Communication and the Nursing Process Communication Is Foundation of Society/ Civilization Why at this point in the course? Aside: write less! Factor Influencing Communication Developmental level esp for transfer of information. Gender --- pt and yours. Sociocultural differences Language and the culture of the hospital. We have our own language. Not the pts job to learn it. Did you void vs pass your water. Health literacy ( 4-5th grade) Fear/insecurity Why does communication break down? Different communication styles High level of activity Frequent interruptions Result: loss of information to death Communication for pt safety? Sentinel https://www.jointcommission.org/assets/1/18/Event_type_2Q_2016.pdf A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: Death Permanent harm Severe temporary harm and intervention required to sustain life Root Cause - Op/Post-op Complication Resulting in death or permanent loss of function N=884 Communication 463 Assessment 424 Root cause - Delay in treatment Resulting in death or permanent loss of function (N=1,013) Communication 816 #I Assessment 784 #2 The majority of events have multiple root causes : Jacho 2013-second quarter 2015 http://www.jointcommission.org/assets/1/18/Root_Cause s_Event_Type_2004-2Q_2015.pdf What Can Go Wrong? CONCERN was communicated – BUT: – PROBLEM: was not clearly stated – PROPOSED ACTION: didn’t happen – DECISION: was not reached In aviation, disasters triggered change Fixation https://www.youtube.com/watch?v=ICqPGkto3Yo Lack of role clarity Lack of procedure (form/checklist) 1900’s handful of dx Now 13,600 different dx 6,00 drugs 4,000 m/s procedures. https://www.youtube.com/watch?v=dfl8Xt8W09A The checklist manifesto Lack of standardization in organizing essential information Speak calmly – do not raise voice Avoid thin air statements – close the loop Get attention, give full attention Step back and assess for causes SBAR a framework for communication to keep pt safe. Situation Background Assessment Recommendation S–B–A-R Situation – “The situation I am calling about” Background – brief, related, to the point Assessment - what you found, what you think Recommendation – what you want SITUATION OFHS state your name and unit The situation I am calling about: (Patient Name and issue ) The situation I am calling about: (Patient Name and issue ) The situation I am calling about: (Patient Name and issue ) BACKGROUND (varies) State the admission diagnosis and date of admission prn State the pertinent medical history A BRIEF synopsis of the treatment to date Assessment Pertinent objective & subjective information – YOU decide but know…. LOC Mental status? Neuro changes Most recent vitals ( all aspects: Pulse rate strength reg irreg ireg ireg – respirs rate labored) Abnormal h/l sounds, labs I/O RECOMMENDATION State what you would like to see done: – Change treatment? – Transfer the patient? – Come to see the patient at this time? – Talk to the family and patient about….? – Ask for a consulting physician to see the patient? Mr. Smith arrives in ER VS 98.7 130 20 84/56 98R/A 8/10. He came in to the ED after a motor vehicle accident. He is AAOx 1 but dizzy. He states he has been healthy until this point but does take a multivitamin daily and is on a low carbohydrate diet. Na 140 K 3.8 CL 104 BUN 20 Creatine 0.8 albumin 3.4 H and H 7 and 21. Beyond sbarMany level of communication AHRQ Team Stepps Nurse Patient Family Communication SBAR possible Exchanging information. Collect data, teach, and provide compassionate care - very different than communicating with your friends. You as the nurse, don’t say anything without a purpose for saying it. Communication in Helping Relationship Not the same as a social relationship or friendship. Social.. Passing in street.. Hi how are you.. Fine, how are you….Startled if someone said: Helping vs. Friendship Helping occurs for a specific purpose with a specific person. Unequal sharing of information.. You do not nor should not discuss your health history. Personal data within reason. Built on pt needs… Purposeful and time limited. You never know where the next ans will take you. Intrapersonal Level of Communication Self talk. + or Negative Stress inducingover generalization forever, never Catastrophizing to Disqualifying the positive, Pts need to know value and harm of each without being trite. (cognitve behavior therapy) Positive Steps toward goal not the goal itself Often where spiritual aspects arise. Great source of strength. Verbal and non verbal communication The pts verbal and non verbal communication and objective data. –Is there congruence among the 3? Your verbal and non verbal communication to the pt –Is there congruence? A message is exchanged whether intentional or not… visual, auditory and kinesthetic….. Think soler S: sitting facing the client squarely, not at an angle O: an open posture, arms and legs uncrossed L: leaning (at times) towards the person E: eye contact, without staring R: relaxed posture. Communicate via ( pt to nurses and v v) Eye contact Facial expression Posture Gait beyond neuro Gestures …. Sounds…. Cry…to hummmph to (opps) https://www.youtube.com/watch?v=CZ1CATNbXg0 http://video.google.com/videosearch?sourceid=navclient&gfns=1&rlz=1T4ADBF_enUS298US299&q=wall%20E&um=1&ie=UTF-8&sa=N&hl=en&tab=wv# Communicate via Touch Distracter from pain. Pain is worse when alone. Hand is often most effective to show you care. You are there esp. if eyes covered. You are the human being touching the human being in a mass of chaos. You understand. You know words are useless. Communicate via Actions Actions speak: – Cool cloth. – Dim the lights. – Push med slowly Explain your actions when they can be misconstrued. (looking at IV or Computer. I need to check your labs Mr. Smith….your urine output is good sir..is a little low. Communicate with Space Space esp. if angry. Often evaporates in emergency. Try to reestablish as much as possible even if only with a warning that “I am going to….”conveying respect. Remember esp for long term facilities There are no professional pts. Extreme Caution with Humor Laughter communicates humor to mortal fear. Must look at pt situation and clues. You use humor very cautiously. Report (no pts) often see as a release. How you say = what you mean? I’ll be back when I can…. I’ll be checking on my other pts, I expect to be back in about 2 hours, please put your light on if you need anything. Allow me Still FOR YOU” does a lot! “Yet” ? But ‘Why’ questions vs what questions? Why didn’t you take your medication? What stopped you from taking your medication? Why did you discharge yourself? What happened that led you to discharge yourself from hospital? Why did you say that? What caused you to say that? Sit with silence - takes practice 5 seconds without “filling” the space – You have time – Not a casual conversation – You are thinking How was your day ( but mean it) If it is not a question then don’t make it a question. Would you please stop hitting your little brother? Is it nice to throw the cat in the washing machine? Would you like to get oob today? Open vs closed questioning Each has its place I am having chest pain – – focus this down - close it up…Not .”would you like to tell me more about you chest pain ” – go to 7 attributes I don’t feel so well – open this up Factor Influencing Communication Physical, Mental, Emotional State Yours also…..not the best time to enter into a tough conversation ?..try and control the environment. Factor Influencing Communication Roles and Responsibilities: Pt roles…watch taking care of dr or nurse…lawyer….stereotyping. The professional is in charge and accountable for outcomes. Your ability determines outcomes of care. Caring .. “I will be your nurse today.. how is your pain…” Competence.. “if you are ok, allow me to….” places the pt ahead of the task and establishes a level of competence.” Pt at center of task - Again, “for you” “ Why vs what” Listen to your pt. Reflect back. I hear you saying Barriers to communication Hearing. Mental, physical, emotional, state. Foreign language. Special needs – coma, vents, aphasia, infant, etc. You want things to be OK…can not mislead.. they know anyway…Kind and supportive…give a plan…deal with this Communication for Teaching – Learning Teaching…active, goal-directed process where learning is invited in order to provide the tools for bringing about changed behavior. 1st step Learning….Assimilation of information that may or may not result in a change of behavior. Professional Responsibility ANA – Teaching is an essential function of nursing State Board of Nursing – teaching as a function JCAHO – Mandates evidences of education. – Why do you care: If Joint say jump we say how high. Patient Bill of Rights – Calls for patient understanding of treatment Patient Teaching Find start point ( pt determined) Here is what I am going to teach you Here is why it is important. Get feedback Tell me what you know Teach This is what I taught you. Teach back You are teaching all the time Book stress formal plan…when you are ready… You are ready now for informal teaching…..it is basic part of care. SCD are needed because… We need to get you OOB….; do not get OOB until…. You can’t eat because… This medicine is for your.. You will be going home on Coumadin When you go home you may shower, but not bath because… Here is your call light Every one in the hospital is at risk for falling. All pts are at risk of falling. Teach all pts could open incision on an anticoagulant You are at risk or likely to fall because New med step the last 3 days in bed. New surroundings ABCS Age bone Coags Surgery- high risk for serious injury For all learners – Attention to physical comfort – Mutual Respect – Motivation Felt need to know or it must be explained… Application to current situation Process – Active involvement. – Series of learning plateaus (first plateau may simply be allowing the lesson to begin) – Variety of formats and activities. Example: Pain on admission We will work together to be control your pain to make you as comfortable as possible. We use a scale to allow us to evaluate ….. Example: Orient to room/unit/hospital Most important for safety? Example: Discharge teaching Activity – Walk, stairs, drive, sex, shower, bath Diet Care of drains Medications Follow up visits Sometimes you do have to push – Motivation – Family esp. spouse may need separate support. They are to be the rock, but they are afraid repulsed etc. yet may still very much love and want to support the pt. Education does not = change in behavior, but do not expect change in behavior without education. Motivational teaching Raise subject: Is it okay if I talk with you about some of the questions you answered? Enhance motivation: On the scale of 0 to 10 how ready are you to cut back on your use of If zero: Have you ever done anything while drinking that you later regretted? I can tell you drinking/ smoking at this level can be harmful .. And responsible for….. “How would your drinking have to you have to impact your life in order for you to start thinking about cutting back?” Or you ask Enhance motivation: On the scale of 0 to 10 how ready are you to cut back on your use of They answer 4 …..? Why not If greater than zero why that number and not a lower number!! Why not 3 List problems cause by Benefits hoped for- disadvantages too How to avoid Keep record Keep diary/log post on fridge Slips are lessons, not failure Quitting. Reducing. Safer The End