nse12 arnold & boggs (interpersonal relationship) chapter...
TRANSCRIPT
NSE12WEEK 2
Arnold & Boggs (Interpersonal Relationship)
Chapter 3: Clinical Judgment: Applying Critical Thinking and Ethical Decision pp. 4955
CRITICAL THINKING
Critical thinking is an analytical process in which you purposefully use specific thinking skills to make complex clinical decisions.
APA definition: critical thinking is a purposeful, selfregulating process of interpretation, analysis, evaluation, and inference for the purpose of making judgments
o Allows for nurses to modify the care plan based on the client’s responses to their nursing interventions
More than just a cognitive process of following steps; requires an affective component: the willingness to engage in selfreflective inquiry
CHARACTERISTICS OF A CRITICAL THINKER
TABLE 1 Characteristics of a Critical ThinkerAttitude • Develops an analytical thinking ability
• Maintains an inquisitive mind set, systematically seeking solutions
• Displays openminded and flexible thinking processThought Processes • Is reflective
• Combines existing knowledge and standards with new information (transformation)
• Thinks in an orderly way, especially in complex situations (logical reasoning)
• Incorporates creative thinking• Diligently perseveres in seeking relevant information• Discards irrelevant information (discrimination)• Considers alternate solutions
Actions • Recognizes when information is missing and seeks new input
• Revises actions based on new input• Evaluates solutions and outcomes
Expert nurses constantly scan for new information and reassess their client’s situation; does not think linearly
Novice nurses think linearly, collect lots of facts but not logically organize them, and fail to make many connections with past knowledge
o Assessments tend to be more generalized and less focused; tend to jump to diagnosis without recognizing need to obtain more facts
BARRIERS TO THINKING CRITICALLY AND REASONING ETHICALLY
Attitudes and Habits
Attitudes such as “my way is better,” interfere with ability to empower clients to make own decisions
Thinking habits can impede communication with clients or families making complex bioethical choices i.e. accustomed to acknowledging “only one right answer,”
Behavior barriers include automatically responding defensively when challenged or resisting changes, etc
Cognitive barriers, such as thinking in stereotypes, also interfere with our ability
Cognitive Dissonance
Cognitive dissonance refers to the mental discomfort you feel when there is a discrepancy between what you already believe and some new information that doesn’t go along with your view.
Holding of two or more conflicting values at the same time
Personal Values versus Professional Values
Personal values develop over lifetime through influences of family, religious beliefs, and life experience
Values change as we mature in ability to think critically, logically, and morallyo Strongly held values then become part of selfconcept
Education as nurses help us acquire professional value system
Box 1 Five Core values of Professional NursingIdentified by the American Association of Colleges of Nursing (AACN):
1. Human dignity2. Integrity3. Autonomy4. Altruism5. Social Justice
VALUES CLARIFICATION AND THE NURSING PROCESS
Nursing process offers many opportunities to incorporate values clarification into your care; during assessment, you can obtain assessment of client’s values with regard to health system
o I.e. patient has obstructive pulmonary disease and has difficulty breathing, but insists on smoking
o Is it appropriate to intervene?o Smoking is detrimental and as a nurse, you find value of health in conflict
with client’s value of smokingo When values differ, care for client within his reality; he has right to make
decisions not always congruent with healthcare providers When identifying specific nursing diagnoses, important that diagnoses isn’t biased
o I.e. spiritual distress related to conflict between spiritual beliefs and prescribed health treatments
In planning phase, important to identify and understand client’s value system as foundation for developing most appropriate interventions – those that support client’s health beliefs likely to be received more favorably
Interventions include values clarification as guideline for care; help clients examine alternatives
During evaluation phase, examine how well nursing and client goals were met while keeping within client’s value system
SOLVING ETHICAL DILEMMAS IN NURSING
Ethical issues nurses commonly face today can be placed in three general categories:1. Moral uncertainty
o Occurs when a nurse is uncertain as to which moral rules (i.e. values, beliefs, or ethical principles) apply to a given situation
o I.e. should terminally ill patient who is in and out of a coma and chooses not to eat or drink anything be required to have IV therapy for hydration purposes? Does giving IV therapy constitute giving the client extraordinary measures to prolong life? Is it more comfortable or less comfortable for the dying client to maintain a high hydration level?
o Nurse is unable to identify the situation as a moral problem or to define specific moral rules that apply
o Helpful strategies: using the values clarification process, developing a specific philosophy of nursing, acquiring knowledge about ethical principles
2. Ethical or moral dilemmas o Occurs when two or more issues conflict o I.e. organ harvesting of severely braindamaged infant that will definitely
dieo Is it right to remove organs before child’s death even if it may save lives
of several other infants o There’s no single “right” solution & is up to the discretion of the nurse
3. Moral distress
o Occurs when the nurse knows what is “right” but is bound to do otherwise because of legal or institutional constraints
o I.e. terminally ill client who doesn’t have a “do not resuscitate” medical order and thus attempts must be made
Chapter 4: SelfConcept in the NurseClient Relationship pp. 6282
BASIC CONCEPTS
Selfconcept integral component of nurseclient relationships; healthy selfconcept reflects attitudes, emotions, and values that are realistically consistent with meaningful purposes in life and satisfying to individual
Characteristics of a healthy selfconcept relevant to appreciation of selfconcept’s role in communication:
→ Congruence between real and ideal self→ Realistic life goals→ Distinct sense of identity→ High selfesteem→ Satisfaction with role performance → Emotional stability→ Satisfaction with body image→ Spiritual wellbeing
DEFINITION
Selfconcept refers to an acquired set of thoughts, feelings, attitudes, and beliefs that individuals have about the nature and organization of their personality.
o Help people experience who they are and what they’re capable of becoming physically, emotionally, intellectually, socially, and spiritually in relationship or community
o Creates and reflects our personal reality and worldview Four aspects of selfconcept – physical, cognitive, emotional, and spiritual –
represent holistic self & are important determinants of behavior
FEATURES AND FUNCTIONS OF SELFCONCEPT
Selfconcept is an active source of information about the self; isn’t necessarily a unified concept
o Can consist of multiple selfimages, some may not match with each other or be supportive of the whole
I.e. a star athlete can be a marginal student Which is the true selfimage, or are both valid?
o Provides important bridges to meaning; help people make personal sense of their past, how it relates to present, and how it might to the future
o Personal decisions congruent with selfconcept affirm sense of selfidentity
Possible Selves
Possible selves is a term used to explain the futureoriented component of selfconcept. Future expectations important variable in goal setting and motivation Selfperceptions of personal health and wellbeing may be as important as
objective data for predicting healthy outcomes over time Communication can provide important support for exploring positive possibilities
for personal identity and helping clients reframe/avoid establishing negative possible selves
SelfConcept/Environmental Relationships
Social environment plays important role in shaping a person’s selfconceptReflective appraisals refer to the personalized messages received from others that help shape selfconcepts and contribute to selfevaluations.
Understanding interplay between person and environment in explaining selfconcept has important implications to nurseclient relationships
Reciprocal relationship in which nurse’s perceptions of self limit or enhance communication and support or diminish client’s sense of selfesteem
Welldefined, accurate selfconcept allows nurses to effectively communicate in most situations
Though cognitive awareness of selfconcept never fully completes, Johari Window provides disclosure/feedback model to help people learn more about self concept
1. Open self (arena): what is known to self and others2. Blind self: what is known by others, but not by self3. Hidden self (façade): what is known by self, but not by others4. Unknown self: what is unknown to self and also unknown to others
Increasing open area through asking for and receiving feedback (decreasing blind self), and using selfdisclosure (decreasing hidden self) leads to more authentic selfawareness
Decreasing level of unknown self through selfdiscovery, new observations by others, and mutual illuminations of experiences increases open area
APPLICATIONS
SELFCONCEPT AS A NURSING DIAGNOSIS
Four aspects of selfconcept are relevant to consider in nurseclient relationships: 1. Body image2. Personal identity3. Selfesteem4. Spirituality
Relevant to selfconcept are nursing diagnoses related to body image, human dignity, personal identity, powerlessness, selfconcept, and selfesteem
BODY IMAGE
Body images are the physical dimension of selfconcept.
Assessment Strategies
Meaning of body images important to assess because it differs from person to person
Assessment data supporting nursing diagnosis related to selfconcept disturbance in body image may include one or more following behaviors:
o Verbal expression of negative feelings about the bodyo No mention of changes in body structure and function, or preoccupation
with changed body structure or functiono Reluctance to look at or touch a changed body structure o Social isolation and loss of interest in friends after a change in body
structure, appearance, or functiono Physical changes usually require significant psychosocial and role
performance adjustment; a comprehensive assessment should include the client’s strengths and limitations, expressed needs and goals, the nature and accessibility of the client’s support oonansystem, and the impact of body image change on lifestyle
Supportive Nursing Strategies
Nurses see clients with serious body image changes on the regular; for clients, it’s unique
Showing client that physical change doesn’t frighten nurse reduces fear that people will turn away
Following options allow nurses to help clients become adjusted with their new selfconcept of body image:
o Anticipatory guidance with visitors also helps promote acceptanceo Providing relevant information and creating opportunities for clients to ask
questions make it acceptable for them to explore changes in selfconcept related to body image
o Validation checks and suggesting realistic responses can facilitate communication about alterations in body image
o Introduce adaptive functioning by helping clients anticipate & respond with dignity to the reaction of others
o Asking questions about what clients expect, provide coaching, and helping clients identify social supports
PERSONAL IDENTITY
Personal identity is described as an interpersonal psychological process consisting of a person’s perceptions or images of personal abilities, characteristics, and potential growth potential. Personal identity is based on cognitive understandings of the selfderived from perceptual and cognitive processing of personally relevant data about the self.
Person’s selfconcept anchored in selfdescriptions advanced by culture; clear cultural identity positive related to selfconcept clarity and self esteem
Understanding differences in cultural worldview orientation helps nurses frame interventions in ways that support ethnocultural variations
o I.e. Western cultures tend to be individualistic; Asian cultures tend to be collectivists
Responding to Cognitive Distortions. • Not so much what happens to us as it is how we interpret and respond to
circumstances that create problems
Box 2 Common Cognitive Distortions→ “All or nothing” thinking – the situation is all good or all bad; a person is
trustworthy or untrustworthy→ Overgeneralizing – one incident is treated as if it happens all the time; picking out
a single detail and dwelling on it→ Mind reading and fortunetelling – deciding a person doesn’t like you without
checking it out; assuming a bad outcome with no evidence to support it→ Personalizing – seeing yourself as flawed, instead of separating the situation as
something you played a role in but did not cause→ Acting on “should” and “ought to” – deciding in your mind what is someone
else’s responsibility without perpetual checks; trying to meet another’s expectations without regard for whether if makes sense to do so
→ “Awfulizing” – assuming the worst; every situation has a catastrophic interpretation and anticipated outcome
• Cognitive behavioral therapy (CBT) is the treatment of choice for clients with significant perceptual/cognitive distortions
• People are taught to recognize their cognitive distortions when thoughts interact with inner emotions to control behavior
• Awareness is followed with strategies designed to reframe negative thinking patterns
o Provision of additional information, using Socratic questioning, modeling cues to behavior, and coaching clients to challenge cognitive distortions
through use of positive selftalk, mindfulness, values exploration, and present orientation
Selftalk is a cognitive strategy people can use to lessen cognitive distortions.
SelfEsteem: Emotional Aspects of Personal Identity
Selfesteem is defined as the emotional value a person places on his or her personal selfworth in relation to others and the environment.
Mirrors a person’s inner sense of self and adds additional filter to perceptual and cognitive awareness of self
Reflects cultural norms, genetic temperament, and supportive relationships
SELFEFFICACY
Selfefficacy strong associated with selfesteem and nursing diagnosis of powerlessness; those who believe they can handle threatening situations value their competence and ability to succeed
o Less likely to harbor selfdoubts or dwell on personal deficiencies Selfefficacy is a term originally developed by Albert Bandura (2007) in referring to a person’s perceptual belief that he or she has the capability to perform general or specific life tasks successfully.
People develop selfefficacy through personal experience with mastering tasks, seeing others similar to them accomplish, and through verbal support
Spiritual Aspects of Personal Identity
Spirituality is a unified concept, closely linked to a person’s worldview, providing a foundation for a personal belief system about the nature of God or a Higher Power, moralethical conduct, and reality.
Spirituality often used interchangeably with religion but key difference is that religion involves formal acceptance of belief and values within organized faith community; spirituality describes selfchosen beliefs and values that give meaning to person’s life, may or may not be associated with particular faith
Spiritual aspects of selfconcept can be expressed through: o Membership in specific religious faith community with set of formal,
organized beliefso Nature, meditation, or other personalized life ways & practices linked with
higher purpose in lifeo Cultural and family beliefs about forgiveness, justice, human rights, right
and wrong learned in early childhoodo Crisis or existential situations that stimulate a search for purpose,
meaning, and values lying outside the self
Chapter 5: The NurseClient Relationship pp. 8889
Therapeutic Use of Self
Therapeutic relationship combination of what the nurse does and who the nurse is in relation to clients and families
Most important tool nurses have at disposal is use of self LaSala (2009) uses words of Florence Nightingale, that nurse achieves “the moral
ideal” whenever they use “the whole self” to form relationships with “the whole of the person receiving care” to explain optimum involvement of self in nurseclient relationship
Authenticity
Authenticity is a precondition for therapeutic use of self in nurseclient relationship
Requires recognizing personal vulnerabilities, strengths, and limitations Nurses need to clear about personal values, beliefs, stereotypes, and personal
perspectives because it can influence client decisions Nurses’ responsibility to resolve interpersonal issues getting in the way of
relationship
SelfAwareness
Requires reflective process seeking to understand one’s personal values, feelings, attitudes, motivations, strengths, and limitations – and how these affect practice and client relationships
Critically & simultaneously examining behaviors of client and nurse, nurses can create safe, trustworthy, and caring relational structure
Potter & Perry (Canadian Fundamentals of Nursing)
Chapter 7: Nursing Values and Ethics pp. 8182
A value is a strong personal belief and an ideal that a person or group believes to have merit.Ethics is study of the philosophical ideals of right and wrong behavior based on what you ought (or ought not) to do.
Healthcare providers agree to national codes of ethics that offer guidelines for responding to difficult situations
o I.e. Canadian Nurses Association (CNA, 2008) publishes a code of ethics that outlines nurses’ professional values and ethical commitments to their patients and the communities they serve
VALUES
In nursing, value statements express broad ideals of nursing care and demonstrate reasonable directions for practice
CNA Code of Ethics for Registered Nurses is centered around seven core values:1. Providing safe, compassionate, competent, and ethical care2. Promoting health and wellbeing3. Promoting and respecting informed decision making4. Preserving dignity5. Maintaining privacy and confidentiality6. Promoting justice7. Being accountable
Values Formation
Throughout childhood and adolescence, people learn to distinguish right from wrong and to form values on which to base their actions à moral development; family experiences strongly influence value formation
Person’s culture, ethnic background, religious community, and other social settings such as schools and work environments shape values as well
Cultural values are those adopted as a result of a social setting. Over time, a person acquires values by choosing some that are strongly upheld in
the community and discarding or transforming others
Values Clarification
To adopt new values, you must first be aware of existing values and how they affect behavior
Values clarification is the process of appraising personal values. o It’s a process of personal reflection; by clarifying your values, you make
careful choices and thus achieve greater selfawareness and personal insight
Understanding personal values, you’ll become more sensitive to values of others In value conflict, personal values are ad odds with those of your
patient/colleague/institution Enhancing skill of values clarification opens possibilities to help patients identify
their personal priorities, values, and emotions; may help resolve conflicts between values and behaviors
Chapter 25: SelfConcept pp. 396414
Selfconcept is the mental image that one has of oneself. Composite of ideas, feelings and attitudes that a person has about their identity,
worth, strengths, and limitations
SCIENTIFIC KNOWLEDGE BASE
Factors that influence selfconcept: family, relationships with others, gender, developmental stage, SES, culture, and environment
NURSING KNOWLEDGE BASE
Components and Interrelated Terms of SelfConcept
Many components to selfconcept; those particularly related to nurses are identity, body image, role performance, and selfesteem
Selfesteem and selfconcept are used interchangeably but selfesteem stems from and influences selfconcept
Selfconcept is a descriptive term; selfesteem is an evaluative term o I.e. Who am I? vs Am I worthy?
Identity.Identity involves the internal sense of individuality, wholeness, and consistency of a person over time and in various circumstances.
Influenced by age, gender, social class, ethnicity, and culture Body Image.Body image involves attitudes related to the body, including physical appearance, structure, or function.
Influenced by changes in health statuses, cognitive growth, physical development, and cultural and societal attitudes and values
Role Performance.Role performance is the way in which individuals perceive their ability to carry out significant roles.
Roles followed in given situations involve socialization to expectations or standards of behavior
Learned behaviors approved by society are through the following processes:o Reinforcement extinction: certain behaviors become common or are
avoided, depending on whether they are approved and reinforced or are discouraged and punished
o Inhibition: a person learns to refrain from certain behaviors, even when tempted to engage in them
o Substitution: a person replaces on behavior with another, which provides the same personal gratification
o Imitation: a person acquires skills or behaviors by observing and then imitating the skills and behaviors of other members of the family or other social or cultural groups
o Identification: a person internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self
SelfEsteem.Selfesteem is an individual’s overall sense of selfworth or the emotional appraisal of selfconcept.
Identity Stressors. Developmental markers such as puberty, menopause, retirement and decreasing
physical abilities may affect identity Adults generally have more stable identity and thus more firmly developed self
concept than do younger people
Cultural and social stressors may effect an adult’s identity more than personal stressors
o I.e. maintaining balance between family and work Identity confusion results when people do not maintain a clear, consistent, and continuous consciousness of personal identity. Body Image Stressors.
Changes in appearance, structure, or function of a body part requires adjustment A person’s perception of the change and importance placed on body image affects
the significance of the loss of function or change in appearanceRole Performance Stressors.
Normal changes with roles are associated with growth and maturation Situational transitions occur when relationships or jobs change
Role conflict results when a person simultaneously assumes two or more roles that are inconsistent, contradictory, or mutually exclusive.
o I.e. when a middleage woman with teenage children assumes responsibility for caring for her older parents, conflicts may arise in relation to both the adult child and the caregiver of her parents
The sick role involves the expectations of other people and society about how a person should behave when sick. Role ambiguity involves unclear role expectations.
People are unsure about what to do or how to behave; often stressful and confusing
Role strain is the stress or strain experienced by an individual when behaviors, expectations, or obligations associated with a single social role are incompatible.
Those who feel inadequate or unsuited for a new social role may experience role strain
Role overload involves having more roles or responsibilities within a role than are manageable.
SelfEsteem Stressors. Stressors vary with developmental stages Perceived inability to meet parental expectations, harsh criticism, inconsistent
discipline, and unresolved sibling rivalry may reduce children’s selfwroth
CRITICAL THINKING
Critical thinking approach to care is essential; requires synthesis of knowledge, experience, information gathered from clients and families, critical thinking qualities, and intellectual and professional standards
Solid clinical judgment requires anticipating required information, collecting and analyzing data, and making appropriate decisions regarding client care