Interpersonal Relationships Professional Communication Skills For Nurses 7Th Edition Elizabeth Arnold Full Chapter

Interpersonal Relationships:
Professional Communication Skills for

Nurses 7th Edition Elizabeth Arnold
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CONTENTS
PART I CONCEPTUAL FOUNDATIONS OF INTERPERSONAL RELATIONSHIPS AND PROFESSIONAL
COMMUNICATION SKILLS
1 Theory Based Perspectives and Contemporary Dynamics 1
2 Professional Guides for Nursing Communication 22
3 Clinical Judgment and Ethical Decision Making 40
4 Clarity and Safety in Communication 57
PART II ESSENTIAL COMMUNICATION SKILLS

5 Developing Therapeutic Communication Skills 75
6 Variation in Communication Styles 99
7 Intercultural Communication 113
8 Therapeutic Communication in Groups 136
PART III THERAPEUTIC INTERPERSONAL RELATIONSHIP SKILLS

9 Self Concept in Professional Interpersonal Relationships 159
10 Developing Therapeutic Relationships 180
11 Bridges and Barriers in Therapeutic Relationships 202
12 Communicating with Families 217
13 Resolving Conflicts between Nurse and Client 241
PART IV COMMUNICATING TO FOSTER HEALTH LITERACY, HEALTH PROMOTION AND PREVENTION

OF DISEASE AMONG DIVERSE POPULATIONS
14 Communicating to Encourage Health Literacy, Health Promotion, and Prevention of Disease 261
15 Health Teaching and Coaching 284
16 Empowerment Oriented Communication Strategies to Reduce Stress 309
PART V ACCOMMODATING CLIENTS WITH SPECIAL COMMUNICATION NEEDS

17 Communicating with Clients Experiencing Communication Deficits 333
18 Communicating with Children 345
19 Communicating with Older Adults 364
20 Communicating with Clients in Crisis 387
21 Communicating with Clients and Families at End of Life 407
PART VI COLLABORATIVE AND PROFESSIONAL COMMUNICATION

22 Role Relationships and Interprofessional Communication 428
23 Communicating with Other Health Professionals 450
24 Communicating for Continuity of Care 469
25 Documentation in an Electronic Era 492
26 Communication at the Point of Care: Application of e-Health Technologies 509
SEVENTH
EDITION
Interpersonal
Relationships
Professional Communication
Skills for Nurses
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, FNP-CS

Family Nurse Practitioner
Associate Professor Emeritus
College of Health and Human Services
University of North Carolina Charlotte
Charlotte, North Carolina
3251 Riverport Lane
St. Louis, Missouri 63043
INTERPERSONAL RELATIONSHIPS: PROFESSIONAL

COMMUNICATION SKILLS FOR NURSES, SEVENTH EDITION ISBN: 978-0-323-24281-3
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International Standard Book Number: 978-0-323-24281-3
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

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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

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
This page intentionally left blank
REVIEWERS AND CONTRIBUTOR
REVIEWERS Robyn C. Leo, MS, RN
Associate Professor Nursing
Amy Ellsworth, AND Worcester State University
Nursing Instructor Putnam, Connecticut
Kirkwood Community College
Cedar Rapids, Iowa Scott A. Davis
Police Officer
Cindy Carter, MSN, RN, IBCLC, RLC, ICCE Crisis Intervention Team (CIT) Coordinator
Nursing Instructor Montgomery County Police Department,
Colorado Christian University Gaithersburg, Maryland
Indiana Wesleyan University
Texas Health Resources Danette Yolanda Wall, DNP, MSN, MBA, ACRN,
Nocona, Texas RN, CPHQ, LNC
Chief Operating Officer
Kim Clevenger, EdD, MSN, RN, BC Odot, LLC
Baccalaureate & RN-BSN Program Coordinator Clinical Advisor Quality Improvement
Associate Professor of Nursing Humana CarePlus, Inc.
Morehead State University Tampa, Florida
Morehead, Kentucky
Brian Zager, MA
Dr. Bonnie DeSimone, EdD, RN, BC PhD Candidate
Professor of Nursing Department of Speech Communication
Coordinator of the ABSN Weekday Southern Illinois University
Division of Nursing Carbondale, Illinois
Dominican College of Blauvelt
Orangeburg, New York
CONTRIBUTOR
Linda Finch, PhD, ANP-BC Shari Kist, PhD, RN, CNE
Associate Professor/Associate Dean-Retired Assistant Professor
Loewenberg School of Nursing Goldfarb School of Nursing
University of Memphis Barnes-Jewish College
Memphis, Tennessee St. Louis, Missouri
Shari Kist, PhD, RN, CNE

Assistant Professor
Goldfarb School of Nursing at Barnes-Jewish
College
St. Louis, Missouri
v
ACKNOWLEDGMENTS
Elizabeth C. Arnold
The seventh edition of Interpersonal Relationships: W. Ryan, PhD, RN, CRNP; Michelle Michael, PhD,
Professional Communication Skills for Nurses continues APRN, PNP; Barbara Harrison, RN, PMH-NP; Ann
to reflect the ideas and commitment of our students, O’Mara, PhD, RN, AOCN, FAAN; Barbara Dobish,
valued colleagues, clients, and the editorial staff at MS, RN; Anne Marie Spellbring, PhD, RN, FAAN;
Elsevier. The first edition, aligned with an interper- Kristin Bussell, MS, RN, CS-P; Patricia Harris, MS,
sonal relationship communication seminar developed APRN, NP; and Jacqueline Conrad, BS, RN, from
at the University of Maryland School of Nursing, was the University of Maryland; Ann Mabe Newman,
published 25 years ago. Developing effective commu- DSN, RN, CS and David R. Langford, RN, DSNc,
nication was important then and it remains central to from the University of North Carolina Charlotte, and
effective clinical practice in contemporary health care. Dr. Bonnie DeSimone from Dominican College of
The text was originally designed by faculty to facilitate Blauvelt. Nurses in the community: Luwana Cam-
nursing students’ understanding of therapeutic com- eron, RN; Nancy Pashby, RN; Mary Jane Joseph, RN;
munication in clinical settings, using case examples and Dr. Stephanie Wright provided valuable input
and experiential simulations. At this point in time, related to their clinical expertise. We are indebted to
professional nursing role relationships and the use of Dr. Shari Kist of the Goldfarb School of Nursing at
relational communication in health care is more com- the Barnes-Jewish College for her thoughtful revi-
plex and multi-layered. sion of Chapter 12.
The scope of content in the seventh edition reflects We acknowledge with deep gratitude the unique
a markedly different contemporary health care land- Elsevier team efforts of Melissa Rawe, Associate Con-
scape, one which is open-ended, client-activated tent Development Specialist, Jamie Randall, Content
and interdisciplinary in function and skill develop- Strategist, and Marquita Parker, Senior Project Man-
ment. The vitality of its contents reflects the com- ager-book production. Their dedicated commitment to
mitment of faculty and students from many nursing the completion of this text and expertise were notable
programs and the clinical nurses who have deepened in making the revision process for this seventh edition
the understanding of the materials presented in this a seamless and timely developmental experience.
text through their positive support, ideas, and con- Finally, we acknowledge the loving support of our
structive feedback. In particular, the voices of the families and Michael J. Boggs for their unflagging
following faculty and professional nurses have con- support and encouragement.
tributed directly and indirectly to the development
of this text: Verna Carson, PhD, RN, PCNS; Judith
vii
PREFACE
Elizabeth C. Arnold
Recognition of the importance of therapeutic com- editions, the organization of the chapters has been sig-
munication and professional relationships with clients nificantly revised based on reviewer comments. Part I,
and families as a primary means of achieving treatment Conceptual Foundations of Interpersonal Relation-
goals in health care continues to be the underlying ships and Professional Communication Skills, provides
theme in Interpersonal Relationships: Professional Com- a theory-based approach to therapeutic relationships
munication Skills for Nurses. This seventh edition has and communication in nursing practice and identi-
been thoroughly revised, rewritten, and updated to meet fies professional, legal, and ethical standards guiding
the challenge of serving as a primary communication professional actions. Chapters describe the relevance
resource for nursing students and professional nurses. of critical thinking to clinical reasoning and key link-
While maintaining the integrity of previous text ages between communication clarity and client safety
versions, the seventh edition introduces a broadened in health care situations. Part II, Essential Communi-
interprofessional perspective on communication, cation Skills, focuses on development of therapeutic
occasioned by historical transformational changes communication skills. Chapters in this second section
currently occurring in contemporary health care also address variations in communication styles, inter-
delivery. Expanded content is competency based and cultural communication diversity, and group commu-
draws from many different sources: Joint Commission nication strategies.
Standards, the Institute of Medicine (IOM) reports, Part III, Therapeutic Interpersonal Relationship Skills
QSEN, communication theory, Essentials of Bacca- begins with a chapter on the role of self-concept and
laureate Education, systems thinking and interprofes- measurable personal characteristics, as a key influ-
sional team-based communication, as advocated by encer of communication in therapeutic relationships.
AHRQ’s TeamSTEPPS program. The content, exer- The chapter on therapeutic communication presents
cises, and case examples are intentionally integrated to a structured approach to the competency skills nurses
support students in developing the interpersonal and need for effective communication in health care set-
technical communication skills required in contem- tings. Chapters on client-centered and family-centered
porary health care environments. Examples provide relationships explore basic concepts of therapeutic
students with opportunities to apply new research and communication and applications of strategies nurses
new technologies to their practice. can use with individuals and families. Bridges and bar-
Content in this text, as in previous editions’ can riers to the development and maintenance of thera-
be used as individual teaching modules, as a primary peutic relationships highlight key relational elements
text, or as a communication resource integrated across in professional interactions with clients and families.
the curriculum. New subject matter related to inter- The final chapter in Part III addresses conflict resolu-
professional team communication and nursing leader- tion strategies in nurse-client relationships.
ship reflect the latest applications of communication Part IV, Communicating to Foster Health Literacy,
in contemporary health care delivery across clinical Health Promotion, and Prevention of Disease among
settings. Knowledge and skills related to spirituality, Diverse Populations, provides students with the neces-
health literacy promotion, interdisciplinary think- sary background and communication approaches to
ing, advocacy and social responsibility are expanded effectively cope with the unique complexities of cli-
in this edition. These topics are addressed as relevant ent/family health care needs across clinical settings,
components of interprofessional and client-centered including cultural and language diversity. This section
relationships of health care. also focuses on strategies to enhance health literacy,
Although the seventh edition is divided into six the nature and scope of health teaching, and commu-
sections, using a similar format to that of previous nication with clients in stressful situations.
ix
x Preface
Part V, Accommodating Clients with Special Com- their professional communication skills in a safe learn-
munication Needs provides students with a basic ing environment. Learning exercises are designed to
understanding of the communication accommoda- encourage self-reflection about how one’s personal
tions needed by clients with specialized communica- practice fits with the larger picture of contemporary
tion needs. Specific chapters offer communication nursing, health practice models, and interdisciplin-
strategies nurses and other health providers can use ary team communication. Through active experiential
to respond effectively with children and older adults. involvement with relationship-based communication
Content on communicating with clients in crisis situ- principles, students can develop confidence and skill
ations and in palliative care complete Part V. with using patient-centered communication in real-
Contemporary nurses are living and practicing in a life team-based clinical settings. The comments and
rapidly changing collaborative interprofessional health reflections of other students provide a unique, enrich-
care environment in which they are expected to take ing perspective on the wider implications of commu-
an active leadership role. The professional health care nication in clinical practice.
landscape remains still generally uncharted and open Communication is thought of as the primary
to interpretation. medium for moving quality care in our health system
Part VI, Collaborative and Professional Communi- forward. This text gives voice to the centrality of com-
cation, proactively prepares students to develop communication as the basis for helping clients, families,
petence and self assurance as professional nurses. and communities make sense of relevant health issues
Chapters address the major behavioral elements, and develop effective ways of coping with them. Our
habits of thinking, and feeling deemed essential to hope is that the seventh edition will continue to serve
developing productive collegial working relationships as a primary reference source for nurses seeking to
within the nursing profession and interprofessionally improve their communication and relationship skills
with team members of other disciplines. Part VI dis- across traditional and nontraditional health care set-
cusses role relationships and speaks to the significance tings. As the most consistent health care provider
of nursing leadership and collaborative team commu- in many clients’ lives, the nurse bears an awesome
nication strategies. The importance of communicat- responsibility to provide communication that is pro-
ing for continuity of care, electronic documentation, fessional, honest, empathetic, and knowledgeable in
application of e-health information technologies, and a person-to-person relationship that is without equal
technology integrated applications at point of care are in health care. As nurses, we are answerable to our
also addressed. clients, our profession, and ourselves to communicate
Each chapter is designed to illuminate the con- with clients in a therapeutic manner and to advo-
nection between theory and practice by presenting cate for their health care and well-being within the
basic concepts, followed by clinical applications, using larger sociopolitical community. We invite you as stu-
updated references and instructive case examples. dents, practicing nurses, and faculty to interact with
Developing an Evidence-Based Practice boxes offer a the material in this text, learning from the content
summary of a current research article related to each and experiential exercises but also seeking your own
chapter subject and are intended to stimulate aware- truth and understanding as professional health care
ness of the essential links between research and prac- providers.
tice. The Ethical Dilemmas presented in each chapter Instructor Resources are available on the text-
offer the student an opportunity to reflect on common book’s Evolve web site. New PowerPoint presenta-
ethical situations, which occur on a regular basis in tions include audience response questions, teaching
health care relationships. New to the seventh edition tips and lecture ideas, instructor-focused exercises,
are Discussion Questions at the end of each chapter. and case studies. A revised Test Bank reflecting the
References have been chosen and suitably updated to updated content in the text is also included. Instruc-
align with the content in each chapter. tors are encouraged to contact their Elsevier sales
Experiential exercises provide students with the representative to gain access to these valuable teach-
opportunity to practice, observe, and critically evaluate ing tools.
CHAPTER 1
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. 6. Explain the role of systems thinking in contemporary
2. Describe the art and science of nursing. health care.
3. Discuss the core constructs of professional nursing’s 7. Identify issues related to health care reform.
metaparadigm. 8. Apply Institute of Medicine (IOM) recommendations as a
4. Compare and contrast different models of communication. framework for the study of relationships and communi-
5. Identify relevant theoretical frameworks used in nursing cation skills in nursing practice.
relationships. 9. Discuss implications for the future of nursing.
C hapter 1 identifies selected conceptual frameworks

relevant to the study of client-centered communi-
cation, and professional relationships in a contemporary
Over the next 150 years, nursing evolved into a rec-
ognizable highly respected profession. The discipline’s
unique body of knowledge and theoretical perspectives
health care system. Socioeconomic factors related to help define the nursing discipline, and strengthen its
health care reform and the driving forces of Institute of voice in effectively responding to the current global
Medicine (IOM) reports outline some of the changes health care crisis (Smith and McCarthy, 2010). The
required to transform the health care system. profession’s next step is to solidly position professional
nursing practice as having a key role within a larger
collaborative health care team paradigm.
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 occu-
pation 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
high-quality care, Nightingale viewed nursing as both a
science and an art form (Alligood, 2014). Nurses see clients at their most vulnerable in health situations.
2 Part 1 Conceptual Foundations of Interpersonal Relationships
to nursing practice, education, and research didn’t

THE DISCIPLINE OF NURSING really take hold until the 1950s (Alligood, 2014).
Litchfield and Jonsdottir (2008) contend that our Today, nursing frameworks serve as a contextual back-
“discipline is relational and creative in practice” (p. 79). ground for practice and research. Common conceptual
Professional nursing is a “practice” discipline, which threads enable nurses, and the general public, to have
combines specialized knowledge and skills with pru- a clearer understanding of the domain of professional
dent clinical judgment to meet client, family, and com- nursing. Theoretical constructs in nursing strengthen
munity health care needs. Donaldson and Crowley the focus of the discipline, and provide a foundation
(1978) characterize the discipline of nursing as having for generating hypotheses in research. As the profes-
a specialized perspective related to sion positions itself to play a key role in a transformed
• “Principles and laws that govern the life pro- health care system, there is a noticeable shift from the-
cesses, well-being, and optimum functioning of ory development to a new era of theory applicability
human beings, sick or well; and utilization (Alligood, 2010).
• Patterning of human behavior in interaction with Expectations for professional nursing practice in
the environment in critical life situations; and the twenty-first century are being recast within collab-
• Processes by which positive changes in health orative team care approaches rather than separated by
status are affected.” (p. 113). discipline-specific care for clients (Ritter-Teitel, 2002).
As the discipline of nursing evolved, apprentice-type Nurses are expected to pool their expertise with other
training was replaced with a higher level of nursing providers through a skilled network of team-based
education provided at the college level. Today, profes- care for the benefit of clients and their families.
sional nursing education begins at the undergraduate
level, with a growing number of nurses choosing gradu- NURSING’S METAPARADIGM
ate studies to support differentiated advanced prac- Individual nursing theories represent different inter-
tice roles and/or research opportunities. Nurses with pretations of the phenomenon of nursing, but central
advanced preparation are prepared to function as nurse constructs: person, environment, health, and nursing
practitioners, clinical specialists, administrators, and are found in all theories and models (Karnick, 2013;
educators. Today nurses represent the largest group of Marrs and Lowry, 2006). They are referred to as nurs-
health care professionals in the United States (IOM, ing’s metaparadigm. The four constructs continue
2010; Pelletier and Stichler, 2013). The scope of practice to comprise the metalanguage about the primary
for professional nurses has increased exponentially, and emphasis of nursing practice ( Jarrin, 2012).
is increasingly practiced within the context of supportive
collaborative interdisciplinary health care teams. Concept of Person
Person, is defined as the recipient of nursing care, hav-
ing unique biopsychosocial and spiritual dimensions.
THE SCIENCE OF NURSING The concept of “person” supersedes health diagnosis
Nursing theory represents the basis for science of apart from, and before a specific health care problem
nursing. Theory development is essential to main- is considered. Person factors “comprise features of the
taining the truth of any discipline (Reed and Shearer, individual that are not part of a health condition or
2007). Nursing theory emerged as a serious form of health states” (World Health Organization [WHO],
study in the 1940s and 1950s as a means to identify the 2001, p. 17). Gender, lifestyle, coping styles, habits,
unique specialized body of knowledge associated with among others, are considered person attributes. The
the discipline of nursing. The intent was to examine term is applied to individuals, family units, the com-
the phenomenon of professional nursing in systematic munity, and target populations such as the elderly or
ways as a means of clarifying its unique body of knowl- mentally ill—anyone in need of health care. In health
edge, making visible the nature of its domain, inform- care settings, and throughout this text, person may
ing clinical practice, and forming a basis for research be referred to as “patient” or “client.” The complex-
related to its practice domain. ity of “person” is a holistic concept. It is evidenced in
Nursing theories and models, used to describe, patient-centered care, “which honors patients’ pref-
explain, predict, and prescribe phenomena applicable erences, needs, and values; applies biopsychosocial
Chapter 1 Theory Based Perspectives and Contemporary Dynamics 3
perspectives… and forces a strong partnership between characteristics. WHO (1946) defines health as “a state
patient and clinician (Greene et al., 2012, p. 49). of complete physical, mental, social well-being, not
Knowledge of the “client as a person” is the start- merely the absence of disease or infirmity” (p. 3). This
ing point in health care delivery, essential to both cli- definition has not been amended to date.
ent safety and quality of care (Zolnierek, 2013). Client Nordstrom and colleagues (2013) describe the
centered care considers the impact of an illness or injury healthy person as the person who is able to “realize
on a person—not only physiologically, but mentally, his or her vital goals, not vital goals in general”
spiritually, and socially. Client preferences, perceptions, (p. 361). For example, an active 80-year-old woman
beliefs, and values, combined with clinical facts, and the can consider herself quite healthy, despite hav-
nurse’s self-awareness (personal ways of knowing) form ing osteoporosis and a controlled heart condition.
an essential understanding of each person’s unique clin- Wellness is a dimension of health, evidenced in sat-
ical situation. Protecting a client’s basic integrity and isfaction with a person’s quality of life and sense of
health rights is an ethical responsibility of nurse to cli- well-being. Health is a value-laden concept, which
ent, whether the person is a contributing member of includes both the general state of the person, and
society, a critically ill newborn, a comatose client, or a objective medical data. Culture and life experiences
seriously mentally ill individual (Shaller, 2007). influence how people think about health, well-
ness, illness and treatment implications. Health
Concept of Environment is a social concern, particularly for people who do
Environment refers to the internal and external con- not have personal control over their health, or the
text of the client, as it shapes and is affected by a cli- necessary resources to enhance their health status.
ent’s health care situation. Person and environment are Contemporary concepts of health encompass disease
so intertwined that to consider person as an isolated prevention, chronic care self-management and pro-
variable in a health care situation without considering moting healthy lifestyle behaviors, such that nurses
environmental factors acting as barriers or supports to can anticipate and respond to the needs of those at
healing is impracticable (WHO, 2001). That clients greatest risk for adverse health situations.
cannot be successfully treated apart from their envi- During the last century, most professional care was
ronments is a central thesis in Nightingale’s nursing delivered in acute care settings, based on a disease-
framework, and Martha Rogers’s Science of Unitary focused medical model. Switching to today’s com-
Human Beings. munity focus recognizes the fact that chronic medical
Environment plays a significant role in health pro- conditions account for most of today’s care, with most
motion, disease prevention, and care of individuals being treated in the community (Henley and colleagues,
with chronic conditions within the community. The 2011). The environment and health ecology has
concept of environment reflects multiple factors of emerged as an intertwined concept as health care is
cultural, developmental, and social determinants that becoming a global enterprise. In fact, health care access
influence a client’s health perceptions and behavior. is considered a social ecological determinant of health
Examples of environmental factors include poverty, (McGibbon et al., 2008).
level of education, religious or spiritual beliefs, type Healthy People 2020 (DHHS, 2010) considers
of community (rural, or urban), family strengths and quality of life to be a key outcome of disease preven-
challenges, access to resources, and level of social sup- tion, health promotion and maintenance activities.
port are examples of a client’s environmental context. Quality of life is defined as a subjective experience
Even climate, space, pollution, and food choices are of well-being and general satisfaction with one’s life
important dimensions of environment that nurses that includes, but is not limited to, physical health.
may need to consider in choosing appropriate nursing Nurses play a major role in assessing health behav-
interventions. iors, and negotiating lifestyle changes that allow
individuals and families to achieve and maintain
Concept of Health a healthy lifestyle. Exercise 1-1, The Meaning of
The word health derives from the word whole. Health Health as a Nursing Concept, provides an oppor-
is a multidimensional concept, having physical, psy- tunity to explore the multidimensional meaning of
chological, sociocultural, developmental, and spiritual health.
EXERCISE 1-1 The Meaning of Health as a Nursing Concept

Purpose: To help students understand the dimensions 4. In a larger group, share your definitions of health
of health as a nursing concept. and defining characteristics of a healthy person.
Procedure Discussion
1. Think of a person whom you think is healthy. 1. Were you surprised by any of your thoughts about
In a short report (1-2 paragraphs), identify being healthy?
characteristics that led you to your choice of 2. Did your peers define health in similar ways?
this person. 3. Based on the themes that emerged, how is health
2. In small groups of three or four, read your stories determined?
to each other. As you listen to other students’ 4. Is illness the opposite of being healthy?
stories, write down themes that you note. 5. In what ways, if any did you find concepts of health
3. Compare themes, paying attention to similarities to be culture or gender bound?
and differences, and developing a group definition 6. In what specific ways can you as a health care
of health derived from the stories. provider support the health of your client?
EXERCISE 1-2 What Is Professional Nursing?

Purpose: To help students develop an understanding 2. In small groups of three to five students, discuss
of professional nursing. findings and develop a group definition of profes-
sional nursing.
Procedure
1. Interview a professional nurse who has been in Discussion
practice for more than 12 months. Ask for descrip- 1. What does nursing mean to you?
tions of what he or she considers professional 2. Is your understanding of nursing different from
nursing to be today, in what ways he or she thinks those of the nurse(s) you interviewed?
nurses make a difference, and how the nurse feels 3. As a new nurse, how would you want to present
the role might evolve within the next 10 years. yourself?
Concept of Nursing participation in shaping health policy and in patient

Kim (2010) terms the nursing construct in nursing’s and health systems management, and education are
also key nursing roles (ICN, 2014).
metaparadigm as the practice domain of nursing. The
overarching goal of nursing activities is to empower New specialty and advanced practice roles as nurse
clients and strengthen their skill sets by providing practitioners, doctors of nursing practice, clinical nurse
them with the support they need to achieve optimal leader roles in hospitals and clinics reinforce the com-
health and well-being. Nursing actions help clients plexity of the discipline. Nurses are increasingly involved
achieve identifiable health goals through a continuum in community advocacy. They are actively shaping public
of services ranging from health promotion and health health policies and have assumed transformational roles
education, to direct care, rehabilitation, and research in practice, research, and education. Mallock (2014)
evaluation. Exercise 1-2, What Is Professional Nursing?, can help
you look at your philosophy of nursing.
The International Council of Nurses’ (ICN) definition
Finkelman and Kenner (2009) differentiate between
of nursing states:
Nursing encompasses autonomous and collaborative
the science and art of nursing, stating that, “knowledge
care of individuals of all ages, families, groups and represents the science of nursing, and caring represents
communities, sick or well and in all settings. Nurs- the art of nursing” (p. 54). Both are required for safe
ing includes the promotion of health, prevention of quality care. The science of nursing provides an essen-
illness, and the care of ill, disabled and dying people. tial knowledge base for professional nursing, but it is
Advocacy, promotion of a safe environment, research, the art of nursing that takes into account the variations
in unique client characteristics and life experiences, with clients as unique human beings. Nurses
which influence client choices in health care. may not be able to define why they intuitively
believe something is true, but they trust this
THE ART OF NURSING knowledge. They have experiential knowledge
The “art of nursing” represents a seamless interactive of their own responses, plus knowledge of pro-
process in which nurses blend their knowledge, skills, fessional experiences with other clients fac-
and scientific understandings with their individualized ing similar situations. Self-awareness provides
knowledge of each client as a unique human being with nurses with a different authentic dimension
physical, cognitive, emotional, and spiritual needs. Indi- of what it means to live through a particular
vidualized knowledge is assembled from each “nurse’s health disruption.
mode of being, knowing, and responding” to each cli- • Aesthetic ways of knowing are sometimes
ents’ unique care needs (Gramling, 2004, p. 394). Nurses referred to as the “art of nursing” because this
use classic patterns of knowing to bridge the interper- knowledge links the humanistic components
sonal space between science and client-centered needs of care with its scientific application. There is a
to individualize client-centered care (Zander, 2007). deeper appreciation of the whole person or situ-
ation, a moving beyond the superficial to see the
Patterns of Knowing experience as part of a larger whole. Esthetic
Knowledge rarely proceeds to understanding in a knowledge enables nurses to experientially know
simple direct way. In clinical practice where so many about the fear behind a client’s angry response,
dynamics are involved, a broad spectrum of knowledge the courage of a client with stage four cancer
is essential. In a seminal work, Carper (1978) main- offering her suffering up for her classmates,
tains that nurses use multiple forms of knowledge the pain of a father cutting off funds for a drug
to inform their praxis. She describes four patterns of addicted son. Aesthetic ways of knowing can be
knowing embedded in nursing practice: empirical, enhanced with storytelling, in which nurses seek
personal, aesthetic, and ethical. Although described as to understand the experience of the client’s per-
individual prototypes, Carper emphasizes that in prac- sonalized journey through illness (Leight, 2002).
tice, these patterns inform care as an integrated form • Ethical ways of knowing refer to the moral
of knowledge. Holtslander (2008) notes that “this aspects of nursing care (Altman, 2007; Porter
integrated, inclusive, and eclectic approach is reflective et al., 2011). This knowledge helps nurses provide
of the goals of nursing, which are to provide effective, principled care when confronted with moral issues
efficient, and compassionate care while considering in health care. Ethical ways of knowing encompass
individuality, context, and complexity” (p. 25). The four knowledge of what is right and wrong, attention
patterns (ways) of knowing consist of: to standards and codes in making moral choices,
• Empirical ways of knowing: knowledge that is responsibility for one’s actions, and protection of
objective and observable. Empirical knowledge the client’s autonomy and rights.
draws upon verifiable data from science. The Exercise 1-3, Patterns of Knowing in Clinical Prac-
process of empirical ways of knowing includes tice, provides practice with using patterns or ways of
logical reasoning and problem solving. Nurses knowing in clinical practice.
use empirical ways of knowing to provide scien- Chinn and Kramer (2011) introduced a fifth pat-
tific rationales when choosing appropriate nurs- tern, emancipatory ways of knowing, which includes the
ing interventions. nurse’s awareness of social problems and social justice
• Personal ways of knowing: Personal knowl- support for issues affecting health care delivery to clients
edge is “characterized as subjective, concrete and populations. The concept of emancipatory knowing
and existential” (Carper, 1978, p. 251). Personal expands the nurse’s praxis role within the larger health
knowing is relational. It is a pattern of knowing care arena. By recognizing, and acting upon the social,
about self and other, which occurs when nurses political, and economic determinants of health and well-
connect with the humanness of the client being, nurses are in a better position to act as advocates
experience. Personal knowledge develops when in helping the nation identify and reduce the inequities
nurses intuitively understand and connect in health care (Chinn and Kramer, 2011).
EXERCISE 1-3 Patterns of Knowing in Clinical Practice

Purpose: To help students understand how patterns of 5 months ago. Although her daughter lives in the area,
knowing can be used effectively in clinical practice. Mrs. Jackson has little contact with her. This distresses
her greatly, as she describes being very close with her
Procedure until 8 years ago. She feels safe in her new environ-
1. Break into smaller groups of three to four students. ment but complains that she is very lonely and is not
Identify a scribe for each student group. interested in joining activities. She has a male friend
2. Using the following case study, decide how in the complex, but recently he has been showing less
you would use empirical, personal, ethical, and interest. Her surgery is scheduled for tomorrow, but
aesthetic patterns of knowing to see that Mrs. she has not yet signed her consent form. She does not
Jackson’s holistic needs were addressed in the have advance directives.
next 48 hours.
Discussion
Case Study 1. In a large group, have each student share their
Mrs. Jackson, an 86-year-old widow, was admitted to findings.
the hospital with a hip fracture. She has very poor eye- 2. For each pattern of knowing, write the suggestions
sight because of macular degeneration and takes eye on the board.
drops for the condition. Her husband died 5 years ago, 3. Compare and contrast the findings of the different
and she subsequently moved into an assisted hous- groups.
ing development. She had to give up driving because 4. Discuss how the patterns of knowing add to an
of her eyesight and sold her car to another resident understanding of the client in this case study.
Caring As professional nurses assume broader leadership roles

The concept of caring is a characteristic of all helping in health care, caring should be embodied as a visible
professions. In nursing practice, caring is considered an component of relationships with all members of the
essential functional construct and core value of nursing health care team.
practice (Wagner and Whaite, 2010; Watson, 2005).
Caring strengthens patient-centered knowledge and
adds depth to nursing competencies that nurses bring
COMMUNICATION THEORY
to the clinical situation. Empathy serves as the connec- Effective communication with clients, families,
tive caring bridge between health providers and clients. coworkers, and other health care professionals involved
Clark (2010) describes empathetic understanding as with the care of clients is an essential foundation of
consisting of a health provider’s combined subjective effective health care. Hargie (2011) asserts, “communi-
experiencing of what it is like to be a client, an inter- cation represents the very essence of the human con-
personal understanding of what the client is currently dition” (p. 2). Communication is a human enterprise
experiencing in the moment, and an objective empathy and a fundamental underpinning of all nurse-client
related to a broader understanding of a client’s situa- interactions. Through purposeful communication, you
tion from outside the client’s frame of reference. can help clients and families make sense of their health
Crowe (2000) suggests, “Caring does not involve needs, assist them in learning how to self-manage
specific tasks, instead it involves the creation of a sus- chronic health conditions, and provide therapeutic
tained relationship with the other” (p. 966). Caring is support for decision making.
the component of care best remembered by clients and Communication takes place intrapersonally (within
nurses. In a qualitative research study, graduate nurses the self ) or interpersonally (with others). Intrapersonal
described characteristics of professional caring in their communication occurs in the form of a person’s inner
practice as (a) giving of self, (b) involved presence, thoughts and beliefs, colored by feelings that influence
(c) intuitive knowing and empathy, (d) supporting behavior. It often is a hidden component of the com-
the client’s integrity, and (e) professional competence munication process related to either nurse or client’s past
(Arnold, 1997). experience and something within the current discussion.
The American Nurses Association (ANA, 2010) Understanding of intrapersonal meanings requires self-
affirms that “the essence of nursing is caring” (p. 45). awareness and reflection as it usually is not a spoken part
of the message. In addition, seeking frequent validation BOX 1-1 Basic Assumptions of
from the receiver incorporates client feedback to improve Communication Theory
nurse/client collaboration and mutual understanding of
the message and/or the process itself. • All behavior is communication and it is impossible
Interpersonal communication is defined as a recip- to not communicate.
• Every communication has a content and a rela-
rocal, interactive, dynamic process, having value, cul-
tionship (metacommunication) aspect.
tural, emotive, and cognitive variables that influence • We only know about ourselves and others
its transmission and reception. Interpersonal commu- through communication.
nication theories are concerned with the transmission • Faulty communication results in flawed feeling
of information and with how people create meaning. and acting.
• Feedback is the only way we know that our per-
Through speech, touch, listening, and responding, peo-
ceptions about meanings are valid.
ple construct personal meanings and share them with • Silence is a form of communication.
others. Most of us take interpersonal communication • All parts of a communication system are interre-
for granted until we cannot engage in the process, or lated and affect one another.
it is no longer a part of our lives. Human interpersonal • People communicate through words (digital com-
munication) and through nonverbal behaviors and
communication is unique. Only human beings have
analog-verbal modalities; both forms are needed
large vocabularies and are capable of learning new lan- to interpret a message appropriately.
guages as a means of sharing their ideas and feelings.
(Adapted from Bateson G, 1979 Mind and nature Dutton: New York;
Relational communication is an important source of Watzlawick P, Beavin-Bavelas J, Jackson D (1967) Some tentative axi-
personal expression and influence. Included in the con- oms of communication. In Pragmatics of Human Communication—
cept are language, gestures, body movements, eye con- A Study of Interactional Patterns, Pathologies and Paradoxes,
pp. 29–52. New York, W. W. Norton.)
tact, and personal or cultural symbols. People combine
words and nonverbal signals into a montage to convey
intended meaning, exchange or strengthen ideas and level and to communicate downward to coworkers for
feelings, and to share significant life experiences. whom the person is responsible.
Communication has both content and relationship
dimensions (Watzlawick et al., 1967). The content LINEAR MODELS
dimension of communication (verbal component) The linear model is the simplest communication
refers to shared verbal, written, or digitally delivered model, consisting of sender, message, receiver, and
data. The relationship dimension (expressed nonver- context. Linear models identify the process of com-
bally through metacommunication) helps the receiver munication focus only on the sending and receipt of
interpret the meaning of the message. People tend to messages, and do not necessarily consider commu-
pay more attention to nonverbal communication than nication as enabling the development of cocreated
to words especially when they are not congruent with meanings between communicators.
each other. Basic assumptions related to the concept of • The sender is the source, or initiator of the mes-
communication are presented in Box 1-1. sage. The sender encodes the message (i.e., puts
Channels of communication is the term used the message into verbal or nonverbal symbols that
to designate one or more of the connectors through the receiver can understand). Encoding a message
which a person receives a message. Primary channels appropriately requires a clear understanding of the
of human communication include the five senses: receiver’s mental frame of reference (e.g., feelings,
sight, hearing, taste, touch, and smell. Technology has personal agendas, past experiences). Therapeutic
introduced secondary channels of communication in communication requires that the helping person
the form of media messaging. as sender has a health-related purpose.
In professional business settings, the term has • The message consists of the transmitted verbal
a different connotation. Channels of communica- or nonverbal expression of thoughts and feel-
tion describe the hierarchy of reporting relationships ings. Effective messages are relevant, authentic,
individuals need to respect when communicating and expressed in understandable language.
with coworkers and authority figures. Each person is • The receiver is the recipient of the message.
expected to answer to the person at the next higher The receiver needs to be open to hearing what
the sender is saying. Once received, the receiver “noise” factor can compromise successful interper-
decodes the message and internally interprets its sonal communication.
meaning to make personal sense of the message.)
An open listening attitude and suspension of TRANSACTIONAL MODELS OF COMMUNICATION
judgment strengthens the possibility of accurately Transactional models expand the nature of linear mod-
decoding a sender’s message. els by including internal forms in the context of the
The context of the interaction refers to all the communication, feedback loops, and validation. These
factors that influence how a message is received. models employ systems concepts in that the human
The most critical variable is the presence of noise, system (client) receives information from the environ-
which is defined as anything that interferes with the ment (input), internally processes the received data,
effective transmission, reception, or understanding and interprets its meaning (throughput). The result is
of a message. “Noise” is a concept found in both new information or behavior (output). Feedback loops
linear and transactional models. Linear models (from the receiver or the environment) validate the
only consider external phenomena. Physical noise information or allow the human system to correct its
occurs in the form of environmental distractors original information. In doing so, transactional models
such as people talking loudly, babies crying, chil- draw attention to communication as having purpose,
dren running around, music or TV playing, exces- and meaning making attributes. Figure 1-1 shows the
sive room temperature, poor seating, and lack of components of transactional models.
privacy. In transactional models, noise also includes Transactional models conceptualize interpersonal
internal interference factors. Physiological noise communication as a reciprocal interaction in which
includes internal distractors such as feeling tired, sender and receiver influence each other as they con-
anxious, angry, worried, or being too sick to fully verse. Each person constructs a mental picture of the
attend to the message. Psychological noise refers to other, including perceptions of the other person’s atti-
a preconceived bias about the speaker or listener, tude and possible reaction to the message. Individual
differences in role status, ethnic or cultural differ- perceptions influence the transmission of the message
ences that influence transmission of messages, and and its meaning to one or both of the communicators.
how they are received. Semantic noise is concerned Because the sender and receiver communicate at the
with the use of uncommon abstract words, not easily same time, the conversation becomes a richer process
understood by one of the communicators. Even one and more than the sum of its parts.
Situational contextual inputs

a. Distracting stimuli b. Interpersonal space c. Timing
Channels of communication
Vocal, visual, kinesic,
taste, smell
Feedback loops
Interpersonal personal contextual concepts

a. Role relationships
b. Level of experience Knowledge, previous experience,
c. Other team and family inputs culture, internal frame of reference,
Knowledge, goals, culture, values,
communication abilities, set factors, values, set factors
internal reference
Figure 1-1 Transactional model of communication.

Transactional models capture the importance of respect, helpful genuineness, and concreteness—are
interpersonal engagement in verbal and nonverbal discussed in Chapters 5, 6 and 10.
communication. They reflect the development of col-
laborative meanings, which are cocreated from the FRAMEWORKS USED IN THERAPEUTIC
symbolic exchanges between the communicators. Role RELATIONSHIPS
relationships between communicators can influence Commonly used frameworks used in professional nurs-
communication. Often role relationships are uncon- ing relationships include Erikson’s psychosocial devel-
sciously acted on, without taking their nature or impli- opment theory, Maslow’s basic human needs model,
cations for successful communication into account. Peplau’s psychosocial relationship nursing theory, gen-
Lack of awareness can compromise the effect of impor- eral systems theory, and communication models.
tant messages. Exercise 1-4, Comparing Linear and
Transactional Models of Communication, provides Developmental Theory
an opportunity to contrast the efficacy of linear versus Erik Erikson’s theory of psychosocial development is
transactional models. considered an important conceptual framework for
People take either symmetric or complementary understanding human personal development (Erikson,
roles in communicating. Symmetric role relationships 1950). Erikson’s model represents one of the most solid
are equal, whereas complementary role relationships theories of psychosocial development across the life span.
typically operate with one person holding a higher Nurses use this framework to assess developmental
position than the other in the communication process. client needs and to design developmentally age-appropriate
Nurses assume a complementary role of clinical expert nursing interventions.
available for information and consultation to achieve According to Erikson, human development occurs
mutually determined health goals, and a symmetric role in universally defined sequential maturity stages. Each
in working with the client as partner on developing stage builds on the previous stage and requires a higher
mutually defined goals and the means to achieve them. level of expected psychosocial competence. A person
experiences each new set of expectations in the form
THERAPEUTIC COMMUNICATION of a psychosocial crisis. Confronting and successfully
Therapeutic communication is a term originally coined mastering tensions associated with each develop-
by Ruesch (1961) to describe a goal-directed form of mental psychosocial crisis, helps a person develop an
communication used in health care to achieve goals associated ego strength. Failure to mature psychoso-
that promote client health and well-being. Doheny cially results in a core weakness or pathology. Erikson
and colleagues (2007) observed that “when certain identifies the first four stages of ego identity as build-
skills are used to facilitate communication between ing blocks for ego identity, which he considers the
nurse and client in a goal directed manner, the thera- keystone of psychosocial development. The last three
peutic communication process occurs” (p. 5). Core developmental stages help refine the ego identity in
dimensions of therapeutic communication—empathy, the adult segment of the life cycle.
EXERCISE 1-4 Comparing Linear and Transactional Models of Communication

Purpose: To help students see the difference between Discussion
linear and circular models of communication. 1. Was there a difference in your level of comfort? If
so, in what ways?
Procedure 2. Was there any difference in the amount of informa-
1. Role-play a scenario in which one person provides tion you had as a result of the communication? If
a scene that might occur in the clinical area using a so, in what ways?
linear model: sender, message, and receiver. 3. What implications does this exercise have for your
2. Role-play the same scenario using a circular model, future nursing practice?
framing questions that recognize the context
of the message and its potential impact on the
receiver, and provide feedback.
Spiritual distress, anxiety,

Self- hopelessness,
Actualization ineffective role performance
Powerlessness Self-esteem: chronic low,

Self-Esteem situational low
Social isolation, Family coping:

ineffective community coping
Love and Belonging compromised, disabling
Health/home Therapeutic regimen,
maintenance, impaired
Safety and Security ineffective management
Physiological Needs
Ventilation, impaired spontaneous;

deficient fluid volume
Figure 1-2 Nursing Diagnosis Categories corresponding with Maslow’s hierarchy of needs.
Life circumstances, culture, and timing can affect As essential needs are satisfied, people move into higher
age-related psychosocial ego development, such that it psychosocial areas of development. Maslow defines
progresses at a faster or slower pace, and the behaviors basic (deficiency) needs as those required for human
indicating psychosocial competence may differ. survival. First-level basic physiological needs include
hunger, thirst, sexual appetites, and sensory stimula-
Peplau’s Interpersonal Relationship Model tion. Maslow’s second level, safety and security needs,
Hildegard Peplau (1952, 1997) offers the best-known includes both physical safety and emotional security,
nursing model for the study of interpersonal relation- for example, financial safety, freedom from injury, safe
ships in health care. Her model describes how the neighborhood, and freedom from abuse.
nurse-client relationship can facilitate the identifi- Satisfaction of basic deficiency needs allows for
cation and accomplishment of therapeutic goals to attention to growth needs, which Maslow termed love
enhance client and family well-being (see Chapter 10). and belonging needs, followed by self-esteem needs.
In contemporary practice, Peplau’s framework is more Love and belonging needs relate to emotionally expe-
applicable today with long term relationships in reha- riencing being a part of a family, and/or community.
bilitation centers, long-term care, and nursing homes. Self-esteem needs refer to a person’s need for recogni-
Despite the brevity of the alliances in acute care set- tion and appreciation. A sense of dignity, respect, and
tings, basic principles of being a participant-observer approval by others for oneself is the hallmark of suc-
in the relationship, building rapport, developing a cessfully meeting self-esteem needs.
working partnership, and terminating a relationship Maslow’s highest level of need satisfaction, self-
remain relevant. actualization, refers to a person’s need to achieve his
or her maximum potential. Self-actualized individuals
Basic Needs Theory are not superhuman; they are subject to the same feel-
The ICN declares, “human needs guide the work of ings of insecurity that all individuals experience, but
nursing” (2010). Abraham Maslow’s needs theory they recognize and accept their vulnerability as part of
(1970) is a framework that nurses use to prioritize the human condition. Not everyone reaches Maslow’s
client needs, and develop relevant nursing approaches self-actualization stage.
(see Chapters 2 and 10). Maslow’s model proposes that Figure 1-2 shows Maslow’s model as a pyramid,
people are motivated to meet their needs in an ascend- with need requirements occurring in ascending fashion
ing order beginning with meeting basic survival needs. from basic survival needs through self-actualization.
EXERCISE 1-5 Maslow’s Hierarchy of Needs

Purpose: To help students understand the usefulness 3. Share examples with the larger group and dis-
of Maslow’s theory in clinical practice. cuss the concept of prioritization of needs using
Maslow’s hierarchy.
Procedure
1. Divide the class into small groups, with each group Discussion
assigned to a step of Maslow’s hierarchy. Each 1. In what ways is Maslow’s hierarchy helpful to the
group will then brainstorm examples of that need nurse in prioritizing client needs?
as it might present in clinical practice. 2. What limitations do you see with the theory?
2. Identify potential responses from the nurse that
might address each need.
Nurses use Maslow’s theory to prioritize nursing parts of the system contribute to its overall functioning
interventions. Exercise 1-5 provides practice with at macro and micro levels. New skills and competencies
using Maslow’s model in clinical practice. introduced into nursing contemporary curriculums are
based on systems approaches to help nurses collabo-
rate effectively with other disciplines having different
APPLICATIONS agendas and priorities to achieve common goals. Frenk
and colleagues (2010) suggest that “the core space of
GENERAL SYSTEMS THEORY every health system is occupied by the unique encoun-
A systems framework forms the contextual under- ter between one set of people who need services and
pinning for the study of contemporary professional another who have been entrusted to deliver them”
nursing in the United States. Beginning with the idea (p. 7). Note that patient/client is represented as the
that each person is “different from and greater than core of the health care system diagram in Figure 1-3.
the sum of his or her parts (Chinn and Kramer, 2011, A GST approach highlights the interdependence
p. 47), a systems framework provides a solid foundation among all parts of a system and confirms how each
for understanding the nature of communication and part supports the system as a functional, ordered
group dynamics. From a systems perspective, everything whole. Berkes and colleagues (2003) state that GST,
within the health care system is interrelated and inter- “emphasizes connectedness, context and feedback,
dependent (Porter O’Grady and Malloch, 2014). Col- a key concept that refers to the result of any behav-
laboration and teamwork provider relationships, family ior that may reinforce (positive feedback) or modify
relationships, continuity of care, and newly redefined (negative feedback) subsequent behavior” (p. 5).
system linkages between education, service, and research In Figure 1-3, notice the outermost system ring
are best interpreted within a systems framework. The relates to regulatory bodies. This relates to care deliv-
WHO has defined a health system as “all organizations, ered by integrated care facilities, which are subject to
people and actions whose primary intent is to promote, significant government regulation and joint commis-
restore or maintain health” (WHO, 2007, p. 2). sion oversight. Health care systems are viewed as inte-
General systems theory (GST), initially described by grated wholes whose properties cannot be effectively
Ludwig von Bertalanffy (1968), focuses on process and reduced to a single unit (Porter O’ Grady and Malloch,
the interconnected relationships comprising the “whole.” 2014.) The interacting parts work together to achieve
Over the years, systems thinking has been transformed important goals. Only by looking at the whole picture
into a “meta-language which can be used to talk about can one fully appreciate its meaning of how its indi-
the subject matter of many different fields (Checkland, vidual parts work together. How health providers use
1999). Even our bodily functions depend on an under- collaborative and networking skills to achieve clinical
standing of the interrelationships among body systems. outcomes become the measure of competence from a
Adaptive system models help health professionals systems perspective. There is a contemporary emphasis
understand how the interrelationships among different on interrelationships, and behavioral patterns within
ISSUES RELATED TO HEALTH CARE REFORM

Creasia and Frieberg (2011) note that, historically sig-
nificant changes in nursing and nursing education are
PATIENT linked to socioeconomic factors and nursing issues. Pro-
fessional nursing is practiced today in an unprecedented
CARE TEAM era of shifting health care environments, momentous
Frontline care providers
(health care professionals, family
advances in health science, and unparalleled evolving
members, and others) technologies. Socioeconomic issues, such as the dra-
matic growth in health care options, population demo-
graphics, serious nursing, and physician shortages, the
economics of health care, and documented concerns
ORGANIZATION
Infrastructure/resources about safety and quality in health care, have prompted
(hospitals, clinics, nursing, a fast-moving mandate to transform the current health
homes, etc.)
care system. Most health care is delivered in commu-
ENVIRONMENT nity-based primary care settings with an emphasis on
Regulatory, market, and policy framework
(public and private regulators, insurers, prevention and support for self-management of chronic
health care purchasers, research health conditions. In 2000, the Pew Health Professions
funders, et al.)
Report identified 21 competencies needed to reframe
Figure 1-3 Conceptual drawing of a four-level health care nursing practice for a new century (Bellack and O’Neil,
system, with the client (patient) as its core concept. (From Reid 2000). These competencies are identified in Box 1-2.
PP, Compton WD, Grossman JH, et al., editors, for the Com- Nurses are expected to have knowledge about and
mittee on Engineering and the Health Care System, National apply a variety of paradigms to real-life situations in
Academy of Engineering, Institute of Medicine. Building a
clinical practice. Client roles have evolved from being
better delivery system: a new engineering/health care part-
nership. Washington, DC, 2005, National Academies Press, passive recipients of health care into active autono-
p. 20. Available at http://www.nap.edu/catalog/11378.html.) mous partners with providers. Shared authority over
decision making, and multiple perspectives in health
care management across a continuum of care that
the organizational system. Porter O’Grady and Malloch extends into the community is the new norm.
observe “to the extent that the balance and harmony are In 2010, the Patient Protection and Affordable
sustained, the organization’s life is advanced.” (p. 15). Care Act (PPACA) was signed into federal law. This
System boundaries separate the system from the law ushers in the most significant change to the U.S.
environment. Boundaries are arbitrary parameters, health care system since the establishment of Medi-
which distinguish what belongs with the system, and care in 1965 (Kaiser Permanente, 2013). U.S. citizens
what lies outside of it. The environment consists of any- and legal immigrants will be required to have a basic
thing that affects system functioning, but it is not part level of health care insurance.
of the system. Each system is separated by boundaries, Nurse practitioners (NPs), physicians, and physician
which control the exchange of information, energy, and assistants will continue to be the principal providers
resources into and out of the system. Flexible boundaries of primary care in the United States, and the need for
allow new information to flow in and out of the system, continuity of care through collaborative team work
whereas rigid boundaries do not. A system with flexible will become even more important. To adequately dress
boundaries is termed an open system. A closed system increased expectations for skilled health care, special
has rigid boundaries; not much crosses its boundaries. attention to the role of nurses, particularly advanced
Outcomes are referred to as output. Any changes in the practice registered nurses (APRNs) becomes critical.
system will influence the outcome or output. Feedback Managed care, the emergence of transdisciplinary
loops (what others from the environment say about the professional roles as the preferred model of provider ser-
process) inform the system of changes needed for input vice delivery, public reporting of clinical outcomes, and
so as to achieve more effective outcomes. For example, inclusion of client quality of life and satisfaction with
a client’s response to a treatment offers feedback on care are now expected clinical outcomes. Table 1-1 iden-
whether to change a medication, or continue with it. tifies seven conditions and their evolutionary correlates
BOX 1-2 Pew Commission’s Recommendations to Nursing Programs: 21 Nursing

Competencies Needed for the Twenty-First Century
1. Embrace a personal ethic of social responsibility 11. Practice relationship-centered care with individu-
and service. als and families.
2. Exhibit ethical behavior in all professional 12. Provide culturally sensitive care to a diverse society.
activities. 13. Partner with communities in health care decisions.
3. Provide evidence-based, clinically competent 14. Use communication and information technology
care. effectively and appropriately.
4. Incorporate the multiple determinants of health in 15. Work in interdisciplinary teams.
clinical care. 16. Ensure care that balances individual, professional,
5. Apply knowledge of the new sciences. system, and societal needs.
6. Demonstrate critical thinking, reflection, and 17. Practice leadership.
problem-solving skills. 18. Take responsibility for quality of care and health
7. Understand the role of primary care. outcomes at all levels.
8. Rigorously practice preventive health care. 19. Contribute to continuous improvement of the
9. Integrate population-based care and services into health care system.
practice. 20. Advocate for public policy that promotes and
10. Improve access to health care for those with protects the health of the public.
unmet health needs. 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.
TABLE 1-1 Criteria for Survival of the Nursing Profession Based on Evolutionary Principles
Criteria or Condition Evolutionary Principle
Nursing needs to be In nature, an organism will survive only if it occupies a niche, that is, performs a specific
relevant. role that is needed in its environment.
Nursing must be In every environment, there is a limited amount of resources. Organisms that are more
accountable. efficient and use the available resources more effectively are much more likely to be
selected by the environment.
Nursing needs to In nature, an organism will survive only if it is unique. If it ceases to be so, it is in danger
retain its uniqueness of losing its niche or role in the environment. In other words, it might lose out if the new
while functioning in species is slightly better adapted to the role, or if physically similar enough, it might
a multidisciplinary even breed with that species and thus completely lose its identity. Successful organisms
setting. must also learn to coexist with many different species so that their role complements
that of the other organisms.
Nursing needs to be In nature, organisms often are required to defend their niche and their territory usually
visible. by an outward display that allows other similar species to be aware of their presence.
By being “visible,” similar species can avoid direct conflict. 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.
Nursing needs to have In nature, if a species is to survive, it must make its presence felt not just to its immedi-
a global impact. ate 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.
Nurses need to be In evolution, the organisms that survive are, more often than not, innovators that have the
innovators. flexibility to come up with new and different solutions to rapid changes in environmental
conditions.
Nurses need to be During evolution, when new niches open up, it is never possible for more than one
both exceptionally species to occupy one niche. Only the best adapted and most competent among
competent and strive the competing organisms will survive; all others, even if only slightly less competent,
for excellence. 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.
needed to secure a key player role for nurses in the new

health care delivery system. Living with Getting
Porter O’Grady and Malloch (2014) refer to today’s illness/ better
disability acute
health care system as being radically transformed with chronic care
new nonlinear and socially transformational realities. care
The context of professional interpersonal relationships Cross cutting
in nursing and health care includes broader interconnec- systems
interventions
tions with other clinicians, health care decision makers,
and other policy makers. Health care decision makers Coping with Staying
include the client as a key agent. The IOM recom- end of life healthy
mendations described in the following section call for palliative preventive
care care
a systems-based team-care environment across clinical
settings and collaborative teamwork across disciplines
as the best means of reducing health disparities and Figure 1-4 Priority Areas for National Action. Four stages
of life and health are described in the four circles, connected
promoting safe quality care. Communication skills and by the need for coordination across time and health care.
the development of stronger collaborative team-based (From Adams K, Corrigan JM, editors, for the Committee on
professional interpersonal relationships will be key to Identifying Areas for Quality Improvement, Board on Health
integrating these competencies in health care delivery. Care Services, Institute of Medicine. Priority areas for national
action: transforming health care quality. Washington, DC,
2003, National Academies Press.)
IMPACT OF INSTITUTE OF MEDICINE REPORT
RECOMMENDATIONS
A series of IOM reports serve as a major force in driv- relevant to nursing and transformation in health care
ing and shaping the sweeping changes occurring in the are presented in Table 1-2.
health care delivery system nationally and globally. The IOM recommendations have been endorsed by
overarching goals of these efforts relate to the American Association of Colleges of Nursing,
1. Improving the patient’s (client’s) experience National State Boards of Nursing, and the American
of care Nurses Association. These reports serve as a dynamic
2. Improving the health of individuals and foundation for aligning interprofessional competency
populations domains with contextualized individual professional
3. Reducing the per capita cost of health care circumstances in professional education (Interprofes-
Over the past decade, a dramatic paradigm shift sional Education Collaborative Expert Panel, 2011).
has emerged beginning with the publication of two Expanded curriculum development is deemed
IOM reports detailing serious quality and safety essential to reforming the health care system. Frenk
problems with health care delivery in the United and colleagues (2010) describes the need to approach
States, and calling for radical change. Four priori- interdisciplinary education using “a global out-
ties for national action were identified as depicted in look, a multiprofessional perspective, and a systems
Figure 1-4. approach” (p. 5).
An initial IOM report, To Err Is Human (2000) The IOM report Health Professions Education: A
drew attention to serious lapses in safety and quality Bridge to Quality (2003) calls for the restructuring of
in health care. A second report, Crossing the Quality clinical education responsive to the twenty-first cen-
Chasm, called for an innovative transformed health tury health system transformation goals of providing
care system that is evidence-based, patient-centered, the highest quality and safest medical care possible.
and systems oriented. It identified expected quality This report identified five core areas of competency,
performance goals: effectiveness, timeliness, patient- required to cross the bridge to quality:
centeredness, efficiency, and equity (IOM, 2001). The • Delivering patient-centered care
goals place clients at the center of the health care team. • Working as part of interdisciplinary teams
Subsequent IOM reports advocate an integrated inter- • Practicing evidence-based medicine
disciplinary team approach, with shared accountability • Focusing on quality improvement
for outcomes, as the preferred delivery system. Reports • 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
Institute of Medicine Report Identified Goals
2000: To err is human: building • Establish a national focus to enhance knowledge base of safety.
a safer health system • Develop a public mandatory reporting system to identify and learn
from errors.
• Implement safety systems to ensure safe practices at the delivery level.
• Raise performance standards and expectations for safety improvement.
2003: Health professions Competency in:
education: a bridge to quality • Delivering patient-centered care,
• Working as part of interdisciplinary teams,
• Practicing evidence-based medicine,
• Focusing on quality improvement and
• Using information technology.
2009: Redesigning continuing • Bring together health professionals from different disciplines in tailored
education in the health learning environments.
professions • Replace the current culture of continuing education (CE) with a new vision
of professional development.
• Establish a national interprofessional CE institute to foster improvements.
2010: The future of nursing: • Practice at the full extent of their education and training
leading change, advancing • Achievement of higher levels of education and training through an
health improved education system that promotes seamless academic progression
• Full partnership with physicians and other health professionals in redesign-
ing health care in the United States
• Better data collection and improved information infrastructure regarding
workforce planning and policy making
• Remove scope of practice barriers
2010: Healthy People 2020 1. Attain high-quality, longer lives free of preventable disease, disability,
(www.healthypeople.gov) injury, and premature death.
2. Achieve health equity, eliminate disparities, and improve the health of all
groups.
3. Create social and physical environments that promote good health for all.
4. Promote quality of life, healthy development, and healthy behaviors across
all life stages.
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 con- patient preferences, needs, and values” (2001). Patient-
ceptual underpinnings for communication and inter- centered approaches view the client as a primary
personal relationships in professional nursing practice source of influence and core decision maker on the
are discussed and integrated throughout the text. These health care team. Nurses are charged with understand-
are briefly described in the following sections. ing and anticipating client needs rather than simply
interacting with presenting health care circumstances.
Delivering Client-Centered Care Carl Rogers’ person-centered relationship model
Whereas client-centered care is now mandated as an (1946) offers a conceptual basis for studying “client/
essential characteristic of contemporary health care patient-centered” care. Rogers believed that support
delivery, it is a core value that nursing has always cham- for the individual integrity and self-responsibility
pioned. The IOM defines patient-centered care as of each client in an empathetic, accepting relation-
“care that is respectful of and responsive to individual ship empowered clients to become self-directed and
develop new skills. He pointed to the primacy of the study of interdisciplinary collaboration. Each collab-
client as the most important source of knowledge, and orative team takes collective ownership of treatment
a fundamental agent of healing. He described the cli- goals, determines the professional activities needed to
ent/health provider relationship as an equal partner- achieve them, and has ongoing reflective communica-
ship. Rogers believed that “the constructive forces in tion about their process. Personal characteristics and
the individual can be trusted, and that the more deeply the professional makeup of the team, the team’s struc-
they are relied upon, the more deeply they are released” tural characteristics, and its level of experience with
(Rogers, 1946, p. 418). Learning about the client’s val- interdisciplinary collaborative approaches influence
ues, preferences, and perceptions related to the client’s collaborative effectiveness (Bronstein, 2003). A multi-
health care situation are critical dimensions of contem- dimensional construct, defines “client,” individually, or
porary client-centered relationships (see Chapter 10). broadly as its core, and as an integral decision maker
Client-centered care requires that scientific guide- on the health care team.
lines be balanced with values-based nursing knowl- Interprofessional collaboration requires communi-
edge. Frist (2005) asserted that the focus of the cation and relationship skills that nurses can only be
twenty-first-century health care system must ensure taught with interdisciplinary curriculum exposures
that clients have access to the safest and highest- involving more than one discipline (Bjorke and Haavie,
quality care, regardless of how much they earn, where 2006). Applications of interdisciplinary collabora-
they live, how sick they are, or the color of their skin tion involve a socialization process that ideally begins
(p. 468). early in the student’s professional education. Students
develop broader habits of inquiry and a comprehensive
WORKING AS PART OF INTERDISCIPLINARY TEAMS understanding of how to work with other professional
Health care reform calls for collaborative interdisci- disciplines productively. They learn firsthand about the
plinary teams of health care professionals, rather single value of a collective systems approach to diagnosis and
practitioners assuming responsibility for the health treatment in a time of diminishing resources.
care of clients (Batalden et al., 2006; IOM, 2003). The
concept of collaboration is based on the premise that PRACTICING EVIDENCE-BASED NURSING
no single health care discipline can provide complete The scope of practice and nature of work for contem-
care for clients with multiple health and social care porary nurses has become multidimensional, multire-
needs. lational, and highly complex. Practicing evidence based
Interprofessional care teams are peopled by highly nursing (EBP) is every nurse’s responsibility. What this
skilled professionals working together with a client for means is that nurses should conscientiously keep up to
the common purpose of improving a client’s health date with the latest research and any published prac-
status. Professional team providers have complemen- tice guidelines relevant to guiding their nursing prac-
tary interdependent professional roles supported by tice (Rycroft-Malone et al., 2004). Applications for
mutual respect and power sharing. Collaborative health magnet status (Chapter 22) require proof of evidence-
care efforts represent a non-hierarchal system of care based practice. The strength of EBP lies in the blend-
delivery. Care coordination, and making connections ing of extensive clinical experience with sound clinical
between multiple care providers is viewed as an essential research and professional judgment in real-time client
component of collaboration (Craig et al., 2011). situations. EBP provides the foundational knowledge
Recommendations from the IOM Report: Health and facilitates the self-confidence new nurses need
Professions Education: A Bridge to Quality (2003) led to to interact effectively on interdisciplinary health care
the Quality and Safety Education for Nurses (QSEN) teams (Pfaff, et al., 2013). The collective wisdom of
initiative (Cronenwett et al., 2007) discussed in Chap- EBP is dynamically related to nursing theory through
ter 2, and integrated throughout the text. QSEN com- empirical ways of knowing. The concept of EBP con-
petencies provide a solid conceptual framework for sists of four elements:
professional nursing education curriculums at all levels, 1. Best practices, derived from consensus statements
and for clinical practice. developed by expert clinicians and researchers
Bronstein’s model is a frequently used conceptual 2. Evidence from scientific findings in research-based
framework (Kilgore and Langford, 2010) for the studies found in published journals
3. Clinical nursing expertise of professional nurses, families, researchers, payers, planners and educators—to
including knowledge of pathophysiology, phar- make the changes that will lead to better patient outcomes
macology, and psychology (health), better system performance (care) and better pro-
4. Preferences and values of clients and family mem- fessional development” (p. 2). Quality improvement (QI)
bers (Sigma Theta Tau International, 2003) is the responsibility of everyone in the organizational sys-
tem, including clients. QI processes provide a measurable
Developing an Evidence-Based Practice systematic way to ensure that the goals of care are
• Appropriate: for the client, and care requirements
Stans S, Stevens A, Beurskens J. Interprofessional
• Adequate: to meet clinical requirements and cli-
practice in primary care: development of a tailored
process model. J Multi Health Care. 6:139-147, ent needs, including level of resources and skill
2013. mix of providers.
• Effective: care meets or exceed established stan-
Background: This qualitative study investigated dards of care
interprofessional practice in a primary care setting,
• Efficient: in terms of cost and time
using the domains of the chronic care model as a
framework. A target intervention consisting of three Although the defining purpose of QI is health
steps described targets for improvement for chil- improvement, an essential component is identifying the
dren with complex care needs, identified barriers resources to make care delivery an equitable reality for
and facilitators influencing interprofessional practice, all (WHO, 2000). QI processes require that each orga-
and developed a tailored interprofessional process
nizational system, together with all of its stakeholders,
model.
develop a quality philosophy that matches the unique
Methodology: A qualitative methodology con- needs of the organization. Competency domains act as
sisting of 13 semistructured interviews with the chil- flexible practice guidelines, which are applicable across
dren’s parents and professionals involved in the care professions (Interprofessional Expert Panel, 2011).
of the children. Data were analyzed using direct con-
tent analysis. This step led to the development of a
project group that formulated an interprofessional
USING INFORMATICS
process through process mapping. The world from an interpersonal communication per-
spective is much different than it was even a decade
Findings: The most significant barrier to imple- ago—smaller and substantively better connected
menting the interprofessional practice related to
through technology. Smith and Wilson, (2010) note,
the lack of structure in the care process and know-
ing what should be involved in the process in inter- “interpersonal relationships can be initiated, escalated,
professional practice. Study participants expressed maintained, and dissolved either wholly, or in part,
the need to have structured communication through through mediated technology” (p. 14). Digital commu-
face-to-face meetings, and an electronic clinical infor- nication greatly expands interpersonal and professional
mation system.
communication, but a word of caution is needed. Tex-
Application to Your Clinical Practice: Regular ting, Instagrams, and e-mails do not allow the receiver
multidisciplinary meetings, structured communica- to see facial expressions, hear the tonality of a message,
tion, and a defined system for division of tasks—“who or readily interpret an emotionally charged commu-
does what” and “when” is essential for successful nication. Clarity and conciseness are essential, and all
team process.
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
FOCUSING ON QUALITY IMPROVEMENT mechanism as presented earlier (particularly in remote
Quality improvement in nursing historically began areas, where there is a scarcity of health care providers),
with Florence Nightingale’s use of morbidity and mor- and as a way to track clinical data. Two important out-
tality statistics to improve the quality of care during comes are reduction of health costs and access to care
the Crimean War (Sousa and Corning-Davis, 2013). (Peck, 2005; Cipriano and Murphy, 2011).
Batalden and Davidoff (2007) define quality improve- The following case example represents a “virtual”
ment (QI) as “the combined and unceasing efforts of application of communication through technology
everyone—healthcare professionals, patients and their from the perspective of a Canadian nurse caring for a
client in a remote area as it might occur in contempo- collaboration and decision-making. High quality tech-
rary practice. The video system used in the case study nology can empower client self-management, and
has a monitoring device on both ends, with voice acti- improve health outcomes (Wagner et al., 2010). Con-
vation. The personalized contact allows clients and versely, technology can contribute to dehumanization
caregivers to communicate directly with each other in health care delivery. It is only as useful as the abil-
from distant locations. ity of the people who control its use and the quality
of information that is collected and shared. The client,
Case Example not the information alone, should be the primary focus
The computer gently hums to life as community health directing care.
nurse Rachel Muhammat logs into Nursenet. She asks a The general public routinely uses computers and
research partner, a cyberware specialist in London, Eng- technical devices to access health-related information.
land, for the results from a trial on neurologic side effects Health care providers use the Internet to collaborate
of ocular biochips. Rachel, as part of a 61-member team about research, and to seek consultation about the
in 23 countries, is studying six clients with the chips. Then management of care delivery, referrals, and sharing of
it is down to local business. Rachel e-mails information
other health-related information and concerns. Secured
on air contaminant syndrome to a client down the street
Web portals that meet the Health Insurance Portabil-
whose son is susceptible to the condition and tells her
about a support group in Philadelphia. She contacts a ity and Accountability Act (HIPAA) requirements are
qigong specialist to see if he can teach the boy breath- customized to meet the information needs of, or about,
ing exercises and schedules an appointment with an designated groups of people (Moody, 2005). Tech-
environmental nurse specialist. Moments before her 9:45 nology enhances the potential for global health care.
appointment, Rachel gets into her El-van and programs Health experts in geographically distant areas through-
it to an address 2 kilometers away. Her client, Mr. Chan, out the world can share information and draw impor-
lost both legs in a subway accident and needs to be pre- tant conclusions about health care issues in real time.
pared for a bionic double-leg transplant. Together, they Technology is routinely and extensively used in
assess his needs and put together a team of health work- nursing education. Use of high-fidelity simulations
ers, including a surgeon, physical therapist, acupuncturist,
help nurse educators and students develop critical
and home care helpers. She talks to him about the trans-
plant, and they hook up to his virtual reality computer to
thinking and collaborative management skills in a safe,
see and talk to another client who underwent the same realistic environment. Students receive feedback from
procedure. Before leaving, Mr. Chan grasps her hand and the “simulated” patient. Simulations allow students
thanks her for helping him. Rachel hugs him and urges from different health disciplines to share methods of
him to e-mail her if he has any more questions (Sibbald, reasoning, situational awareness, shared language, and
1995, p. 33 [quoted in Clark, 2000]). behaviors in different clinical scenarios. As students
communicate, and jointly explain their thinking pro-
Technology advances provide nurses with new capa- cesses about the clinical scenario, they develop a shared
bilities for transmission of data within and between cognition that is more comprehensive than what could
care settings. Electronic records and communication be attained by a single discipline focus.
technologies have revolutionized the way health infor-
mation is processed (Cipriano and Murphy, 2011).
Virtually every major health care system has switched
THE FUTURE OF NURSING
to electronic medical record (EMR) keeping and bar The challenges and opportunities for professional
code scanners for medications or identification. Web nurses today are unparalleled. Currently, there is
portals and other technological supports, which were a major shortage of professional nurses. The rapid
not possible even a decade ago, assist clients at entry expansion of the populations requiring health care has
points to an increasingly complex health care system. caused the scope and complexity of nursing practice to
Technology provides a powerful way to enhance access expand exponentially particularly over the past decade.
and coordination of health information across health Nursing is recognized as a critical professional body
care systems. Promoting greater availability of infor- needed to transform the health care system in line
mation transfer between client consumers and relevant with the IOM’s (2001) vision of a “high performance,
health care providers can and improve patient/clinican client centered health care system.” A tidal wave of
current and projected changes in the health care sys- communication theory to the study of developmental
tem creates the need for nurses to clearly “own” the theories used by nurses as presented in this chapter
essence of professional nursing and to redefine their helps nurses integrate scientific understandings with a
professional role responsibilities within a collaborative personalized approach to individual clients.
interdisciplinary patient-centered health care system. Hildegard Peplau’s theory of interpersonal rela-
IOM (2014) notes: Contemporary professionalism tionships forms a theoretical basis for understand-
supports team based processes of multiple professions ing the nurse’s role in the nurse-client relationship.
working together with cross-disciplinary responsibili- Concepts from other developmental and psycho-
ties and accountability for achieving improved clinical logical theories broaden the nurse’s perspective and
outcomes IOM, 2014. understanding of client behaviors. Nurses use Erik-
No longer labeled the “invisible profession” (Andrist son’s model of psychosocial development to provide
et al., 2006), nurses are slated to become key players in nursing care in line with developmental needs of their
a transformed health care system. In 2010, IOM and clients and Maslow’s need theory to prioritize care
Robert Wood Johnson Foundation released its report activities. Carl Rogers’s emphasizes a client-centered
on the future of nursing, entitled The Future of Nursing: approach and identifies conditions needed to facilitate
Leading Change, Advancing Health. Four recommenda- personality change through increased insight and self
tions emphasize nursing’s leadership role in facilitating understanding (Anderson, 2001). He offered basic
the transformation of the health care system. concepts concerning characteristics the nurse needs
1. Nurses should practice to the full extent of their for developing effective interpersonal relationships
education and training. with clients. Therapeutic communication is used in
2. Nurses should achieve higher levels of education the nurse-client relationship as a primary means of
and training through an improved education sys- achieving treatment goals.
tem that promotes seamless academic progression. Dramatic transformational changes in the health
3. Nurses should be full partners, with physicians care delivery system will require nurses to embrace
and other health professionals, in redesigning new competencies consistent with advances in sci-
health care in the United States. ence, contemporary health care, and shifting demo-
4. Effective workforce planning and policy making graphic diversity of health care consumers. Highly
require better data collection and an improved skilled nurses are needed to provide complex care and
information infrastructure (Litwack, 2013, IOM, leadership in a transdisciplinary health care system.
2010). IOM recommendations, and those of other nation-
Changes in nursing education will be key to achiev- ally recognized health care experts, create a mandate
ing these goals. Substantially more nurses will need for increased numbers of baccalaureate and advanced
to be educated at the graduate level; a baccalaureate practice nurses to handle the complex demands of
degree in nursing will become essential (Aiken, 2011). contemporary care delivery. Nurses have an unprec-
edented opportunity to make a difference and shape
the future of nursing practice through communication
SUMMARY at every level in health care delivery.
Chapter 1 identifies various theory-based concepts
important to the understanding of professional and
nurse-client relationships in contemporary health care ETHICAL DILEMMA What Would You Do?
delivery. Concepts of nursing’s metaparadigm, found
across all nursing models include person, environment, Craig Montegue is a difficult client to care for. As his
nurse, you find his constant arguments, poor hygiene,
health, and nursing. “Ways of knowing” help nurses
and the way he treats his family very upsetting. It is
to frame their interactions with clients and families difficult for you to provide him with even the most
based on forms of knowledge reflecting a different set basic care, and you just want to leave his room as
of assumptions regarding client needs. These models quickly as possible. How could you use a patient-
bring order to nursing practice and provide a cognitive centered approach to understanding Craig? What are
the ethical elements in this situation, and how would
theoretical basis for nursing research. The process of you address them in implementing care for Craig?
communication is analyzed and the contributions of
Clark DJ: Old wine in new bottles: delivering nursing in the 21st
DISCUSSION QUESTIONS century, J Nurs Scholarsh 32(1):11–15, 2000.
Clark A: Empathy: An integral model in the counseling program,
1. In what ways does the discipline of nursing today J. Couns Dev. 88(3):348–356, 2010.
reflect or refute the disciplines’ original three Creasia J, Friberg E: Conceptual Foundations: The Bridge to Professional
themes identified in Donaldson and Crowley’s Nursing Practice, St. Louis, Missouri, 2011, Elsevier Mosby.
Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell
seminal article of 1978? P, Warren J: Quality and safety education for nurses, Nurs Outlook
2. How would you envision the nature of professional 55:122–131, 2007.
nursing practice in the future? Craig C, Eby D, Whittington J: Care coordination model: Better care
3. What do you consider to be the unique attributes of at lower cost for people with multiple health and social needs. IHI
innovation series white paper, Cambridge Massachusetts , Institute
the nursing professionals today? for Healthcare Improvement, 2011. Available on www.IHI.org.
Crowe M: The nurse-client relationship: a consideration of its discursive
content, J Adv Nurs 31(4):962–967, 2000.
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CHAPTER 2
Professional Guides for Nursing

Communication
OBJECTIVES
At the end of the chapter, the reader will be able to:
1. Describe the impact on nursing communication of stan- 3. Discuss legal and ethical standards in nursing practice
dards and guidelines for care and communication issued relevant to communication.
by multiple organizations. 4. Discuss client privacy in light of the Health Insurance
2. Discuss competencies expected of the newly graduated Portability and Accountability Act (HIPAA) of 1996—
nurse as listed by Quality and Safety Education for Nurses regulations, confidentiality, and informed consent—as
(QSEN) and other organizations, specifically as they affect guides to action in nurse-client relationships.
communication.
BASIC CONCEPTS
T his chapter introduces the student to standards
and guidelines that directly or indirectly influence
nursing communication. Included in this chapter is a
STANDARDS AS GUIDES TO
brief overview of the nursing process. COMMUNICATION IN CLINICAL NURSING
As nurses we are guided by standards, policies, ethical
codes, and laws. Factors external to the nursing profes-
sion, such as technology innovations, research reports,
and government mandates, are driving major changes
in the way nurses communicate. As described in
Chapter 1, American laws such as Patient Protection
and Affordable Care Act (2010), as well as guidelines
from professional organizations, affect our practice
and communications.
In an ideal work environment, we nurses dem-
onstrate professional conduct by using established
evidence-based “best practices” to provide safe, high-
quality care for our clients. In an ideal work environ-
ment, we have excellent communication with our
client and their families. In an ideal work environ-
The nurse in all professional relationships, practices with
ment, we have excellent, effective communication
compassion and respect for the inherent dignity, worth, and with all members of the interdisciplinary health care
uniqueness of every individual. team, while maintaining confidentiality (Amer, 2013).
Chapter 2 Professional Guides for Nursing Communication 23
Nursing is working toward these goals by implement- with the workload. A surgeon arrives and rapidly gives
ing new clear, complete communication practices. This verbal instructions to limit his pre-op craniotomy patient’s
is essential to workplace efficiency and delivery of head hair shaving to the incision site only tomorrow when
high-quality, safe care to clients. A number of inter- the preparation procedure is done in the operating suite.
national, national, and professional organizations have As a student, Kay never spoke to a physician. He writes
issued standards, guidelines, and recommendations an order stating “client will be shaved according to head
impacting the way nurses communicate. nurse’s instructions.” He asks Kay to call the operating
room to relay these instructions, which she does. Nothing
EFFECTIVE COMMUNICATION is in the record describing the area to be shaved. When
the day shift arrives in the surgical suite, the telephone
Effective communication is defined as a two-way
message from Kay is not passed on. The client’s head is
exchange of information among clients and health pro- completely shaved, and a lawsuit is threatened.
viders ensuring that the expectations and responsibili-
ties of all are clearly understood. It is an active process 1. What standards of communication were violated?
for all involved. Two-way communication provides 2. What do you think is wrong with this entire work
feedback, which enables understanding by both send- environment?
3. What would you change in this unfortunate but true
ers and receivers. It is timely, accurate, and usable. Mes-
situation?
sages are processed by all parties until the information
is clearly understood by all and integrated into care
(adapted from The Joint Commission [TJC, 2011]. ORGANIZATIONS OR AGENCIES ISSUING
Effective and correct communication is clear, concise,
concrete, complete, and courteous.
HEALTH CARE COMMUNICATION
Communication problems occur when there are GUIDELINES
failures in one or more categories: the system, the The World Health Organization (WHO), a part of
transmission, or in the reception. System failures the United Nations, has actively sought to improve
occur when the necessary channels of communication worldwide client safety and this has affected expec-
are absent or not functioning. Transmission failures tations for nursing communication. In 2005 WHO
occur when the channels exist but the message is never designated The Joint Commission International as the
sent or is not clearly sent. Reception failures occur WHO Collaborating Center for patient safety solu-
when channels exist and necessary information is sent, tions. In 2007, WHO (TJC International, n.d.) pub-
but the recipient misinterprets the message. lished nine solutions for increasing health care safety.
Why are nurses interested in using communication Number two is “correctly identifying the patient,” and
standards to modify and clarify their own communica- number three is “better communication during patient
tion? Ideally because we are motivated to provide the hand-over” (from one caregiver to another).
best, safest possible care. Failure to adhere to estab- The Code of Ethics of the International Council of
lished nursing practice and professional performance Nurses (ICN) describes nurse activities in relation to
standards could result in a negative civil judgment people, practice, profession, and coworkers (ICN, 2012).
against a professional nurse. Consider the unfortunate Description of elements set expectations for communi-
but true case of a new graduate nurse as shown in the cation. One example would be “ensures confidentiality.”
following case example. As highlighted in the Institute of Medicine (IOM)
report “Crossing the Quality Chasm” described in
Case Example: Graduate Nurse Kay Chapter 1, health care providers are refocusing on
Immediately following graduation from her nursing pro- patient-centered care as the core concept in improving
gram, Kay Smite, GN, takes an entry position on a busy our health care system. Since the IOM implicated poor
surgical unit in a small-size general hospital. With no ori- communication as a causative factor in 70% of health
entation she was assigned to work evening shift, with one care errors, many other organizations have issued
registered nurse and two aides. During her second week standards and guidelines that affect the way nurses
when the registered nurse calls in ill, Kay is told by the communicate. The IOM specifically included “accu-
evening supervisor that she is “charge nurse” this evening,
rate, complete communication” as one of eight goals
and a float nurse will be sent as soon as possible to help
they established to improve safe care outcomes for
clients. IOM specifically advocates use of standard- and safe ethical clinical practice. Professional stan-
ized communication tools. Standardized formats and dards of practice serve the dual purpose of providing a
tools for communication are described in Chapter 4. standardized benchmark for evaluating the quality of
One example of standardized communication is the their nursing care and offering the consumer a com-
situation, background, assessment, recommendation mon means of understanding nursing as a professional
(SBAR) format. service relationship. In this way, they communicate
Situation (What is going on with the client?) with the public as to what can be expected from pro-
Background (What is key information/context?) fessional nurses. In support of recommendations from
Assessment (What do I think the problem is?) a IOM and a Robert Wood Johnson (RWJ)–funded
Recommendation (What do I want to be done?) initiative to transform the practice of nursing (IOM,
Since every member of the health team uses this 2010), ANA is encouraging nurses to act as full part-
same standard format for communicating problems, ners in redesigning the health care system, especially
they easily understand each other. by taking an active part in collecting and communicat-
The Agency for Healthcare Research and Qual- ing information.
ity (AHRQ) in the U.S. Department of Health and The American Association of Colleges of Nursing
Human Services has taken a leading role in health care (AACN) makes recommendations for nursing curri-
in the United States to improve client safety. AHRQ’s cula. For example, they suggest nursing students learn
role, as mandated by Congress, is to prevent medical application of evidence-based clinical practices. An
errors and promote client safety. They fund research example of a specific communication recommendation
and compile evidence to develop and publish “best is learning standard protocol for “handing off ” commu-
practices” evidenced-based care protocols. An amaz- nication when one nurse turns over care of the client
ing number of resources can easily be accessed on the to another. Another is mastering open communication
Internet such as (www.ahrq.gov/). and interdisciplinary cooperation techniques especially
for working in health care teams (AACN, 2006).
PROFESSIONAL NURSING ORGANIZATIONS
QUALITY AND SAFETY IN NURSING EDUCATION
ISSUING HEALTH CARE COMMUNICATION More than a decade ago, nursing leaders established
GUIDELINES a national initiative, Quality and Safety Education
Professional nursing organizations all over the world for Nurses (QSEN), to transform nursing education
have established standards for nursing care that specify by building on IOM’s recommendations to identify
clear, comprehensive communication as a requirement. essential competencies for nurses, to be taught within
Nurses are expected to demonstrate communication nursing curricula (Cronenwett et al., 2007). QSEN
skills to effectively implement care and client safety identifies six areas of nursing competency as well as
within the context of the interprofessional health care the knowledge, skills, and attitudes (KSA) associ-
team (American Association of Colleges of Nursing ated with each competency as needed by all nurses
[AACN], 2008). Internationally, examples include (Barnsteiner et al., 2013; Disch, 2012). With signifi-
guidelines from the College of Nurses of Ontario, cant funding from the Robert Wood Johnson Founda-
Canada, who advocate that among other behaviors, tion, a national advisory board at QSEN continues to
nurses develop clear goal-directed communication help educational institutions pursue quality and safety
processes, sharing information frequently with clients, goals by providing training, resources, and consultants
families, and colleagues (www.cno.org/Global/docs/ to translate QSEN competencies into teaching strate-
prac/41070_refusing.pdf ). Other countries such as gies. In each of the six competencies, QSEN specifies
Great Britain also address the need for effective nurse the knowledge, skills, and attitudes that are the learn-
communication. ing objectives for each competency (see Table 2-1 for
The American Nurses Association (ANA) is examples).
a national professional organization for registered Patient-centered care is the first competency.
nurses. The ANA publishes standards of performance Defined as empowering the client/family to be a full
such as ANA’s Scope and Standards of Nursing Practice. partner in providing compassionate, coordinated care.
These help ensure professional nursing competence In terms of “knowledge,” you are expected to integrate
TABLE 2-1 QSEN’s Six Prelicensure Competencies, Definitions,

and Selected Communication Examples
Partial Examples:
Competency Definition K = knowledge; S = skill; A = attitude
1. Patient-centered care (Arnold Focus on fully partnering with client (K) Integrate understanding of arts,
and Boggs discussed in every to provide care that incorporates sciences, including communication, to
chapter) his or her values and preferences apply nursing process.
to give safe, caring, compassionate (S) Use communication skills in intake
effective care. clinical interview to ask about client
To do so requires us to communicate preferences, to develop care plan,
client preferences to other health to communicate these to others. Use
team members. communication tools.
(A) Value client expertise and input.
2. Teamwork and collaboration For teamwork we need mutual (K) Know scope of practice. Analyze dif-
(Arnold and Boggs discussed respect, open communication, and ferences in communication styles.
in Chapters 2, 4, 6, and 22-24) shared decision making with all (S) Adapt own style to the needs of the
team members. team in the current situation. Commu-
nicate openly, share in decision making,
resolve potential conflicts.
(A) Respect contributions of every team
member.
3. Evidence-based practice (EBP) Incorporate the best practices based (K) Identify sources of EBP. Differentiate
(Arnold and Boggs discussed on newest evidence with our clinical quality of evidence.
in Chapters 1, 2, 4, and 23, expertise to deliver optimal care. (S) Use EBPs, after analyzing research
with examples and application findings and care protocols relevant
to practice in every chapter) to our client’s diagnosis; communicate
these to others.
(A) Value research, appreciate need to
seek EBP information.
4. Quality improvement Collect data on common outcome (K) Identify differences between our
(Arnold and Boggs discussed measures of our care to compare agency practices and “best practices.”
in Chapters 4 and 25) with accepted outcomes (S) Use communication tools to make
(benchmarks). client care explicit.
(A) Value own and others contributions.
5. Safety (Arnold and Boggs Minimize risk of harm…, analyzing (K) Analyze safety processes in own
incorporated throughout with root causes of error, moving from workplace.
focused discussion in a blame culture to a just culture (S) Speak up proactively (about poten-
Chapters 4 and 25) should increase communication, tial safety violations) and report near
prevent future problems, result is misses.
safer care.
(A) Appreciate how variation from estab-
lished protocols creates risk.
6. Informatics (Arnold and Use technology to effectively (K) Contrast benefits and limitations of
Boggs discussed in communicate and manage client different communication technologies.
Chapters 4, 25, and 26) care…, make decisions, and access (S) Use electronic skills to access avail-
evidence-based treatment informa- able databases to design an effective,
tion. evidence-based care plan.
(A) Protect confidentiality.
QSEN, Quality and Safety Education for Nurses.

multiple dimensions of care, including communication, Additional QSEN competencies are defined for
to involve the client and family. In terms of “skills,” you graduate nursing education (Disch and Barnsteiner,
are expected to elicit client values and preferences dur- 2012).
ing your initial interview and care plan development These and other QSEN competencies will be dis-
and to communicate client preferences to other mem- cussed throughout this book, as related to communi-
bers of the health care team. In terms of “attitudes,” you cation. For more information and descriptions of the
are to value expressions of client values, as well as their knowledge, skills, and attitudes attached to each com-
expertise regarding their own health status. In meeting petency, refer to www.QSEN.com. Other models are
the QSEN competency of providing patient-centered also available that identify core competencies expected
care, do you communicate with client and family mem- of nurses. All of them stress excellent communica-
bers to engage them in planning care? tion, coordination, and collaborative skills. For exam-
Teamwork and collaboration is another expected ple, Lenburg’s Competency Outcomes Performance
nurse competency. You are expected to be able to func- Assessment Model (COPA) includes oral skills, writ-
tion effectively within nursing and an interprofessional ing skills, and electronic skills (Amer, 2013).
team, to foster open communication, mutual respect, and
shared decision making to achieve quality care. A partial OTHER PROFESSIONAL ORGANIZATIONS
example of expected knowledge objectives for this com- AND ACCREDITING AGENCIES ISSUING
petency are that you know the various roles and scope of
practice for team members and are able to analyze dif-
COMMUNICATION GUIDELINES AFFECTING
ferences in communication style preferences for client, NURSING
family, and for other members of the health care team. The Joint Commission (TJC) is the organiza-
In terms of “skill,” you are expected to be able to adapt tion that regulates hospitals in the United States.
your own style of communicating and able to initiate To obtain reimbursement from insurance, a health
actions to resolve any conflicts. In terms of “attitudes,” care organization must have TJC accreditation. TJC
your behavior shows that you value teamwork and dif- attributes more than 60% of sentinel events to mis-
ferent styles of communication (www.QSEN.org/). communication. So they specifically have some regu-
As a student, are you having experiences in which you lations focused on improving communication, such
directly communicate with physicians? as requirements to use checklists. TJC mandates that
As you can see in Table 2-1, communication is a hospitals effectively communicate with patients when
major component of most of these six competencies. providing services, identifying client oral and written
The QSEN web site gives you access to the case study communication needs to facilitate the exchange of
of Lewis Blackman, a healthy, active 15-year-old, information during the care process (TJC, R3 Report,
who died unnecessarily following elective surgery n.d., PC.02.01.21). TJC’s Accreditation Manual for
(www.qsen.org/videos/the-lewis-blackman-story). Hospitals says that staff must be aware of relevant
This case details a series of miscommunications and policies for meeting patient communication needs
lack of intervention by staff nurses and physicians. In (TJC, 2011a).
addition to the inaction on the part of nurses, frag- TJC defines effective communication as that
mentation of the care system and the barrier of the which is timely, accurate, complete, unambiguous, and
physician-nurse power hierarchy are implicated. When understood by the recipient. Goal number 2 of their
members of the health care team are not empowered National Patient Safety Goals (TJC, 2011b) aims at
to speak up and participate, a major threat to client structuring and improving communication to improve
safety occurs. Just as it does when members of fam- effectiveness among caregivers. Section 2E of the
ily are not empowered (Acquaviva, 2013). Blackman’s goals specifically addresses communication guidelines
mother, Helen Haskell, states that it is her belief that needed to manage handoff communication. When
“Lewis’ death could have been averted by a knowl- your client is handed off or transferred into the care of
edgeable, assertive nurse.” Effectively working as part another caregiver on your unit or to another location,
of a health care team requires open communication, TJC encourages staff to follow a standard communi-
mutual respect, and shared decision making with cli- cation protocol. These standardized communication
ent and family included. tools are described in detail in Chapter 4.
TJC also mandates that written nursing policies BOX 2-1 American Nurses Association
with specific standards of care be available on all nurs- Code of Ethics for Nurses
ing units. TJC has 15 standards-based performance
areas. Professional standards of practice provide defini- 1. The nurse, in all professional relationships,
tions of the minimum competencies needed for quality practices with compassion and respect for the
inherent dignity, worth, and uniqueness of every
professional nursing practice. Presented as principled
individual, unrestricted by considerations of social
statements, they designate the knowledge and clini- or economic status, personal attributes, or the
cal skills required of nurses to practice competently nature of health problems.
and safely. 2. The nurse’s primary commitment is to the patient,
whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives
ETHICAL STANDARDS AND ISSUES to protect the health, safety, and rights of the
patient.
Nurses are subjected to numerous ethical and legal 4. The nurse is responsible and accountable for
duties in their professional role (McGowan, 2012). individual nursing practice and determines
Nurses have an ethical accountability to the clients the appropriate delegation of tasks consistent
with the nurse’s obligation to provide optimum
they serve that extends beyond their legal responsi-
patient care.
bility in everyday nursing situations. Ethical issues of 5. The nurse owes the same duties to self as to
particular relevance to the nurse-client relationship others, including the responsibility to preserve
relate to caring for clients in ambulatory managed care integrity and safety, to maintain competence, and
settings, the rights of clients participating in research, to continue personal and professional growth.
6. The nurse participates in establishing, maintain-
caring for mature minors, client education, right to die
ing, and improving health care environments and
issues, transfer to long-term care of elderly clients, and conditions of employment conducive to the provi-
telehealth nursing. The process for applying ethical sion of quality health care and consistent with the
decision making will be described in Chapter 3. values of the profession through individual and
collective action.
ETHICAL CODES 7. The nurse participates in the advancement
of the profession through contributions to
All legitimate professions have standards of conduct. practice, education, administration, and
Nurses of every nation are guided by written profes- knowledge development.
sional ethical codes. An International Code of Ethics 8. The nurse collaborates with other health profes-
was adopted by ICN in 1953 and revised in 2012. sionals and the public in promoting community,
national, and international efforts to meet health
This code identifies four fundamental nursing respon-
needs.
sibilities as being to promote health, prevent illness, 9. The profession of nursing, as represented by
restore health, and alleviate suffering. Moreover the associations and their members, is responsible
code says each nurse has the responsibility to main- for articulating nursing values, for maintaining the
tain a clinical practice that promotes ethical behavior, integrity of the profession and its practice, and
for shaping social policy.
while sustaining collaborative, respectful relation-
ships with coworkers. Among many elements of the Reprinted from the American Nurses Association (ANA, 2001) by
permission.
code, those addressing communication state we need
to ensure that each client receives accurate, sufficient
communication in a timely manner and to maintain
confidentiality. rights, provide a mechanism for professional account-
Professional nurses, regardless of setting, are ability, and educate professionals about sound ethical
expected to follow ethical guidelines in their practice. conduct. Codes of ethics for nurses are found in most
As listed in Box 2-1, American Nurses Association other nations. For example, there is the Canadian
Code of Ethics for Nurses (with interpretive state- Nurses Association Code of Ethics for Registered
ments) (ANA, 2001) establishes principled guidelines Nurses (1997).
designed to protect the integrity of clients related to A Code of Ethics for Nurses provides a broad con-
their care, health, safety, and rights. It provides ethi- ceptual framework outlining the principled behav-
cal guidelines for nurses designed to protect client iors and value beliefs expected of professional nurses
EXERCISE 2-1 Applying the Code of Ethics for Nurses to Professional

and Clinical Situations
Purpose: To help students identify applications of the to live. The health care team is considering place-
Code of Ethics for Nurses. ment of a feeding tube based on his wife’s wishes.
His wife agrees that he probably will not survive,
Procedure but wants the feeding tube just in case the doctors
Break into small groups of four or five students to con- are wrong.
sider the following clinical scenarios: 4. Dr. Holle criticizes a nurse in front of a client and
1. Barbara Kohn is a 75-year-old woman who lives the client’s family.
with her son and daughter-in-law. She reveals to Share each ethical dilemma with the group and col-
you that her daughter-in-law keeps her locked in laboratively come up with a resolution that the group
her room when she has to go out because she agrees on, using the nurse’s code of ethics to work
does not want her to get in trouble. She asks you through the situation.
not to say anything as that will only get her into
trouble. Discussion
2. The nursing supervisor asks you to “float” to 1. What types of difficulty did your group encounter
another unit that will require some types of skills in resolving different scenarios?
that you believe you do not have the knowledge or 2. What type of situation offers the most challenge
skills to perform. When you explain your problem, ethically?
she tells you that she understands, but the unit is 3. Were there any problems in which the code of eth-
short staffed and she really needs you to do this. ics was not helpful?
3. Bill Jackson is an elderly client who suffered a 4. How can you use what you learned in this exercise
stroke and is uncommunicative. He is not expected in your nursing practice?
in delivering health care to individuals, families, and are held legally accountable for all aspects of the nurs-
communities. Ethical standards of behavior require a ing care we provide to clients and families, including
clear understanding of the multidimensional aspects documentation and referral. Of special relevance to
of an ethical dilemma, including intangible human communication within the nurse-client relationship
factors that make each situation unique (e.g., personal are issues of professional liability, informed consent,
and cultural values or resources). and confidentiality.
When an ethical dilemma cannot be resolved
through interpersonal negotiation, an ethics commit- CLASSIFICATIONS OF LAWS IN HEALTH CARE
tee composed of biomedical experts reviews the case As nurses, we need to take into consideration two
and makes recommendations. Of particular impor- types of law related to our care. Statutory laws are
tance to the nurse-client relationship are ethical direc- legislated laws, drafted and enacted at federal or state
tives related to the nurse’s primary commitment to levels. Medicare and Medicaid amendments to the
• The client’s welfare Social Security Act are examples of federal statutory
• Respect for client autonomy laws. Each state’s Nurse Practice Act is an example of
• Recognition of each individual as unique and statutory law.
worthy of respect and advocacy Civil laws are developed through court decisions,
• Truth telling which are created through precedents, rather than
Exercise 2-1 provides an opportunity to consider written statutes. Most infractions for malpractice and
the many elements in an ethical nursing dilemma. negligence are covered by civil law and are referred to
as torts. A tort is defined as a private civil action that
causes personal injuries to a private party. Deliberate
LEGAL STANDARDS intent is not present. Four elements are necessary to
As stressed in the IOM/RWJ report, nurses must be qualify for a claim of malpractice or negligence.
accountable for their own contributions to delivery of • The professional duty was owed to client (pro-
high-quality care (2010). As professional nurses, we fessional relationship).
• A breach of duty occurred in which the nurse documentation represents a permanent record of the
failed to conform to an accepted standard of care. client’s health care experience. In the eyes of the law,
• Causality in which a failure to act by professional failure to document in written form any of these ele-
standards was a proximate cause of the resulting ments means the actions were not taken.
injury.
• Actual damage or injuries resulted from breach
of duty.
APPLICATIONS
As nurses, we are legally bound by the principles of As illustrated in Figure 2-1, Communication in the
civil tort law to provide the care that any reasonably Nursing Process, communication standards and skills
prudent nurse would provide in a similar situation. If are an integral component of the knowledge, experi-
taken to court, this standard would be the benchmark ence and skills, and attitudes encompassed in using
against which our actions would be judged. the nursing process to deliver care. Standards for
Criminal law is reserved for cases in which there is nurse behaviors are specified in professional codes
intentional misconduct or a serious violation of profes- and guidelines, including clarity and completeness of
sional standards of care. The most common nurse vio- communication. Nursing students need opportunities
lation of criminal law is failure to renew a professional to practice effectively communicating before enter-
nursing license, which means that a nurse is practicing ing the workforce. Throughout this book, emphasis
nursing without a license. is placed on the importance of guiding your practice
through application of both professional standards and
LEGAL LIABILITY IN NURSE-CLIENT RELATIONSHIPS evidence-based practices in your nursing care.
In the nurse-client relationship, the nurse is respon- Discussing case studies and exercises offers opportuni-
sible for maintaining the professional conduct of the ties to hone communication skills.
relationship. Examples of unprofessional conduct in
the nurse-client relationship include:
• Breaching client confidentiality
EVIDENCE-BASED PRACTICE
• Verbally or physically abusing a client As discussed in Chapter 1, evidenced-based prac-
• Assuming nursing responsibility for actions tice (EBP) guidelines are clinical behaviors compiled
without having sufficient preparation from the best current research evidence available and
• Delegating care to unlicensed personnel, which the expertise of clinicians. IOM’s The Future of Nurs-
could result in client injury ing report specifies that nursing education provide
• Following a doctor’s order that would result in opportunities for students to develop competency in
client harm the use of EBP and collaborative teamwork to ensure
• Failing to assess, report, or document changes in the delivery of safe, patient-centered care across set-
client health status tings (IOM, 2010). Use of EBPs are also a QSEN
• Falsifying records competency. Each nurse is expected to be able to
• Failing to obtain informed consent integrate “best current evidence” with clinical exper-
• Failure to question a physician’s orders, if they are tise and client/family preferences and values to deliver
not clear optimum care (Barnsteiner et al., 2013). In develop-
• Failure to provide required health teaching ing this skill, you learn to determine which data are
• Failure to provide for client safety (e.g., not putting scientifically valid and useful in guiding your practice.
the side rails up on a client with a stroke) By consulting EBP guidelines, your ability to make
Effective and frequent communication with clients specific clinical decisions about care for your cli-
and other providers is one of the best ways to avoid or ent is enhanced, so you can give the highest quality
minimize the possibility of harm leading to legal liability. care. Do you have a clinical question? Many sources
are available to you, such as guidelines from agencies
DOCUMENTATION AS A LEGAL RECORD such as AHRQ or speciality nursing organizations
As described in Chapter 25, nurses are responsible for (www.guideline.gov/index.aspx).
accurate and timely documentation of nursing assess- Much of nursing and medicine is not yet based on
ments, care given, and the responses of the client. This evidence. When a guideline is not yet available, you
KNOWLEDGE
Underlying disease process
Normal growth and development
Normal physiology and psychology
Normal assessment findings
Health promotion
Assessment skills
Communication skills
STANDARDS
EXPERIENCE
NURSING PROCESS ANA Scope and Standards of Nursing Practice
Previous patient care experience Specialty standards of practice
Assessment Intellectual standards of
Validation of assessment findings
Observation of assessment techniques measurement
Evaluation Diagnosis
Implementation Planning
ATTITUDES
Perseverance
Fairness
Integrity
Confidence
Creativity
Figure 2-1 Communication in the nursing process. (Modified from Potter PA, Perry AG, Stockert PA, et al. Fundamentals of
nursing, ed 8, St. Louis, 2013, Mosby.)
can access specific journal research articles using any

of several databases such as CINAHL (QSEN mod-
USING THE NURSING PROCESS
ule on EBP). Careful critical thinking is needed when IN NURSE-CLIENT RELATIONSHIPS
relying on just one study’s findings. As Disch (2012,b) The nurses’ primary duty is to provide the client with
points out, even when we have available best evidence, competent, safe, consistent, and ethical care. The most
sometimes we choose to not apply it. Her example is common configuration for collecting, organizing, and
that oral care is often not done, even though strong analyzing client data remains the nursing process. The
evidence exists that oral care reduces ventilator-asso- purpose of the nursing process is to diagnose and treat
ciated pneumonia. Use the EBP samples provided in human responses to actual or potential health prob-
this book to stimulate discussion and to encourage you lems (ANA, 2010). Since the nursing process is an
to seek out those you can apply in your clinical practice. interpersonal, client-centered process involving many
team members, communication is a major component.
Assessment data, nursing diagnosis, and goals for
STANDARDS treatment are systematically documented and shared
Application of standards of professional communica- with nurses and other health professionals. Figure 2-1
tion necessitates use of critical thinking and problem- illustrates how the nursing process is central to our
solving skills in all aspects of care (described in care of clients. Input from your knowledge, skills/expe-
Chapter 3). Clarity of communication is crucial. Many rience, and your attitudes contribute to your use of the
of the organizations cited earlier recommend use of nursing process, just as do the standards we discuss in
standardized communication formats. Failure to follow this chapter. While standards include standards for
accepted codes and standards of behavior can result in nursing practice and evidence-based practice guide-
potential harm to clients, termination of employment, lines, we focus chapter discussion on communication
state licensure disciplinary action, or litigation. standards.
Developing an Evidence-Based Practice

This is an example of one of several research studies reviewed by recommendations for nursing care. Among many
experts to compile the Mosby’s Nursing Consult Evidence-Based guidelines they listed these nursing actions:
Nursing Recommendations for the category Pressure Ulcers • Nurses need to access skin condition and risk for
(http://www.nursingconsult.com/nursing/login?env=PROD&URI=/
ulcers on admission and at least daily.
nursing/evidence-based-nursing/monograph%3Fmonograph_id%
3D189626).
• Nurses should reposition immobile clients at least
every 2 hours using a 30-degree tilt during the
Moore Z, Cowman S, Conroy RM. A randomized night.
controlled clinical trial of repositioning, using the • Nurses should reposition chair-bound clients every
30-degree tilt for the prevention of pressure ulcers, hour if they cannot change their position them-
J Clin Nurs 20(17/18): 2633-2644, 2011. selves.
This was a prospective, randomized study that com- • Nurses need to keep client skin clean and dry and
pared two methods of positioning 213 geriatric clients avoid vigorous massage of skin over bony promi-
to prevent development of pressure ulcers (bed sores). nences.
The treatment group had their positions changed This site also provides you with information for dis-
using a tilt every 2 hours during the night, while control charge planning and evaluation. It goes on to list the
group members were repositioned the standard posi- Nursing Outcomes Classification (NOC) and Nursing
tion change schedule of every 6 hours during the night. Interventions Classification (NIC) categories and codes.
Explore this web site for other specific EBP guide-
Results: Thirteen of the control group developed lines. Then for fun, check out the sites available to you
pressure ulcers as compared to only three in the group from the Agency for Healthcare Research and Quality
whose positions were changed more frequently. The (AHRQ.gov), including their hyperlinks to YouTube, for
authors concluded that more frequent repositioning videos that you can use in teaching young clients (www.
especially using the 30-degree tilt is more effective. youtube.com/user/AHRQHealthTV/).
Just click on “prevention is the key to a healthy life”
Application to your clinical practice: The Mosby or other topics.
evidence-based practice (EBP) site reviewed addi-
tional studies and summarized the data to make EBP
The nursing process consists of five progressive or referral. Although there is an ordered sequence of
phases: assessment, problem identification and diagno- nursing activities, each phase is flexible, flowing into
sis, outcome identification and planning, implementa- and overlapping with other phases of the nursing pro-
tion, and evaluation. As a dynamic, systematic clinical cess. For example, in providing a designated nursing
management tool, it functions as a primary means of intervention, you might discover a more complex need
directing the sequence, planning, implementation, and than what was originally assessed. This could require a
evaluation of nursing care to achieve specific health modification in the nursing diagnosis, identified out-
goals. Continual and timely communication is a com- come, intervention, or the need for a referral.
ponent of each step in the nursing process. Specifically
the role communication plays is ASSESSMENT
• Establishing and maintaining a therapeutic You employ communication skills in beginning the
relationship initial step in your client-centered approach to assess-
• Helping client to promote, maintain, or restore ment. You systematically gather data about the client
health, or to achieve a peaceful death seeking service. The assessment process begins when
• Facilitating client management of difficult you first meet the client and family. Introducing your-
health care issues through communication self and explaining the purpose of the assessment
• Providing quality nursing care in a safe and effi- interview helps put the client at ease.
cient manner Next in this assessment process is the intake
The nursing process is closely aligned with meeting assessment, done to obtain information about the cli-
professional nursing standards in the total care of the ent’s problem history. Using your verbal interviewing
client. Table 2-2 illustrates the relationship. skills as well as observations about nonverbal cues,
The nursing process begins with your first encoun- you use open-ended and focused questions to collect
ter with a client and family, and ends with discharge data about
TABLE 2-2 Relationship of the Nursing Process to Professional Nursing Standards

in the Nurse-Client Relationship
Nursing Process: Assessment Related Nursing Standard
Collects data/information from: The nurse collects data throughout the nursing pro-
• Client history/interview cess related to client strengths, limitations, available
• Own observations; physical examination resources, and changes in the client’s condition.
• The family
• Past records/tests
• Other members of health team
Analyzes data The nurse organizes cluster behaviors and makes
inferences based on subjective and objective client
data, combined with personal and scientific nursing
knowledge.
Verifies data The nurse verifies data and inferences with client to
ensure validity.
Nursing Process: Diagnosis
Identifies health care needs/problems and formulates The nurse develops a comprehensive biopsychosocial
biopsychosocial statements statement that captures the essence of the client’s
health care needs/problems (see Box 2-2, Gordon’s
Functional Health Patterns)
Nurse validates the accuracy of the statement with the
client and family; this statement becomes the basis for
nursing diagnoses.
Establishes nursing diagnosis The nurse develops relevant nursing diagnoses. Priori-
Nurse uses NANDA approved diagnoses and codes tizes them based on the client’s most immediate needs
in the current health care situation (see Table 2-3,
Identifying Nursing Problems Associated with Maslow’s
Hierarchy of Needs).
Nursing Process: Outcome Identification and Planning
Identifies expected outcomes (for each NANDA diagno- The nurse and client mutually and realistically develop
sis, there are several NOC suggested outcomes) expected outcomes based on client needs, strengths,
and resources.
Specifies short-term goals The nurse and client mutually and realistically develop
expected outcomes based on client needs, strengths,
and resources.
Nursing Process: Implementation
Takes appropriate nursing action interventions. The nurse encourages, supports, and validates the cli-
Nursing interventions alter client’s status/symptoms. ent in taking agreed-on action to achieve goals and
expected outcomes through integrated, therapeutic
nursing interventions and communication strategies.
Nursing Process: Evaluation
Evaluates goal achievement. The nurse and client mutually evaluate attainment
Expected outcome is stated and nurse is quickly able to of expected outcomes and survey each step of the
identify client’s current status. nursing process for appropriateness, effectiveness,
adequacy, and time efficiency.
Modifies the plan if evaluation shows expected outcome
not achieved.
NANDA, North American Nursing Diagnosis Association; NOC, Nursing Outcomes Classification.
• The current problem for which the client seeks BOX 2-2 Gordon’s Functional Health
treatment Patterns
• The client’s perception of his or her health
patterns 1. Health perception-health management pattern
• Presence of other health risk and protective 2. Nutritional-metabolic pattern
3. Elimination pattern
factors
4. Activity-exercise pattern
• Relevant social, occupational, and family history 5. Sleep-rest pattern
• The client’s medical and psychiatric history (e.g., 6. Cognitive-perceptual pattern
previous hospitalizations, family history, medical 7. Self-perception-self-concept pattern
and psychiatric treatment, and medications) 8. Role-relationship pattern
9. Sexuality-reproductive pattern
• The client’s coping patterns
10. Coping-stress tolerance pattern
• Level and availability of the client’s support 11. Value-belief pattern
system
Assessment of client needs should take the client’s
entire experience of an illness, rather than simply with normal health standards, behavior patterns, and
focusing on clinical data related to the diagnosis. In developmental norms. Gordon’s Functional Health
addition to your interview, assessment includes infor- Patterns (Box 2-2) provide a useful structure for clus-
mation you obtain from existing records, past diag- tering assessment data and help direct the choice of
nostic testing, information from family, and in some nursing diagnoses. The determination of whether
instances, contact with previous health care providers, a pattern is functional or dysfunctional is based on
schools, or other referral sources. As new informa- established norms for age and sociocultural standards
tion becomes available, you are expected to refine and (Gordon, 2007).
update the original assessment. A nursing diagnoses describes the client’s human
Two types of data are collected during an assess- responses to health issues and medical diagnoses. They
ment interview. Subjective data refers to the client’s provide a platform for independent and dependent
perception of data and what the client or family says nursing actions and should complement, not compete,
about the data (e.g., “I have a severe pain in my chest”). with the actual medical diagnosis of a health problem.
Client data about alternative forms of treatment, The nursing diagnosis consists of three parts: prob-
medications, and previously used care systems are rel- lem, cause, and evidence (North American Nursing
evant pieces of information. Objective data refers to Diagnosis Association [NANDA], 2011).
data that are directly observable or verifiable through • Problem: A statement identifying a health
physical examination or tests (e.g., an abnormal elec- problem or alteration in a client’s health status,
trocardiogram). Combined, these data will present a requiring nursing intervention. Using a list of
complete picture of the client’s health problem. the most recent NANDA diagnoses, you would
Observations of the client’s appearance and nonver- pick a NANDA diagnosis that best represents
bal behaviors can help you make inferences. Through- the identified problem or potential problem.
out the assessment phase, you will need to validate the • Cause: A statement specifying the probable caus-
information you receive from the client and significant ative or risk factors contributing to the existence
others to make sure that the data are complete and or maintenance of the health care problem. The
accurate. Ask the client for confirmation that your per- cause of a problem can be psychosocial, physi-
ceptions and problem analysis are correct periodically ologic, situational, cultural, or environmental in
throughout the assessment interview, and summarize nature. The phrase “related to” (R/T) serves to
your impressions at the end. connect the problem and causative statements.
Example: “Impaired communication related to a
NURSING DIAGNOSES cerebrovascular accident.”
Once the assessment is complete and you have base- • Evidence: A statement identifying the clini-
line data, the next step is to analyze the information cal evidence (behaviors, signs, symptoms) that
and identify gaps in the data collection or content. support the diagnosis. An example of a nursing
One way to do this is to compare individual client data diagnosis statement would be “Impaired verbal
Another random document with
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gong. It is not surprising that Bradbury’s spirits, low when he reached
the place, should have sunk to zero long before the gangplank was
lowered and the passengers began to stream down it.
His wife was among the first to land. How beautiful she looked,
thought Bradbury, as he watched her. And, alas, how intimidating.
His tastes had always lain in the direction of spirited women. His first
wife had been spirited. So had his second, third and fourth. And the
one at the moment holding office was perhaps the most spirited of
the whole platoon. For one long instant, as he went to meet her,
Bradbury Fisher was conscious of a regret that he had not married
one of those meek, mild girls who suffer uncomplainingly at their
husband’s hands in the more hectic type of feminine novel. What he
felt he could have done with at the moment was the sort of wife who
thinks herself dashed lucky if the other half of the sketch does not
drag her round the billiard-room by her hair, kicking her the while
with spiked shoes.
Three conversational openings presented themselves to him as he
approached her.
“Darling, there is something I want to tell you—”
“Dearest, I have a small confession to make—”
“Sweetheart, I don’t know if by any chance you remember
Blizzard, our butler. Well, it’s like this—”
But, in the event, it was she who spoke first.
“Oh, Bradbury,” she cried, rushing into his arms, “I’ve done the
most awful thing, and you must try to forgive me!”
Bradbury blinked. He had never seen her in this strange mood
before. As she clung to him, she seemed timid, fluttering, and—
although a woman who weighed a full hundred and fifty-seven
pounds—almost fragile.
“What is it?” he inquired, tenderly. “Has somebody stolen your
jewels?”
“No, no.”
“Have you been losing money at bridge?”
“No, no. Worse than that.”
Bradbury started.
“You didn’t sing ‘My Little Grey Home in the West’ at the ship’s
concert?” he demanded, eyeing her closely.
“No, no! Ah, how can I tell you? Bradbury, look! You see that man
over there?”
Bradbury followed her pointing finger. Standing in an attitude of
negligent dignity beside a pile of trunks under the letter V was a tall,
stout, ambassadorial man, at the very sight of whom, even at this
distance, Bradbury Fisher felt an odd sense of inferiority. His
pendulous cheeks, his curving waistcoat, his protruding eyes, and
the sequence of rolling chins combined to produce in Bradbury that
instinctive feeling of being in the presence of a superior which we
experience when meeting scratch golfers, head-waiters of
fashionable restaurants, and traffic-policemen. A sudden pang of
suspicion pierced him.
“Well?” he said, hoarsely. “What of him?”
“Bradbury, you must not judge me too harshly. We were thrown
together and I was tempted—”
“Woman,” thundered Bradbury Fisher, “who is this man?”
“His name is Vosper.”
“And what is there between you and him, and when did it start,
and why and how and where?”
Mrs. Fisher dabbed at her eyes with her handkerchief.
“It was at the Duke of Bootle’s, Bradbury. I was invited there for the
week-end.”
“And this man was there?”
“Yes.”
“Ha! Proceed!”
“The moment I set eyes on him, something seemed to go all over
me.”
“Indeed!”
“At first it was his mere appearance. I felt that I had dreamed of
such a man all my life, and that for all these wasted years I had been
putting up with the second-best.”
“Oh, you did, eh? Really? Is that so? You did, did you?” snorted
Bradbury Fisher.
“I couldn’t help it, Bradbury. I know I have always seemed so
devoted to Blizzard, and so I was. But, honestly, there is no
comparison between them—really there isn’t. You should see the
way Vosper stood behind the Duke’s chair. Like a high priest
presiding over some mystic religious ceremony. And his voice when
he asks you if you will have sherry or hock! Like the music of some
wonderful organ. I couldn’t resist him. I approached him delicately,
and found that he was willing to come to America. He had been
eighteen years with the Duke, and he told me he couldn’t stand the
sight of the back of his head any longer. So—”
Bradbury Fisher reeled.
“This man—this Vosper. Who is he?”
“Why, I’m telling you, honey. He was the Duke’s butler, and now
he’s ours. Oh, you know how impulsive I am. Honestly, it wasn’t till
we were half-way across the Atlantic that I suddenly said to myself,
‘What about Blizzard?’ What am I to do, Bradbury? I simply haven’t
the nerve to fire Blizzard. And yet what will happen when he walks
into his pantry and finds Vosper there? Oh, think, Bradbury, think!”
Bradbury Fisher was thinking—and for the first time in a week
without agony.
“Evangeline,” he said, gravely, “this is awkward.”
“I know.”
“Extremely awkward.”
“I know, I know. But surely you can think of some way out of the
muddle!”
“I may. I cannot promise, but I may.” He pondered deeply. “Ha! I
have it! It is just possible that I may be able to induce Gladstone Bott
to take on Blizzard.”
“Do you really think he would?”
“He may—if I play my cards carefully. At any rate, I will try to
persuade him. For the moment you and Vosper had better remain in
New York, while I go home and put the negotiations in train. If I am
successful, I will let you know.”
“Do try your very hardest.”
“I think I shall be able to manage it. Gladstone and I are old
friends, and he would stretch a point to oblige me. But let this be a
lesson to you, Evangeline.”
“Oh, I will.”
“By the way,” said Bradbury Fisher, “I am cabling my London
agents to-day to instruct them to buy J. H. Taylor’s shirt-stud for my
collection.”
“Quite right, Bradbury darling. And anything else you want in that
way you will get, won’t you?”
“I will,” said Bradbury Fisher.
CHAPTER III
KEEPING IN WITH VOSPER
The young man in the heather-mixture plus fours, who for some
time had been pacing the terrace above the ninth green like an
imprisoned jaguar, flung himself into a chair and uttered a snort of
anguish.
“Women,” said the young man, “are the limit.”
The Oldest Member, ever ready to sympathise with youth in
affliction, turned a courteous ear.
“What,” he inquired, “has the sex been pulling on you now?”
“My wife is the best little woman in the world.”
“I can readily believe it.”
“But,” continued the young man, “I would like to bean her with a
brick, and bean her good. I told her, when she wanted to play a
round with me this afternoon, that we must start early, as the days
are drawing in. What did she do? Having got into her things, she
decided that she didn’t like the look of them and made a complete
change. She then powdered her nose for ten minutes. And when
finally I got her on to the first tee, an hour late, she went back into
the clubhouse to ’phone to her dressmaker. It will be dark before
we’ve played six holes. If I had my way, golf-clubs would make a
rigid rule that no wife be allowed to play with her husband.”
The Oldest Member nodded gravely.
“Until this is done,” he agreed, “the millennium cannot but be set
back indefinitely. Although we are told nothing about it, there can be
little doubt that one of Job’s chief trials was that his wife insisted on
playing golf with him. And, as we are on this topic, it may interest you
to hear a story.”
“I have no time to listen to stories now.”
“If your wife is telephoning to her dressmaker, you have ample
time,” replied the Sage. “The story which I am about to relate deals
with a man named Bradbury Fisher—”
“You told me that one.”
“I think not.”
“Yes, you did. Bradbury Fisher was a Wall Street millionaire who
had an English butler named Blizzard, who had been fifteen years
with an earl. Another millionaire coveted Blizzard, and they played a
match for him, and Fisher lost. But, just as he was wondering how he
could square himself with his wife, who valued Blizzard very highly,
Mrs. Fisher turned up from England with a still finer butler named
Vosper, who had been eighteen years with a duke. So all ended
happily.”
“Yes,” said the Sage. “You appear to have the facts correctly. The
tale which I am about to relate is a sequel to that story, and runs as
follows:
You say (began the Oldest Member) that all ended happily. That
was Bradbury Fisher’s opinion, too. It seemed to Bradbury in the
days that followed Vosper’s taking of office as though Providence,
recognising his sterling merits, had gone out of its way to smooth the
path of life for him. The weather was fine; his handicap, after
remaining stationary for many years, had begun to decrease; and his
old friend Rupert Worple had just come out of Sing-Sing, where he
had been taking a post-graduate course, and was paying him a
pleasant visit at his house in Goldenville, Long Island.
The only thing, in fact, that militated against Bradbury’s complete
tranquillity was the information he had just received from his wife that
her mother, Mrs. Lora Smith Maplebury, was about to infest the
home for an indeterminate stay.
Bradbury had never liked his wives’ mothers. His first wife, he
recalled, had had a particularly objectionable mother. So had his
second, third, and fourth. And the present holder of the title
appeared to him to be scratch. She had a habit of sniffing in a
significant way whenever she looked at him, and this can never
make for a spirit of easy comradeship between man and woman.
Given a free hand, he would have tied a brick to her neck and
dropped her in the water-hazard at the second; but, realising that this
was but a Utopian dream, he sensibly decided to make the best of
things and to content himself with jumping out of window whenever
she came into a room in which he happened to be sitting.
His mood, therefore, as he sat in his Louis Quinze library on the
evening on which this story opens, was perfectly contented. And
when there was a knock at the door and Vosper entered, no
foreboding came to warn him that the quiet peace of his life was
about to be shattered.
“Might I have a word, sir?” said the butler.
“Certainly, Vosper. What is it?”
Bradbury Fisher beamed upon the man. For the hundredth time,
as he eyed him, he reflected how immeasurably superior he was to
the departed Blizzard. Blizzard had been fifteen years with an earl,
and no one disputes that earls are all very well in their way. But they
are not dukes. About a butler who has served in a ducal household
there is something which cannot be duplicated by one who has
passed the formative years of his butlerhood in humbler
surroundings.
“It has to do with Mr. Worple, sir.”
“What about him?”
“Mr. Worple,” said the butler, gravely, “must go. I do not like his
laugh, sir.”
“Eh?”
“It is too hearty, sir. It would not have done for the Duke.”
Bradbury Fisher was an easy-going man, but he belonged to a
free race. For freedom his fathers had fought and, if he had heard
the story correctly, bled. His eyes flashed.
“Oh!” he cried. “Oh, indeed!”
“Yes, sir.”
“Is zat so?”
“Yes, sir.”
“Well, let me tell you something, Bill—”
“My name is Hildebrand, sir.”
“Well, let me tell you, whatever your scarlet name is, that no butler
is going to boss me in my own home. You can darned well go
yourself.”
“Very good, sir.”
Vosper withdrew like an ambassador who has received his papers;
and presently there was a noise without like hens going through a
hedge, and Mrs. Fisher plunged in.
“Bradbury,” she cried, “are you mad? Of course Mr. Worple must
go if Vosper says so. Don’t you realise that Vosper will leave us if we
don’t humour him?”
“I should worry about him leaving!”
A strange, set look came into Mrs. Fisher’s face.
“Bradbury,” she said, “if Vosper leaves us, I shall die. And, what is
more, just before dying I shall get a divorce. Yes, I will.”
“But, darling,” gasped Bradbury, “Rupert Worple! Old Rupie
Worple! We’ve been friends all our lives.”
“I don’t care.”
“We were freshers at Sing-Sing together.”
“I don’t care.”
“We were initiated into the same Frat, the dear old Cracka-Bitta-
Rock, on the same day.”
“I don’t care. Heaven has sent me the perfect butler, and I’m not
going to lose him.”
There was a tense silence.
“Ah, well!” said Bradbury Fisher with a deep sigh.
That night he broke the news to Rupert Worple.
“I never thought,” said Rupert Worple sadly, “when we sang
together on the glee-club at the old Alma Mater, that it would ever
come to this.”
“Nor I,” said Bradbury Fisher. “But so it must be. You wouldn’t have
done for the Duke, Rupie, you wouldn’t have done for the Duke.”
“Good-bye, Number 8,097,564,” said Rupert Worple in a low
voice.
“Good-bye, Number 8,097,565,” whispered Bradbury Fisher.
And with a silent hand-clasp the two friends parted.
With the going of Rupert Worple a grey cloud seemed to settle

upon the glowing radiance of Bradbury Fisher’s life. Mrs. Lora Smith
Maplebury duly arrived; and, having given a series of penetrating
sniffs as he greeted her in the entrance-hall, dug herself in and
settled down to what looked like the visit of a lifetime. And then, just
as Bradbury’s cup seemed to be full to overflowing, Mrs. Fisher drew
him aside one evening.
“Bradbury,” said Mrs. Fisher. “I have some good news for you.”
“Is your mother leaving?” asked Bradbury eagerly.
“Of course not. I said good news. I am taking up golf again.”
Bradbury Fisher clutched at the arms of his chair, and an ashen
pallor spread itself over his clean-cut face.
“What did you say?” he muttered.
“I’m taking up golf again. Won’t it be nice? We’ll be able to play
together every day.”
Bradbury Fisher shuddered strongly. It was many years since he
had played with his wife, but, like an old wound, the memory of it still
troubled him occasionally.
“It was Vosper’s idea.”
“Vosper!”
A sudden seething fury gripped Bradbury. This pestilent butler was
an absolute home-wrecker. He toyed with the idea of poisoning
Vosper’s port. Surely, if he were to do so, a capable lawyer could
smooth things over and get him off with, at the worst, a nominal fine.
“Vosper says I need exercise. He says he does not like my
wheezing.”
“Your what?”
“My wheezing. I do wheeze, you know.”
“Well, so does he.”
“Yes, but a good butler is expected to wheeze. A wheezing woman
is quite a different thing. My wheezing would never have done for the
Duke, Vosper says.”
Bradbury Fisher breathed tensely.
“Ha!” he said.
“I think it’s so nice of him, Bradbury. It shows he has our interests
at heart, just like a faithful old retainer. He says wheezing is an
indication of heightened blood-pressure and can be remedied by
gentle exercise. So we’ll have our first round to-morrow morning,
shall we?”
“Just as you say,” said Bradbury dully. “I had a sort of date to make
one of a foursome with three men at the club, but—”
“Oh, you don’t want to play with those silly men any more. It will be
much nicer, just you and I playing together.”
It has always seemed to me a strange and unaccountable thing

that nowadays, when gloom is at such a premium in the world’s
literature and all around us stern young pessimists are bringing
home the bacon with their studies in the greyly grim, no writer has
thought of turning his pen to a realistic portrayal of the golfing wife.
No subject could be more poignant, and yet it has been completely
neglected. One can only suppose that even modern novelists feel
that the line should be drawn somewhere.
Bradbury Fisher’s emotions, as he stood by the first tee watching
his wife prepare to drive off, were far beyond my poor power to
describe. Compared with him at that moment, the hero of a novel of
the Middle West would have seemed almost offensively chirpy. This
was the woman he loved, and she was behaving in a manner that
made the iron sink deep into his soul.
Most women golfers are elaborate wagglers, but none that
Bradbury had ever seen had made quite such a set of Swedish
exercises out of the simple act of laying the clubhead behind the ball
and raising it over the right shoulder. For fully a minute, it seemed to
him, Mrs. Fisher fiddled and pawed at the ball; while Bradbury,
realising that there are eighteen tees on a course and that this
Russian Ballet stuff was consequently going to happen at least
seventeen times more, quivered in agony and clenched his hands till
the knuckles stood out white under the strain. Then she drove, and
the ball trickled down the hill into a patch of rough some five yards
distant.
“Tee-hee!” said Mrs. Fisher.
Bradbury uttered a sharp cry. He was married to a golfing giggler.
“What did I do then?”
“God help you, woman,” said Bradbury, “you jerked your head up
till I wonder it didn’t come off at the neck.”
It was at the fourth hole that further evidence was afforded the
wretched man of how utterly a good, pure woman may change her
nature when once she gets out on the links. Mrs. Fisher had played
her eleventh, and, having walked the intervening three yards, was
about to play her twelfth when behind them, grouped upon the tee,
Bradbury perceived two of his fellow-members of the club. Remorse
and shame pierced him.
“One minute, honey,” he said, as his life’s partner took a
stranglehold on her mashie and was about to begin the movements.
“We’d better let these men through.”
“What men?”
“We’re holding up a couple of fellows. I’ll wave to them.”
“You will do nothing of the sort,” cried Mrs. Fisher. “The idea!”
“But, darling—”
“Why should they go through us? We started before them.”
“But, pettie—”
“They shall not pass!” said Mrs. Fisher. And, raising her mashie,
she dug a grim divot out of the shrinking turf. With bowed head,
Bradbury followed her on the long, long trail.
The sun was sinking as they came at last to journey’s end.
“How right Vosper is!” said Mrs. Fisher, nestling into the cushions
of the automobile. “I feel ever so much better already.”
“Do you?” said Bradbury wanly. “Do you?”
“We’ll play again to-morrow afternoon,” said his wife.
Bradbury Fisher was a man of steel. He endured for a week. But

on the last day of the week Mrs. Fisher insisted on taking as a
companion on the round Alfred, her pet Airedale. In vain Bradbury
spoke of the Green Committee and their prejudice against dogs on
the links. Mrs. Fisher—and Bradbury, as he heard the ghastly words,
glanced involuntarily up at the summer sky, as if preparing to dodge
the lightning-bolt which could scarcely fail to punish such blasphemy
—said that the Green Committee were a lot of silly, fussy old men,
and she had no patience with them.
So Alfred came along—barking at Bradbury as he endeavoured to
concentrate on the smooth pronation of the wrists, bounding ahead
to frolic round distant players who were shaping for delicate chip-
shots, and getting a deep toe-hold on the turf of each successive
green. Hell, felt Bradbury, must be something like this, and he
wished that he had led a better life.
But that retribution which waits on all, both small and great, who
defy Green Committees had marked Alfred down. Taking up a
position just behind Mrs. Fisher as she began her down swing on the
seventh, he received so shrewd a blow on his right foreleg that with
a sharp yelp he broke into a gallop, raced through a foursome on the
sixth green, and, charging across country, dived head-long into the
water-hazard on the second; where he remained until Bradbury, who
had been sent in pursuit, waded in and fished him out.
Mrs. Fisher came panting up, full of concern.
“What shall we do? The poor little fellow is quite lame. I know, you
can carry him, Bradbury.”
Bradbury Fisher uttered a low, bleating sound. The water had had
the worst effect on the animal. Even when dry, Alfred was always a
dog of powerful scent. Wet, he had become definitely one of the six
best smellers. His aroma had what the advertisement-writers call
“strong memory value.”
“Carry him? To the car, do you mean?”
“Of course not. Round the links. I don’t want to miss a day’s golf.
You can put him down when you play your shots.”
For a long instant Bradbury hesitated. The words “Is zat so?”
trembled on his lips.
“Very well,” he said, swallowing twice.
That night, in his du Barri bedroom, Bradbury Fisher lay sleepless

far into the dawn. A crisis, he realised, had come in his domestic
affairs. Things, he saw clearly, could not go on like this. It was not
merely the awful spiritual agony of playing these daily rounds of golf
with his wife that was so hard to endure. The real trouble was that
the spectacle of her on the links was destroying his ideals, sapping
away that love and respect which should have been as imperishable
as steel.
To a good man his wife should be a goddess, a being far above
him to whom he can offer worship and reverence, a beacon-star
guiding him over the tossing seas of life. She should be ever on a
pedestal and in a shrine. And when she waggles for a minute and a
half and then jerks her head and tops the ball, she ceases to be so.
And Mrs. Fisher was not merely a head-lifter and a super-waggler;
she was a scoffer at Golf’s most sacred things. She held up scratch-
men. She omitted to replace divots. She spoke lightly of Green
Committees.
The sun was gilding Goldenville in its morning glory when
Bradbury made up his mind. He would play with her no more. To do
so would be fair neither to himself nor to her. At any moment, he felt,
she might come out on the links in high heels or stop to powder her
nose on the green while frenzied foursomes waited to play their
approach-shots. And then love would turn to hate, and he and she
would go through life estranged. Better to end it now, while he still
retained some broken remains of the old esteem.
He had got everything neatly arranged. He would plead business
in the City and sneak off each day to play on another course five
miles away.
“Darling,” he said at breakfast, “I’m afraid we shan’t be able to
have our game for a week or so. I shall have to be at the office early
and late.”
“Oh, what a shame!” said Mrs. Fisher.
“You will, no doubt, be able to get a game with the pro or
somebody. You know how bitterly this disappoints me. I had come to
look on our daily round as the bright spot of the day. But business is
business.”
“I thought you had retired from business,” said Mrs. Lora Smith
Maplebury, with a sniff that cracked a coffee-cup.
Bradbury Fisher looked at her coldly. She was a lean, pale-eyed
woman with high cheek-bones, and for the hundredth time since she
had come into his life he felt how intensely she needed a punch on
the nose.
“Not altogether,” he said. “I still retain large interests in this and
that, and I am at the moment occupied with affairs which I cannot
mention without revealing secrets which might—which would—which
are—Well, anyway, I’ve got to go to the office.”
“Oh, quite,” said Mrs. Maplebury.
“What do you mean, quite?” demanded Bradbury.
“I mean just what I say. Quite!”
“Why quite?”
“Why not quite? I suppose I can say ‘Quite!’ can’t I?”
“Oh, quite,” said Bradbury.
He kissed his wife and left the room. He felt a little uneasy. There
had been something in the woman’s manner which had caused him
a vague foreboding.
Had he been able to hear the conversation that followed his
departure, he would have been still more uneasy.
“Suspicious!” said Mrs. Maplebury.
“What is?” asked Mrs. Fisher.
“That man’s behaviour.”
“What do you mean?”
“Did you observe him closely while he was speaking?”
“No.”
“The tip of his nose wiggled. Always distrust a man who wiggles
the tip of his nose.”
“I am sure Bradbury would not deceive you.”
“So am I. But he might try to.”
“I don’t understand, mother. Do you mean you think Bradbury is
not going to the office?”
“I am sure he is not.”
“You think—?”
“I do.”
“You are suggesting—?”
“I am.”
“You would imply—?”
“I would.”
A moan escaped Mrs. Fisher.
“Oh, mother, mother!” she cried. “If I thought Bradbury was untrue
to me, what I wouldn’t do to that poor clam!”
“I certainly think that the least you can do, as a good womanly
woman, is to have a capable lawyer watching your interests.”
“But we can easily find out if he is at the office. We can ring them
up on the ’phone and ask.”
“And be told that he is in conference. He will not have neglected to
arrange for that.”
“Then what shall I do?”
“Wait,” said Mrs. Maplebury. “Wait and be watchful.”
The shades of night were falling when Bradbury returned to his
home. He was fatigued but jubilant. He had played forty-five holes in
the society of his own sex. He had kept his head down and his eye
on the ball. He had sung negro spirituals in the locker-room.
“I trust, Bradbury,” said Mrs. Maplebury, “that you are not tired after
your long day?”
“A little,” said Bradbury. “Nothing to signify.” He turned radiantly to
his wife.
“Honey,” he said, “you remember the trouble I was having with my
iron? Well, to-day—”
He stopped aghast. Like every good husband it had always been
his practice hitherto to bring his golfing troubles to his wife, and in
many a cosy after-dinner chat he had confided to her the difficulty he
was having in keeping his iron-shots straight. And he had only just
stopped himself now from telling her that to-day he had been hitting
’em sweetly on the meat right down the middle.
“Your iron?”
“Er—ah—yes. I have large interests in Iron—as also in Steel, Jute,
Woollen Fabrics, and Consolidated Peanuts. A gang has been trying
to hammer down my stock. To-day I fixed them.”
“You did, did you?” said Mrs. Maplebury.
“I said I did,” retorted Bradbury, defiantly.
“So did I. I said you did, did you?”
“What do you mean, did you?”
“Well, you did, didn’t you?”
“Yes, I did.”
“Exactly what I said. You did. Didn’t you?”
“Yes, I did.”
“Yes, you did!” said Mrs. Maplebury.
Once again Bradbury felt vaguely uneasy. There was nothing in
the actual dialogue which had just taken place to cause him alarm—
indeed, considered purely as dialogue, it was bright and snappy and
well calculated to make things gay about the home. But once more
there had been a subtle something in his mother-in-law’s manner
which had jarred upon him. He mumbled and went off to dress for
dinner.
“Ha!” said Mrs. Maplebury, as the door closed.
Such, then, was the position of affairs in the Fisher home. And
now that I have arrived thus far in my story and have shown you this
man systematically deceiving the woman he had vowed—at one of
the most exclusive altars in New York—to love and cherish, you—if
you are the sort of husband I hope you are—must be saying to
yourself: “But what of Bradbury Fisher’s conscience?” Remorse, you
feel, must long since have begun to gnaw at his vitals; and the
thought suggests itself to you that surely by this time the pangs of
self-reproach must have interfered seriously with his short game,
even if not as yet sufficiently severe to affect his driving off the tee.
You are overlooking the fact that Bradbury Fisher’s was the trained
and educated conscience of a man who had passed a large portion
of his life in Wall Street; and years of practice had enabled him to
reduce the control of it to a science. Many a time in the past, when
an active operator on the Street, he had done things to the Small
Investor which would have caused raised eyebrows in the fo’c’sle of
a pirate sloop—and done them without a blush. He was not the man,
therefore, to suffer torment merely because he was slipping one over
on the Little Woman.
Occasionally he would wince a trifle at the thought of what would
happen if she ever found out; but apart from that, I am doing no
more than state the plain truth when I say that Bradbury Fisher did
not care a whoop.
Besides, at this point his golf suddenly underwent a remarkable
improvement. He had always been a long driver, and quite abruptly
he found that he was judging them nicely with the putter. Two weeks
after he had started on his campaign of deception he amazed
himself and all who witnessed the performance by cracking a
hundred for the first time in his career. And every golfer knows that in
the soul of the man who does that there is no room for remorse.
Conscience may sting the player who is going round in a hundred
and ten, but when it tries to make itself unpleasant to the man who is
doing ninety-sevens and ninety-eights, it is simply wasting its time.
I will do Bradbury Fisher justice. He did regret that he was not in a
position to tell his wife all about that first ninety-nine of his. He would
have liked to take her into a corner and show her with the aid of a
poker and a lump of coal just how he had chipped up to the pin on
the last hole and left himself a simple two-foot putt. And the forlorn
feeling of being unable to confide his triumphs to a sympathetic ear
deepened a week later when, miraculously achieving ninety-six in
the medal round, he qualified for the sixth sixteen in the annual
invitation tournament of the club to which he had attached himself.
“Shall I?” he mused, eyeing her wistfully across the Queen Anne
table in the Crystal Boudoir, to which they had retired to drink their
after-dinner coffee. “Better not, better not,” whispered Prudence in
his ear.
“Bradbury,” said Mrs. Fisher.
“Yes, darling?”
“Have you been hard at work to-day?”
“Yes, precious. Very, very hard at work.”
“Ho!” said Mrs. Maplebury.
“What did you say?” said Bradbury.
“I said ho!”
“What do you mean, ho?”
“Just ho. There is no harm, I imagine, in my saying ho, if I wish to.”
“Oh, no,” said Bradbury. “By all means. Not at all. Pray do so.”
“Thank you,” said Mrs. Maplebury. “Ho!”
“You do have to slave at the office, don’t you?” said Mrs. Fisher.
“I do, indeed.”
“It must be a great strain.”
“A terrible strain. Yes, yes, a terrible strain.”
“Then you won’t object to giving it up, will you?”
Bradbury started.
“Giving it up?”
“Giving up going to the office. The fact is, dear,” said Mrs. Fisher,
“Vosper has complained.”
“What about?”
“About you going to the office. He says he has never been in the
employment of any one engaged in commerce, and he doesn’t like it.
The Duke looked down on commerce very much. So I’m afraid,
darling, you will have to give it up.”
Bradbury Fisher stared before him, a strange singing in his ears.
The blow had been so sudden that he was stunned.
His fingers picked feverishly at the arm of his chair. He had paled
to the very lips. If the office was barred to him, on what pretext could
he sneak away from home? And sneak he must, for to-morrow and
the day after the various qualifying sixteens were to play the match-
rounds for the cups; and it was monstrous and impossible that he
should not be there. He must be there. He had done a ninety-six,
and the next best medal score in his sixteen was a hundred and one.
For the first time in his life he had before him the prospect of winning
a cup; and, highly though the poets have spoken of love, that
emotion is not to be compared with the frenzy which grips a twenty-
four handicap man who sees himself within reach of a cup.
Blindly he tottered from the room and sought his study. He wanted
to be alone. He had to think, think.
The evening paper was lying on the table. Automatically he picked
it up and ran his eye over the front page. And, as he did so, he
uttered a sharp exclamation.
He leaped from his chair and returned to the boudoir, carrying the
paper.
“Well, what do you know about this?” said Bradbury Fisher, in a
hearty voice.

Interpersonal Relationships Professional Communication Skills For Nurses 7Th Edition Elizabeth Arnold Full Chapter

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Interpersonal Relationships:

Professional Communication Skills for

PART II ESSENTIAL COMMUNICATION SKILLS

PART III THERAPEUTIC INTERPERSONAL RELATIONSHIP SKILLS

PART IV COMMUNICATING TO FOSTER HEALTH LITERACY, HEALTH PROMOTION AND PREVENTION

PART V ACCOMMODATING CLIENTS WITH SPECIAL COMMUNICATION NEEDS

PART VI COLLABORATIVE AND PROFESSIONAL COMMUNICATION

Family Nurse Psychotherapist

Kathleen Underman Boggs, PhD, FNP-CS

INTERPERSONAL RELATIONSHIPS: PROFESSIONAL

International Standard Book Number: 978-0-323-24281-3

Content Strategist: Jamie Randall

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Sydney Lavarnway, may you find strong mentors.

Shari Kist, PhD, RN, CNE

Theory Based Perspectives and

C hapter 1 identifies selected conceptual frameworks

to nursing practice, education, and research didn’t

EXERCISE 1-1 The Meaning of Health as a Nursing Concept

EXERCISE 1-2 What Is Professional Nursing?

Concept of Nursing participation in shaping health policy and in patient

EXERCISE 1-3 Patterns of Knowing in Clinical Practice

Caring As professional nurses assume broader leadership roles

Situational contextual inputs

Interpersonal personal contextual concepts

Figure 1-1 Transactional model of communication.

EXERCISE 1-4 Comparing Linear and Transactional Models of Communication

Spiritual distress, anxiety,

Powerlessness Self-esteem: chronic low,

Social isolation, Family coping:

Ventilation, impaired spontaneous;

EXERCISE 1-5 Maslow’s Hierarchy of Needs

ISSUES RELATED TO HEALTH CARE REFORM

BOX 1-2 Pew Commission’s Recommendations to Nursing Programs: 21 Nursing

needed to secure a key player role for nurses in the new

Professional Guides for Nursing

TABLE 2-1 QSEN’s Six Prelicensure Competencies, Deﬁnitions,

QSEN, Quality and Safety Education for Nurses.

EXERCISE 2-1 Applying the Code of Ethics for Nurses to Professional

can access specific journal research articles using any

Developing an Evidence-Based Practice

TABLE 2-2 Relationship of the Nursing Process to Professional Nursing Standards

With the going of Rupert Worple a grey cloud seemed to settle

It has always seemed to me a strange and unaccountable thing

Bradbury Fisher was a man of steel. He endured for a week. But

That night, in his du Barri bedroom, Bradbury Fisher lay sleepless

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