Nursing_Fundamentals_Catalogue

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CHAPTER 22 Working With dying, death and grief

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thegriever.A listof localpsychologistsorcounsellorswho are skilled in bereavement support can be an invaluable resource,as cananafter-hours telephone supportnumber or liaisonpersons in thegriever’s community. CLINICALREASONINGPROCESS Grieving isanatural response toa lossand isconsidered tobe abeneficialcopingprocess. It isalsoa reactiveprocessandhas therapeuticvalue.Grieving ishealthyandenables thebereaved to reflectonandaccept the realityof the loss.Thenursemust feelconfident toassess the situationcriticallyandmakean initialneedsanalysis.Theoverallgoalofnursingassessment is togather relevant informationanddata inorder togaina totalviewof theclient’shealthandpsychosocial status.By carefullyexploring informationgained from interactionand collating thedata inapreciseandmethodicalway,appropriate judgementsanddecisionscanbemade toworkwith theclient in theirgrievingprocess.Assessmentprovidesanopportunity for thenurse toexplorewith theclient information relating to perceivedandactualpriorityproblems (mentalandphysical). MAKINGAPPROPRIATE JUDGEMENTSAND DECISIONS Verbalandnon-verbalcommunication techniquescan encourage freeflowof informationandprovidemeaningful data forevaluation (seeChapter12).These include listening, reflecting,clarifying,usingnon-verbalcues,appropriateuseof silence, sharingperceptions,confrontingcontradictionsand reviewing thediscussions. Cultureanddevelopmentalconsiderationsare two factors that influencecommunication.Culturehasaprofoundeffecton the waypeoplecommunicateandbehave. It is therefore important tokeep inmind thatculturaldifferencesmay influencehow verbalandnon-verbalmessagesare interpreted.Forexample, in manySouth-EastAsiancultures–ofwhich thereare significant immigrantpopulations inbothAustraliaandNewZealand– manywomenavoideyecontactwithmen.Conversely,many Westernwomen lookdirectlyat theperson towhom theyare talking. Ageordevelopmental level canalsoaffect theway the assessment ishandled,especially if theclient isveryyoungor veryold. In theyoung,communicationdependson thechild’s cognitivematurity,asnotedabove. In theelderly,consideration mustbegiven to theextent towhich thememoryand sensory functionmaybeaffectedby theageingprocess.Thereare times whenboth theyoungand theelderly, inparticular,arehesitant to sharepersonal information,anddevelopingcommunication skills thatmaximise thepossibilityofopencommunication isa priority for studentnurses. Duringperiodsof lossoranticipated loss,aclient’semotions andbehavioursmaybe ina stateofflux.Thismakesassessment all themorechallenging.Nurses shouldnotassume they knowhowaclientor familymemberswill react.Continual assessment isessential if supportand/or interventionsare tobe compatiblewith theircurrentneeds.Assessmentof theclient and familybeginsbyexploring themeaningof the loss to the people involved.Examplesof topics tobeexplored include the survivor’smodelof theworld,personalcharacteristics suchas personality,values, thenatureof family relationships, support systems,natureof loss,culturaland spiritualbeliefs, lossof

personal lifegoals,hope,phaseofgrief, risksandnursing role perceptions. When interviewing theclientand family, it is important thatan honestandempatheticapproach is taken.Bemindfulof setting the toneanddirectionof the interview,andofestablishing amutualunderstandingof thepurposeof theexchange. In the initialphase it is important toestablish rapport,ensure acomfortableandnon-threatening settingandclarify the expectationsorgoalsof the interview. Establishing rapport Establishing trustand rapport isachallengingprocess, particularlygiven theculturaldiversityofAustralianandNew Zealandpopulations.Acleardemonstrationof respect for the clientandanacceptanceof theclient’suniquenessasaperson facilitate rapport.Greet theclientbynameand introduce yourself. It isusualpracticenot touse theclient’sfirstname unless invited todo so. InAustralasian society,offering to shake hands isoneway todemonstrate sincerityandacceptance. Non-verbalbehaviours Non-verbalbehaviours shouldmatch theverbalmessages. Appropriateand sensitiveeyecontactandnon-intimidating positioning shouldbeused.Sincereandopeneyecontact (except incertaincultures/circumstances) isoftenvitalwith avulnerableperson,asnormalcontactwithothersmaybe disruptedby theemotionsgenerated fromcircumstances surrounding thedeath.Positionyourself so thatyouare facing theclient. If theclient is seated, sitata slightangleoppositebut facing,withanappropriatedistancebetween.Avoidnon-verbal behaviours suchas frowningoryawning,orexpressionsof impatienceorboredom,which implya lackof interest.When beginning the interview, itmaybeappropriate to startwith abriefbutcasualconversation thathelps theclient relax. Client-focusedcasualconversationmayhelpalleviateany awkwardness theclientmay feel in talking toa stranger in the healthcare setting.Casualconversationcanalsobea sourceof valuable information. Ensuringcomfort Ensure that theexchangeof information takesplace inaprivate setting free from interruptionsanddistractions. It is important toclarify that theclient is feelingup to the interviewbefore starting.Verbal therapeuticcommunication techniques involve open-endedquestions thatgive theclienta senseofcontrol over theprocess– forexample, ‘Tellmeaboutyour family’, ‘Howareyou feelingnow?’or ‘Whatcanyou tellmeaboutyour relationshipwithX?’ Definingexpectations At thebeginningofany interaction it is important toclarifywhat both thenurseand theclientexpect from theexchange.Make itclear thatany informationexchangedwillbe treatedwith sensitivityand respect.This isespecially important inAustralian Indigenousculturewhere theabusesof thepastcontinue to have impactsonestablishing trust in services (seeChapter14). During theassessmentphase, it is important to focusonhow theclient is reacting,notonhowyoubelieve they shouldbe reacting.Give specialattention togrief-relatedbehaviours displayedby theclient,andpaycarefulattention to theclient’s experienceand the tasksofgrief thatmaybe left incomplete, whichmay threaten theclient’spsychologicalorphysical

Clinical reasoning process

4 CHAPTER

Developing clinical reasoning for nursing practice

ClintDouglas and JackieCrisp

Learningoutcomes Mastery of contentwill enable you to: • understand the value of using a reflective and systematic approach to clinical reasoning • discuss theways inwhich a systematic approach to clinical reasoning enhances nursing knowledge and skilldevelopment • discuss theways inwhich nursing knowledge and skill development enhances the process of clinical reasoning • explain how using a systematic approach to clinical reasoning contributes to the visibility of nursing practice • explain the relationship between critical thinking and clinical reasoningwithin nursing practice • discuss the sixbasic domains evidentwithin all processes of clinical reasoning • use criticalquestioningwithin each of the six basic domains of the clinical reasoning process.

KEYTERMS Actionplanning, p. 51 Clinical reasoning cycle,p. 50 Clinical reasoning models,p. 47 Cognitivebias, p. 47 Criticalquestions, p. 56 Critical thinking, p. 49 Goals andpriorities, p. 50

Information/data, p. 51 Judgements and decisions,p. 51 Nursing knowledge, p. 52 Nursingmodels, p. 47 Outcomes,p. 49 Reasoningprocess, p. 49

PART 4 ADAPTING NURSING: PEOPLE, CONTEXT AND CULTURE

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(Ramsden 2002, Reimer-Kirkham et al 2009). Cultural safety focuseson how people are treated in society ,not how theyareculturallydifferent .That is, the importofdiversity is turnedon itshead incultural safety,as it is social responses to diversity that create health impacts not the existence of the diversity itself (Cox& Simpson 2015). Consequently, cultural safety is about power – personal, professional and institutional power in health services, and the impact on thosewho use the service; the peoplewho define the An exampleofbeing culturally unsafe MrsG is anAboriginalwoman in her 40swho goes to the hospital in the rural townwhere she lives at about11.45 am on aMondaymorning, to see a doctor.She has pains in the stomach that have kept her awake all night and got worse after breakfast.She is accompanied by a female cousin,MrsS,who is some years younger.Although only in her 40s,MrsG is a respected elder in her community, a fact that reflects the statistically reduced life expectancy of Aboriginal people. MrsG is told by the young female nurse at the front desk to take a seat in the sparse basicwaiting room. There are nomagazines, television or tea-making facilities here, such as onemight find in city hospitals.By 1.00 pm no one has come to seeMrsG and she’s not been offered somuch as a drink ofwater. Feeling frustrated andworried aboutMrsG,MrsS finally finds the courage to confront the nurse and askswhen the doctorwill be there to seeMrsG. The nurse responds by saying, ‘Doctor is on his lunch break.’She then says toMrsS, ‘Are you a drinker too, love?’At thisMrsG gets up and says to her cousin, ‘Let’s go along’, and they leave the hospitalwithout being seen. MrsG still has abdominal pain and bothwomen are angry at being referred to as ‘drinkers’, especially as both are teetotallers and devoutChristians. Lessons to be learnt from this example are: • the clientswere culturally unsafe – theywere demeaned,diminished and disempowered • the nurse and the hospital neglected their duty of care • the nurse has unexamined prejudices towards Aboriginal people and operates on stereotypes • the use of the term ‘love’ from a youngwhitewoman was offensive to such respected leaders in the community • access of these clients to health serviceswas limited by the hospital’s lunch-time policy • itmay take years for eitherwoman or their large extended families to seek help from the hospital again. Cox L2007 Fear, trust andAborigines: the historical experience of state institutions and current encounters in the health system,Health andHistory 9(2):70–92.Reproducedwith permission. CLINICAL EXAMPLE

awareness of themselves as cultural beings. Further, all healthprofessionalsneed toconsiderhowculture,classand socialmarginality impactonbothhealthandhealthcare. In the following sectionswewill show that social responses to clients’class,ethnicity,genderorabilities influencepeople’s lifechancesandhealth.Suchconcernsare intimatelyrelated to the social determinants of health, that is, to factors beyond the controlandbehavioursof individuals.To come to gripswith these complex issueswe introduce you now to themodel of cultural safety and discussmore fully the specific conceptualisation of culture that underlies the modeland its focuson the socialdeterminantsofhealth. Cultural safety Cultural safety ( kawa whakaruruhau ) was developed within theMāori community in the 1990s byMāorinurse scholarIrahapetiRamsden inAotearoaNewZealand(1993, 2002).Ramsdenandcolleaguesdeveloped themodelpartly in response to a first-yearMāori nursing student’s astute comment: ‘Youpeople talk about legal safety, ethical safety, safety in clinical practice and a safe knowledge base, but whataboutculturalsafety?’(Ramsden2002:1).TheseMāori nursing students alerted Ramsden to the expectations they felt to conform to the dominant institutional culture and their experience of non-Māori ‘experts’ lecturing to them about traditionalMāori culture.Their experiences suggested that there was only one correct, authentic way of beingMāori, which, as urbanMāori whose ancestors experienced thedisruptionsofcolonisation, theycouldnot embrace. Cultural safety therefore aimed for cultural change by exposing and addressing such power imbalances to decrease the impact of cultural dominance and racism in health care, education and research (McCleland 2011). Ramsden also saw that nursing curricula were devoid of structural issues and were designed by and for those who did not share her cultural position or experience of colonisation. She challenged this cultural dominance, particularly theway it shapedpolicyanddevelopednurses asmerebiomedical techniciansrather thanagentsofsocial change (Ramsden 2002).Ramsden saw cultural safety as away for nurses to consider how their socialisation and cultural position impacted on their work, emphasising the links between ill-health and dispossession, economic status and political agendas. This social determinants approach contrastswith individualist biomedical notions that illnessesmerelyoccur ‘withinbodies’. Underpinnedbycriticalsocialtheory,culturalsafetyalso recognises thatnursingcare,educationandresearcharenot value neutral activities but reflect socio-political contexts and thevalues,assumptionsandprioritiesof those involved

Learning outcomes

Clinical examples

CHAPTER 3 Engaging patiEnts and kEEping thEm safE

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CHAPTER 9 Examining thE Ethical practicE of nursing

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of ‘characterological excellence’ in determining ethical conduct (Oakley 2006, Van Hooft 2014).This is made manifest by the expression of suchmoral virtues as care, compassion, kindness, empathy, sympathy, altruism, generosity, respectfulness, trustworthiness, personal integrity, wisdom, courage and fairness.Virtue theorists claim that without the characterological excellence of virtue, ‘a person could, robot-like, obey everymoral rule and lead the perfectlymoral life’, but in doing sowould be actingmore like ‘a perfectly programmed computer’ than amorally responsible human being (Pence 1991). There isa sense inwhichbeingmoral involvesmuchmore thanmerely following rules; themissing link, claimvirtue theorists, is character.On thispoint,Pence (1991)writes: we need to know much more about the outer shell of behaviour to make such judgments, that is, we need to know what kind of person is involved, how the person thinks of other people, how he or she thinks of his or her owncharacter,how theperson feelsaboutpastactions,and alsohow theperson feelsabout theactionsnotdone. Virtue ethics is particularly relevant to nursing and to nursing ethics since virtuous conduct is intricately linked to therapeutic healing behaviours and the promotion of humanhealth andwellbeing. The nursing profession’swell-articulated ethic of care (regardedbymany influentialnurse theoristsas themoral foundation, essence, ideal and imperative of nursing) is consistent with a virtue theory of ethics (see the classic works of the following nurse theorists:Benner&Wrubel 1989,Gaut 1991,Gaut&Leininger 1991,Leininger 1988, 1990, Roach 1987,Watson 1985a, 1985b). Significantly, virtue ethics is enjoying a renaissance in the nursing ethics literature – particularly in regard to the issue of caring forvulnerableandmarginalisedgroupsofpeopleat risk of being treated as ‘different’ by healthcare providers (Armstrong2006,2007). cross-cultural ethics As highlighted by the ‘Mr G’ case discussed on p. 139, anotherperspectiveon ethics andbioethics thatwarrants considerationbynurses is cross-cultural ethics.Thebasic assumptions of cross-cultural ethics reflect the views that: n ethics isverymuch aproductof the culture, society andhistory fromwhich ithas emerged n all cultureshave amoral system,butwhat this system is andhow it is appliedwillvary across, and sometimes evenwithin,different cultures n there isno such thing as auniversal ethic; that is,one ultimate standardofmoral conductwhich applies to allpeople equally regardlessof their individual circumstances, context and culture– inotherwords,

a ‘one sizefits all’ approach to ethics (Johnstone2012, 2016). In any culturally diverse society it is imperative that a culturally informed,knowledgeableand sensitiveapproach to health care is taken (Johnstone 2012, Johnstone & Kanitsaki 2008). One reason for this is that a failure to adopt such an approach can result in otherwise serious moral harm being caused to people.Cross-cultural ethics, therefore,goesfarbeyondmerelyconsideringandcritiquing the nature and content of mainstream ethical theories; it also involves a systematic examination of the moral implicationsofculturaland linguisticdiversity inhealthcare domains; for example, the extent towhichpatientsofnon- English-speaking and diverse cultural backgrounds suffer unnecessarily on account of the cultural and language differencesbetween themand theirprofessionalcarers (see deBruijneetal2013,Divietal2007, Johnstone&Kanitsaki 2006,2009a,Suurmondetal2010). Nurses and other healthcareworkers have a stringent moralresponsibility toavoidand/orprevent theotherwise avoidable moral harms that can result from a failure to take into account the language and cultural needs of theirpatients (Johnstone&Kanitsaki 2006, 2008, 2009a). The harmful aftermath of racism in health care is a particular example of this.Racism in nursing and health care is a problem that has not been formally recognised as an important ethical professional issue (Johnstone & Kanitsaki 2009b, 2010). A cross-cultural approach to ethics would not only help identify the existence of racism in nursing and healthcare contexts, but also guide an effective response for dealingwith it and, if not successful in eradicating it, at leastminimise its harmful consequences topatienthealth. Truth-telling around cancer and other life-limiting diagnoses stands as one of the most controversial issues in cross- cultural health care. Research has shown that truth-telling is not just an issue for people fromGreek backgrounds, but also for people from other traditional cultural backgrounds (e.g. Iranian, Pakistani, Japanese, Italian, Korean,Chinese). In these cases, truth-telling about a diagnosis of serious life-limiting illnesses (especially cancer-related illnesses) is regardedasharmful, ‘undesirable’andhence tobeavoided– most notably on the grounds that it could undermine the ill lovedone’shopeand thewill to live (Johnstone2012,2016). Problems most commonly arise in situations where the healthcare provider (e.g. doctor, nurse) does not share the same cultural background as the patient and family,whose cultural world views are unfamiliar and even confronting to them andwhich they do not understand. WORKING WITH DIVERSITY

RESEARCH HIGHLIGHT

Research highlights

in decision-making about the care they receive. A meaningful relationship with the patient enables you as thenurse tomake sound clinical decisions that are based on thepatient’sbest interests. • nurses’ values andbeliefs (e.g. their thoughts, perceptions, attitudes and associatedbehaviours) • nurses’ knowledge and skills (both clinical skills and supportbehaviours) • nurses’ ability to communicate effectively in a variety ofways • how thephysical and social contexts inwhich care is takingplace affect thenurse–patient relationship Patient safety was of central concern to Florence Nightingale as reflected in her quote, ‘the very first requirement in a hospital is that it should do the sick no harm’ (Nightingale1859).Safetycontinues tobeaconcern for many modern healthcare systems, with evidence suggesting thatNightingale’sdoctrineof ‘doingnoharm’ is notbeing completely followed.The InstituteofMedicine’s (IOM) landmark publication Crossing theQualityChasm (2001), for example, argued that theUShealthcare system was failing todeliverconsistent,high-qualitymedicalcare, with such care instead frequently harming or injuring patients. The IOM called for fundamental changes to 21st-centuryhealthcare systems to ensure the safetyof all patients. In this part of the chapter, we consider how the Fundamentals of Care Framework helps you to address Research focus developing apositive relationshipwithpatients is known tobe important for thedeliveryof high-quality care.this paper sought to identify the factors that contribute to the developmentof a caring relationshipbetween thenurse andpatient. Researchabstract the study involved conducting an umbrella review. Umbrella reviewsbring together evidence from existing systematic reviews inorder to synthesise the available evidenceon aparticular topic.thisumbrella review looked at studies examiningpatients’ andnurses’ perspectivesonwhat is important in the nurse–patient relationship.theumbrella review identified six key areas that are associatedwithdeveloping andmaintaining caring,positive nurse–patient relationships.they are: • nurses’ andpatients’ expectationsof the relationship safety as one of the fundamentals of care

patient safety concerns when providing care. As can be seen from Figure 3-1, safety is conceptualised as a fundamentalof care, alongwithother fundamentals such asnutrition,hydrationandelimination.Thenurse–patient relationship is central to ensuring this fundamental need is appropriately met. While policy and organisational structures focusingon safetyundoubtedlyhave an impact on the ability of nurses to deliver safe and effective care, our focus in this chapter ison equipping you as a student and beginning nurse with the skills to operate in a safe manner.That is, to ensure patient safety becomes part of yourpersonal andprofessional responsibility as anurse. Patient safety encompasses three interrelated elements: physical, psychosocial and environmental safety.At the intersectionof thesedifferent typesof safety lies thepatient’s personalsafety (seeFigure3-2). It isonly when each of these types of safety are appropriatelymet that patients can be considered safe. Ensuring patients’ personal safety requires nurses to embed patients’ needs in their thinking, reflection and assessment processes (Kitson et al 2014). Careful assessment and planning prior toany interventionor interactionwithapatientwill ensure that injury and harm do not occur and that any safety risks are reduced. positive relationshipwith theirpatientsbut can also experienceguilt and frustrationwhen agoodquality nurse–patient relationship is not achieved. Reference WiechulaR et al 2015Umbrella reviewof the evidence: What factors influence the caring relationship between anurse andpatient? Journalofadvanced nursing,doi:10.111/jan.12862. • the impactof the relationshiponpatients/families, nurses and nursing students. Evidence-basedpractice • the nurse–patient relationship shouldbebasedon nursing’s inbuilt values such as trust, sympathy, support and responsibility, and these values should be reflected in the attitudes andbehavioursof nurses. • Compassionate care and technical skill are equally important indeveloping andmaintaining the nurse–patient relationship. • nurses need to consider the context inwhich they areproviding care andhow thismight impact the nurse–patient relationship. • the nurse–patient relationship notonly has an impactonpatients and families/carers,buton nurses aswell.nurses findgreat reward in a

PART 1 EVOLVING NURSING: NURSING AND THE HEALTHCARE ENVIRONMENT

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Nursing’s contribution to these three elements is greater than any other health profession.The nursingworkforce is the single largest clinical workforce with the most direct clinical care time.Nurses continue to provide care with resilience and versatility, while often withminimal resources and organisational support.Nursing can be, as the International Council of Nurses (ICN 2015) states, ‘a force for change’. Unfortunately, reform may have short-term goals, including immediate funding reductions. As the largest workforce and, therefore, the highest cost burden, the nursingworkforce isoften cut, leaving fewerpeople todo morework. Research shows that RN staffing levels have direct implications for patient care. It demonstrates that hospitalswith a higher ratio of degree-preparedRNs-to- patients have lower mortality rates (Aiken et al 2014). Hospitals with lower RN staffing numbers are linked to an increasednumberof adverse events including falls and medication errors (Duffield et al 2014). As a result, the aimsofhealthcare reform arenot realised. The escalating costs of health care require that measuresbe taken to contain costs to levels that countries can afford and sustain.Thesepressureshighlight theneed for how resources in health care, particularly nursing, can be used to their optimal level. When the nursing profession is optimised, evidence demonstrates that the quality of health service provision improves.When the qualityof services improve, resourcesareoftenusedmore efficiently. For example, an optimised and appropriately resourcednursingworkforce is linked to reduced adverse events (asmentioned above), improved health literacy of patients, reduced length of stay, decreased readmission rates, improved hospital avoidance and better patient outcomes (Aitken2014).As such, the threeaimsofhealth reform canbe achieved. • CRITICALREFLECTION POINT Whywould supportingRNs towork to their full scope ofpracticecreateamoreefficienthealth system?How important ishealth literacy to the futureofhealthcare provisionandhowcannursingcontribute to improving health literacy? Nursing leadership and healthcare reform The nursing profession is uniquely placed to lead healthcare reform . Nurses have close interaction with patients and their families in all health settings across the health continuum. They can help interpret and understand people’s needs and expectations for health care.Theyareactively involved indecision-makingwithin

the clinical team and inmanagement.They do thiswith a foundation of care informed by research and evidence. This understanding, experience and proximity to the patients’ needs are critical components of what nursing canbring to the table andhow it can enable reform. As such, nurses have an important contribution to make in health service planning, management and policy setting. Nurses must contribute to public policy development throughmanagement and leadership roles at all levels andwithdirect engagementwith theirprofes- sionalorganisations.Toachieve this levelof responsibility, itcannotbeassumed that itwillautomaticallybeprovided to the profession.Historically, inmany instances, nurses have been left out of the decision-making process and have been leftwith implementing an initiative or policy thathasnotbeenwell informed.The roleof theprofession therefore must be proactive to maintain this level of influence and involvement. Just as important as the planning and policy setting, nursesneed tobe leaders inhealthcaremanagement.The InternationalCouncilofNurses(2015)assertsthatnursing servicesmust be directlymanaged by nurses.The reason for this is that the professionmust be responsible for the professionalpractice ofnursing.Noprofession outside of nursing iswell positioned enough to be held to account and to lead the scope of practice and the standards for practiceof theRN. • CRITICALREFLECTION POINT Thinkabouta recenthealth issuediscussed in thenews. Didnursinghavea voice?Howdo you thinknursescan promote their stories, insights, researchandexpert opinions via socialmedia? Regulation of the nursing profession TheNursing andMidwifery Board ofAustralia (NMBA) and Nursing Council of New Zealand are responsible for professional regulation and setting standards, codes and guidelines for thenursing andmidwiferyprofessions (Box 1-2).The role of professional colleges and associa- tions in developing specific standards of practice and credentialling individual nurses is increasing. RNs are individuallyaccountable for theirownpracticeandhavea personal responsibility tomaintain their competency and meet professional standards in order to maintain their licence to practise.The role of theRN has evolved along with changes in advancing technology, newly defined patient needs and changes to the way health care is delivered. In thisway, it isnotunreasonable to expect that the roleof theRNwill continue to evolve and change. It is

Working with diversity

Critical reflection points

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| Empowering Knowledge