NUR219 The Use of Technologies to Assist in Effective Communication

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Interpersonal Relationships Professional Communication Skills for Nurses SEVENTH EDITION Elizabeth C. Arnold, PhD, RN, PMHCNS-BC Associate Professor, Retired, University of Maryland School of Nursing, Baltimore, Maryland Family Nurse Psychotherapist, Montgomery Village, Maryland Kathleen Underman Boggs, PhD, FNPCS Family Nurse Practitioner, Associate Professor Emeritus, College of Health and Human Services, University of North Carolina Charlotte, Charlotte, North Carolina 2 Table of Contents Cover image Title page Copyright Dedication Reviewers and contributor Acknowledgments Preface Part I. Conceptual Foundations of Interpersonal Relationships and Professional Communication Skills Chapter 1. Theory Based Perspectives and Contemporary Dynamics Basic Concepts The Discipline of Nursing The Science of Nursing Communication Theory Applications The Future of Nursing Summary Discussion Questions Chapter 2. Professional Guides for Nursing Communication Basic Concepts Organizations or Agencies Issuing Health Care Communication Guidelines Professional Nursing Organizations Issuing Health Care Communication Guidelines Other Professional Organizations and Accrediting Agencies Issuing Communication Guidelines Affecting Nursing Ethical standards and Issues Legal Standards Applications Evidence-Based Practice Standards Using the Nursing Process in Nurse-Client Relationships Application of Ethical and Legal Guidelines Summary 3 Discussion Questions Chapter 3. Clinical Judgment and Ethical Decision Making Basic Concepts Ethical Reasoning Critical Thinking Applications Participation in clinical Research Solving Ethical Dilemmas in Nursing Professional Values Acquisition Applying Critical Thinking to the Clinical Decision-Making Process Summary Discussion Questions Chapter 4. Clarity and Safety in Communication Basic Concepts General Safety Communication Guidelines for Organizations Barriers to Safe, Effective Communication in the Health Care System Innovations that Foster Safety Applications Tools for Safer Care Team Training Models Client Safety Outcomes of Team Training Programs Other Specific Nursing Efforts Summary Discussion Questions Part II. Essential Communication Skills Chapter 5. Developing Therapeutic Communication Skills Basic Concepts Verbal Communication Nonverbal (Behavioral) Communication Purpose of Client-Centered Communication Theoretical Perspectives Applications Building Rapport Asking Questions Empathetic Listening for Understanding Themes Observing Nonverbal Behaviors Observing Communication Patterns Using Active Listening Responses Verbal Responses 4 Other Forms of Communication Using Technology in Communication Summary Reflective Discussion Questions Chapter 6. Variation in Communication Styles Basic Concepts Verbal Communication Verbal Style Factors that Influence Nurse-to-Client Professional Communication Nonverbal Communication Communication Accommodation Theory Effects of Sociocultural Factors on Communication Applications Interpersonal NUR219 The Use of Technologies to Assist in Effective Communication

Competence Style Factors that Influence Relationships Advocate for Continuity of Care Summary Discussion Questions Chapter 7. Intercultural Communication Basic Concepts Applications Cultural Competence Care of the Culturally Diverse Client Theoretical Frameworks Cultural Implications in Client-Centered Decision Making Working with Language Barriers Communication Principles Key Cultural Groups Poverty Summary Discussion Questions Chapter 8. Therapeutic Communication in Groups Basic Concepts Characteristics of Small Group Communication Applications to Health-Related Groups Group Leadership Applications Applications in Therapeutic Groups Types of Therapeutic Groups Group Principles Applied to Professional Work Groups Summary Discussion Questions 5 Part III. Therapeutic Interpersonal Relationship Skills Chapter 9. Self Concept in Professional Interpersonal Relationships Basic Concepts Theoretical Frameworks Applications Patterns and Nursing Diagnosis Related to Self-Concepts Personal Identity Self-Esteem Self-Efficacy Summary Discussion Questions Chapter 10. Developing Therapeutic Relationships Basic Concepts Definitions Level of Involvement Therapeutic Use of Self Applications Adaptation for Short-Term Relationships Summary Discussion Questions Chapter 11. Bridges and Barriers in Therapeutic Relationships Basic Concepts Respect Caring Empowerment Trust Empathy Mutuality Veracity Other Barriers to the Relationship Applications Steps in the Caring Process Strategies for Empowerment Application of Empathy to Levels of Nursing Actions Reduction of Barriers in Nurse-Client Relationships Veracity and Trust Respect for Personal Space Violation of Confidentiality Avoiding Cross-Cultural Dissonance 6 Summary Discussion Questions Chapter 12. Communicating with Families Basic Concepts Family Composition Theoretical Frameworks Applications Assessment Applying the Nursing Process Summary Discussion Questions Chapter 13. Resolving Conflicts between Nurse and Client Basic Concepts Nature of Conflict Causes of Conflict Risk for Violence: Incidence Statistics Stage of Anger Conflict Outcomes: Why Work for Conflict Resolution? Understand Own Personal Responses to Conflict Outcome: Positive Growth Outcome: Dysfunction, Such as Unresolved Conflict Nature of Assertive Behavior Safety Applications Preventing Conflict Assessing the Presence of Conflict in the Nurse-Client Relationship Techniques for Conflict Resolution Nursing Communication Interventions: Following the C.A.R.E. Steps The Anger Management Process: Nursing Behaviors to Avoid Violent Client Behavior Conflict Communication Skills Clinical Encounters with Angry Clients Strategies Useful During Clinical Encounters with Violent Clients Defusing Potential Conflicts when Providing Home Health Care Summary Discussion Questions Part IV. Communicating to Foster Health Literacy, Health Promotion and Prevention of Disease among Diverse Populations Chapter 14. Communicating to Encourage Health Literacy, NUR219 The Use of Technologies to Assist in Effective Communication

Health 7 Promotion, and Prevention of Disease Basic Concepts Definitions Global and National Health Promotion Agendas Theory-Based Frameworks Applications Health Education for Health Promotion Community Voices in Health Promotion Activities Summary Discussion Questions Chapter 15. Health Teaching and Coaching Basic Concepts Theoretical Frameworks Domains of Learning Core Dimensions of Client Education Applications Summary Discussion Questions Chapter 16. Empowerment Oriented Communication Strategies to Reduce Stress Basic Concepts Stress Frameworks Coping Applications Summary Discussion Questions Part V. Accommodating Clients with Special Communication Needs Chapter 17. Communicating with Clients Experiencing Communication Deficits Basic Concepts Legal Mandates Home-Based Health Care Types of Deficits Applications Early Recognition of Communication Deficits Assessment of Current Communication Abilities Communication Strategies Client Advocacy 8 Summary Discussion questions Chapter 18. Communicating with Children Basic Concepts Attitude Cognition Interpersonal Applications Assessment Communicating with Children with Psychological Behavioral Problems Communicating with Physically Ill Children in the Hospital and Ambulatory Clinic Communication with Infants from Birth to 12 Months Communication with Children 1 to 3 Years of Age (Toddlers) Communication with Children 3 to 5 Years (Preschoolers) Communication with Children 6 to 11 Years (School Age) Communication with Children Older than 11 Years of Age (Adolescents) Forming Health Care Partnerships with Parents Summary Discussion Questions Chapter 19. Communicating with Older Adults Basic Concepts Concepts of Aging Theoretical Frameworks Applications Assessment Strategies with Older Adult Clients Empowerment: Building on Client Strengths Relationships with Cognitively Impaired Older Adults Summary Discussion Questions Chapter 20. Communicating with Clients in Crisis Basic Concepts Theoretical Frameworks Applications Structuring Crisis Intervention Strategies Mental Health Emergencies Disaster Management Helping Children Cope With Trauma Helping Older Adults Cope With Trauma Summary Discussion Questions Chapter 21. Communicating with Clients and Families at End of Life 9 Basic Concepts Theoretical Frameworks The Nature of Grief and Grieving Patterns of Grieving Applications Pain Management Communication in End-of-Life Care Addressing Cultural and Spiritual Needs Palliative Care for Children Helping Clients Achieve a Good Death Caring of the Client After Death Stress Issues for Nurses in Palliative Care Settings Summary Discussion Questions Part VI. Collaborative and Professional Communication Chapter 22. Role Relationships and Interprofessional Communication Basic Concepts Nursing Education and Professional Role Development Applications Creating Supportive Work Environments Developing Leadership Skill Sets Client Advocacy Roles Summary Discussion Questions Chapter 23. Communicating with Other Health Professionals Basic Concepts Standards for a Healthy Work Environment Creating A Collaborative Culture of Regard to Eliminate Disruptive Behavior Applications NUR219 The Use of Technologies to Assist in Effective Communication

Conflict Resolution Conflict Resolution Delegation or Supervision of Unlicensed Personnel Strategies A Nurse Can Use to Communicate and Help Create a Better Work Environment Advocacy Strategies to Remove Barriers to Communication with Other Professionals Develop A Support System Organizational Strategies for Conflict Prevention and Resolution: Work Toward an Organizational Climate of Mutual Respect Summary 10 Discussion Questions Chapter 24. Communicating for Continuity of Care Basic Concepts Continuity of Care Concepts Applications Relational Continuity Essential Elements of Relational Continuity Informational Continuity Transition and Discharge Planning in Continuity of Care Management Continuity Summary Discussion Questions Chapter 25. Documentation in an Electronic Era Basic Concepts Documenting Client Information Plan of Care Standards: Ethical, Regulatory, and Professional Applications Communicating Medical Orders Workload and Work-Arounds Documenting on A Client’s Health Record Confidentiality Coding Classification of Care: Use of Standardized Terminologies and Taxonomies Reference Terminology Systems that Exchange Data Between Classification Systems Summary Discussion Questions Chapter 26. Communication at the Point of Care: Application of e-Health Technologies Basic Concepts Decentralized Access: Technology for Communicating at the Point of Care Enhanced Work Flow: Remote Site Monitoring, Diagnosis, Treatment, and Communication Computerized Clinical Decision Support Systems Client Engagement Technology for Client Health Self-Management Outcomes of Technology Use Applications Clinical Decision Support Systems Application of Clinical Guidelines to Practice mHealth: Technology for Client Engagement Issues 11 Professional Online Nursing Education Summary Discussion Questions Glossary Photograph Credits Index 12 Copyright 3251 Riverport Lane St. Louis, Missouri 63043 INTERPERSONAL RELATIONSHIPS: PROFESSIONAL COMMUNICATION SKILLS FOR NURSES, SEVENTH EDITION ISBN: 978-0-32324281-3 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. NUR219 The Use of Technologies to Assist in Effective Communication

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all 13 appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2011, 2007, 2003, 1999, 1995, and 1989. International Standard Book Number: 978-0-32324281-3 Herdman, T.H. (Ed.) Nursing Diagnoses-Definitions and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited. Content Strategist: Jamie Randall Content Development Manager: Jean Fornango Associate Content Development Specialist: Melissa Rawe Publishing Services Manager: Julie Eddy Senior Project Manager: Marquita Parker Designer: Julia Dummitt Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 14 Dedication To the memory of my husband George Arnold who believed in me and supported me unconditionally, and to all the students I have had the privilege of teaching. Elizabeth C. Arnold To Sydney Lavarnway, may you find strong mentors. Kathleen Underman Boggs 15 Reviewers and contributor Reviewers Amy Ellsworth, AND Nursing Instructor Kirkwood Community College Cedar Rapids, Iowa Cindy Carter, MSN, RN, IBCLC, RLC, ICCE Nursing Instructor Colorado Christian University Indiana Wesleyan University Texas Health Resources Nocona, Texas Kim Clevenger, EdD, MSN, RN, BC Baccalaureate & RN-BSN Program Coordinator Associate Professor of Nursing Morehead State University Morehead, Kentucky Dr. Bonnie DeSimone, EdD, RN, BC Professor of Nursing Coordinator of the ABSN Weekday Division of Nursing Dominican College of Blauvelt Orangeburg, New York Linda Finch, PhD, ANP-BC NUR219 The Use of Technologies to Assist in Effective Communication

Associate Professor/Associate Dean-Retired Loewenberg School of Nursing University of MemphisMemphis, Tennessee Shari Kist, PhD, RN, CNE Assistant Professor Goldfarb School of Nursing at Barnes-Jewish College St. Louis, Missouri Robyn C. Leo, MS, RN 16 Associate Professor Nursing Worcester State University Putnam, Connecticut Scott A. Davis Police Officer Crisis Intervention Team (CIT) Coordinator Montgomery County Police Department,Gaithersburg, Maryland Danette Yolanda Wall, DNP, MSN, MBA, ACRN, RN, CPHQ, LNC Chief Operating Officer Odot, LLC Clinical Advisor Quality Improvement Humana CarePlus, Inc. Tampa, Florida Brian Zager, MA PhD Candidate Department of Speech Communication Southern Illinois UniversityCarbondale, Illinois Contributor Shari Kist, PhD, RN, CNE Assistant Professor Goldfarb School of Nursing Barnes-Jewish CollegeSt. Louis, Missouri 17 Acknowledgments Elizabeth C. Arnold Kathleen Underman Boggs The seventh edition of Interpersonal Relationships: Professional Communication Skills for Nurses continues to reflect the ideas and commitment of our students, valued colleagues, clients, and the editorial staff at Elsevier. The first edition, aligned with an interpersonal relationship communication seminar developed at the University of Maryland School of Nursing, was published 25 years ago. Developing effective communication was important then and it remains central to effective clinical practice in contemporary health care. The text was originally designed by faculty to facilitate nursing students’ understanding of therapeutic communication in clinical settings, using case examples and experiential simulations. At this point in time, professional nursing role relationships and the use of relational communication in health care is more complex and multilayered. The scope of content in the seventh edition reflects a markedly different contemporary health care landscape, one which is open-ended, clientactivated and interdisciplinary in function and skill development. The vitality of its contents reflects the commitment of faculty and students from many nursing programs and the clinical nurses who have deepened the understanding of the materials presented in this text through their positive support, ideas, and constructive feedback. In particular, the voices of the following faculty and professional nurses have contributed directly and indirectly to the development of this text: Verna Carson, PhD, RN, PCNS; Judith W. Ryan, PhD, RN, CRNP; Michelle Michael, PhD, APRN, PNP; Barbara Harrison, RN, PMH-NP; Ann O’Mara, PhD, RN, AOCN, FAAN; Barbara Dobish, MS, RN; Anne Marie Spellbring, PhD, RN, FAAN; Kristin Bussell, MS, RN, CS-P; Patricia Harris, MS, APRN, NP; and Jacqueline Conrad, BS, RN, from the University of Maryland; Ann Mabe Newman, DSN, RN, CS and David R. Langford, RN, DSNc, from the University of North Carolina Charlotte, and Dr. Bonnie DeSimone from Dominican College of Blauvelt. Nurses in the community: Luwana Cameron, RN; Nancy Pashby, RN; Mary Jane Joseph, RN; and Dr. Stephanie Wright provided valuable input related to their clinical expertise. We are indebted 18 to Dr. Shari Kist of the Goldfarb School of Nursing at the Barnes-Jewish College for her thoughtful revision of Chapter 12. NUR219 The Use of Technologies to Assist in Effective Communication

We acknowledge with deep gratitude the unique Elsevier team efforts of Melissa Rawe, Associate Content Development Specialist, Jamie Randall, Content Strategist, and Marquita Parker, Senior Project Manager-book production. Their dedicated commitment to the completion of this text and expertise were notable in making the revision process for this seventh edition a seamless and timely developmental experience. Finally, we acknowledge the loving support of our families and Michael J. Boggs for their unflagging support and encouragement. 19 Preface Elizabeth C. Arnold Kathleen Underman Boggs Recognition of the importance of therapeutic communication and professional relationships with clients and families as a primary means of achieving treatment goals in health care continues to be the underlying theme in Interpersonal Relationships: Professional Communication Skills for Nurses. This seventh edition has been thoroughly revised, rewritten, and updated to meet the challenge of serving as a primary communication resource for nursing students and professional nurses. While maintaining the integrity of previous text versions, the seventh edition introduces a broadened interprofessional perspective on communication, occasioned by historical transformational changes currently occurring in contemporary health care delivery. Expanded content is competency based and draws from many different sources: Joint Commission Standards, the Institute of Medicine (IOM) reports, QSEN, communication theory, Essentials of Baccalaureate Education, systems thinking and interprofessional team-based communication, as advocated by AHRQ’s TeamSTEPPS program. The content, exercises, and case examples are intentionally integrated to support students in developing the interpersonal and technical communication skills required in contemporary health care environments. Examples provide students with opportunities to apply new research and new technologies to their practice. Content in this text, as in previous editions’ can be used as individual teaching modules, as a primary text, or as a communication resource integrated across the curriculum. New subject matter related to interprofessional team communication and nursing leadership reflect the latest applications of communication in contemporary health care delivery across clinical settings. Knowledge and skills related to spirituality, health literacy promotion, interdisciplinary thinking, advocacy and social responsibility are expanded in this edition. These topics are addressed as relevant components of interprofessional and client-centered relationships of health care. Although the seventh edition is divided into six sections, using a similar 20 format to that of previous editions, the organization of the chapters has been significantly revised based on reviewer comments. Part I, Conceptual Foundations of Interpersonal Relationships and Professional Communication Skills, provides a theory-based approach to therapeutic relationships and communication in nursing practice and identifies professional, legal, and ethical standards guiding professional actions. NUR219 The Use of Technologies to Assist in Effective Communication

Chapters describe the relevance of critical thinking to clinical reasoning and key linkages between communication clarity and client safety in health care situations. Part II, Essential Communication Skills, focuses on development of therapeutic communication skills. Chapters in this second section also address variations in communication styles, intercultural communication diversity, and group communication strategies. Part III, Therapeutic Interpersonal Relationship Skills begins with a chapter on the role of self-concept and measurable personal characteristics, as a key influencer of communication in therapeutic relationships. The chapter on therapeutic communication presents a structured approach to the competency skills nurses need for effective communication in health care settings. Chapters on client-centered and family-centered relationships explore basic concepts of therapeutic communication and applications of strategies nurses can use with individuals and families. Bridges and barriers to the development and maintenance of therapeutic relationships highlight key relational elements in professional interactions with clients and families. The final chapter in Part III addresses conflict resolution strategies in nurse-client relationships. Part IV, Communicating to Foster Health Literacy, Health Promotion, and Prevention of Disease among Diverse Populations, provides students with the necessary background and communication approaches to effectively cope with the unique complexities of client/family health care needs across clinical settings, including cultural and language diversity. This section also focuses on strategies to enhance health literacy, the nature and scope of health teaching, and communication with clients in stressful situations. Part V, Accommodating Clients with Special Communication Needs provides students with a basic understanding of the communication accommodations needed by clients with specialized communication needs. Specific chapters offer communication strategies nurses and other health providers can use to respond effectively with children and older adults. Content on communicating with clients in crisis situations and in palliative care complete Part V. Contemporary nurses are living and practicing in a rapidly changing collaborative interprofessional health care environment in which they are expected to take an active leadership role. The professional health care landscape remains still generally uncharted and open to interpretation. 21 Part VI, Collaborative and Professional Communication, proactively prepares students to develop competence and self assurance as professional nurses. Chapters address the major behavioral elements, habits of thinking, and feeling deemed essential to developing productive collegial working relationships within the nursing profession and interprofessionally with team members of other disciplines. Part VI discusses role relationships and speaks to the significance of nursing leadership and collaborative team communication strategies. The importance of communicating for continuity of care, electronic documentation, application of e-health information technologies, and technology integrated applications at point of care are also addressed. Each chapter is designed to illuminate the connection between theory and practice by presenting basic concepts, followed by clinical applications, using updated references and instructive case examples. NUR219 The Use of Technologies to Assist in Effective Communication

Developing an Evidence-Based Practice boxes offer a summary of a current research article related to each chapter subject and are intended to stimulate awareness of the essential links between research and practice. The Ethical Dilemmas presented in each chapter offer the student an opportunity to reflect on common ethical situations, which occur on a regular basis in health care relationships. New to the seventh edition are Discussion Questions at the end of each chapter. References have been chosen and suitably updated to align with the content in each chapter. Experiential exercises provide students with the opportunity to practice, observe, and critically evaluate their professional communication skills in a safe learning environment. Learning exercises are designed to encourage self-reflection about how one’s personal practice fits with the larger picture of contemporary nursing, health practice models, and interdisciplinary team communication. Through active experiential involvement with relationship-based communication principles, students can develop confidence and skill with using patient-centered communication in real-life team-based clinical settings. The comments and reflections of other students provide a unique, enriching perspective on the wider implications of communication in clinical practice. Communication is thought of as the primary medium for moving quality care in our health system forward. This text gives voice to the centrality of communication as the basis for helping clients, families, and communities make sense of relevant health issues and develop effective ways of coping with them. Our hope is that the seventh edition will continue to serve as a primary reference source for nurses seeking to improve their communication and relationship skills across traditional and nontraditional health care settings. As the most consistent health care provider in many clients’ lives, the nurse bears an awesome responsibility to provide 22 communication that is professional, honest, empathetic, and knowledgeable in a person-to-person relationship that is without equal in health care. As nurses, we are answerable to our clients, our profession, and ourselves to communicate with clients in a therapeutic manner and to advocate for their health care and well-being within the larger sociopolitical community. We invite you as students, practicing nurses, and faculty to interact with the material in this text, learning from the content and experiential exercises but also seeking your own truth and understanding as professional health care providers. Instructor Resources are available on the textbook’s Evolve web site. New PowerPoint presentations include audience response questions, teaching tips and lecture ideas, instructor-focused exercises, and case studies. A revised Test Bank reflecting the updated content in the text is also included. Instructors are encouraged to contact their Elsevier sales representative to gain access to these valuable teaching tools. 23 PA R T I Conceptual Foundations of Interpersonal Relationships and Professional Communication Skills OUTLINE Chapter 1. Theory Based Perspectives and Contemporary Dynamics Chapter 2. Professional Guides for Nursing Communication Chapter 3. Clinical Judgment and Ethical Decision Making Chapter 4. Clarity and Safety in Communication 24 CHAPTER 1 25 Theory Based Perspectives and Contemporary Dynamics Elizabeth C. Arnold Objectives At the end of the chapter, the reader will be able to: 1. Identify essential characteristics of the nursing discipline. NUR219 The Use of Technologies to Assist in Effective Communication

2. Describe the art and science of nursing. 3. Discuss the core constructs of professional nursing’s metaparadigm. 4. Compare and contrast different models of communication. 5. Identify relevant theoretical frameworks used in nursing relationships. 6. Explain the role of systems thinking in contemporary health care. 7. Identify issues related to health care reform. 8. Apply Institute of Medicine (IOM) recommendations as a framework for the study of relationships and communication skills in nursing practice. 9. Discuss implications for the future of nursing. Chapter 1 identifies selected conceptual frameworks relevant to the study of client-centered communication, and professional relationships in a contemporary health care system. Socioeconomic factors related to health care reform and the driving forces of Institute of Medicine (IOM) reports outline some of the changes required to transform the health care system. 26 Basic Concepts Historically, nursing is as old as humankind. Originally nursing was practiced informally by religious orders dedicated to care of the sick, and later in the home by female caregivers with no formal education (Egenes, 2009). Nursing was not identifiable as a distinct occupation until the 1854 Crimean War when Florence Nightingale’s Notes on Nursing (1860, 2010) introduced the world to the functional roles of professional nursing, and the need for formal education (D’Antonio, 2010). Her use of statistical data to document the need for hand washing in preventing infection marks her as the profession’s first nurse researcher. An early advocate for highquality care, Nightingale viewed nursing as both a science and an art form (Alligood, 2014). Over the next 150 years, nursing evolved into a recognizable highly respected profession. The discipline’s unique body of knowledge and theoretical perspectives help define the nursing discipline, and strengthen its voice in effectively responding to the current global health care crisis (Smith and McCarthy, 2010). The profession’s next step is to solidly position professional nursing practice as having a key role within a larger collaborative health care team paradigm. Nurses see clients at their most vulnerable in health situations. 27 The Discipline of Nursing Litchfield and Jonsdottir (2008) contend that our “discipline is relational and creative in practice” (p. 79). Professional nursing is a “practice” discipline, which combines specialized knowledge and skills with prudent clinical judgment to meet client, family, and community health care needs. Donaldson and Crowley (1978) characterize the discipline of nursing as having a specialized perspective related to • “Principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well; • Patterning of human behavior in interaction with the environment in critical life situations; and • Processes by which positive changes in health status are affected.” (p. 113). As the discipline of nursing evolved, apprentice-type training was replaced with a higher level of nursing education provided at the college level. Today, professional nursing education begins at the undergraduate level, with a growing number of nurses choosing graduate studies to support differentiated advanced practice roles and/or research opportunities. NUR219 The Use of Technologies to Assist in Effective Communication

Nurses with advanced preparation are prepared to function as nurse practitioners, clinical specialists, administrators, and educators. Today nurses represent the largest group of health care professionals in the United States (IOM, 2010; Pelletier and Stichler, 2013). The scope of practice for professional nurses has increased exponentially, and is increasingly practiced within the context of supportive collaborative interdisciplinary health care teams. 28 The Science of Nursing Nursing theory represents the basis for science of nursing. Theory development is essential to maintaining the truth of any discipline (Reed and Shearer, 2007). Nursing theory emerged as a serious form of study in the 1940s and 1950s as a means to identify the unique specialized body of knowledge associated with the discipline of nursing. The intent was to examine the phenomenon of professional nursing in systematic ways as a means of clarifying its unique body of knowledge, making visible the nature of its domain, informing clinical practice, and forming a basis for research related to its practice domain. Nursing theories and models, used to describe, explain, predict, and prescribe phenomena applicable to nursing practice, education, and research didn’t really take hold until the 1950s (Alligood, 2014). Today, nursing frameworks serve as a contextual background for practice and research. Common conceptual threads enable nurses, and the general public, to have a clearer understanding of the domain of professional nursing. Theoretical constructs in nursing strengthen the focus of the discipline, and provide a foundation for generating hypotheses in research. As the profession positions itself to play a key role in a transformed health care system, there is a noticeable shift from theory development to a new era of theory applicability and utilization (Alligood, 2010). Expectations for professional nursing practice in the twenty-first century are being recast within collaborative team care approaches rather than separated by discipline-specific care for clients (Ritter-Teitel, 2002). Nurses are expected to pool their expertise with other providers through a skilled network of team-based care for the benefit of clients and their families. Nursing’s Metaparadigm Individual nursing theories represent different interpretations of the phenomenon of nursing, but central constructs: person, environment, health, and nursing are found in all theories and models (Karnick, 2013; Marrs and Lowry, 2006). They are referred to as nursing’s metaparadigm. The four constructs continue to comprise the metalanguage about the primary emphasis of nursing practice (Jarrin, 2012). Concept of Person Person, is defined as the recipient of nursing care, having unique biopsychosocial and spiritual dimensions. NUR219 The Use of Technologies to Assist in Effective Communication

The concept of “person” supersedes health diagnosis apart from, and before a specific health care 29 problem is considered. Person factors “comprise features of the individual that are not part of a health condition or health states” (World Health Organization [WHO], 2001, p. 17). Gender, lifestyle, coping styles, habits, among others, are considered person attributes. The term is applied to individuals, family units, the community, and target populations such as the elderly or mentally ill—anyone in need of health care. In health care settings, and throughout this text, person may be referred to as “patient” or “client.” The complexity of “person” is a holistic concept. It is evidenced in patient-centered care, “which honors patients’ preferences, needs, and values; applies biopsychosocial perspectives… and forces a strong partnership between patient and clinician (Greene et al., 2012, p. 49). Knowledge of the “client as a person” is the starting point in health care delivery, essential to both client safety and quality of care (Zolnierek, 2013). Client centered care considers the impact of an illness or injury on a person —not only physiologically, but mentally, spiritually, and socially. Client preferences, perceptions, beliefs, and values, combined with clinical facts, and the nurse’s self-awareness (personal ways of knowing) form an essential understanding of each person’s unique clinical situation. Protecting a client’s basic integrity and health rights is an ethical responsibility of nurse to client, whether the person is a contributing member of society, a critically ill newborn, a comatose client, or a seriously mentally ill individual (Shaller, 2007). Concept of Environment Environment refers to the internal and external context of the client, as it shapes and is affected by a client’s health care situation. Person and environment are so intertwined that to consider person as an isolated variable in a health care situation without considering environmental factors acting as barriers or supports to healing is impracticable (WHO, 2001). That clients cannot be successfully treated apart from their environments is a central thesis in Nightingale’s nursing framework, and Martha Rogers’s Science of Unitary Human Beings. Environment plays a significant role in health promotion, disease prevention, and care of individuals with chronic conditions within the community. The concept of environment reflects multiple factors of cultural, developmental, and social determinants that influence a client’s health perceptions and behavior. NUR219 The Use of Technologies to Assist in Effective Communication

Examples of environmental factors include poverty, level of education, religious or spiritual beliefs, type of community (rural, or urban), family strengths and challenges, access to resources, and level of social support are examples of a client’s environmental context. Even climate, space, pollution, and food choices are important dimensions of environment that nurses may need to consider in 30 choosing appropriate nursing interventions. Concept of Health The word health derives from the word whole. Health is a multidimensional concept, having physical, psychological, sociocultural, developmental, and spiritual characteristics. WHO (1946) defines health as “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity” (p. 3). This definition has not been amended to date. Nordstrom and colleagues (2013) describe the healthy person as the person who is able to “realize his or her vital goals, not vital goals in general” (p. 361). For example, an active 80-year-old woman can consider herself quite healthy, despite having osteoporosis and a controlled heart condition. Wellness is a dimension of health, evidenced in satisfaction with a person’s quality of life and sense of well-being. Health is a value-laden concept, which includes both the general state of the person, and objective medical data. Culture and life experiences influence how people think about health, wellness, illness and treatment implications. Health is a social concern, particularly for people who do not have personal control over their health, or the necessary resources to enhance their health status. Contemporary concepts of health encompass disease prevention, chronic care self-management and promoting healthy lifestyle behaviors, such that nurses can anticipate and respond to the needs of those at greatest risk for adverse health situations. During the last century, most professional care was delivered in acute care settings, based on a disease-focused medical model. Switching to today’s community focus recognizes the fact that chronic medical conditions account for most of today’s care, with most being treated in the community (Henley and colleagues, 2011). The environment and health ecology has emerged as an intertwined concept as health care is becoming a global enterprise. In fact, health care access is considered a social ecological determinant of health (McGibbon et al., 2008). Healthy People 2020 (DHHS, 2010) considers quality of life to be a key outcome of disease prevention, health promotion and maintenance activities. NUR219 The Use of Technologies to Assist in Effective Communication

Quality of life is defined as a subjective experience of well-being and general satisfaction with one’s life that includes, but is not limited to, physical health. Nurses play a major role in assessing health behaviors, and negotiating lifestyle changes that allow individuals and families to achieve and maintain a healthy lifestyle. Exercise 1-1, The Meaning of Health as a Nursing Concept, provides an opportunity to explore the multidimensional meaning of health. E X E R C I S E 1 – 1 The Meaning of Health as a Nur sing 31 Concept Purpose: To help students understand the dimensions of health as a nursing concept. Procedure 1. Think of a person whom you think is healthy. In a short report (1-2 paragraphs), identify characteristics that led you to your choice of this person. 2. In small groups of three or four, read your stories to each other. As you listen to other students’ stories, write down themes that you note. 3. Compare themes, paying attention to similarities and differences, and developing a group definition of health derived from the stories. 4. In a larger group, share your definitions of health and defining characteristics of a healthy person. Discussion 1. Were you surprised by any of your thoughts about being healthy? 2. Did your peers define health in similar ways? 3. Based on the themes that emerged, how is health determined? 4. Is illness the opposite of being healthy? 5. In what ways, if any did you find concepts of health to be culture or gender bound? 6. In what specific ways can you as a health care provider support the health of your client? E X E R C I S E 1 – 2 What I s P r of essional Nur sing? Purpose: To help students develop an understanding of professional nursing. Procedure 1. Interview a professional nurse who has been in practice for more than 12 months. Ask for descriptions of what he or she considers professional nursing to be today, in what ways he or she thinks nurses make a difference, and how the nurse feels the role might evolve within the next 10 years. 2. In small groups of three to five students, discuss findings and develop 32 a group definition of professional nursing. Discussion 1. What does nursing mean to you? 2. Is your understanding of nursing different from those of the nurse(s) you interviewed? 3. As a new nurse, how would you want to present yourself? Concept of Nursing Kim (2010) terms the nursing construct in nursing’s metaparadigm as the practice domain of nursing. The overarching goal of nursing activities is to empower clients and strengthen their skill sets by providing them with the support they need to achieve optimal health and well-being. Nursing actions help clients achieve identifiable health goals through a continuum of services ranging from health promotion and health education, to direct care, rehabilitation, and research evaluation. NUR219 The Use of Technologies to Assist in Effective Communication

The International Council of Nurses’ (ICN) definition of nursing states: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles (ICN, 2014). New specialty and advanced practice roles as nurse practitioners, doctors of nursing practice, clinical nurse leader roles in hospitals and clinics reinforce the complexity of the discipline. Nurses are increasingly involved in community advocacy. They are actively shaping public health policies and have assumed transformational roles in practice, research, and education. Mallock (2014) Exercise 1-2, What Is Professional Nursing?, can help you look at your philosophy of nursing. Finkelman and Kenner (2009) differentiate between the science and art of nursing, stating that, “knowledge represents the science of nursing, and caring represents the art of nursing” (p. 54). Both are required for safe quality care. The science of nursing provides an essential knowledge base for professional nursing, but it is the art of nursing that takes into account the variations in unique client characteristics and life experiences, which influence client choices in health care. 33 The Art of Nursing The “art of nursing” represents a seamless interactive process in which nurses blend their knowledge, skills, and scientific understandings with their individualized knowledge of each client as a unique human being with physical, cognitive, emotional, and spiritual needs. Individualized knowledge is assembled from each “nurse’s mode of being, knowing, and responding” to each clients’ unique care needs (Gramling, 2004, p. 394). Nurses use classic patterns of knowing to bridge the interpersonal space between science and client-centered needs to individualize client-centered care (Zander, 2007). Patterns of Knowing Knowledge rarely proceeds to understanding in a simple direct way. In clinical practice where so many dynamics are involved, a broad spectrum of knowledge is essential. In a seminal work, Carper (1978) maintains that nurses use multiple forms of knowledge to inform their praxis. She describes four patterns of knowing embedded in nursing practice: empirical, personal, aesthetic, and ethical. Although described as individual prototypes, Carper emphasizes that in practice, these patterns inform care as an integrated form of knowledge. Holtslander (2008) notes that “this integrated, inclusive, and eclectic approach is reflective of the goals of nursing, which are to provide effective, efficient, and compassionate care while considering individuality, context, and complexity” (p. 25). The four patterns (ways) of knowing consist of: • Empirical ways of knowing: knowledge that is objective and observable. Empirical knowledge draws upon verifiable data from science. NUR219 The Use of Technologies to Assist in Effective Communication

The process of empirical ways of knowing includes logical reasoning and problem solving. Nurses use empirical ways of knowing to provide scientific rationales when choosing appropriate nursing interventions. • Personal ways of knowing: Personal knowledge is “characterized as subjective, concrete and existential” (Carper, 1978, p. 251). Personal knowing is relational. It is a pattern of knowing about self and other, which occurs when nurses connect with the humanness of the client experience. Personal knowledge develops when nurses intuitively understand and connect with clients as unique human beings. Nurses may not be able to define why they intuitively believe something is true, but they trust this knowledge. They have experiential knowledge of their own responses, plus knowledge of professional experiences with other clients facing similar situations. Self-awareness provides nurses with a different authentic dimension of what it means to live through a particular health disruption. • Aesthetic ways of knowing are sometimes referred to as the “art of nursing” because this knowledge links the humanistic components of 34 care with its scientific application. There is a deeper appreciation of the whole person or situation, a moving beyond the superficial to see the experience as part of a larger whole. Esthetic knowledge enables nurses to experientially know about the fear behind a client’s angry response, the courage of a client with stage four cancer offering her suffering up for her classmates, the pain of a father cutting off funds for a drug addicted son. Aesthetic ways of knowing can be enhanced with storytelling, in which nurses seek to understand the experience of the client’s personalized journey through illness (Leight, 2002). • Ethical ways of knowing refer to the moral aspects of nursing care (Altman, 2007; Porter et al., 2011). This knowledge helps nurses provide principled care when confronted with moral issues in health care. Ethical ways of knowing encompass knowledge of what is right and wrong, attention to standards and codes in making moral choices, responsibility for one’s actions, and protection of the client’s autonomy and rights. Exercise 1-3, Patterns of Knowing in Clinical Practice, provides practice with using patterns or ways of knowing in clinical practice. Chinn and Kramer (2011) introduced a fifth pattern, emancipatory ways of knowing, which includes the nurse’s awareness of social problems and social justice support for issues affecting health care delivery to clients and populations. The concept of emancipatory knowing expands the nurse’s praxis role within the larger health care arena. By recognizing, and acting upon the social, political, and economic determinants of health and wellbeing, nurses are in a better position to act as advocates in helping the nation identify and reduce the inequities in health care (Chinn and Kramer, 2011). NUR219 The Use of Technologies to Assist in Effective Communication

E X E R C I S E 1 – 3 Patter ns of Knowing in Clinical P r actice Purpose: To help students understand how patterns of knowing can be used effectively in clinical practice. Procedure 1. Break into smaller groups of three to four students. Identify a scribe for each student group. 2. Using the following case study, decide how you would use empirical, personal, ethical, and aesthetic patterns of knowing to see that Mrs. Jackson’s holistic needs were addressed in the next 48 hours. Case Study 35 Mrs. Jackson, an 86-year-old widow, was admitted to the hospital with a hip fracture. She has very poor eyesight because of macular degeneration and takes eye drops for the condition. Her husband died 5 years ago, and she subsequently moved into an assisted housing development. She had to give up driving because of her eyesight and sold her car to another resident 5 months ago. Although her daughter lives in the area, Mrs. Jackson has little contact with her. This distresses her greatly, as she describes being very close with her until 8 years ago. She feels safe in her new environment but complains that she is very lonely and is not interested in joining activities. She has a male friend in the complex, but recently he has been showing less interest. Her surgery is scheduled for tomorrow, but she has not yet signed her consent form. She does not have advance directives. Discussion 1. In a large group, have each student share their findings. 2. For each pattern of knowing, write the suggestions on the board. 3. Compare and contrast the findings of the different groups. 4. Discuss how the patterns of knowing add to an understanding of the client in this case study. Caring The concept of caring is a characteristic of all helping professions. In nursing practice, caring is considered an essential functional construct and core value of nursing practice (Wagner and Whaite, 2010; Watson, 2005). Caring strengthens patient-centered knowledge and adds depth to nursing competencies that nurses bring to the clinical situation. Empathy serves as the connective caring bridge between health providers and clients. Clark (2010) describes empathetic understanding as consisting of a health provider’s combined subjective experiencing of what it is like to be a client, an interpersonal understanding of what the client is currently experiencing in the moment, and an objective empathy related to a broader understanding of a client’s situation from outside the client’s frame of reference. Crowe (2000) suggests, “Caring does not involve specific tasks, instead it involves the creation of a sustained relationship with the other” (p. 966). Caring is the component of care best remembered by clients and nurses. In a qualitative research study, graduate nurses described characteristics of professional caring in their practice as (a) giving of self, (b) involved presence, (c) intuitive knowing and empathy, (d) supporting the client’s integrity, and (e) professional competence (Arnold, 1997). NUR219 The Use of Technologies to Assist in Effective Communication

36 The American Nurses Association (ANA, 2010) affirms that “the essence of nursing is caring” (p. 45). As professional nurses assume broader leadership roles in health care, caring should be embodied as a visible component of relationships with all members of the health care team. 37 Communication Theory Effective communication with clients, families, coworkers, and other health care professionals involved with the care of clients is an essential foundation of effective health care. Hargie (2011) asserts, “communication represents the very essence of the human condition” (p. 2). Communication is a human enterprise and a fundamental underpinning of all nurse-client interactions. Through purposeful communication, you can help clients and families make sense of their health needs, assist them in learning how to self-manage chronic health conditions, and provide therapeutic support for decision making. Communication takes place intrapersonally (within the self) or interpersonally (with others). Intrapersonal communication occurs in the form of a person’s inner thoughts and beliefs, colored by feelings that influence behavior. It often is a hidden component of the communication process related to either nurse or client’s past experience and something within the current discussion. Understanding of intrapersonal meanings requires self-awareness and reflection as it usually is not a spoken part of the message. In addition, seeking frequent validation from the receiver incorporates client feedback to improve nurse/client collaboration and mutual understanding of the message and/or the process itself. Interpersonal communication is defined as a reciprocal, interactive, dynamic process, having value, cultural, emotive, and cognitive variables that influence its transmission and reception. Interpersonal communication theories are concerned with the transmission of information and with how people create meaning. Through speech, touch, listening, and responding, people construct personal meanings and share them with others. Most of us take interpersonal communication for granted until we cannot engage in the process, or it is no longer a part of our lives. Human interpersonal communication is unique. Only human beings have large vocabularies and are capable of learning new languages as a means of sharing their ideas and feelings. Relational communication is an important source of personal expression and influence. Included in the concept are language, gestures, body movements, eye contact, and personal or cultural symbols. People combine words and nonverbal signals into a montage to convey intended meaning, exchange or strengthen ideas and feelings, and to share significant life experiences. Communication has both content and relationship dimensions (Watzlawick et al., 1967). The content dimension of communication (verbal component) refers to shared verbal, written, or digitally delivered data. The relationship dimension (expressed nonverbally through 38 metacommunication) helps the receiver interpret the meaning of the message. NUR219 The Use of Technologies to Assist in Effective Communication

People tend to pay more attention to nonverbal communication than to words especially when they are not congruent with each other. Basic assumptions related to the concept of communication are presented in Box 1-1. Channels of communication is the term used to designate one or more of the connectors through which a person receives a message. Primary channels of human communication include the five senses: sight, hearing, taste, touch, and smell. Technology has introduced secondary channels of communication in the form of media messaging. In professional business settings, the term has a different connotation. Channels of communication describe the hierarchy of reporting relationships individuals need to respect when communicating with coworkers and authority figures. Each person is expected to answer to the person at the next higher level and to communicate downward to coworkers for whom the person is responsible. B O X 1 – 1 Basic Assum ptions of Com m unication Theor y • All behavior is communication and it is impossible to not communicate. • Every communication has a content and a relationship (metacommunication) aspect. • We only know about ourselves and others through communication. • Faulty communication results in flawed feeling and acting. • Feedback is the only way we know that our perceptions about meanings are valid. • Silence is a form of communication. • All parts of a communication system are interrelated and affect one another. • People communicate through words (digital communication) and through nonverbal behaviors and analog-verbal modalities; both forms are needed to interpret a message appropriately. (Adapted from Bateson G, 1979 Mind and nature Dutton: New York; Watzlawick P, Beavin-Bavelas J, Jackson D (1967) Some tentative axioms of communication. In Pragmatics of Human Communication—A Study of Interactional Patterns, Pathologies and Paradoxes, pp. 29–52. New York, W. W. Norton.) 39 Linear Models The linear model is the simplest communication model, consisting of sender, message, receiver, and context. Linear models identify the process of communication focus only on the sending and receipt of messages, and do not necessarily consider communication as enabling the development of cocreated meanings between communicators. • The sender is the source, or initiator of the message. The sender encodes the message (i.e., puts the message into verbal or nonverbal symbols that the receiver can understand). Encoding a message appropriately requires a clear understanding of the receiver’s mental frame of reference (e.g., feelings, personal agendas, past experiences). Therapeutic communication requires that the helping person as sender has a healthrelated purpose. NUR219 The Use of Technologies to Assist in Effective Communication

• The message consists of the transmitted verbal or nonverbal expression of thoughts and feelings. Effective messages are relevant, authentic, and expressed in understandable language. • The receiver is the recipient of the message. The receiver needs to be open to hearing what the sender is saying. Once received, the receiver decodes the message and internally interprets its meaning to make personal sense of the message.) An open listening attitude and suspension of judgment strengthens the possibility of accurately decoding a sender’s message. The context of the interaction refers to all the factors that influence how a message is received. The most critical variable is the presence of noise, which is defined as anything that interferes with the effective transmission, reception, or understanding of a message. “Noise” is a concept found in both linear and transactional models. Linear models only consider external phenomena. Physical noise occurs in the form of environmental distractors such as people talking loudly, babies crying, children running around, music or TV playing, excessive room temperature, poor seating, and lack of privacy. In transactional models, noise also includes internal interference factors. Physiological noise includes internal distractors such as feeling tired, anxious, angry, worried, or being too sick to fully attend to the message. Psychological noise refers to a preconceived bias about the speaker or listener, differences in role status, ethnic or cultural differences that influence transmission of messages, and how they are received. Semantic noise is concerned with the use of uncommon abstract words, not easily understood by one of the communicators. Even one “noise” factor can compromise successful interpersonal communication. 40 Transactional Models of Communication Transactional models expand the nature of linear models by including internal forms in the context of the communication, feedback loops, and validation. These models employ systems concepts in that the human system (client) receives information from the environment (input), internally processes the received data, and interprets its meaning (throughput). The result is new information or behavior (output). Feedback loops (from the receiver or the environment) validate the information or allow the human system to correct its original information. In doing so, transactional models draw attention to communication as having purpose, and meaning making attributes. Figure 1-1 shows the components of transactional models. Transactional models conceptualize interpersonal communication as a reciprocal interaction in which sender and receiver influence each other as they converse. NUR219 The Use of Technologies to Assist in Effective Communication

Each person constructs a mental picture of the other, including perceptions of the other person’s attitude and possible reaction to the message. Individual perceptions influence the transmission of the message and its meaning to one or both of the communicators. Because the sender and receiver communicate at the same time, the conversation becomes a richer process and more than the sum of its parts. FIGURE 1-1 Transactional model of communication. Transactional models capture the importance of interpersonal engagement in verbal and nonverbal communication. They reflect the development of collaborative meanings, which are cocreated from the symbolic exchanges between the communicators. Role relationships between communicators can influence communication. Often role relationships are unconsciously acted on, without taking their nature or implications for successful communication into account. Lack of awareness 41 can compromise the effect of important messages. Exercise 1-4, Comparing Linear and Transactional Models of Communication, provides an opportunity to contrast the efficacy of linear versus transactional models. People take either symmetric or complementary roles in communicating. Symmetric role relationships are equal, whereas complementary role relationships typically operate with one person holding a higher position than the other in the communication process. Nurses assume a complementary role of clinical expert available for information and consultation to achieve mutually determined health goals, and a symmetric role in working with the client as partner on developing mutually defined goals and the means to achieve them. Therapeutic Communication Therapeutic communication is a term originally coined by Ruesch (1961) to describe a goal-directed form of communication used in health care to achieve goals that promote client health and well-being. Doheny and colleagues (2007) observed that “when certain skills are used to facilitate communication between nurse and client in a goal directed manner, the therapeutic communication process occurs” (p. 5). Core dimensions of therapeutic communication—empathy, respect, helpful genuineness, and concreteness—are discussed in Chapters 5, 6 and 10. Frameworks Used in Therapeutic Relationships Commonly used frameworks used in professional nursing relationships include Erikson’s psychosocial development theory, Maslow’s basic human needs model, Peplau’s psychosocial relationship nursing theory, general systems theory, and communication models. Developmental Theory Erik Erikson’s theory of psychosocial development is considered an important conceptual framework for understanding human personal development (Erikson, 1950). NUR219 The Use of Technologies to Assist in Effective Communication

Erikson’s model represents one of the most solid theories of psychosocial development across the life span. Nurses use this framework to assess developmental client needs and to design developmentally age-appropriate nursing interventions. According to Erikson, human development occurs in universally defined sequential maturity stages. Each stage builds on the previous stage and requires a higher level of expected psychosocial competence. A person experiences each new set of expectations in the form of a psychosocial crisis. Confronting and successfully mastering tensions associated with 42 each developmental psychosocial crisis, helps a person develop an associated ego strength. Failure to mature psychosocially results in a core weakness or pathology. Erikson identifies the first four stages of ego identity as building blocks for ego identity, which he considers the keystone of psychosocial development. The last three developmental stages help refine the ego identity in the adult segment of the life cycle. E X E R C I S E 1 – 4 Com par ing Linear and Tr ansactional Models of Com m unication Purpose: To help students see the difference between linear and circular models of communication. Procedure 1. Role-play a scenario in which one person provides a scene that might occur in the clinical area using a linear model: sender, message, and receiver. 2. Role-play the same scenario using a circular model, framing questions that recognize the context of the message and its potential impact on the receiver, and provide feedback. Discussion 1. Was there a difference in your level of comfort? If so, in what ways? 2. Was there any difference in the amount of information you had as a result of the communication? If so, in what ways? 3. What implications does this exercise have for your future nursing practice? 43 FIGURE 1-2 Nursing Diagnosis Categories corresponding with Maslow’s hierarchy of needs. Life circumstances, culture, and timing can affect age-related psychosocial ego development, such that it progresses at a faster or slower pace, and the behaviors indicating psychosocial competence may differ. Peplau’s Interpersonal Relationship Model Hildegard Peplau (1952, 1997) offers the best-known nursing model for the study of interpersonal relationships in health care. Her model describes how the nurse-client relationship can facilitate the identification and accomplishment of therapeutic goals to enhance client and family wellbeing (see Chapter 10). In contemporary practice, Peplau’s framework is more applicable today with long term relationships in rehabilitation centers, long-term care, and nursing homes. NUR219 The Use of Technologies to Assist in Effective Communication

Despite the brevity of the alliances in acute care settings, basic principles of being a participantobserver in the relationship, building rapport, developing a working partnership, and terminating a relationship remain relevant. Basic Needs Theory The ICN declares, “human needs guide the work of nursing” (2010). Abraham Maslow’s needs theory (1970) is a framework that nurses use to prioritize client needs, and develop relevant nursing approaches (see Chapters 2 and 10). Maslow’s model proposes that people are motivated to meet their needs in an ascending order beginning with meeting basic survival needs. As essential needs are satisfied, people move into higher psychosocial areas of development. Maslow defines basic (deficiency) needs as those required for human survival. First-level basic physiological needs include hunger, thirst, sexual appetites, and sensory stimulation. Maslow’s second level, safety and security needs, includes both physical 44 safety and emotional security, for example, financial safety, freedom from injury, safe neighborhood, and freedom from abuse. Satisfaction of basic deficiency needs allows for attention to growth needs, which Maslow termed love and belonging needs, followed by selfesteem needs. Love and belonging needs relate to emotionally experiencing being a part of a family, and/or community. Self-esteem needs refer to a person’s need for recognition and appreciation. A sense of dignity, respect, and approval by others for oneself is the hallmark of successfully meeting self-esteem needs. Maslow’s highest level of need satisfaction, self-actualization, refers to a person’s need to achieve his or her maximum potential. Self-actualized individuals are not superhuman; they are subject to the same feelings of insecurity that all individuals experience, but they recognize and accept their vulnerability as part of the human condition. Not everyone reaches Maslow’s self-actualization stage. Figure 1-2 shows Maslow’s model as a pyramid, with need requirements occurring in ascending fashion from basic survival needs through selfactualization. Nurses use Maslow’s theory to prioritize nursing interventions. Exercise 1-5 provides practice with using Maslow’s model in clinical practice. E X E R C I S E 1 – 5 Maslow’s Hier ar chy of Needs Purpose: To help students understand the usefulness of Maslow’s theory in clinical practice. Procedure 1. Divide the class into small groups, with each group assigned to a step of Maslow’s hierarchy. Each group will then brainstorm examples of that need as it might present in clinical practice. 2. Identify potential responses from the nurse that might address each need. 3. Share examples with the larger group and discuss the concept of prioritization of needs using Maslow’s hierarchy. Discussion 1. In what ways is Maslow’s hierarchy helpful to the nurse in prioritizing client needs? 2. What limitations do you see with the theory? 45 Applications General Systems Theory A systems framework forms the contextual underpinning for the study of contemporary professional nursing in the United States. NUR219 The Use of Technologies to Assist in Effective Communication

Beginning with the idea that each person is “different from and greater than the sum of his or her parts (Chinn and Kramer, 2011, p. 47), a systems framework provides a solid foundation for understanding the nature of communication and group dynamics. From a systems perspective, everything within the health care system is interrelated and interdependent (Porter O’Grady and Malloch, 2014). Collaboration and teamwork provider relationships, family relationships, continuity of care, and newly redefined system linkages between education, service, and research are best interpreted within a systems framework. The WHO has defined a health system as “all organizations, people and actions whose primary intent is to promote, restore or maintain health” (WHO, 2007, p. 2). General systems theory (GST), initially described by Ludwig von Bertalanffy (1968), focuses on process and the interconnected relationships comprising the “whole.” Over the years, systems thinking has been transformed into a “metalanguage which can be used to talk about the subject matter of many different fields (Checkland, 1999). Even our bodily functions depend on an understanding of the interrelationships among body systems. Adaptive system models help health professionals understand how the interrelationships among different parts of the system contribute to its overall functioning at macro and micro levels. New skills and competencies introduced into nursing contemporary curriculums are based on systems approaches to help nurses collaborate effectively with other disciplines having different agendas and priorities to achieve common goals. Frenk and colleagues (2010) suggest that “the core space of every health system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them” (p. 7). Note that patient/client is represented as the core of the health care system diagram in Figure 1-3. A GST approach highlights the interdependence among all parts of a system and confirms how each part supports the system as a functional, ordered whole. Berkes and colleagues (2003) state that GST, “emphasizes connectedness, context and feedback, a key concept that refers to the result of any behavior that may reinforce (positive feedback) or modify (negative feedback) subsequent behavior” (p. 5). 46 In Figure 1-3, notice the outermost system ring relates to regulatory bodies. This relates to care delivered by integrated care facilities, which are subject to significant government regulation and joint commission oversight. Health care systems are viewed as integrated wholes whose properties cannot be effectively reduced to a single unit (Porter O’ Grady and Malloch, 2014.) The interacting parts work together to achieve important goals. Only by looking at the whole picture can one fully appreciate its meaning of how its individual parts work together. NUR219 The Use of Technologies to Assist in Effective Communication

How health providers use collaborative and networking skills to achieve clinical outcomes become the measure of competence from a systems perspective. There is a contemporary emphasis on interrelationships, and behavioral patterns within the organizational system. Porter O’Grady and Malloch observe “to the extent that the balance and harmony are sustained, the organization’s life is advanced.” (p. 15). FIGURE 1-3 Conceptual drawing of a four-level health care system, with the client (patient) as its core concept. (From Reid PP, Compton WD, Grossman JH, et al., editors, for the Committee on Engineering and the Health Care System, National Academy of Engineering, Institute of Medicine. Building a better delivery system: a new engineering/health 47 care partnership. Washington, DC, 2005, National Academies Press, p. 20. Available at http://www.nap.edu/catalog/11378.html.) System boundaries separate the system from the environment. Boundaries are arbitrary parameters, which distinguish what belongs with the system, and what lies outside of it. The environment consists of anything that affects system functioning, but it is not part of the system. Each system is separated by boundaries, which control the exchange of information, energy, and resources into and out of the system. Flexible boundaries allow new information to flow in and out of the system, whereas rigid boundaries do not. A system with flexible boundaries is termed an open system. A closed system has rigid boundaries; not much crosses its boundaries. Outcomes are referred to as output. Any changes in the system will influence the outcome or output. Feedback loops (what others from the environment say about the process) inform the system of changes needed for input so as to achieve more effective outcomes. For example, a client’s response to a treatment offers feedback on whether to change a medication, or continue with it. Issues Related to Health Care Reform Creasia and Frieberg (2011) note that, historically significant changes in nursing and nursing education are linked to socioeconomic factors and nursing issues. Professional nursing is practiced today in an unprecedented era of shifting health care environments, momentous advances in health science, and unparalleled evolving technologies. Socioeconomic issues, such as the dramatic growth in health care options, population demographics, serious nursing, and physician shortages, the economics of health care, and documented concerns about safety and quality in health care, have prompted a fast-moving mandate to transform the current health care system. Most health care is delivered in community-based primary care settings with an emphasis on prevention and support for selfmanagement of chronic health conditions. In 2000, the Pew Health Professions Report identified 21 competencies needed to reframe nursing practice for a new century (Bellack and O’Neil, 2000). NUR219 The Use of Technologies to Assist in Effective Communication

These competencies are identified in Box 1-2. Nurses are expected to have knowledge about and apply a variety of paradigms to real-life situations in clinical practice. Client roles have evolved from being passive recipients of health care into active autonomous partners with providers. Shared authority over decision making, and multiple perspectives in health care management across a continuum of care that extends into the community is the new norm. In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into federal law. This law ushers in the most significant change to 48 the U.S. health care system since the establishment of Medicare in 1965 (Kaiser Permanente, 2013). U.S. citizens and legal immigrants will be required to have a basic level of health care insurance. Nurse practitioners (NPs), physicians, and physician assistants will continue to be the principal providers of primary care in the United States, and the need for continuity of care through collaborative team work will become even more important. To adequately dress increased expectations for skilled health care, special attention to the role of nurses, particularly advanced practice registered nurses (APRNs) becomes critical. Managed care, the emergence of transdisciplinary professional roles as the preferred model of provider service delivery, public reporting of clinical outcomes, and inclusion of client quality of life and satisfaction with care are now expected clinical outcomes. Table 1-1 identifies seven conditions and their evolutionary correlates needed to secure a key player role for nurses in the new health care delivery system. TABLE 1-1 Criteria for Survival of the Nursing Profession Based on Evolutionary Principles Criteria or Condition Nursing needs to be relevant. Nursing must be accountable. Nursing needs to retain its uniqueness while functioning in a multidisciplinary setting. Nursing needs to be visible. Nursing needs to have a global impact. Nurses need to be innovators. Nurses need to be both exceptionally competent and strive for excellence. Evolutionary Principle In nature, an organism will survive only if it occupies a niche, that is, performs a specific role that is needed in its environment. In every environment, there is a limited amount of resources. Organisms that are more efficient and use the available resources more effectively are much more likely to be selected by the environment. In nature, an organism will survive only if it is unique. If it ceases to be so, it is in danger of losing its niche or role in the environment. In other words, it might lose out if the new species is slightly better adapted to the role, or if physically similar enough, it might even breed with that species and thus completely lose its identity. Successful organisms must also learn to coexist with many different species so that their role complements that of the other organisms. In nature, organisms often are required to defend their niche and their territory usually by an outward display that allows other similar species to be aware of their presence. By being “visible,” similar species can avoid direct conflict. NUR219 The Use of Technologies to Assist in Effective Communication

In addition, visibility is also important for recognition by members of their own species, to allow for the formation of family and social units, based on cooperation and respect. In nature, if a species is to survive, it must make its presence felt not just to its immediate neighbors but to all the members of its environment. Often, this results in a species adapting a unique presence, whether it is a color pattern, smell, or sound. In evolution, the organisms that survive are, more often than not, innovators that have the flexibility to come up with new and different solutions to rapid changes in environmental conditions. During evolution, when new niches open up, it is never possible for more than one species to occupy one niche. Only the best adapted and most competent among the competing organisms will survive; all others, even if only slightly less competent, will die. From Bell (1997) as cited in Gottlieb L, Gottlieb B: Evolutionary principles can guide nursing’s future development, J Adv Nurs 28(5):1099, 1998. B O X 1 – 2 Pew Com m ission’s Recom m endations to Nur sing P r ogr am s: 21 Nur sing Com petencies Needed f or the Twenty-Fir st Centur y 1. Embrace a personal ethic of social responsibility and service. 49 2. Exhibit ethical behavior in all professional activities. 3. Provide evidence-based, clinically competent care. 4. Incorporate the multiple determinants of health in clinical care. 5. Apply knowledge of the new sciences. 6. Demonstrate critical thinking, reflection, and problem-solving skills. 7. Understand the role of primary care. 8. Rigorously practice preventive health care. 9. Integrate population-based care and services into practice. 10. Improve access to health care for those with unmet health needs. 11. Practice relationship-centered care with individuals and families. 12. Provide culturally sensitive care to a diverse society. 13. Partner with communities in health care decisions. 14. Use communication and information technology effectively and appropriately. 15. Work in interdisciplinary teams. 16. Ensure care that balances individual, professional, system, and societal needs. 17. Practice leadership. 18. Take responsibility for quality of care and health outcomes at all levels. 19. Contribute to continuous improvement of the health care system. 20. Advocate for public policy that promotes and protects the health of the public. 21. Continue to learn and help others learn. From Bellack J, O’Neil E: Recreating nursing practice for a new century: recommendations and implications of the Pew Health Professions Commission’s final report, Nurs Health Care Perspect 21(1):20, 2000. Porter O’Grady and Malloch (2014) refer to today’s health care system as being radically transformed with new nonlinear and socially transformational realities. NUR219 The Use of Technologies to Assist in Effective Communication

The context of professional interpersonal relationships in nursing and health care includes broader interconnections with other clinicians, health care decision makers, and other policy makers. 50 Health care decision makers include the client as a key agent. The IOM recommendations described in the following section call for a systemsbased team-care environment across clinical settings and collaborative teamwork across disciplines as the best means of reducing health disparities and promoting safe quality care. Communication skills and the development of stronger collaborative team-based professional interpersonal relationships will be key to integrating these competencies in health care delivery. Impact of Institute of Medicine Report Recommendations A series of IOM reports serve as a major force in driving and shaping the sweeping changes occurring in the health care delivery system nationally and globally. The overarching goals of these efforts relate to 1. Improving the patient’s (client’s) experience of care 2. Improving the health of individuals and populations 3. Reducing the per capita cost of health care Over the past decade, a dramatic paradigm shift has emerged beginning with the publication of two IOM reports detailing serious quality and safety problems with health care delivery in the United States, and calling for radical change. Four priorities for national action were identified as depicted in Figure 1-4. An initial IOM report, To Err Is Human (2000) drew attention to serious lapses in safety and quality in health care. A second report, Crossing the Quality Chasm, called for an innovative transformed health care system that is evidence-based, patient-centered, and systems oriented. It identified expected quality performance goals: effectiveness, timeliness, patientcenteredness, efficiency, and equity (IOM, 2001). The goals place clients at the center of the health care team. Subsequent IOM reports advocate an integrated interdisciplinary team approach, with shared accountability for outcomes, as the preferred delivery system. Reports relevant to nursing and transformation in health care are presented in Table 1-2. 51 FIGURE 1-4 Priority Areas for National Action. Four stages of life and health are described in the four circles, connected by the need for coordination across time and health care. (From Adams K, Corrigan JM, editors, for the Committee on Identifying Areas for Quality Improvement, Board on Health Care Services, Institute of Medicine. Priority areas for national action: transforming health care quality. Washington, DC, 2003, National Academies Press.) IOM recommendations have been endorsed by the American Association of Colleges of Nursing, National State Boards of Nursing, and the American Nurses Association. NUR219 The Use of Technologies to Assist in Effective Communication

These reports serve as a dynamic foundation for aligning interprofessional competency domains with contextualized individual professional circumstances in professional education (Interprofessional Education Collaborative Expert Panel, 2011). Expanded curriculum development is deemed essential to reforming the health care system. Frenk and colleagues (2010) describes the need to approach interdisciplinary education using “a global outlook, a multiprofessional perspective, and a systems approach” (p. 5). The IOM report Health Professions Education: A Bridge to Quality (2003) calls for the restructuring of clinical education responsive to the twentyfirst century health system transformation goals of providing the highest 52 quality and safest medical care possible. This report identified five core areas of competency, required to cross the bridge to quality: • Delivering patient-centered care • Working as part of interdisciplinary teams • Practicing evidence-based medicine • Focusing on quality improvement • Using information technology (IOM, 2003) TABLE 1-2 National Reports with Goals, Relevant to Nursing’s Role in the Transformation of the Health Care System Data from Institute of Medicine (IOM): To err is human: building a safer health system, Washington, DC, 2000, National Academies Press; IOM: Health professions education: a bridge to quality, Washington, DC, 2003, National Academies Press; IOM: Redesigning continuing education in the health professions, Washington, DC, 2009, National Academies Press; IOM: The future of nursing: leading change, advancing health, Washington, DC, 2010, National Academies Press; IOM: The future of nursing: accomplishments a year after the landmark report (editorial), J Nurs Scholarsh 44(1):1, 2012. IOM competencies identified in Chapter 1 as conceptual underpinnings for communication and interpersonal relationships in professional nursing practice are discussed and integrated throughout the text. These are briefly described in the following sections. Delivering Client-Centered Care Whereas client-centered care is now mandated as an essential characteristic of contemporary health care delivery, it is a core value that nursing has always championed. The IOM defines patient-centered care as “care that is respectful of and responsive to individual patient preferences, needs, and values” (2001). Patient-centered approaches view the client as a primary source of influence and core decision maker on the health care team. 53 Nurses are charged with understanding and anticipating client needs rather than simply interacting with presenting health care circumstances. Carl Rogers’ person-centered relationship model (1946) offers a conceptual basis for studying “client/patient-centered” care. NUR219 The Use of Technologies to Assist in Effective Communication

Rogers believed that support for the individual integrity and self-responsibility of each client in an empathetic, accepting relationship empowered clients to become self-directed and develop new skills. He pointed to the primacy of the client as the most important source of knowledge, and a fundamental agent of healing. He described the client/health provider relationship as an equal partnership. Rogers believed that “the constructive forces in the individual can be trusted, and that the more deeply they are relied upon, the more deeply they are released” (Rogers, 1946, p. 418). Learning about the client’s values, preferences, and perceptions related to the client’s health care situation are critical dimensions of contemporary clientcentered relationships (see Chapter 10). Client-centered care requires that scientific guidelines be balanced with values-based nursing knowledge. Frist (2005) asserted that the focus of the twenty-first-century health care system must ensure that clients have access to the safest and highest-quality care, regardless of how much they earn, where they live, how sick they are, or the color of their skin (p. 468). Working as Part of Interdisciplinary Teams Health care reform calls for collaborative interdisciplinary teams of health care professionals, rather single practitioners assuming responsibility for the health care of clients (Batalden et al., 2006; IOM, 2003). The concept of collaboration is based on the premise that no single health care discipline can provide complete care for clients with multiple health and social care needs. Interprofessional care teams are peopled by highly skilled professionals working together with a client for the common purpose of improving a client’s health status. Professional team providers have complementary interdependent professional roles supported by mutual respect and power sharing. Collaborative health care efforts represent a non-hierarchal system of care delivery. Care coordination, and making connections between multiple care providers is viewed as an essential component of collaboration (Craig et al., 2011). Recommendations from the IOM Report: Health Professions Education: A Bridge to Quality (2003) led to the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007) discussed in Chapter 2, and integrated throughout the text. QSEN competencies provide a solid conceptual framework for professional nursing education curriculums at 54 all levels, and for clinical practice. Bronstein’s model is a frequently used conceptual framework (Kilgore and Langford, 2010) for the study of interdisciplinary collaboration. Each collaborative team takes collective ownership of treatment goals, determines the professional activities needed to achieve them, and has ongoing reflective communication about their process. Personal characteristics and the professional makeup of the team, the team’s structural characteristics, and its level of experience with interdisciplinary collaborative approaches influence collaborative effectiveness (Bronstein, 2003). A multidimensional construct, defines “client,” individually, or broadly as its core, and as an integral decision maker on the health care team. NUR219 The Use of Technologies to Assist in Effective Communication

Interprofessional collaboration requires communication and relationship skills that nurses can only be taught with interdisciplinary curriculum exposures involving more than one discipline (Bjorke and Haavie, 2006). Applications of interdisciplinary collaboration involve a socialization process that ideally begins early in the student’s professional education. Students develop broader habits of inquiry and a comprehensive understanding of how to work with other professional disciplines productively. They learn firsthand about the value of a collective systems approach to diagnosis and treatment in a time of diminishing resources. Practicing Evidence-Based Nursing The scope of practice and nature of work for contemporary nurses has become multidimensional, multirelational, and highly complex. Practicing evidence based nursing (EBP) is every nurse’s responsibility. What this means is that nurses should conscientiously keep up to date with the latest research and any published practice guidelines relevant to guiding their nursing practice (Rycroft-Malone et al., 2004). Applications for magnet status (Chapter 22) require proof of evidence-based practice. The strength of EBP lies in the blending of extensive clinical experience with sound clinical research and professional judgment in real-time client situations. EBP provides the foundational knowledge and facilitates the selfconfidence new nurses need to interact effectively on interdisciplinary health care teams (Pfaff, et al., 2013). The collective wisdom of EBP is dynamically related to nursing theory through empirical ways of knowing. The concept of EBP consists of four elements: 1. Best practices, derived from consensus statements developed by expert clinicians and researchers 2. Evidence from scientific findings in research-based studies found in published journals 55 3. Clinical nursing expertise of professional nurses, including knowledge of pathophysiology, pharmacology, and psychology 4. Preferences and values of clients and family members (Sigma Theta Tau International, 2003) Developing an Evidence-Based Practice Stans S, Stevens A, Beurskens J. Interprofessional practice in primary care: development of a tailored process model. J Multi Health Care. 6:139147, 2013. Background: This qualitative study investigated interprofessional practice in a primary care setting, using the domains of the chronic care model as a framework. A target intervention consisting of three steps described targets for improvement for children with complex care needs, identified barriers and facilitators influencing interprofessional practice, and developed a tailored interprofessional process model. Methodology: A qualitative methodology consisting of 13 semistructured interviews with the children’s parents and professionals involved in the care of the children. Data were analyzed using direct content analysis. NUR219 The Use of Technologies to Assist in Effective Communication

This step led to the development of a project group that formulated an interprofessional process through process mapping. Findings: The most significant barrier to implementing the interprofessional practice related to the lack of structure in the care process and knowing what should be involved in the process in interprofessional practice. Study participants expressed the need to have structured communication through face-to-face meetings, and an electronic clinical information system. Application to Your Clinical Practice: Regular multidisciplinary meetings, structured communication, and a defined system for division of tasks—“who does what” and “when” is essential for successful team process. Focusing on Quality Improvement Quality improvement in nursing historically began with Florence Nightingale’s use of morbidity and mortality statistics to improve the quality of care during the Crimean War (Sousa and Corning-Davis, 2013). Batalden and Davidoff (2007) define quality improvement (QI) as “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better 56 system performance (care) and better professional development” (p. 2). Quality improvement (QI) is the responsibility of everyone in the organizational system, including clients. QI processes provide a measurable systematic way to ensure that the goals of care are • Appropriate: for the client, and care requirements • Adequate: to meet clinical requirements and client needs, including level of resources and skill mix of providers. • Effective: care meets or exceed established standards of care • Efficient: in terms of cost and time Although the defining purpose of QI is health improvement, an essential component is identifying the resources to make care delivery an equitable reality for all (WHO, 2000). QI processes require that each organizational system, together with all of its stakeholders, develop a quality philosophy that matches the unique needs of the organization. Competency domains act as flexible practice guidelines, which are applicable across professions (Interprofessional Expert Panel, 2011). Using Informatics The world from an interpersonal communication perspective is much different than it was even a decade ago—smaller and substantively better connected through technology. Smith and Wilson, (2010) note, “interpersonal relationships can be initiated, escalated, maintained, and dissolved either wholly, or in part, through mediated technology” (p. 14). Digital communication greatly expands interpersonal and professional communication, but a word of caution is needed. Texting, Instagrams, and e-mails do not allow the receiver to see facial expressions, hear the tonality of a message, or readily interpret an emotionally charged communication. NUR219 The Use of Technologies to Assist in Effective Communication

Clarity and conciseness are essential, and all electronic messages are subject to HIPPA regulations. Telehealth is fast becoming an integral part of the health care system, used both as a live interactive mechanism as presented earlier (particularly in remote areas, where there is a scarcity of health care providers), and as a way to track clinical data. Two important outcomes are reduction of health costs and access to care (Peck, 2005; Cipriano and Murphy, 2011). The following case example represents a “virtual” application of communication through technology from the perspective of a Canadian nurse caring for a client in a remote area as it might occur in contemporary practice. The video system used in the case study has a monitoring device on both ends, with voice activation. The personalized contact allows clients 57 and caregivers to communicate directly with each other from distant locations. Case Example The computer gently hums to life as community health nurse Rachel Muhammat logs into Nursenet. She asks a research partner, a cyberware specialist in London, England, for the results from a trial on neurologic side effects of ocular biochips. Rachel, as part of a 61-member team in 23 countries, is studying six clients with the chips. Then it is down to local business. Rachel e-mails information on air contaminant syndrome to a client down the street whose son is susceptible to the condition and tells her about a support group in Philadelphia. She contacts a qigong specialist to see if he can teach the boy breathing exercises and schedules an appointment with an environmental nurse specialist. Moments before her 9:45 appointment, Rachel gets into her El-van and programs it to an address 2 kilometers away. Her client, Mr. Chan, lost both legs in a subway accident and needs to be prepared for a bionic double-leg transplant. Together, they assess his needs and put together a team of health workers, including a surgeon, physical therapist, acupuncturist, and home care helpers. She talks to him about the transplant, and they hook up to his virtual reality computer to see and talk to another client who underwent the same procedure. NUR219 The Use of Technologies to Assist in Effective Communication

Before leaving, Mr. Chan grasps her hand and thanks her for helping him. Rachel hugs him and urges him to e-mail her if he has any more questions (Sibbald, 1995, p. 33 [quoted in Clark, 2000]). Technology advances provide nurses with new capabilities for transmission of data within and between care settings. Electronic records and communication technologies have revolutionized the way health information is processed (Cipriano and Murphy, 2011). Virtually every major health care system has switched to electronic medical record (EMR) keeping and bar code scanners for medications or identification. Web portals and other technological supports, which were not possible even a decade ago, assist clients at entry points to an increasingly complex health care system. Technology provides a powerful way to enhance access and coordination of health information across health care systems. Promoting greater availability of information transfer between client consumers and relevant health care providers can and improve patient/clinican collaboration and decision-making. High quality technology can empower client self-management, and improve health outcomes (Wagner et al., 2010). Conversely, technology can contribute to dehumanization in health care delivery. It is only as useful as the ability of the people who control its use and the quality of information that is collected and shared. The client, 58 not the information alone, should be the primary focus directing care. The general public routinely uses computers and technical devices to access health-related information. Health care providers use the Internet to collaborate about research, and to seek consultation about the management of care delivery, referrals, and sharing of other health-related information and concerns. Secured Web portals that meet the Health Insurance Portability and Accountability Act (HIPAA) requirements are customized to meet the information needs of, or about, designated groups of people (Moody, 2005). Technology enhances the potential for global health care. Health experts in geographically distant areas throughout the world can share information and draw important conclusions about…