Caring in Nursing Practice, Culture and Ethnicity
Ethics and Values, Stress and Coping
NURSING’S THERAPEUTIC VALUE
Nursing is both an art and a science that leads to therapeutic outcomes in clients. The term therapeutic describes actions that are beneficial to the client.
Definition of Nursing
According to the American Nurses Association (ANA) (1995), nursing is defined as “the diagnosis and treatment of human responses to actual or potential health problems” (p. 9). This definition places nursing’s focus on the individual experiencing a health problem rather than on the problem (or disease) itself—that is, on caring for clients as they deal with health issues. Fitzpatrick (1983) perceives nursing “as facilitating the developmental process toward health, thereby helping clients to more fully develop their human potential” (p. 296). The idea of helping persons to grow and achieve their potential is pivotal iursing.
The Canadian Nurses Association (1986), similarly, describes nursing as a caring relationship that helps the client achieve and/or maintain an optimal level of health.
Nursing: A Blend of Art and Science
Nursing creates therapeutic change through the application of scientific principles. As the science of nursing has rapidly progressed over the past decade, nurse theorists have formulated various frameworks by which to organize nursing’s unique body of knowledge. While continuing to expand its theoretical base, nursing must remain firmly rooted in its essence—caring. In other words, nursing does not rely on science alone. The “art” of nursing refers to the caring, compassionate manner in which interventions are performed. “Nursing art is defined as helping patients create coherence in lives threatened by illness and change” (LeVasseur, 1999, p. 48). A prerequisite for the nursing art is the nurse’s committment to helping the client; this trait is also referred to as intentionality. As Isenalumhe (2000) states: Therapeutic use of self marks the art of nursing as different from the science of nursing. . . . The theories, concepts, and standard procedural techniques for clinical performance or practice in any profession constitute its scientific base. . . . The art of nursing can be learned, through shared, as well as hands-on, experience. (p. 25)
Purposes of Nursing
A therapeutic relationship is one that benefits the client’s health status. The therapeutic relationship is based on the belief that a person has a natural drive toward optimal health. Caring—being willing and able to nurture others—is an attribute of the effective nurse. Curing rids the client of the disease or disability; caring nurtures the person even if the disorder is incurable. When it is understood that complete, or perhaps even partial, recovery is not possible, nursing goals focus on facilitating comfort by alleviating pain and promoting as much client autonomy as possible. Nursing promotes healthy lifestyle behaviors, prevents the development of illness and/or injury, and restores individuals to their optimal level of functioning.
Another purpose of nursing is to improve client satisfaction with the delivery of health care services. Consumer satisfaction greatly influences where services are provided. “Nurse caring is an important predictor of patient satisfaction” (Dingman, Williams, Fosbinder, and Warnick, 1999, p. 30). Nurses who demonstrate caring behaviors enhance the quality of care provided; thus, clients are more satisfied with the care delivered in a caring, compassionate manner. The accompanying display lists some specific caring behaviors.
Caring behaviors demonstrated iursing practice
• Demonstration of concern
• Anticipation of client needs
• Providing preprocedural information
• Alleviation of anxiety and fear
• Effective communication
• Responding to client requests
(Data modified from Dingman, S. K., Williams, M., Fosbinder, D., & Warnick, M. [1999]. Implementing a caring model to improve patient satisfaction. Journal of Nursing Administration, 29(12), 30–37.)
Nursing: A Healing Modality
As stated by LeVasseur (1999), “Nurses endeavor to nurse patients through an illness to a satisfactory outcome, whether this is regaining health and function or coping with disability or the ultimate transition of a peaceful death” (p. 61).
Nursing is a humanistic discipline that provides care from a holistic framework. Seeing and responding to the client as a whole person instead of a disease, disorder, or case leads to complete care of the total person.
Healing is the process of recovery from illness, accident, or disability. This return to an optimum level of functioning may occur rapidly or gradually. Healing encompasses the physical, emotional, and spiritual domains of individuals. Nursing and caring are essential components in the healing process. See Chapter 15 for further discussion of nurses as healers.
CARING: AN INTEGRAL COMPONENT OF NURSING
Caring is a universal value that directs nursing practice. Leininger (1981) defines caring in the nurse-client relationship as “the direct (or indirect) nurturant and skillful activities, processes, and decisions related to assisting people to achieve or maintain health.” Even though clients cannot always be cured, caring is ongoing within the nurse-client relationship.
There are numerous concepts relative to caring iursing. Some major ideas related to caring have been postulated in Watson’s Theory of Human Caring,
Leininger’s Theory of Transcultural Caring, and Benner’s Novice to Expert model.
The following carative factors are directly related to the science of caring (Watson, 1999):
• Developing a humanistic-altruistic value system
• Nurturing faith-hope
• Cultivating sensitivities to one’s self and others
Leininger identifies several behaviors as caring and states that these behaviors occur in various cultures; see the accompanying display.
Caring—being willing and able to nurture others—is a hallmark of the effective nurse. Caring occurs when a nurse acts in a genuine, authentic manner with the client. The professional mask is removed, allowing the nurse to respond in a compassionate manner. Providing emotional support is central to the act of caring.
Caring is more than an intuitive process; it can be learned both intellectually and interpersonally. One learns caring by interacting with others who demonstrate caring. Wheurses exhibit caring behaviors, they are serving as role models—to students, colleagues, clients, and families. Caring is a process and an art that requires commitment and knowledge. Caring is a combination of behaviors and attitudes. The way in which nursing actions are implemented expresses caring. Specific behaviors that indicate caring are provision of information, relief of pain, spending time with clients and families, and promoting client autonomy. Treating each client in a dignified, courteous manner is the true expression of caring. Touch is an effective method for communicating a sense of caring.
Touch, no matter how well intended, may sometimes be misinterpreted by a client. Therefore, it is wise to avoid touching clients who are suspicious, hostile, or very confused.
Dingman et al. (1999) described the following as nursing behaviors that demonstrate caring:
• Introduce self to client.
• Call clients by their preferred names.
• Spend time with the client to review the plan of care.
Care in the High-Tech Environment
Caring is the soul of nursing. It is what clients want and need most from nurses. Although technological advances have resulted in many possibilities in health care, the major risk of reliance on technology is that clients can be perceived as objects. The focus of attention becomes the disease, instead of the individual experiencing the illness. The professional nurse treats each client with respect and dignity because “persons in a technologically driven health care system will feel the need to be comforted, listened to, and treated with the utmost dignity and respect”.
Depersonalization is the process in which individuals are treated as objects instead of people. Some dehumanizing actions are checking on the equipment and not the person, failing to respond to the client, or communicating a lack of interest in what the client says.
Nursing care counteracts depersonalization by seeing that “technology can be used so that care is person focused rather than technologically focused”.
The reason people are admitted to acute care facilities is to receive nursing care. Most diagnostic testing, treatment procedures, and some surgical interventions can be performed in outpatient settings such as clinics or physicians’ offices. While receiving care, people want to be treated with compassion. The nontechnical element of care makes clients feel cared for as individuals; the use of high-touch activities communicates caring. As society continues to place a high value on technology, caring is often undervalued. Nursing makes a crucial contribution by valuing both care and technology.
Ideally, “in the best of nursing practice, science and technology are only the tools for caring” (Benner & Wrubel, 1989, p. 211). Nursing care counteracts depersonalization by emphasizing a client’s individuality. It is through caring that the nurse humanizes the client.
Simpson (1999) states, “no matter how advanced we get technologically, humans and human interaction are at the core of everything that humans do” (p. 33).
NURSE-CLIENT RELATIONSHIP
Caring is communicated interpersonally, thus the vehicle for communicating a caring intent is the nurse-client relationship.
The nurse-client relationship is the one-to-one interactive process between client and nurse that is directed at improving the client’s health status or assisting in problem solving. The primary goal of the relationship is the client’s achievement of therapeutic outcomes. The nurse-client relationship is a planned process that focuses on meeting the needs of the client. There are many differences between the therapeutic nurse-client relationship and a social relationship
The interactive process between client and nurse greatly influences the client’s progress in healing. Peplau (1952), the first nurse theorist to define nursing as an interpersonal process, viewed the nurse-client relationship as the basis of nursing. Interpersonal skills are the foundation for establishing the therapeutic relationship.
Only through interacting does the nurse have the ability to adequately assess the client’s needs, teach methods for best meeting those needs, empower the client to achieve goals, and evaluate the outcome of nursing interventions.
Phases of Therapeutic Relationship
The three phases of the nurse-client relationship are orientation, working, and termination. These phases overlap and influence each other. Each phase is characterized by specific client behaviors and nursing goals. Figure 11-3 illustrates the phases of the interactive relationship.
Orientation Phase
The orientation (or introductory) phase is the first stage of the therapeutic relationship, in which the nurse and client become acquainted with each other, establish trust, and determine the expectations of the other.
Usually, the only knowledge the client and nurse have of each other is preconceived ideas. The nurse gets to know the client as an individual by giving up biases and judgmental thoughts. This stage is especially important because it is the time in which the foundation for the relationship is established.
The most important nursing goal during the orientation phase is to assess the client—to determine the client’s needs, knowledge base, strengths and limitations, coping mechanisms, and support system. Often clients do not express their needs directly; behavior is the only clue to their needs. The nurse’s goal is to determine the real meaning of the behavior and to assess the client’s perception of the most crucial needs and problems.
To reduce a client’s anxiety and promote trust, the nurse provides some specific information. Information the client should receive during the orientation phase includes:
• Nurse’s name
• Nurse’s role
• Confidentiality and its parameters
• Reasons the nurse must ask questions
The usual response of the client in the orientation stage is anxiety, which can result from several factors:
• Fear of the unknown
• Pain or distress
• Unfamiliar environment
• Undergoing unfamiliar, often painful, procedures
• Loss of freedom
As a result of the client’s insecurity, anxiety escalates.
Because anxiety is communicated interpersonally, the nurse should project a calm, relaxed attitude during every interaction with the client to decrease anxiety.
Another behavior frequently exhibited by the client during the orientation stage is testing. The client attempts to determine the degree of the nurse’s trustworthiness. Through behavior, the client is asking:
• Is the nurse truly willing to help?
• Is the nurse competent to help?
• Is the nurse reliable and trustworthy?
The nurse answers such questions through consistent, reliable behavior which promotes the development of trust.
Working Phase
The working phase is the second stage of the therapeutic relationship in which problems are identified, goals are established, and problem-solving methods are selected. Actions are chosen after carefully considering both the consequences of actions and the client’s values. It is necessary to consider the client’s value system when determining problem-solving methods. Client participation increases when consideration of values is incorporated into care planning. See Chapter 16 for a complete discussion of the concepts of culture, one of which is a system of dominant values.
The client engages with the nurse in active problem solving to achieve mutually developed outcomes. The nurse seeks to maximize the client’s success in problem solving. Behaviors that indicate the client is in the working phase are:
• Asking questions about own problems
• Seeking clarification from the nurse
• Being attentive to instructions
• Asking for more information about his role in recovery
Nursing goals to be achieved during the working phase are to:
• Reevaluate goals and related activities as new information arises
• Support realistic problem-solving activities of the client
Termination Phase
The termination phase is the third and final stage of the of the therapeutic relationship. It focuses on the evaluation of goal achievement and effectiveness of treatment.
It is important that the client has been prepared for the final stage of the relationship by encouraging discussion of feelings. Some clients welcome this final phase, whereas other clients who have become overly dependent on their nurse will be more resistant to saying goodbye.
Planning for termination is actually initiated during the beginning of the relationship. A relationship that ends abruptly is likely to place the client at risk for difficulties such as increased:
• Anxiety levels
• Frustration
• Suspiciousness
• Unwillingness to engage in future relationships with health care providers
Evaluation is the primary goal for the client and nurse in the third stage of the nurse-client relationship.
Questions to be answered include:
• Were the goals meaningful?
• Were the goals realistic?
• Were the client and family actively involved?
The following nursing checklist can be used to evaluate skill in establishing a therapeutic nurse-client relationship.
THERAPEUTIC USE OF SELF
The interpersonal process betweeurse and client is a therapeutic process because interventions are planned and implemented to benefit the client. The nurse’s most effective tool for bringing about positive change is the therapeutic use of self, a process in which nurses deliberately plan their actions and approach the relationship with a specific goal in mind before interacting with the client. The nurse’s most effective tool for demonstrating caring is not some technologically sophisticated machine with lights and alarms but rather one’s self. Figure 11-4 illustrates therapuetic use of self. Therapeutic use of self is “an opportunity for the nurse to be with persons at a human-to-human level” (Bernado, 1998, p. 48). The term presence refers to the process of “just being with” another. According to Bulechek and McCloskey (1985), presence is “a therapeutic tool of the nurse an intervention instrument by merely remaining physically present with the patient” (p. 31).
Therapeutic use of self involves verbal and nonverbal communication. Just as important as what one says is how one says it. In this deliberate, planned approach, the nurse communicates a sense of caring and willingness to help: the nurse is committed to helping clients find ways to help themselves. The nurse’s true expression of humanistic concern for a client is shown by taking the time to simply “be with” the client. Watson (1988) describes therapeutic use of self as the transpersonal aspect of nursing, that is, “an intersubjective human-to-human relationship in which the person of the nurse affects and is affected by the person of the other. Both are fully present in the moment and feel a union with the other” (p. 32).
CHARACTERISTICS OF THERAPEUTIC RELATIONSHIPS
“The route to therapeutic support for any client starts with establishing a positive relationship” (Isenalumhe, 2000, p. 25). To establish therapeutic relationships, the nurse must possess certain interpersonal skills (listed in the accompanying display), in order to encourage the client’s expression of feelings.
The term catharsis, which refers to the relief experienced from verbalizing one’s problems, is illustrated in Figure 11-5. This “getting things off one’s chest” is a universal experience that is therapeutic for individuals experiencing anxiety. Nurses use interpersonal skills to help clients meet their needs. A discussion of each characteristic follows.
Warmth
Warmth means exhibiting positive behaviors toward the client. Respect, genuine interest, caring—all are expressions of warmth. The nurse who demonstrates warmth is approachable and available rather than aloof. Warmth means projecting a friendly, interested attitude without overwhelming the client with a false sense of cheerfulness.
The nurse demonstrating warmth responds to the client as one human being to another. The therapeutic nurse is approachable and available yet maintains objective boundaries.
Hope
Hope means anticipating the future by helping clients look realistically at their potential. Hope is strengthened by relationships with others; social isolation reinforces a sense of despair. Many clients, especially those with great losses, experience distress, despair, and hopelessness. The reemergence of hope may be a gradual process. Hope is not to be confused with false reassurance. “Hope is the energy source that allows individuals to plan, act, and achieve” (Forbes, 1994, p. 6).
Rapport
Rapport is a bond or connection between two people that is based on mutual trust. Such a bond does not just happen spontaneously; it is planned by the nurse who purposefully implements behaviors that promote trust.
The nurse sets the tone of the relationship by creating an atmosphere in which the client feels free to express feelings. When seeking to establish trust, the nurse recognizes the client as a unique individual and reinforces that individuality. In other words, actions that humanize the client are therapeutic. To establish rapport, the nurse’s actions show that the client is considered important.
Actions are implemented to boost the level of the client’s self-esteem. Nonverbal interventions are of utmost importance in helping establish rapport.
Interacting with family and significant others is also helpful in establishing rapport with the client (Figure 11-6). Recognizing the importance of the family’s influence on the healing process allows the nurse to bond with those who will encourage and support the client.
Trust
Trust must be present for help to be given and received. A therapeutic relationship is firmly rooted in trust. How does the nurse promote a trusting relationship? Three major activities will facilitate the development of trust: consistency, respect, and honesty. Table 11-3 lists actions that facilitate the development of trust. Being consistently trustworthy is an expression of the nurse’s personal integrity and builds the foundation for nursing effectiveness.
Empathy
Empathy—understanding another person’s perception of the situation—is a key element in the therapeutic relationship.
The phrase “Walk a mile in my shoes” describes empathy well. The empathic nurse understands that the client’s perception of the situation is real to the client. By perceiving clients’ understanding of their oweeds, the nurse is better able to assist clients in determining what will work best. Empathy enables the nurse to assist the client to become a fully participating partner in treatment rather than a passive recipient of care.
Through empathy, the nurse validates the experiences of the client. The challenge for the nurse is to see the world from the client’s perspective with as much understanding as possible. Empathy is not the same as sympathy. Sympathy is rarely therapeutic; in fact, a barrier occurs when the nurse is caught in sympathy and becomes paralyzed by the expression of pity. For example, through empathic listening does the nurse encourage the client to find meaning in his experience and move on to problem solving.
Acceptance
Accepting the client as a person worthy of dignity and respect is basic to providing nursing care. Acceptance means accepting and working with clients, even those who sometimes exhibit undesirable behaviors. It is extremely important for the nurse to show acceptance of the client while setting limits on unhealthy or undesirable behavior. The accepting nurse conveys the message that the client does not have to put on a front. The client knows it is safe to be genuine because of the nurse’s acceptance.
Acceptance means caring for individuals whose value system may differ greatly from that of the nurse and not expressing shock or surprise at the client’s behavior.
Active Listening
Active listening (listening that focuses on the feelings of the individual who is speaking) is the basic skill for interpersonal effectiveness. Active listening is facilitated by attending behaviors, a set of nonverbal listening skills that conveys interest in what the other person is saying.
These behaviors allow the nurse to show caring, concern, and acceptance. Behaviors such as sitting down, maintaining eye contact, facing the client, and head nodding facilitate the development of trust. Active listening requires the nurse to turn down inner dialogue. Total attention must be focused on what the client is saying.
Also, it is important for the nurse to avoid looking rushed or distracted. The primary message that is communicated through active listening is the nurse’s concern and intent to assist in problem solving. Active listening is required in every nurse-client relationship.
The active listener is cognizant of all three elements of communication: the verbal, paraverbal, and nonverbal. The verbal message is what is said.
Paraverbal communication is the way in which a person speaks, including voice tone, pitch, and inflection, and the nonverbal message is body language. The active listener pays attention to all three aspects to hear the true intent of the communicator.
Active listening means that the nurse focuses on the feelings behind the words, not just the words themselves. It is important for the nurse to note any incongruities between the client’s verbal and nonverbal messages. For example, if the client says, “Oh, I’m just fine!” and is slumped over with head hanging down, there is an incongruity—the behavior and the words do not match.
The client’s expression of feelings demonstrates trust in the nurse. This expression of trust must be recognized and respected. By listening carefully to the client, the nurse is able to learn what the client perceives as the most crucial problem. Listening is the first step in personalizing care for each client. Listening can improve client outcomes.
Humor
Humor is another characteristic of therapeutic nurses. The use of humor as a therapeutic intervention is not a new concept for nurses. Nightingale (1860) recognized the influence of the mind on the body and acknowledged humor as an important nursing intervention.
As shown in Figure 11-7, humor can assist in establishing a relationship because it helps break the ice, decreases fear, and establishes trust. Humor is a medium for sharing; thus, it can be used to strengthen the therapeutic relationship.
Humor is defined to a great deal by one’s cultural background, so it is imperative that the nurse be sensitive to the client’s interpretation and use of humor. A humor assessment can be conducted by noting:
• What makes the client smile or laugh
• The use of jokes by clients
• Type of humor expressed by the client
Humor is a powerful tool for coping. Humor helps individuals to relieve stress and to express anger in a socially acceptable manner.
Nurses turn to humor to defuse the stress of the lifeand-death situations that they face on a daily basis.
Although humor can relieve tension and stabilize highstress situations, it must be used with caution. It can be dangerous and destructive if used carelessly.
Compassion
Compassion is truly caring about what happens to another person. Kindness and genuine concern are demonstrated through compassionate acts. Some behaviors that communicate the nurse’s compassion include:
• Acting on the belief that everyone is equally deserving of care.
• Treating individuals with dignity.
• Respecting a client’s privacy—simple acts such as keeping the client covered and knocking on the door before entering the room show compassion.
Other examples of compassion are a nurse caring for the homeless in a shelter or holding the hand of a person with acquired immunodeficiency syndrome (AIDS).
Self-Awareness
Self-awareness is necessary for the nurse to be therapeutic. Being aware of one’s feelings is the first step in developing therapeutic behavior. Knowledge of one’s assets is necessary in that effective nurses are able to identify their own skills and abilities. Conversely, only after identifying deficits in knowledge and skills can the nurse initiate necessary improvements. This process of analyzing one’s strengths and limitations is an ongoing basic part of learning. The therapeutic nurse knows that learning is a lifelong process that contributes to growth—personally and professionally. Self-awareness allows the nurse to remain objective, that is, separate enough to distinguish one’s own feelings and needs from those of the client.
Nonjudgmental Approach
Nonjudgmental behavior must be used if nursing interventions are to be therapeutic. Nonjudgmental means acting without biases, preconceptions, or stereotypes.
Nonjudgmental nurses do not evaluate the client’s moral values nor tell the client what to do; these nurses accept people as they are. Nonjudgmental nurses do not stereotype people, nor expect others to behave in certain ways because they belong to a certain group. Judgment influences perceptions because people tend to see what they expect to see.
According to Sayer (1992, p. 48): We see individuals as being representative of a social group. Here our own stereotypes and prejudices about the group come into play. Individuals may be seen as a representative of race, age group, socioeconomic level, gender, occupation, or disability. They will then be given the characteristics we believe people in that group have.
Judgmental behavior based on biases can interfere with the therapeutic value of nursing interventions. It is nontherapeutic for nurses to allow biased views that stem from personal values to influence their actions. The initial assessment of clients is often influenced by preconceived ideas.
Becoming nonjudgmental is an ongoing process. In a classic article, Blumenstock (1970, p. 37) stated: Becoming nonjudgmental is hard work and a life time process, for none of us is ever free of judgmental feelings arising from our own evolving values. Thus, each of us is always in a state of “becoming.”
There are several steps in becoming nonjudgmental:
• The first step is the most difficult—recognizing that one’s thought are biased and prejudicial.
• Second, to change, nurses must accept their own feelings.
• The third step is identifying the source of the negative feelings—not to blame but to gain an understanding of the origins.
To counter such negative feelings, learn about different cultures. Getting to know people with diverse cultural backgrounds expands the knowledge base and helps one become more tolerant and open-minded.
Flexibility
Flexibility is another trait necessary for nurses to create a therapeutic relationship. A flexible nurse is one who is ready for the unexpected—knowing that every day is filled with unplanned events and situations. The flexible nurse is able to adapt by “taking things in stride” and making necessary adjustments. Some of the unexpected events require immediate actions. The flexible nurse is able to establish priorities by determining which needs are urgent and which can be tended to later. Staying calm during a crisis is characteristic of the flexible nurse.
Risk-Taking
Risk-taking is a behavior that leads to innovative problem solving. To become effective risk-takers, nurses must give themselves permission to try something new, to step outside the ordinary, and to not be bound by tradition or fear. The result is creative solutions to problems.
Successful risk-takers give themselves credit for trying something new regardless of the outcome. Smart risktakers learn from those risk-taking ventures that are less than successful. They do not allow themselves to become complacent, content to stay at a comfortable plateau.
THERAPEUTIC VALUE OF THE NURSING PROCESS
The nursing process provides a framework for the delivery of compassionate care. It gives direction by organizing the nurse’s actions: assessing, diagnosing, planning, implementing, and evaluating.
The nursing process itself is therapeutic because it focuses on the client’s response to illness, disease, or disability rather than just on the problem. By focusing on the caring aspects, the nursing process helps nursing define its practice. Professional accountability is reinforced by the use of this process, which is client-centered.
When functioning within the parameters of the nursing process, the nurse assumes a variety of roles.
NURSING ROLES
A role is a set of expected behaviors associated with a person’s status or position. Role includes behaviors, rights, and responsibilities. Nurses function in a variety of roles every day (see the accompanying display). Often roles overlap, which may lead to a conflict in expectations or responsibilities. A discussion of some predominant nursing roles follows.
Caregiver
The caregiver is the role most commonly associated with nursing by the general public. In the role of caregiver, the nurse provides direct care when clients are unable to meet their oweeds. Specific activities characteristic of the caregiver role include feeding, bathing, and administering medications.
Counselor
When acting as a counselor, the nurse assists clients with problem identification and resolution. The counselor facilitates client action and does not tell clients what to do but assists clients to make their own decisions.
Counseling is done to help clients increase their coping skills. Clients are frequently counseled in stress management, how to deal with chronic conditions, grief and bereavement. Effective counseling is holistic, in that it addresses the individual’s emotional, psychological, spiritual, and cognitive dimensions.
Teacher
Teaching is an intrinsic part of nursing. The nurse views each interaction as an opportunity for education; both client and nurse can learn something from every
encounter with each other. Teaching by nurses can be formal, informal, intentional, or incidental.
Client Advocate
A client advocate is a person who speaks up for or acts on behalf of the client. Advocacy empowers clients to be partners in the therapeutic process rather than passive recipients of care. The relationship that encourages client empowerment is one of mutual participation by client and nurse. Clients and families are actively involved in establishing goals.
Frequently, clients and families do not communicate their concerns to physicians but will do so to the nurse with whom a bond has been established. Nurses function as client advocates by listening and communicating the expressed concerns to other health care providers and including those concerns into care planning.
Change Agent
Nurses who function in the role of change agent recognize that change is a complex process. The nurse change agent is proactive (takes the initiative to make things happen) rather than reactive (responding to things after they have happened). Change should not be done in a random manner. It should be planned carefully and implemented in a deliberate way to facilitate the client’s progress.
Team Member
A vital role of the nurse is that of team member. The nurse does not function in isolation but rather works with other members of the health care team. Collaboration requires the nurse to use effective interpersonal skills and promotes continuity of care.
Resource Person
The nurse functions as a resource person by providing skilled intervention and information. Identifying resources and making referrals as needed also fall under the auspices of this role. Nurses must consider the client strengths and access to resources, including physical, intellectual, economic, social, and environmental.
KEY CONCEPTS
• Caring is the fundamental value iursing.
• Today’s “high-tech” environment requires that nurses provide humanistic caring.
• The therapeutic nurse-client relationship is the one-to-one interactive process between client and nurse that is directed at improving the client’s health status or assisting in problem solving.
• Therapeutic relationships differ from social relationships in that they are deliberately planned, focus on client problems, and communicate acceptance of the client.
• Nursing is an interpersonal process between someone who needs help in meeting needs and someone who is competent to assist in meeting those needs.
• The three interwoven phases of the nurse-client relationship are orientation, working, and termination.
• Therapeutic use of self is a process in which nurses deliberately plan their actions and approach the relationship with a specific goal in mind before interacting with the client.
• Several interpersonal characteristics and skills can be developed to increase the therapeutic value of a nurse’s interventions. These include warmth, hope, rapport, trust, empathy, acceptance, active listening, humor, compassion, awareness, nonjudgmental attitude, flexibility, and risk-taking.
• The nursing process is the framework for providing compassionate care.
• Nurses function in a variety of roles when working with clients. The roles overlap and have specific responsibilities.
CULTURE AND ETHNICITY
CONCEPTS OF CULTURE
Each individual is culturally unique. Behavior, self-perception, and judgment of others all depend on one’s cultural perspective. This section discusses the concepts of culture, race, ethnicity, and stereotyping and provides an overview of the dominant cultural values in the United States. To provide holistic care, the nurse needs a thorough understanding of the following concepts.
Culture
Culture refers to knowledge, beliefs, behaviors, ideas, attitudes, values, habits, customs, languages, symbols, rituals, ceremonies, and practices that are unique to a particular group of people. This structure of knowledge, behaviors, and values provides a group with a “blueprint” or a general design for living “that guide their worldview and decision-making” (Purnell & Paulanka, 1998, p. 4).
Culture is not static nor is it uniform among all members within cultural groups. Culture represents adaptive dynamic processes learned through life experiences.
People have culturally predetermined values and beliefs that may change as new information is gained. There is much diversity among cultural groups. Such differences result from individual perspectives and practices.
Consider for example how a family deals with a crisis. A crisis may cause some families to become closer, whereas the same situation may cause another family to withdraw and create distance among its members.
Cultural messages are transmitted in a variety of ways such as through schools and churches. The various media are also powerful transmitters and shapers of culture.
People learn about culture through traditions. When people state “That’s how we’ve always done it,” they are describing cultural traditions. Cultural beliefs, values, customs, and behaviors are transmitted from one generation to another. Grandparents, other elders, and parents teach children cultural expectations and norms through role modeling, demonstration, and discussion (Figure 16-1).
Characteristics of Culture
Differences exist among cultural groups and among individuals within a single culture. Despite these variances, all cultures exhibit the characteristics shown in the accompanying display.
Ethnicity and Race
Ethnicity is a cultural group’s perception of themselves (group identity). This self-perception influences how the group’s members are perceived by others. Ethnicity is a sense of belongingness and a common social heritage that is passed from one generation to the next. Members of an ethnic group demonstrate their shared sense of identity in common customs and traits.
Race refers to a grouping of people based on biological similarities. Members of a racial group have similar physical characteristics such as blood group, facial features, and color of skin, hair, and eyes. There is often overlap between racial and ethnic groups because the cultural and biological commonalities support one another (Giger & Davidhizar, 1999). The similarities of people in racial and ethnic groups reinforce a sense of commonality and cohesiveness.
Labeling and Stereotyping
Problems arise when differences across and within cultural groups are misunderstood. Misperception, confusion, and ignorance often accompany people’s expectations of others. There are numerous ways in which people are different and, thus, classified by others.
Members of some cultural groups have historically and globally experienced oppression in the forms of racism, sexism, and classism. The basic underlying premise of these biases is that one way is assumed to be better or “right” and every other way is inferior.
Ethnocentrism is the belief that one’s own culture is superior to all others. According to the American Nurses Association (1994): This belief is common to all cultural groups, all groups regard their own culture as not only the best but also the correct, moral, and only way of life. This belief is pervasive, often unconscious and is imposed on every aspect of day-to-day interaction and practices including health care. It is this attitude which creates problems betweeurses and clients of diverse cultural groups. (p. 3)
Ethnocentrism results in oppression. Oppression occurs when the rules, modes, and ideals of one group are imposed on another group. Oppression is based on cultural biases, which stem from values, beliefs, tradition, and cultural expectations. Racism, a form of oppression, is defined as discrimination directed toward individuals who are misperceived to be inferior due to biologic differences.
Stereotyping is an expectation that all people within the same racial, ethnic, or cultural group act alike and share the same beliefs and attitudes. Stereotyping results in labeling people according to cultural preconceptions; therefore, an individual’s unique identity is often ignored.
Dominant Values in the United States
Cultural differences refer to values, practices, and rituals that vary from those of the dominant culture. The dominant culture of the United States is composed of white middle-class Protestants of European ancestry. A dominant culture is the group whose values prevail within a society. The European value orientation has had an important influence on U.S. culture, as illustrated by the following dominant beliefs:
• Achievement and success
• Individualism, independence, and self-reliance
• Activity, work, and ownership
• Efficiency, practicality, and reliance on technology
• Material comfort
• Competition and achievement
• Youth and beauty
Frequently, these dominant values (which may be blatant or subtle) conflict with the values of minority groups. A minority group can be composed of an ethnic, racial, or religious group that constitutes less than a numerical majority of the population. Because of their cultural or physical characteristics, such groups are labeled and treated differently from others in the society. Minority groups are usually considered to be less powerful than the dominant group (Giger & Davidhizar, 1999).
People assume the characteristics of the dominant culture through acculturation (process of learning norms, beliefs, and behavioral expectations of a group). Acculturation is encouraged through schools and the media. Assimilation is “cultural and structural blending into a dominant entity” (Kavanaugh et al., 1999, p. 10).
Cultural assimilation occurs when individuals from a minority group are absorbed by the dominant culture and take on the characteristics of the dominant culture.
MULTICULTURALISM IN THE UNITED STATES
“The United States, already one of the most diverse societies in the world, is becoming increasingly multicultural and multilingual” (Lester, 1998, p. 26). The U.S. population is composed of many ethnic/racial subcultures. A subculture is a group of people “who have experiences different from those of the dominant culture by virtue of status, ethnic background, residence, religion, education, or other factors that functionally unify the group” (Purnell & Paulanka, 1998, p. 8). It is important to note that, even though a number of these subcultures possess less than their equal shares of money, influence, and prestige, these populations are increasing at a rapid rate. “By the year 2050, white Americans’ share of the total population will decline from 75% to under 50%. In many localities so called minorities are now, in fact, the majority” (American Nurses Association, 1998, p. 5).
The numbers of immigrants and refugees entering the United States from non-European countries have added to this multicultural composition within the American universal culture. Native Americans, African-Americans, Asian-Americans, and Hispanic Americans will be the most populous groups in the future. All four of these cultural groups have shown significant growth and are expected to increase. Within the next 50 years, the Asian population is expected to increase to 11%, the Black population to 16%, and the Hispanic population to 21% (Campinha-Bacote, 1999, p. 203).
Value of Diversity
Cultural diversity is the differences among people that result from ethnic, racial, and cultural variables.
“Cultural diversity refers to the differences between people based on a shared ideology and value set of beliefs, norms, customs, and meanings evidenced in a way of life” (American Nurses Association, 1994, p. 2). The United States has a vast potential of human resources, which with divergent viewpoints and behaviors, enriches the sociopolitical climate. New ideas, other viewpoints, increased problem-solving approaches, and increased tolerance are all outcomes of a diverse population.
In addition to these advantages, there are also some disadvantages to living and working within such a culturally diverse environment. For example, the amount and types of variances can lead to splitting and ethnocentrism.
Cultural diversity presents special challenges for nurses who must provide care that is congruent with a person’s expectations. Nurses caring for clients who are different from themselves must remember to determine the client’s perception and significance (meaning) of the event (illness). The nurse honors each individual’s differences while understanding that culture influences how clients are viewed and treated within health care settings.
ORGANIZING PHENOMENA OF CULTURE
Cultural factors determine the worth of behaviors, whether behaviors are acceptable, and whether behaviors are incorporated into daily living. When these behavioral concepts are applied to health, they influence the individual’s expectation of health care.Diversity among cultural groups regarding expectations influences health care. The nurse must be sensitive to the client’s cultural context in order to provide care that meets individual needs. Each cultural group has the same basic organizational factors (see the accompanying display). Following is a discussion of the six organizing factors that must be considered when delivering culturally competent care.
Communication
Communication is the vehicle for transmitting and preserving culture. To share complete and accurate information, nurses must be aware of the cultural variances related to communication.
Nurses provide information to clients by using two types of communication: verbal and nonverbal. Verbal communication consists of words, both spoken and written. When cultural variances exist, communication problems may occur. The nurse must validate the meaning of and interpret words to ensure that clients receive the intended message.
For example, a communication barrier exists when different languages are spoken by the client and nurse. In such cases, the use of an interpreter facilitates communication.
The interpreter can either be a bilingual family member or staff member. Even when both client and nurse speak the same language, communication problems may occur because of varying cultural contexts in which words have different meanings to different people.
Nonverbal communication consists of body language (such as facial expressions, posture, and gestures); the use of silence; and paralinguistic cues (voice tone, pitch, and rate). An example of how nonverbal communication can be culturally misunderstood is the presence or absence of eye contact. For example, in Native American and Asian-American cultures, eye contact is considered intrusive and disrespectful. However, in the dominant U.S. cultural group, eye contact between individuals indicates trustworthiness.
Space
An individual’s personal space includes one’s body, the surrounding environment, and objects and people within that environment. Culture determines the amount of social distance tolerated by a person. Members of British, German, and American cultures usually require more personal space than do people of Hispanic and French backgrounds (Giger & Davidhizar, 1999).
Nurses must be aware of the client’s degree of comfort with closeness since diverse groups have varying norms for the use of touch. Touch may be perceived as invasive by clients from some cultures. Who can touch a person, when a person can be touched, and what forms of touch are appropriate are culturally determined. For example, members of the dominant U.S. culture often greet each other with handshakes while it is commonly accepted in European cultures to greet others with a kiss on the cheek.
Orientation to Time
Time orientation (being focused on the past, the present, or the future) varies according to cultural group.
European Americans are future oriented as evidenced by their development of plans, such as retirement savings.
Many Native Americans have a different concept of time in that they tend to live in the present moment (Giger & Davidhizar, 1999). For many Native Americans, watching the clock and timeliness/tardiness have little importance.
Time is considered a circular, rather than a linear, process. Most health care providers value quickness and efficiency, which is interpreted by members of the
Lakota tribe as insincerity and a lack of interest (Kavanagh et al., 1999). The nurse’s nonverbal behavior can be changed to build interpersonal rapport by spending time, sitting down with clients, and demonstrating presence.
Social Organization
Social organization refers to the ways in which groups determine rules of acceptable behavior and roles of individual members. Examples of social organizations
include family and other kinship ties, religious groups, and ethnic groups.
Family
General Systems Theory (GST) considers the family to be a system that seeks to maintain balance. From the GST perspective, the family functions as a unit. Thus, if an event affects one family member, all the other members will be affected in one way or another. The various types of family structures are described in the accompanying display. It is vital for the nurse to know who will be involved in making decisions related to health care.
Including the family according to their cultural expectations is a hallmark of quality nursing care. Family patterns usually are of one of three types: linear, collateral, or individualist
In many cultures, the family assumes greater importance than the individual (Figure 16-2). For example, in most Native American tribes, the extended family is the basic family structure. The extended family is also extremely important in Hispanic American cultural groups. In some Hispanic groups, the family may include third and fourth cousins as well as close friends who are not related by ties of kinship.
Pickens (1998) identified the following attributes as necessary for nurses in order to collaborate with families:
• Nonjudgmental attitude (i.e., do not expect all families to be alike and behave similar to one’s own)
• Self-awareness of own preconceptions about family members
• Respect for others’ beliefs and values
• Recognition of families as significant providers of support
• Value the participation of families in caregiving
Gender
Gender roles vary according to cultural context. For example, in families with a patriarchal structure (the man is the head of the household and chief authority figure), the husband/father is the dominant person. Such expectations are the cultural norm for Latino, Hispanic, and traditional Muslim families. The husband/father is the one who makes decisions regarding health care for all family members. Also, in such cultures, the wife is responsible for child care and household maintenance, whereas the father’s role is to protect and support the family members (Luckmann, 2000).
Lifestyle
In addition to an increased heterogeneity of population groups in the United States, lifestyles are also becoming more diverse. Some examples of alternative lifestyles are homosexual couples, single parent families, and communal groups. Figure 16-3 illustrates a variety of types of families. Nurses must demonstrate respect for clients’ lifestyles even when they differ from those of the nurse.
Some specific ways in which nurses can respect clients with differing lifestyles are:
• Be aware of own tendency to be ethnocentric.
• Be sensitive to client’s needs, especially those expressed nonverbally.
• Use self-awareness to determine the impact of own beliefs and values.
Often the nurse and client are of different cultural backgrounds; see Figure 16-4. The nurse must be culturally sensitive in order to promote the development of a therapeutic nurse–client relationship.
Religion
Religious beliefs influence a person’s response to major life events such as birth, illness, and death. Religious practices are often a source of comfort during stressful life events and provide support during the healing process. Crises such as illness and treatment modalities are often the catalyst for increased spiritual needs.
CULTURAL DISPARITIES IN HEALTH AND HEALTH CARE DELIVERY
“Researchers suggest that cultural insensitivity can create more than mere discomfort. It can create real barriers to accessing health care” (Lester, 1998, p. 28).
Language and other cultural differences often present barriers to necessary health care including:
• Appointment procedures
• Transportation
• Directions written in an unfamiliar language.
There are disparities in the health of Americans.
According to the ANA (1998), minorities experience some diseases at a much higher rate than white Americans. The following examples are listed in the ANA’s Position Statement on Discrimination and Racism in Health Care (1998):
• Cancer is the leading cause of death for Chinese and Vietnamese individuals.
• Vietnamese women suffer from cervical cancer at nearly five times the rate of white American women.
• Compared with the general population, Hispanics have a higher incidence of cancer of the stomach, esophagus, pancreas, and cervix.
• African-Americans have a life expectancy that is six years shorter than the life expectancy for white Americans.
• The Native American population has significant rates of diabetes, sudden infant death syndrome, and congenital malformations.
“Overall Native American and Alaskan Native rates of diabetes, tuberculosis, fetal alcohol syndrome, alcohol-related morbidity and mortality, and suicide significantly exceed those of other racial and ethnic groups in the United States” (Kavanagh et al., 1999, p. 10). One of the major objectives established by the U.S. Office of Public Health in its Healthy People 2010 Objectives is the elimination of disparities in health status by providing equitable services for people of all groups (Chrvala & Bulger, 1999).
Vulnerable Populations
As a result of societal changes, more people are at risk for health problems. Groups that are especially susceptible for health-related problems include the poor, the homeless, migrant workers, abused individuals, the elderly, pregnant adolescents, and people with sexually transmitted diseases such as acquired immunodeficiency syndrome (AIDS).
The United States is currently facing many economic, social, and political challenges related to the delivery of health care services to vulnerable population groups (Edelman & Mandle, 1997). As a result, many vulnerable populations are underserved because of the high demand for services, lack of services, and limited availability and access to services.
The Poor
Poverty affects health status and accessibility to health care services. According to the Centers for Disease Control and Prevention (CDC) (1998), “increase in either income or education increases the likelihood of good health status.
This relationship between socioeconomic status and health was observed for persons in every race and ethnic group examined” (p. 52). Living in poverty means being unable to meet the financial demands of basic living expenses, such as food, shelter, and clothing.
Socioeconomic status is determined by family income, educational level, and occupation. “Childhood poverty has long-lasting negative effects on one’s health. Children in low-income families fare less well than children in more affluent families. In 1999, 17% of American children lived in poverty” (U.S. Bureau of the Census, 2000). In
The CDC (1998) has identified the following as health risk factors that are related to lower income:
• Higher prevalence of cigarette smoking
• Greater incidence of obesity
• Elevated blood pressure
• Sedentary lifestyle
• Less likely to be covered by health insurance
• Less likely to receive preventive health care services
Increasing numbers of federally mandated health care initiatives are being implemented to address the historic racial and class disparities in health care.
Entitlement programs imply that the government is legally mandated to provide services to the programs’ eligible populations. Entitlement programs such as Medicare, Medicaid, and Women, Infants, and Children (WIC) were developed, in part, because of social and political pressures. WIC, a special supplemental food program for women, infants, and children, is a U.S.
Public Health sponsored program that targets lowincome pregnant and breastfeeding mothers and their children age 5 years or younger. WIC links health care services, food supplements, and health education into a combined service package for eligible members.
Medicaid is a program designed to provide access to health care for medically needy infants, children, and adults. Medicare is an entitlement program that finances health care services for individuals over the age of 65.
Poverty interferes with a child’s ability to be housed, clothed, and fed adequately and can deprive the child of a safe (physical and psychological) environment.
Children with access to health care have the possibility of getting necessary health care services. Children with health insurance (public or private) are much more likely than children without insurance to have a regular and accessible source of health care (U.S. Bureau of the Census, 2000). “There are many reasons why a child’s parent(s) are uninsured . . . related to employment, limited health care benefits, and recent immigration” (Scott, 2000, p. 26).
The Homeless
Even though it is difficult to determine the exact number of homeless people, it is estimated that 350,000 to 6 million people are homeless in the United States (Walker, 1998, p. 27). Societal factors that contribute to homelessness are:
• Lack of affordable housing
• Increasingly stringent criteria for public assistance
• Decreased availability of social services
• Inadequate or lack of employment
• A history of psychosocial trauma
• Deinstitutionalization of clients from mental health facilities without adequate community support (such as half-way houses and group homes)
Approximately 85% of homeless people are on the streets because they have some form of mental illness or are addicted to alcohol or other drugs (Walker, 1998).
“We must confront the mistakeotion that hopelessness is a choice . . . It’s important to understand the connection between hopelessness and chronic mental illness, for with understanding can come the sensitivity and compassion necessary to serve this population” (Walker, 1998, p. 27).
Those who are homeless are at greater risk for illness and injuries (Edelman & Mandle, 1997). Hatton (1997) identified the following as major health care needs of homeless women: mental health, sexually transmitted diseases, and substance abuse. Access to basic health care services is limited because the homeless lack health insurance coverage. Those few facilities that do provide services to the homeless are not always accessible due to lack of transportation.
Children are especially vulnerable to the perils of homelessness. Presently, the federal government does not regularly collect data on the number of homeless children in the United States. However, 1998 statistics (U.S. Bureau of the Census, 2000) show that 36% of U.S. households with children had housing problems, including physically inadequate housing and crowded housing. Adolescents who are homeless are at high risk for physical and mental health problems, including malnutrition, substance abuse, accidental pregnancy, and sexually transmitted disease.
The social and political reforms that are needed to create solutions to homelessness have just begun. There is great urgency to meet the immediate needs of the homeless and to provide health care that emphasizes both disease prevention and health promotion.
“Nonprofit nursing centers and clinics try to halt the epidemic of uninsured children” (Scott, 2000, p. 26).
Listed below are a few examples of nursing’s efforts in responding to the needs of vulnerable clients:
• Community Volunteers in Medicine is a nonprofit organization in which nurses, doctors, and dentists volunteer their time and services to treat uninsured people of all ages living in Chester County, Pennsylvania.
• Philadelphia-based Regional Nursing Centers Consortium (RNCC) sees approximately 250,000 clients annually. Up to 50% of these clients are uninsured.
• In 1999, LaSalle Neighborhood Nursing Center in Philadelphia identified 300 uninsured children and enrolled them in the Children’s Health Insurance Program (CHIPs) or for medical assistance (Scott, 2000).
Environmental Control
Environmental control refers to the relationships between people and nature and to a person’s perceived ability to control activities of nature, such as factors causing illness.
A person’s belief about the causation of disease will determine the type of treatment (if any) sought.
According to Andrews and Boyle (1998), there are three types of health belief systems: magicoreligious, biomedical, and holistic. The magicoreligious belief system is based on the concept that health and illness are determined by supernatural forces (such as a Higher Power or the gods). The biomedical belief system states that illness is a result of an impairment in physical or biochemical processes. The holistic belief system views health as a result of harmony among the elements of nature; conversely, disease is caused by disharmony.
Folk Medicine
Most cultures have preferences about health care, including:
• The type of care that is necessary and appropriate
• When care/treatment should be sought
• The appropriate caregiver
Because the presence of a folk medicine system (also referred to as alternative medicine) can present challenges to nurses caring for clients from diverse cultures, knowledge of basic beliefs about illness, factors contributing to illness, and home remedies is necessary.
Folk healers are knowledgable about cultural norms and are usually familiar to the one seeking care (Edelman & Mandle, 1997). Table 16-3 presents the various healers within different cultures and describes common folk healing practices within these cultures. Nurses must be able to relate care and treatment to the client’s cultural context to incorporate informal caregivers, healers, and other members of the clients’ support system as allies in treatment. “The patient-centered orientation of nursing makes it imperative that nurses be able to respond to the unique cultural needs of different people. Nurses are challenged to provide effective caring and curing in varied cultural contexts” (Lester, 1998, p. 26).
Biologic Variations
Biologic variations that distinguish one cultural group from another include enzymatic differences and susceptibility to disease (Andrews & Boyle, 1998; Giger & Davidhizar, 1999). Enzymatic differences account for diverse responses of some groups to dietary therapy and drugs (Table 16-4). Nutritional variations include food preferences that may contribute to health problems (Table 16-5).
TRANSCULTURAL NURSING
The American Nurses Association (1994) states that culture is a central concept of nursing. Acknowledgment and acceptance of cultural differences and understanding of culturally specific responses to illness are prerequisites for providing safe and effective care.
The conceptual framework for understanding cultural diversity and providing culturally competent care is based on Leininger’s transcultural nursing theory.
Transcultural nursing, according to Leininger (1978), focuses on the study and analysis of different cultures and subcultures with respect to cultural care, health beliefs and health practices, with the goal of providing health care within the context of the client’s culture.
A basic assumption of transcultural nursing is that when health care providers see problems from the client’s cultural viewpoint, they are more open to understanding, appreciating, and working effectively with these clients (Figure 16-6). Other assumptions of transcultural nursing theory are:
• Every culture has some kind of system for health care that is based on values and behaviors.
• Cultures have certain methods for providing health care. These methods of care are often unknown to nurses from other cultures (Leininger, 1978).
Due to rapid globalization, every nurse must have an understanding of human conditions in diverse societies.
Nurses do not need to travel to foreign countries to engage in international nursing. Nurses encounter cultural diversity everywhere—from inner city hospitals to suburban clinics, from technologically sophisticated institutions to homes in rural, inner city, and suburban areas.
Cultural Competence
Community, social and kinship ties, religion, language, food, and cultural perceptions of illness are all areas that need to be considered by the nurse when working with culturally diverse clients. Cultural diversity challenges nurses to bridge cultural gaps with clients by providing culturally relevant care. An understanding of the client’s cultural context permits nurses to become familiar with the client as a person instead of focusing only on the illness or problem.
Cultural competence is the process through which the nurse provides care that is appropriate to the client’s cultural context. Culturally competent nurses are those who demonstrate knowledge and understanding of the client’s culture; accept and respect cultural differences; and adapt care to be congruent with the client’s culture (Purnell & Paulanka, 1998). Culturally competent nurses have knowledge about cultural values related to health and illness. Also, nurses who provide care in a culturally sensitive manner are flexible in their approaches and thinking. Campinha-Bacote (1999) defines five elements of cultural competence; see Table 16-6 for an explanation of each element.
CULTURAL COMPETENCE AND NURSING PROCESS
Cultural sensitivity is requisite in every phase of the nursing process. The nurse’s role in providing culturally competent care includes performing a cultural assessment, formulating nursing diagnoses, identifying expected client outcomes, planning care to assist clients in achieving the expected outcomes, intervening to address the client’s nursing diagnoses, and evaluating the plan of care. In its Guide to Nurses for Providing Culturally Sensitive Care, the College of Nurses of Ontario (1991) identifies four elements of providing culturally sensitive care: self-reflection, facilitating client choice, gaining cultural knowledge, and effective communication. These four elements permeate the nursing process.
Assessment
Caring for a client from a different culture can be challenging to the nurse. Using the client’s strengths and respecting the client’s values are essential components of effective nursing care. To begin providing culturally competent care, the nurse should use questions to gather information about the client’s cultural background. The factors pertinent to cultural assessment are listed in the accompanying display.
The questions in the Cultural Assessment Interview Guide, shown in Figure 16-7, can either be incorporated into a general nursing assessment tool or used separately as a cultural assessment tool.
Nursing Diagnosis
Diagnoses approved by the North American Nursing Diagnosis Association (NANDA, 2001) are used extensively by nurses. However, one stated disadvantage to NANDA diagnostic statements is that sometimes the diagnoses are worded in ways that result in cultural bias (Luckmann, 2000). The accompanying display lists some diagnoses that may be culturally biased.
Consider the following examples of ways in which these diagnoses may be used in a culturally inappropriate manner:
• Applying the diagnosis impaired verbal communication to clients who speak a language different from the nurse
• Using the diagnosis noncompliance with a client who rejects a prescribed treatment method in order to adhere to their culturally sanctioned folk healing methods
It may be more appropriate to use another term instead of noncompliant. Ward-Collins (1998) suggests “nonadherent” by stating that this term may present less of a stigma to clients than “noncompliant.”
Planning and Outcome Identification
Cultural groups are not homogeneous; there are individual variations in personality, behavior, and expectations.
It is important not to consider one member of a particular group to be like all the others of that same group.
In order to develop effective plans of care, nurses need to understand the following (American Nurses Association, 1994):
• Cultural groups’ perspectives on life processes (e.g, birth, death)
• Cultural definitions of health and illness
• How cultural groups maintain wellness
• Culture’s perspectives on the causes of illness
• Use of healers in the cure and care of illness
• The influence of the nurse’s cultural background on the delivery of care
It is also necessary to consider how the client’s beliefs may impact the plan of care. Cultural beliefs greatly influence perceptions about health and, therefore, may create barriers to adhering to prescribed treatment plans. Culture influences the following:
• Perceptions of illness versus health
• Responses to illness
• Perceptions about the significance of symptoms
• The types of treatment approaches (i.e., alternative and/or conventional) (Muscari, 1998, p. 27).
Implementation
Caring for culturally diverse clients requires three major nursing interventions: self-awareness, use of a nonjudgmental approach, and client education. Each of these aspects are discussed in the following section. The accompanying display provides guidelines for providing culturally sensitive care for clients at home.
Self-Awareness
In an increasingly diverse society, the nurse must be aware of the potential for bias or misunderstanding.
Self-awareness can be used to help nurses recognize their own stereotypes, biases, and prejudgments about clients who are culturally different. Further experience, introspection, and study empower nurses to appreciate their own cultures and the strengths of other cultures.
Nonjudgmental Approach
A nonjudgmental attitude is essential in the provision of culturally sensitive care. When caring in a manner sensitive to the client’s cultural background, the nurse enables the client to offer open, honest feedback, to disagree, or to discuss real or perceived problems. A health care partnership is the outcome of this approach. “A key component of successful interactions with culturally diverse patients is to avoid using stereotypical, judgmental words” (Ward-Collins, 1998, p. 30).
Client Education
Educating clients is an integral part of nursing practice.
Education must be relevant not only to the client’s needs but also must be provided in a culturally sensitive manner. Lester (1998) states “you need to present the information in a way that the patient grabs onto what is important to her. We need to learn how to present teaching so that people can hear it. If people can’t hear it, then we will not succeed in what we are trying to teach” (p. 29). See the Client Teaching Checklist for culturally sensitive teaching guidelines.
Evaluation
The final phase of the nursing process, evaluation, is extremely important in determining the client’s achievement of expected outcomes and the efficacy of nursing interventions in delivery of culturally sensitive care.
Provision of culturally competent care requires that the nurse view the client as a partner of the health care team. It is important to demonstrate caring behaviors rather than just tolerating cultural variations in client’s behavior. Awareness of cultural similarities and variations allow nurses to accept and appreciate the impact of culture on health care.
KEY CONCEPTS
• Every aspect of a person’s life is influenced by one’s culture.
• Behavior affecting health is culturally determined.
• Culture is a dynamic structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, languages, rituals, ceremonies, and practices that are unique to a particular group of people. This structure of knowledge, behaviors, and values provides a group with a “blueprint” for behavior.
• Cultural norms are transmitted from one generation to another.
• Ethnicity is described as a sense of belongingness that is shared by other members of that same group. Ethnic groups are usually composed of people with the same racial composition.
• Race refers to a grouping of people based on biologic similarities. Members of a racial group have similar physical characteristics, such as blood type, facial features, and color of skin, hair, and eyes.
• Members of some racial and ethnic groups have experienced oppression in the forms of racism, sexism, and classism.
• The dominant values of the United States include achievement and success; individualism, independence, and self-reliance; activity, work, and ownership; efficiency, practicality, and reliance on technology; material comfort; competition and achievement; and youth and beauty.
• There is great value in cultural diversity, including a broader perspective of others, enhanced problemsolving ability and creativity, and improved productivity in the workplace.
• The six organizing phenomena of culture are communication, space, orientation to time, social organization, environmental control, and biologic variations.
• Transcultural nursing is based on the belief that wheurses view problems from the client’s cultural viewpoint, they are more open to understanding and working more effectively with clients from other cultures.
• Understanding and accepting cultural differences and responses to illness are prerequisites for providing quality nursing care.
• The provision of culturally sensitive care is achieved through the use of approaches such as non-judgmental attitudes and self-awareness and tools such as cultural assessment guides and client education strategies.
Medical Ethics
Definition
Medical ethics refers to the discussion and application of moral values and responsibilities in the areas of medical practice and research. While questions of medical ethics have been debated since the beginnings of Western medicine in the fifth century B.C., medical ethics as a distinctive field came into prominence only since World War II. This change has come about largely as a result of advances in medical technology, scientific research, and telecommunications. These developments have affected nearly every aspect of clinical practice, from the confidentiality of patient records to end-of-life issues. Moreover, the increased involvement of government in medical research as well as the allocation of health care resources brings with it an additional set of ethical questions.
Description
The Hippocratic tradition
Medical ethics generally traces its origins to the ancient Greek physician Hippocrates (460–377 BC), who is credited with defining the first ethical standard in medicine: “Do no harm.” The oath attributed to Hippocrates was traditionally recited by medical students as part of their medical school’s graduation ceremonies. A modernized version of the Hippocratic Oath that has been approved by the American Medical Association (AMA) reads as follows:
You do solemnly swear, each by whatever he or she holds most sacred
That you will be loyal to the Profession of Medicine and just and generous to its members
That you will lead your lives and practice your art in uprightness and honor
That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice
That you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it
That whatsoever you shall see or hear of the lives of men or women which is not fitting to be spoken, you will keep inviolably secret
These things do you swear. Let each bow the head in sign of acquiescence
And now, if you will be true to this your oath, may prosperity and good repute be ever yours; the opposite, if you shall prove yourselves forsworn.
Religious traditions and medical ethics
Ancient Greece was not the only premodern culture that set ethical standards for physicians. Both Indian and Chinese medical texts from the third century B.C. list certain moral virtues that practitioners were to exemplify, among them humility, compassion, and concern for the patient’s well-being. In the West, both Judaism and Christianity gave extensive consideration to the importance of the physician’s moral character as well as his duties to patients. In Judaism, medical ethics is rooted in the study of specific case histories interpreted in the light of Jewish law. This case-based approach is known as casuistry. In Christianity, ethical reflection on medical questions has taken the form of an emphasis on duty, moral obligation, and right action. In both faiths, the relationship between the medical professional and the patient is still regarded as a covenant or sacred bond of trust rather than a business contract. In contemporary Buddhism, discussions of medical ethics reflect specifically Buddhist understandings of suffering, the meaning of human personhood, and the significance of death.
The Enlightenment and the nineteenth century
The eighteenth century in Europe witnessed a number of medical as well as general scientific advances, and the application of scientific principles to medical education led to a new interest in medical ethics. The first book on medical ethics in English was published by a British physician, Thomas Percival, in
In the middle of the nineteenth century, physicians in the United States and Canada began to form medical societies with stated codes of ethics. These codes were drawn up partly because there was no government licensing of physicians or regulation of medical practice at that time. The medical profession felt a need to regulate itself as well as set itself apart from quacks, faith healers, homeopaths, and other practitioners of what would now be called alternative medicine. The AMA, which was formed in 1847, has revised its Code of Ethics from time to time as new ethical issues have arisen. The present version consists of seven principles. The Canadian Medical Association (CMA) was formed in 1867 and has a Code of Ethics with 40 guidelines for the ethical practice of medicine.
Viewpoints
Theoretical approaches to medical ethics
PHILOSOPHICAL FRAMEWORKS. Since the early Middle Ages, questions of medical ethics have sometimes been discussed within the framework of specific philosophical positions or concepts. A follower of Immanuel Kant (1724–1804), for example, would test an ethical decision by the so-called categorical imperative, which states that one should act as if one’s actions would serve as the basis of universal law. Another philosophical position that sometimes appears in discussions of medical ethics is utilitarianism, or the belief that moral virtue is based on usefulness. From a utilitarian perspective, the best decision is that which serves the greatest good of the greatest number of people. An American contribution to philosophical approaches to medical ethics is pragmatism, which is the notion that practical results, rather than theories or principles, provide the most secure basis for evaluating ethical decisions.
CASUISTRY. Casuistry can be defined as a case-based approach to medical ethics. An ethicist in this tradition, if confronted with a complicated ethical decision, would study a similar but simpler case in order to work out an answer to the specific case under discussion. As has already been mentioned, casuistry has been used as a method of analysis for centuries in Jewish medical ethics.
THE “FOUR PRINCIPLES” APPROACH.
Another approach to medical ethics was developed in the 1970s by a philosopher, Tom Beauchamp, and a theologian, James Childress, who were working in the United States. Beauchamp and Childress drew up a list of four principles that they thought could be weighed against one another in ethical decision-making in medicine. The four principles are:
the principle of autonomy, or respecting each person’s right to make their own decisions
the principle of beneficence, or doing good as the primary goal of medicine
the principle of nonmaleficence, or refraining from harming people
the principle of justice, or distributing the benefits and burdens of a specific decision fairly
One limitation of the “Four Principles” approach is that different persons involved in an ethical decision might well disagree about the relative weight to be given to each principle. For example, a patient who wants to be taken off a life-support system could argue that the principle of autonomy should be paramount, while the clinical staff could maintain that the principles of beneficence and nonmaleficence are more important. The principles themselves do not define or imply a hierarchical ranking or ordering.
Current issues in medical ethics
One well-known writer in the field of medical ethics has recently written an article listing what he considers “cutting-edge” topics in medical ethics. While space does not permit discussion of these subjects here, they serve as a useful summary of the impact of technology and globalization on medical ethics in the new millennium:
End-of-life care. Medical advances that have led to a dramatic lengthening of the life span for adults in the developed countries and a corresponding increase in the elderly population have made end-of-life care a pressing issue.
Medical error. The proliferation of new medications, new surgical techniques, and other innovations means that the consequences of medical errors are often very serious. All persons involved in health care have an ethical responsibility to help improve the quality of care.
Setting priorities. The fair allocation of health care resources is one example of setting priorities.
Biotechnology. Medical ethicists are still divided over the legitimacy of stem cell research, cloning, and other procedures that advances in biotechnology have made possible.
“Health.” The expansion of the Internet and other rapid changes in information technology have raised many questions about the confidentiality of electronic medical records as well as the impact of online education on medical training.
Global bioethics. Global bioethics represents an attempt to consider the ethical problems confronting the poorer countries of the world, rather than concentrating on medical issues from the perspective of the wealthy countries. Of the 54 million deaths that occur each year around the world, 46 million occur in lowand middle-income countries.
Professional implications
One implication for physicians is the importance of studying ethical issues during one’s professional education. Many medical, dental, and nursing schools now include courses in their curricula that deal with such topics as moral decision-making, definitions of life and death, the ethical complexities of professional-patient relationships, and the moral safeguards of medical research. As of 2000, more than 25 universities in the United States and Canada offer graduate degrees in medical ethics.
A second implication is recognizing the necessity of interdisciplinary conversation and cooperation. Physicians can benefit from the insights of scholars in the social sciences, philosophy, theology, law, and history. At the same time, they have much to offer professionals in other fields on the basis of their clinical experience.
Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence and respect for autonomy. It can be distinguished by its emphasis on relationships, human dignity and collaborative care.
Development of subject
The nature of nursing means that nursing ethics tends to examine the ethics of caring rather than ‘curing’ by exploring the relationship between the nurse and the person in care. arly work to define ethics in nursing focused more on the virtues that would make a good nurse, rather than looking at what conduct is necessary to respect the person in the nurse’s care. However, recently, the ethics of nursing has also shifted more towards the nurse’s obligation to respect the human rights of the patient and this is reflected in a number of professional codes for nurses. For example, this is made explicit in the latest code from the International Council of Nurses.
Distinctive nature
Although much of nursing ethics can often appear similar to medical ethics, there are some factors that differentiate it. Generally, the focus of nursing ethics is more on developing a caring relationship than concerns about broader principles, such as beneficence and justice. For example, a concern to promote beneficence may well be expressed in traditional medical ethics by the exercise of paternalism. However, this approach would not be compatible with nursing ethics. This is because nursing theory seeks a collaborative relationship with the person in care. Themes that emphasizes respect for the autonomy and dignity of the patient by promoting choice and control over their environment are commonly seen. This is in contrast to paternalistic practice where the health professional chooses what is in the best interests of the person from a perspective of wishing to cure them.
The distinction can be examined from different ethical angles. Despite the move toward more deontological themes by some, there continues to be an interest in virtue ethics[6] iursing ethics and some support for an ethic of care. This is considered by its advocates to focus more on relationships than principles and therefore to reflect the caring relationship iursing more accurately than other ethical views.
Some themes iursing ethics
Nurses seek to defend the dignity of those in their care. In terms of standard ethical theory, this is aligned with having a respect for people and their autonomous choices. People are then enabled to make decisions about their own treatment. Amongst other things this grounds the practice of informed consent that should be respected by the nurse. Although much of the debate lies in the discussion of cases where people are unable to make choices about their own treatment due to being incapacitated or having a mental illness that affects their judgement.
A way to maintain autonomy is for the person to write an advance directive, outlining how they wish to be treated in the event of them not being able to make an informed choice, thus avoiding unwarranted paternalism.
Another theme is confidentiality and this is an important principle in many nursing ethical codes. This is where information about the person is only shared with others after permission of the person, unless it is felt that the information must be shared to comply with a higher duty such as preserving life.
Also related to information giving is the debate relating to truth telling in interactions with the person in care. There is a balance between people having the information required to make an autonomous decision and, on the other hand, not being unnecessarily distressed by the truth. Generally the balance is in favour of truth telling due to respect for autonomy, but sometimes people will ask not to be told, or may lack the capacity to understand the implications.
By observing the principles above, the nurse can act in a way that respects the dignity of the individual in their care.
Although this key outcome in nursing practice is sometimes challenged by resource, policy or environmental constraints in the practice area.
Nursing values are fundamental to the practice of nursing. They guide standards for action, provide a framework for evaluating behaviour and influence practice decisions. Despite the importance that can be attributed to nursing values, acknowledgement of them is difficult to find in the current debate about how interprofessional working is changing the healthcare system in which nurses currently work. This article argues that the professioeeds to demonstrate that values are not only a theoretical concept but also that they can, and do, have a profound impact on the practical working life of nurses delivering care in collaboration with other professions.
What Does Our Vision Mean?
Trusted Nurses- We aspire to achieve the faith and confidence of those we serve and to be their first choice when they need healthcare services for themselves, their families and friends. We earn their trust based on clinical quality, patient safety, service excellence and integrity.
Caring for Patients’ and Others’ – We provide superior clinical quality and world class service in a patient-first environment. We are the “corner stone” in the interdisciplinary team’s ability to achieve ideal outcomes. We build lasting relationships with our patients, physicians, community, other employees and each other. We recognize individuals and groups for their quality patient care and nursing excellence.
Advancing Practice- We drive superior clinical outcomes through evidence-based, practice-driven protocol’s and the advancement of our practice utilizing formal and continuing education.
What Do Our Values Mean?
Caring – Anticipating and meeting the needs of our patients, physicians, and co-workers
Integrity- Communicate openly and honestly, build trust and conduct ourselves according to the highest ethical standards
Respect- Treat each individual with the highest professionalism and dignity
Commitment – Pledge to support the vision of nursing, the hospital and the system
Loyalty – Dedicate ourselves to our patients, their families, our community and our profession
Excellence – Continue to learn and provide the superior clinical practice to our patients in a healthy work environment.
OUR VALUES ARE:
Concepts that give meaning to an individual’s life.
Influenced by society, family, religion, ect.
Serve as a framework for decision-making.
TYPES OF VALUES
Intrinsic.
Extrinsic
Personal
Professional
CLIENT EDUCATION, STRESS AND COPING
PATIENT EDUCATION
Definition
Patient education involves helping patients become better informed about their condition, medical procedures, and choices they have regarding treatment. Nurses typically have opportunities to educate patients during bedside conversations or by providing prepared pamphlets or handouts. Patient education is important to enable individuals to better care for themselves and make informed decisions regarding medical care.
Description
Patients acquire information about their condition in a variety of ways: by discussing their condition with health professionals; by reading written materials or watching films made available in hospitals or doctors’ offices; through specific health care organizations, such as the American Cancer Association; and through drug advertisements on television and in popular magazines. With the explosion of information on the World Wide Web, patients can access a wide range of medical information, from professional medical journals to on-line support and chat groups with a health focus.
Viewpoints
Being informed about one’s health care options is essential to a patient’s health and well-being. Especially with the increase in managed care, in which economics and efficiency is sometimes paramount, patients may be able to obtain better health care if they are knowledgeable and assertive about their needs and wishes. Informed patients may benefit, for example, by realizing they have a choice of different medications, different treatments, or what lifestyle patterns may affect their condition.
Professional implications
Professional health care givers have traditionally borne the responsibility for patient education. In recent years, however, patients independently have easy access to a wide range of health information. However, many patients cannot easily obtain information, especially if they are not well educated or are not fluent in English. In addition, many patients may not understand enough about their condition to ask relevant questions. Finally, a significant amount of popular information is inaccurate or publicized for a profit motive rather then for education purposes. Patients may not be able to sort out what is true or what is relevant to their own condition.
Another relatively recent aspect of patient education centers around legal ramifications. When a patient is fully informed about the risks and benefits of a particular procedure or therapeutic approach, the likelihood of a lawsuit resulting from a complication is sharply reduced. A patient must be made aware of risks before accepting treatment.
Nurses play an important role in providing health education. They are often the best sources of information regarding caring for patients, such as learning to breast feed, soothing fussy babies, or staying comfortable in the hospital. They may be more accessible than doctors, both because they may spend more time with patients, and because patients may feel less intimidated by nurses and more comfortable asking questions and sharing fears. It is important that nurses do not provide information they are unsure about, or falsely reassure patients about their condition.
Through education, patients can be made aware of their disease process and potential treatment options. But, educating our patients is not as easy as one might think. Our patients come from different ethnic and socioeconomic backgrounds; and they have different treatment priorities. It’s important to have an open discussion with patients and to get to know their expectations and needs.
So, how can effective teaching be accomplished? And, how can effective teaching be done when we, as nurses, have so many other daily demands? These tips could help:
Computer-aided teaching: Computer or other output devices allow patients to view and to hear patient education materials in the hospital and some of these materials can be reviewed at home. Manuals are often made available to accompany the computerised programs. And there is usually a test to evaluate learning once the program is completed.
Video education: Video education is very similar to computer-based training. But, it is more difficult to evaluate learning. A written post-test could be used after the video is reviewed. But, it is important with both of these media to consider the patients’ educational level, language, and hearing/seeing abilities.
Demonstration: Demonstration is another effective patient-teaching technique. Patients can be showed how to complete a task or how a process works in a one-on-one setting, and then they can do the task more effectively at home. However, in an acute care setting this might be more difficult to do. The pace is much faster, but case managers or patient care assistants can be used to assist the nurse if needed. And, demonstration does ensure that patients fully understand the teaching, and it allows them to get feedback and ask questions in a safe arena.
Written material: Written material seems so easy and routine. But, it can be effective. For instance, material with pictures can offer instructions or explanations. Written material related to prescribed medicines is also a necessity. And, it can offer instructions in a step by step fashion. Once again, it is important to evaluate the patients’ literacy level, language, and sight before handing out routine teaching materials.
Discharge instructions: At the time of discharge, patients can be equipped with a set of instructions with follow-up appointments, medication teaching, and phone numbers. Many discharge instructions can easily be printed using PHR and EMR software systems. These instructions usually give phone numbers (of whom to call with questions) and follow-up appointment instructions.
Discharge prescriptions: Prescriptions for discharge medications are usually included in these instructions. It is important to verify that the patient knows the names, the purpose, and the dosage instructions for these medications.
If needed, verify with the case manager that the patient can afford these medications; and if needed, call them into their pharmacy before discharge.
Other information about patient teaching can be obtained from organisations such as the Arthritis Foundation, the American Diabetes Association, and the American Cancer Society. Another valuable resource is the Clinical Practice Guidelines developed by the Agency for Healthcare Research and Quality (AHRQ). These evidence-based interdisciplinary guidelines assist clinicians to prevent, diagnose, treat, and mange clinical conditions, with a focus on patient outcomes.
Effective patient teaching also requires evaluation and ocumentation.
Learning can be evaluated in the following ways:
Asking questions:
Simply ask the patient questions to see whether they is information that needs reinforcing.
Observe return demonstration:
Watch the patient perform a task (i.e. self inject insulin) to see if the technique is correct.
Assess the data:
Ask the patient to record his blood pressure, blood glucose, or weight at home. And, review the records at the next visit.
These records will demonstrate how effective the current treatments have been.
Talk with the patient/family: At the next visit, or before discharge, talk with the family to see how the patient has been doing, or before they leave the hospital, engage in open dialogue about barriers or concerns. This is very similar to the idea of “asking questions, “ but both methods are useful.
Documenting patient teaching
There are many computerised systems out there. And some offices might still use hand-written documentation. Whatever method you use remember that the information must become a part of the patient’s permanent medical record. You can include in the documentation:
Information and skills you have taught
Teaching methods used – brochures, models, videos, demonstration
Patient and family response to teaching
Evaluation of what the patient and family have learned and how learning outcomes were determined
Through teaching and empowering our patients, we are giving them the tools they need to manage their disease process.
Managing the disease process results in fewer hospitalisations and in an improved quality of life.
HOW TO MAKE A NURSING PATIENT TEACHING PLAN
INSTRUCTIONS
Patient Assessment:
1 This step requires the analysis and organization of information about the patient. Determine the patient’s level of understanding about her disease, injury or condition.
2 Use the information gathered about the patient to judge how well she will be able to understand and apply what is taught to her.
3 Be sure to factor in cultural considerations that are specific to that patient such as ethnicity and religion. It will be necessary to factor in any information you have about the patient’s level of development as well. It may be necessary for the nurse to motivate the patient in order for her to learn. Ability to learn is affected if the patient is too tired, in pain, upset or distracted.
Planning
4 Formulate patient goals. Take the patient and the family’s point of view into consideration, as their input will have an effect on their outcomes. Patient outcomes and motivation are directly associated with the amount of input they have in determining their goals. The goals must be realistic and able to be achieved by the patient.
5 Identify how the teaching plan will be carried out. Implement the plan according the patient’s learning style (audio, visual, or kinetic) as opposed to the nurse’s teaching style.
6 Develop nursing goals based on desired health outcomes. They should be patient-centered and based on health outcomes for the patient’s health status and quality of life.
Determine Method of Implementation
7 The method of implementation of the nursing patient teaching plan should be specific to the patient’s learning style and desired outcomes that were identified.
8 Prepare to document patient responses and level of understanding as the nurse perceives them while the teaching plan is implemented.
9 Prepare to document any other relevant information that will assist with the evaluation of learning.
Formulate Evaluation Process
10 An evaluation process will need to be formed in order to assess patient outcomes. The following specific elements of patient learning will need to be evaluated: patient knowledge, behavior, attitude, and skills. The evaluation should include a review of the documentation that details patient responses and level of understanding that were recorded during the implementation steps.
11 The evaluation plan should include observations of the family’s understanding of what will be required of them for the patient to achieve desired outcomes.
12 The last key element of the evaluation plan is the nurse’s recommendation for follow-up procedures to be used in the event that the patient’s learning was not sufficient to produce desired outcomes.
In order to teach, the nurse must first have an understanding of the patient education
The following is a list of strategies that promote the incorporation of teaching into daily nursing practice:
Emphasize what is necessary. In the inpatient setting, many patients fear losing their independence (Jones, 2002). Patients will be motivated to learn what is necessary for them to care for themselves; therefore nurses should emphasize these strategies.
Choose the right time. Remember that when teaching, timing is crucial. For instance, if the patient has just been informed of a diagnosis, he or she will need time to cope with this information. There might be associated feelings of grief, powerlessness, fear, and vulnerability (Jones, 2002). These will cloud the ability to learn.
Look for teaching moments. Like choosing the right time for teaching, it is equally important to “look for teaching moments.” Imagine caring for a patient with end-stage renal disease. A teaching moment would be when the patient receives his tray and there is only a small amount of fluid. In this situation the nurse could ask, “Why is it important for you to monitor your fluid intake?”
Plan teaching during an uninterrupted time. When teaching the patient, timing is crucial. It is not appropriate to fit everything into the day of discharge. Similarly, it would not be appropriate to provide complex lessons during meal time or visiting hours.
Use basic principles. It is important to consider the educational level of the patient when teaching. After all, not everyone has had a nursing education. Some patients might not be able to understand complex medical jargon. They may even be illiterate and are unable to read handouts.
Evaluate the senses. Nurses must evaluate the patient’s ability to see and to hear. For example, if a patient has difficulty seeing, it might not be practical to give her a handout on disease management. If the patient has difficulty hearing, it might not be appropriate to guide her with verbal instructions.
Keep expenses in mind. Many patients, especially elders, live on a fixed income. Therefore, it might not be practical to recommend that they join a fitness center as a means of weight reduction. When recommending a glucometer for the diabetic patient or a scale for the dialysis patient, it is important to consider the cost of each one.
Clearly define goals and objectives. Before beginning, it is important to have a list of goals and objectives that are formulated by the patient and the nurse. The significance of these should be understood by each person, and they should be evaluated on a continuous basis.
Remember to document. When teaching a new skill, documentation is important. This allows the incoming nurse or a nursing assistant to see what has been done and where she should start. Likewise, if the patient has difficulty with a certain skill or needs certain assistance, this should be recorded so that accommodations or further instruction can be provided.
Patient education requires that the nurse think critically. No longer are we simply responsible for administering medications and communicating with physicians. We also play a dynamic role in assuring that the patient is able to be independent in managing his disease.
In essence, we are nurse educators. After all, teaching is a vital component of the nursing process. However, the process is not uniform in nature. In order to promote learning, it is valuable to keep these proposed strategies in mind. And as part of our nursing education about the values of patient teaching, we have to remember that the patient population is indeed heterogeneous.
Feeling like there are too many pressures and demands on you? Losing sleep worrying about tests and schoolwork? Eating on the run because your schedule is just too busy? You’re not alone. Everyone experiences stress at times — adults, teens, and even kids. But there are ways to minimize stress and manage the stress that’s unavoidable.
What Is Stress?
Stress is a feeling that’s created when we react to particular events. It’s the body’s way of rising to a challenge and preparing to meet a tough situation with focus, strength, stamina, and heightened alertness.
The events that provoke stress are called stressors, and they cover a whole range of situations — everything from outright physical danger to making a class presentation or taking a semester’s worth of your toughest subject.
The human body responds to stressors by activating the nervous system and specific hormones. The hypothalamus signals the adrenal glands to produce more of the hormones adrenaline and cortisol and release them into the bloodstream. These hormones speed up heart rate, breathing rate, blood pressure, and metabolism. Blood vessels open wider to let more blood flow to large muscle groups, putting our muscles on alert. Pupils dilate to improve vision. The liver releases some of its stored glucose to increase the body’s energy. And sweat is produced to cool the body. All of these physical changes prepare a person to react quickly and effectively to handle the pressure of the moment.
This natural reaction is known as the stress response. Working properly, the body’s stress response enhances a person’s ability to perform well under pressure. But the stress response can also cause problems when it overreacts or fails to turn off and reset itself properly.
Good Stress and Bad Stress
The stress response (also called the fight or flight response) is critical during emergency situations, such as when a driver has to slam on the brakes to avoid an accident. It can also be activated in a milder form at a time when the pressure’s on but there’s no actual danger — like stepping up to take the foul shot that could win the game, getting ready to go to a big dance, or sitting down for a final exam. A little of this stress can help keep you on your toes, ready to rise to a challenge. And the nervous system quickly returns to its normal state, standing by to respond again wheeeded.
But stress doesn’t always happen in response to things that are immediate or that are over quickly. Ongoing or long-term events, like coping with a divorce or moving to a new neighborhood or school, can cause stress, too.
Long-term stressful situations can produce a lasting, low-level stress that’s hard on people. The nervous system senses continued pressure and may remain slightly activated and continue to pump out extra stress hormones over an extended period. This can wear out the body’s reserves, leave a person feeling depleted or overwhelmed, weaken the body’s immune system, and cause other problems.
What Causes Stress Overload?
Although just enough stress can be a good thing, stress overload is a different story — too much stress isn’t good for anyone. For example, feeling a little stress about a test that’s coming up can motivate you to study hard. But stressing out too much over the test can make it hard to concentrate on the material you need to learn.
Pressures that are too intense or last too long, or troubles that are shouldered alone, can cause people to feel stress overload. Here are some of the things that can overwhelm the body’s ability to cope if they continue for a long time:
being bullied or exposed to violence or injury relationship stress, family conflicts, or the heavy emotions that can accompany a broken heart or the death of a loved one ongoing problems with schoolwork related to a learning disability or other problems, such as ADHD (usually once the problem is recognized and the person is given the right learning support the stress disappears) crammed schedules, not having enough time to rest and relax, and always being on the go Some stressful situations can be extreme and may require special attention and care.
Posttraumatic stress disorder is a very strong stress reaction that can develop in people who have lived through an extremely traumatic event, such as a serious car accident, a natural disaster like an earthquake, or an assault like rape.
Some people have anxiety problems that can cause them to overreact to stress, making even small difficulties seem like crises. If a person frequently feels tense, upset, worried, or stressed, it may be a sign of anxiety. Anxiety problems usually need attention, and many people turn to professional counselors for help in overcoming them.
Signs of Stress Overload
People who are experiencing stress overload may notice some of the following signs:
· anxiety or panic attacks
· a feeling of being constantly pressured, hassled, and hurried
· irritability and moodiness
· physical symptoms, such as stomach problems, headaches, or even chest pain
· allergic reactions, such as eczema or asthma
· problems sleeping
· drinking too much, smoking, overeating, or doing drugs
· sadness or depression
Everyone experiences stress a little differently. Some people become angry and act out their stress or take it out on others. Some people internalize it and develop eating disorders or substance abuse problems. And some people who have a chronic illness may find that the symptoms of their illness flare up under an overload of stress.
Keep Stress Under Control
What can you do to deal with stress overload or, better yet, to avoid it in the first place? The most helpful method of dealing with stress is learning how to manage the stress that comes along with any new challenge, good or bad. Stress-management skills work best when they’re used regularly, not just when the pressure’s on. Knowing how to “de-stress” and doing it when things are relatively calm can help you get through challenging circumstances that may arise.
Here are some things that can help keep stress under control:
Take a stand against overscheduling. If you’re feeling stretched, consider cutting out an activity or two, opting for just the ones that are most important to you.
Be realistic. Don’t try to be perfect — no one is. And expecting others to be perfect can add to your stress level, too (not to mention put a lot of pressure on them!). If you need help on something, like schoolwork, ask for it.
Get a good night’s sleep. Getting enough sleep helps keep your body and mind in top shape, making you better equipped to deal with any negative stressors. Because the biological “sleep clock” shifts during adolescence, many teens prefer staying up a little later at night and sleeping a little later in the morning. But if you stay up late and still need to get up early for school, you may not get all the hours of sleep you need.
Learn to relax. The body’s natural antidote to stress is called the relaxation response. It’s your body’s opposite of stress, and it creates a sense of well-being and calm. The chemical benefits of the relaxation response can be activated simply by relaxing. You can help trigger the relaxation response by learning simple breathing exercises and then using them when you’re caught up in stressful situations. And ensure you stay relaxed by building time into your schedule for activities that are calming and pleasurable: reading a good book or making time for a hobby, spending time with your pet, or just taking a relaxing bath.
Treat your body well. Experts agree that getting regular exercise helps people manage stress. (Excessive or compulsive exercise can contribute to stress, though, so as in all things, use moderation.) And eat well to help your body get the right fuel to function at its best. It’s easy when you’re stressed out to eat on the run or eat junk food or fast food. But under stressful conditions, the body needs its vitamins and minerals more than ever. Some people may turn to substance abuse as a way to ease tension. Although alcohol or drugs may seem to lift the stress temporarily, relying on them to cope with stress actually promotes more stress because it wears down the body’s ability to bounce back.
Watch what you’re thinking. Your outlook, attitude, and thoughts influence the way you see things. Is your cup half full or half empty? A healthy dose of optimism can help you make the best of stressful circumstances. Even if you’re out of practice, or tend to be a bit of a pessimist, everyone can learn to think more optimistically and reap the benefits.
Solve the little problems. Learning to solve everyday problems can give you a sense of control. But avoiding them can leave you feeling like you have little control and that just adds to stress. Develop skills to calmly look at a problem, figure out options, and take some action toward a solution. Feeling capable of solving little problems builds the inner confidence to move on to life’s bigger ones — and it and can serve you well in times of stress.
Build Your Resilience
Ever notice that certain people seem to adapt quickly to stressful circumstances and take things in stride? They’re cool under pressure and able to handle problems as they come up. Researchers have identified the qualities that make some people seem naturally resilient even when faced with high levels of stress.
If you want to build your resilience, work on developing these attitudes and behaviors:
Think of change as a challenging and normal part of life.
See setbacks and problems as temporary and solvable.
Believe that you will succeed if you keep working toward your goals.
Take action to solve problems that crop up.
Build strong relationships and keep commitments to family and friends.
Have a support system and ask for help.
Participate regularly in activities for relaxation and fun.
Learn to think of challenges as opportunities and stressors as temporary problems, not disasters. Practice solving problems and asking others for help and guidance rather than complaining and letting stress build. Make goals and keep track of your progress. Make time for relaxation. Be optimistic. Believe in yourself. Be sure to breathe. And let a little stress motivate you into positive action to reach your goals.
Stress Management
A lot of research has been conducted into stress over the last hundred years. Some of the theories behind it are now settled and accepted; others are still being researched and debated. During this time, there seems to have been something approaching open warfare between competing theories and definitions: Views have been passionately held and aggressively defended.
What complicates this is that intuitively we all feel that we know what stress is, as it is something we have all experienced. A definition should therefore be obvious… except that it is not.
STRESS is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilize.” In short, it’s what we feel when we think we’ve lost control of events.
This is the main definition used by this section of Mind Tools, although we also recognize that there is an intertwined instinctive stress response to unexpected events. The stress response inside us is therefore part instinct and part to do with the way we think.
Fight-or-Flight
Some of the early research on stress (conducted by Walter Cannon in 1932) established the existence of the well-known “fight-or-flight” response. His work showed that when an organism experiences a shock orperceives a threat, it quickly releases hormones that help it to survive.
In humans, as in other animals, these hormones help us to run faster and fight harder. They increase heart rate and blood pressure, delivering more oxygen and blood sugar to power important muscles. They increase sweating in an effort to cool these muscles, and help them stay efficient. They divert blood away from the skin to the core of our bodies, reducing blood loss if we are damaged. As well as this, these hormones focus our attention on the threat, to the exclusion of everything else. All of this significantly improves our ability to survive life-threatening events.
Not only life-threatening events trigger this reaction: We experience it almost any time we come across something unexpected or something that frustrates our goals. When the threat is small, our response is small and we often do not notice it among the many other distractions of a stressful situation.
Unfortunately, this mobilization of the body for survival also has negative consequences. In this state, we are excitable, anxious, jumpy and irritable. This actually reduces our ability to work effectively with other people. With trembling and a pounding heart, we can find it difficult to execute precise, controlled skills. The intensity of our focus on survival interferes with our ability to make fine judgments by drawing information from many sources. We find ourselves more accident-prone and less able to make good decisions.
There are very few situations in modern working life where this response is useful. Most situations benefit from a calm, rational, controlled and socially sensitive approach.
In the short term, we need to keep this fight-or-flight response under control to be effective in our jobs. In the long term we need to keep it under control to avoid problems of poor health and burnout.
Coping With Stress
Stress affects your mind, body, and overall health. When you are feeling stressed, changes may occur in your body:
Your blood pressure may increase.
Your heart rate rises.
Your immune system does not function as well.
Your body’s response to stress could lead to illness.
You can control your stress level by practicing simple relaxation techniques to train your mind to lower your response to the tension.
By using relaxation techniques regularly, you can lower the amount of stress hormones in your blood. This will help you protect yourself from the harmful mental and physical effects of stress.
Breathing
Breathing provides oxygen to your bloodstream and body. When you breathe in, you inhale oxygen. When you breathe out, you exhale carbon dioxide. Your diaphragm (DIEeh-fram) is a sheet-like muscle that separates your stomach (abdomen) and your chest. Your diaphragm works to help you breathe in and out. When you inhale, the diaphragm lowers, your stomach pushes out, and your chest cavity swells. This gives the lungs more space to expand into and increases the amount of air that you can inhale.
Chest Breathing vs. Abdominal Breathing
As we get older, our breathing gets shallower, and most of us use only the upper parts of our chest to breathe. When you breathe from your chest, you inhale about a teacup of oxygen. Instead, you should breathe from your abdomen. When you breathe from your abdomen, you inhale about a quart of oxygen. The more oxygen you inhale, the better.
How you breathe also affects your nervous system. Chest breathing makes your brain create shorter, more restless brain waves. Abdominal breathing makes your brain create longer, slower brain waves. These longer and slower brain waves are similar to the ones your brain makes when you are relaxed and calm. So, breathing from the abdomen helps you relax quickly.
Practice Abdominal Breathing
It may be easier to practice abdominal breathing when you’re lying down. With practice, you should be able to do abdominal breathing anywhere.
Put your right hand on your abdomen, at the navel (belly button), and put your left hand on the center of your chest. You may find it helpful to close your eyes.
Inhale through your mouth more deeply than usual, and pay attention to your abdomen. If you are breathing from your abdomen, you should feel your abdomen rise as your lungs fill with air. The hand on your chest should move only slightly. If your chest rises more than your abdomen, then you are breathing from your chest.
To change from chest to abdominal breathing, exhale all of the air in your lungs. Keep pushing the air out. When you feel like you can’t exhale any more air, pause. Then inhale slowly. When you breathe this way, you push the air out from the bottom of your lungs, and create a vacuum that will pull in an abdominal breath when you inhale.
Do steps 2 and 3 again, but this time, breathe in through your nose. Breathing through your nose is better than breathing through your mouth because your nose:
warms the air .
filters the air
adds moisture to the air
lets you breathe in more air
Mini Relaxation Exercise
A mini relaxation exercise can help you reduce stress and tension immediately. The important part of these exercises is to focus on your breathing. During the exercises, try to breathe from your abdomen. You should feel your stomach rising about an inch as you breathe in, and falling about an inch as you breathe out. Remember, it is impossible to breathe from your abdomen if you are holding your stomach in. Relax your stomach muscles. You can do these exercises with your eyes open or closed. There are a variety of mini relaxation exercises. Choose the one that works best for you.
The following mini relaxation exercises were adapted from the Mind/Body Medical Institute in Boston, Massachusetts.
Exercise #1:
Count very slowly to yourself. Count from 10 down to 0. With the first abdominal breath, say 10 to yourself; with the next breathe, say 9, and so on. If you start feeling light-headed or dizzy, slow down the counting. When you get to 0, see how you are feeling. If you are feeling better, great! If not, try doing it again.
Exercise #2:
As you inhale, count to 4 very slowly and say to yourself “1,2,3,4.” As you exhale, count backwards very slowly and say to yourself “4,3,2,1.” Do this several times.
Exercise #3:
After each time you inhale, pause for a few seconds. After you exhale, pause again for a few seconds. Do this for several breaths.
When to Practice
You can practice the mini relaxation exercises almost anywhere, in any situation, including when you are:
· waiting in line or stuck in traffic
· put on hold during an important phone call
· bothered by something someone has said
· overwhelmed by what you need to accomplish
· in pain
It may seem that there’s nothing you can do about stress. The bills won’t stop coming, there will never be more hours in the day, and your career and family responsibilities will always be demanding. But you have more control than you might think. In fact, the simple realization that you’re in control of your life is the foundation of stress management. Managing stress is all about taking charge: of your thoughts, emotions, schedule, and the way you deal with problems
Identify the sources of stress in your life
Stress management starts with identifying the sources of stress in your life. This isn’t as easy as it sounds. Your true sources of stress aren’t always obvious, and it’s all too easy to overlook your own stress-inducing thoughts, feelings, and behaviors. Sure, you may know that you’re constantly worried about work deadlines. But maybe it’s your procrastination, rather than the actual job demands, that leads to deadline stress.
To identify your true sources of stress, look closely at your habits, attitude, and excuses:
Do you explain away stress as temporary (“I just have a million things going on right now”) even though you can’t remember the last time you took a breather?
Do you define stress as an integral part of your work or home life (“Things are always crazy around here”) or as a part of your personality (“I have a lot of nervous energy, that’s all”).
Do you blame your stress on other people or outside events, or view it as entirely normal and unexceptional?
Until you accept responsibility for the role you play in creating or maintaining it, your stress level will remain outside your control.
Start a Stress Journal
A stress journal can help you identify the regular stressors in your life and the way you deal with them. Each time you feel stressed, keep track of it in your journal. As you keep a daily log, you will begin to see patterns and common themes. Write down:
What caused your stress (make a guess if you’re unsure)
How you felt, both physically and emotionally
How you acted in response
What you did to make yourself feel better
Look at how you currently cope with stress
Think about the ways you currently manage and cope with stress in your life. Your stress journal can help you identify them. Are your coping strategies healthy or unhealthy, helpful or unproductive? Unfortunately, many people cope with stress in ways that compound the problem.
Unhealthy ways of coping with stress
These coping strategies may temporarily reduce stress, but they cause more damage in the long run:
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Smoking Overeating or undereating Zoning out for hours in front of the TV or computer Withdrawing from friends, family, and activities |
Sleeping too much Procrastinating Filling up every minute of the day to avoid facing problems Taking out your stress on others (lashing out, angry outbursts, physical violence) |
Learning healthier ways to manage stress
If your methods of coping with stress aren’t contributing to your greater emotional and physical health, it’s time to find healthier ones. There are many healthy ways to manage and cope with stress, but they all require change. You can either change the situation or change your reaction. When deciding which option to choose, it’s helpful to think of the four As: avoid, alter, adapt, or accept.
Since everyone has a unique response to stress, there is no “one size fits all” solution to managing it. No single method works for everyone or in every situation, so experiment with different techniques and strategies. Focus on what makes you feel calm and in control.
Dealing with Stressful Situations: The Four A’s
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Change the situation: Avoid the stressor Alter the stressor |
Change your reaction: Adapt to the stressor Accept the stressor |
Stress management strategy #1: Avoid unnecessary stress
Not all stress can be avoided, and it’s not healthy to avoid a situation that needs to be addressed. You may be surprised, however, by the number of stressors in your life that you can eliminate.
Learn how to say “no” – Know your limits and stick to them. Whether in your personal or professional life, refuse to accept added responsibilities when you’re close to reaching them. Taking on more than you can handle is a surefire recipe for stress.
Avoid people who stress you out – If someone consistently causes stress in your life and you can’t turn the relationship around, limit the amount of time you spend with that person or end the relationship entirely.
Take control of your environment – If the evening news makes you anxious, turn the TV off. If traffic’s got you tense, take a longer but less-traveled route. If going to the market is an unpleasant chore, do your grocery shopping online.
Avoid hot-button topics – If you get upset over religion or politics, cross them off your conversation list. If you repeatedly argue about the same subject with the same people, stop bringing it up or excuse yourself when it’s the topic of discussion.
Pare down your to-do list – Analyze your schedule, responsibilities, and daily tasks. If you’ve got too much on your plate, distinguish between the “shoulds” and the “musts.” Drop tasks that aren’t truly necessary to the bottom of the list or eliminate them entirely.
Stress management strategy #2: Alter the situation
If you can’t avoid a stressful situation, try to alter it. Figure out what you can do to change things so the problem doesn’t present itself in the future. Often, this involves changing the way you communicate and operate in your daily life.
Express your feelings instead of bottling them up. If something or someone is bothering you, communicate your concerns in an open and respectful way. If you don’t voice your feelings, resentment will build and the situation will likely remain the same.
Be willing to compromise. When you ask someone to change their behavior, be willing to do the same. If you both are willing to bend at least a little, you’ll have a good chance of finding a happy middle ground.
Be more assertive. Don’t take a backseat in your own life. Deal with problems head on, doing your best to anticipate and prevent them. If you’ve got an exam to study for and your chatty roommate just got home, say up front that you only have five minutes to talk.
Manage your time better. Poor time management can cause a lot of stress. When you’re stretched too thin and running behind, it’s hard to stay calm and focused. But if you plan ahead and make sure you don’t overextend yourself, you can alter the amount of stress you’re under.
Stress management strategy #3: Adapt to the stressor
If you can’t change the stressor, change yourself. You can adapt to stressful situations and regain your sense of control by changing your expectations and attitude.
Reframe problems. Try to view stressful situations from a more positive perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time.
Look at the big picture. Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere.
Adjust your standards. Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with “good enough.”
Focus on the positive. When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective.
Adjusting Your Attitude
How you think can have a profound effect on your emotional and physical well-being. Each time you think a negative thought about yourself, your body reacts as if it were in the throes of a tension-filled situation. If you see good things about yourself, you are more likely to feel good; the reverse is also true. Eliminate words such as “always,” “never,” “should,” and “must.” These are telltale marks of self-defeating thoughts.
Stress management strategy #4: Accept the things you can’t change
Some sources of stress are unavoidable. You can’t prevent or change stressors such as the death of a loved one, a serious illness, or a national recession. In such cases, the best way to cope with stress is to accept things as they are. Acceptance may be difficult, but in the long run, it’s easier than railing against a situation you can’t change.
Don’t try to control the uncontrollable. Many things in life are beyond our control— particularly the behavior of other people. Rather than stressing out over them, focus on the things you can control such as the way you choose to react to problems.
Look for the upside. As the saying goes, “What doesn’t kill us makes us stronger.” When facing major challenges, try to look at them as opportunities for personal growth. If your own poor choices contributed to a stressful situation, reflect on them and learn from your mistakes.
Share your feelings. Talk to a trusted friend or make an appointment with a therapist. Expressing what you’re going through can be very cathartic, even if there’s nothing you can do to alter the stressful situation.
Learn to forgive. Accept the fact that we live in an imperfect world and that people make mistakes. Let go of anger and resentments. Free yourself from negative energy by forgiving and moving on.
Stress management strategy #5: Make time for fun and relaxation
Beyond a take-charge approach and a positive attitude, you can reduce stress in your life by nurturing yourself. If you regularly make time for fun and relaxation, you’ll be in a better place to handle life’s stressors when they inevitably come.
Healthy ways to relax and recharge
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Go for a walk. Spend time iature. Call a good friend. Sweat out tension with a good workout. Write in your journal. Take a long bath. Light scented candles. |
Savor a warm cup of coffee or tea. Play with a pet. Work in your garden. Get a massage. Curl up with a good book. Listen to music. Watch a comedy. |
Don’t get so caught up in the hustle and bustle of life that you forget to take care of your oweeds. Nurturing yourself is a necessity, not a luxury.
Set aside relaxation time. Include rest and relaxation in your daily schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.
Connect with others. Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress.
Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.
Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways.
Stress management strategy #6: Adopt a healthy lifestyle
You can increase your resistance to stress by strengthening your physical health.
Exercise regularly. Physical activity plays a key role in reducing and preventing the effects of stress. Make time for at least 30 minutes of exercise, three times per week. Nothing beats aerobic exercise for releasing pent-up stress and tension.
Eat a healthy diet. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day.
Reduce caffeine and sugar. The temporary “highs” caffeine and sugar provide often end in with a crash in mood and energy. By reducing the amount of coffee, soft drinks, chocolate, and sugar snacks in your diet, you’ll feel more relaxed and you’ll sleep better.
Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or drugs may provide an easy escape from stress, but the relief is only temporary. Don’t avoid or mask the issue at hand; deal with problems head on and with a clear mind.
Get enough sleep. Adequate sleep fuels your mind, as well as your body. Feeling tired will increase your stress because it may cause you to think irrationally.
Stress Coping Strategies
Stress may be inevitable, but how you deal with it is largely up to you. Here are some ideas to help you create your own stress defense.
Use your support system – You may feel better sharing your feelings with a caring friend or family member. It can help to know that you’re not the only one who has disagreements with a spouse, problems with parenting or other worries.
Talk it over with yourself – We often have no control over the unpleasant events that happen in our lives, but we can change what we say to ourselves about these events. All our feelings are greatly affected by what we say to ourselves.
Avoid:
Catastrophizing (“This is the worst thing that ever happened to me.”)
Generalizing (“My dog doesn’t like me therefore, no one will.”)
Projecting (“I’m sure this isn’t going to work out.”)
Instead, try telling yourself “I am loved and safe” Practice talking nicely to yourself.
Don’t demand perfection – Ease up on yourself and those around you – accept that everyone has both strengths and shortcomings.
Just say no – Sometimes, we take on too much. You can avoid feeling overburdened by setting realistic goals and priorities. Remember, it’s OK to say no to requests that push you beyond your limits.
Take one thing at a time – Instead of thinking of other things you should be doing, focus on the task at hand and do it well. You’ll enjoy the sense of accomplishment and regain a sense of control.
Strive for balance in your life – Make time for activities and people you enjoy. Taking your mind off stressful matters for a while can help you keep a healthy perspective.
Be active – Walk your dog, go dancing or join a gym. If you’re generally healthy, aim to get at least 2.5 hours a week of moderate-intensity aerobic activity. At least two days a week, work in some muscle-strengthening activity at a moderate intensity or higher. Just be sure to check with your doctor before significantly increasing your level of physical activity.
Eat healthfully – Some people reach for junk food or turn to other unhealthful eating habits when they are under stress. Reduce consumption of caffeine and refined sugar, and increase your consumption of whole grains, nuts, fruits and vegetables.
Avoid unhealthy behaviors – Some people drink too much alcohol or over-eat to cope with stress. Talk with your doctor if you need help.
Get in touch – Hug someone, hold hands or stroke a pet. Physical contact is a great way to relieve stress.
Practice rest and relaxation – Take six deep breaths. Breathe slowly and deeply in through your nose, and out through your mouth. Use your imagination to place yourself on the beach, or in some other pleasant place from the past. Close your eyes and imagine the scene in detail, including all your senses. In just a couple of minutes you can re-experience the pleasure of actually being there. Get at least seven hours of sleep nightly. And, if your health permits, meditation, yoga or even tai chi can help you feel calm. Look for these types of classes in your community or try a video. Even losing yourself in a good book or taking a quiet walk can help you unwind.
Learn to laugh – Rent a comedy video and watch it with others (you’ll laugh more).
Stretch – Stand up. Raise your arms above your head. Stretch left and hold 1-2-3-4. Stretch right and hold. Repeat the stretch several times.
Stop smoking – Nicotine is a stimulant, and it can increase anxiety.
Seek professional help – If your stress your level becomes severe, seek help from a mental health professional who can help determine the best course of treatment for you.
Unfortunately there is no magic wand that will remove the impact of stress on your life. Controlling stress is an active process which means that you will have to take steps to limit its impact. However, there are some very simple steps that you can take to do this which may help your stress levels work for you instead of against you.
Step One: Be careful about what you eat and drink
Try to eat a well balanced diet, eating at least three regular meals a day. Eat foods which will release energy slowly and are likely to have a calming effect. Food or drink high in sugar may give you instant energy, but in the long term may wind you up leaving you feeling more nervy and edgy than you did before.
Limit your consumption of caffeine particularly found in tea, coffee, fizzy soft drinks and “Proplus” tablets. Excess caffeine tends to heighten arousal and increases “jittery” feelings; it can also impair your concentration and may keep you awake at night.
Try to also limit your use of alcohol and to avoid all use of non-prescribed drugs. These may make you feel better in the short term, but can prevent you from sleeping properly; they can also impair your ability to remember the work that you are trying to revise. Some people drink alcohol and / or smoke more to control their stress levels, but it would be a good decision to try to develop more healthy ways of controlling your stress.
Step Two: Get enough sleep
Make sure that you get plenty of rest; six to eight hours a night are recommended. If getting to sleep is a problem, ensure that you have at least a half an hour break from your revision before going to bed. Use this break to do anything relaxing which will take your mind off your work such as:
having a soak in the bath;
chatting to your friends;
writing a letter;
listening to some music.
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Step Three: Take regular exercise
Exercising regularly will not only help to keep you physically healthy, but also uses up the hormones and nervous energy produced when you are stressed. Exercise will also help to relax the muscles which become tense when you are stressed, and, as exercise increases the blood flow around the body, it can help you to think more clearly.
You do not have to take up a strenuous sport: try swimming, walking, cycling or dancing. Anything that gets you moving around and is enjoyable is beneficial, especially if it involves spending at least half an hour in the fresh air every day.
Step Four: Control your breathing
If you notice that you are starting to feel very stressed, for example as you wait for the examination to start, try to regulate your breathing by concentrating on breathing out to a slow count of four; the breathing in will take care of itself. It will be helpful if you practise this exercise when you are not stressed so that you are very familiar with the technique when you need actually need it.
Step Five: Make time for fun
Build leisure time into your revision days and the days that you sit your exams. Get involved in a non-academic activity, such as sports, crafts, hobbies or music. Anything that you find relaxing or enjoyable which will give you a break from thinking or worrying about your exams will be beneficial.
Step Six: Improve your study skills
Effective study skills can reduce stress by making you feel more in control of your work and more confident that you will succeed. Check out the Student Learning Centre’s guide to Revision & Exam Skills; attend one of the Centre’s exam skills workshops or review your approach in an individual consultation with the Centre’s adviser. (Details of how to contact the Centre are provided in the resources section at the end of this guide.) It may also be useful to talk to your course tutor to get subject specific advice to help make your revision more focused.
Remember that most of your fellow students will be feeling the same way as you do. Tell your friends and family how you feel and find ways of relaxing with them which will help to support you.
