Reimbursement
• Information contained in all records

  • Patient identification and demographic data
  • Informed consent for treatment and procedures
  • Admission data
  • Nursing diagnoses or problems and nursing or interdisciplinary care plan
  • Record of nursing care treatment and evaluation
  • Medical history
  • Medical diagnoses
  • Therapeutic orders
  • Medical and health discipline progress notes
  • Physical assessment findings
  • Diagnostic study results
  • Patient education
  • Summary of operative procedures
  • Discharge plan and summary
• Wards records


  • Patient's clinical record
  • Doctor order sheet
  • Reports of laboratory examinations
  • Diet sheet
  • Consent form for operations and anesthesia
  • Intake and output chart
  • Reports of physiotherapy, occupational therapy
  • Instruction book
  • Admission and discharge record
  • Census record
  • Call book
  • Complaint book
  • Indent book
  • Drugs maintenance register
  • Death register
  • Movement register
  • Round register
• Nurses records


  • Nurse's assessment sheet
  • Change of shift record
  • Standardized care plan
  • Nurse's report book
  • Nurse's progress notes
  • Treatment chart
  • Graphic sheet
• Students records


  • Application forms and other reports
  • Admission register
  • A cumulative health record
  • Class attendance and leave record
  • Clinical and field experience, student rotation
  • Internal assessment register- for both theory and practical
  • Mark list
  • Records of extra-curricular activities
  • Practical record book
  • Cumulative student record
  • Student evaluation
• Multidisciplinary communication within the health care team or communication media


  • Records or chart
  • Reports
  • Consultations
  • Referrals
  • Patient rounds
• Common record-keeping forms


  • Admission nursing history form
  • Flow sheets and graphic records
  • Client care summary or kardex
  • Acuity records
  • NCP
  • Traditional care plan
  • Standardized care plans
  • Discharge summary or referral summary forms
• General guidelines for recording

  • Date and time
  • Timing
  • Legibility
  • Permanence
  • Accepted terminology
  • Correct spelling
  • Signature
  • Accuracy
  • Sequence
  • Appropriate
  • Complete
  • Conciseness
  • Legal prudence
• Nurses are legally and ethically obligated to keep client information confidential
• Nurses are responsible for protecting records from all unauthorized readers
• Documentation systems

  • Source-oriented record-traditional method; A separate section for each discipline
  • Narrative
  • Problem-oriented medical record (POMR)
  • Problem Interventions Evaluation model (PIE)
  • Focus charting (FDAR)
  • Charting By Exception (CBE)
  • Computerized Documentation
  • Case Management
• Computerized documentation


  Software programs allow nurses to enter assessment data<|>Computers generate nursing care plans and document care<|>A complete computer-based patient care record is not without legal risks
• Reporting


  • Change of shift
  • Telephone reports
  • Verbal or telephone orders
  • Transfer reports
  • Incident reports
• SBAR

  Situation, Background, Assessment, Recommendation
• Incident reports


  Used to document any unusual occurrence or accident in the delivery of client care (client falls, medication errors)<|>An incident is any event that is not consistent with routine operation of a health care unit or routine care of client