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• Communication is interaction between people and a process of sending and receiving information that must be encoded and decoded for understanding.
• The elements of communication include: Sender, channel, message, receiver, and feedback.

Levels of Communication

• Interpersonal and intrapersonal

• Small group

• Public communication

• Communication involves exchanging information and ideas between individuals or groups with understanding and expression.

Types of Communication and Principles

• Verbal: Speaking and intonations with simplicity, clarity and brevity, timing and relevance, adaptability, credibility and humor.
• Written: Clarity and focus to the point.
• Non-verbal: Personal appearance, posture, gait, facial expression and gestures, eye contact, and touch.

Purpose of Communication in Nursing

• Gathering information to make informed decisions.
• Validating information to confirm accuracy and relevance.
• Sharing information to disseminate knowledge, ideas, and updates.
• Building relationships through meaningful interactions.
• Expressing feelings to connect on a personal level.
• Imagining to share creative thoughts for innovation and understanding.
• Influencing to persuade and guide others.
• Meeting social expectations by fulfilling societal norms.

Importance of Communication in Nursing

• Essential in all aspects of nursing, including prevention, treatment, rehabilitation, and education.
• Effective communication creates a positive patient experience and ensures patient safety.
• Provides information for the patient and others.
• Effective communication engages patients and families in their healthcare, aiding recovery and preventing readmission.
• Nurses communicate with colleagues and other health team members verbally and in writing.
• Effective communication provides job satisfaction and reduces stress.

Effective Communication Skills

• Active listening
• Respect
• Understanding of culture, language, and personal attitude
• Clarity and concise communication
• Compassion

Seven C's of Communication

• Clear
• Concise
• Concrete
• Correct
• Coherent
• Complete
• Courteous

Therapeutic Communication Techniques

• Open-ended questions
• Clarification and verification
• Reflection like asking a client "what do you think or your thoughts?"
• Offering self
• Restating

Non-Therapeutic Communication

• Close-ended questions
• Passing judgement
• Asking "Why?"
• False assurance
• Giving advice
• Biased questions
• Changing subject

Barriers to Effective Communication

• Lack of cultural understanding
• Language differences
• Poor attitude
• Poor knowledge
• Poor timing
• Vague and ambiguous language

Interpersonal Relationships

• Ongoing interactions involving mutual fulfillment and self-disclosure (sharing personal information).

Social and Professional Relationships in Nursing

• Nurse-Patient
• Nurse-Patient's family
• Nurse-Physician
• Nurse-Administrator
• Nurse-Supervisor
• Nurse-Educators
• Nurse-Nurse
• Nurse-Nursing student
• Nurse-Other health care professionals

Elements of Interpersonal Relationships

• Trust
• Caring
• Rapport
• Genuineness
• Respect
• Empathy

Three Types of Interpersonal Relationships

• Social
• Intimate
• Therapeutic

Phases of Therapeutic Relationship

• Pre-interaction: Obtaining patient information.
• Orientation: Establishing trust and rapport, maintaining privacy, gathering information, and formulating nursing diagnoses.
• Working: Maintaining trust, problem-solving, and continuous evaluation.
• Termination: Goals are met, patient discharge, or end of clinical rotation.

Documenting and Reporting

• Quality client care relies effective communication among healthcare professionals through discussions, reports, and records for coordination and collaboration.

• Communication includes discussions, reports, and records.

• A discussion is an informal verbal exchange to identify or solve a problem.

• A report is oral, written, or computer-mediated communication to convey info.

• A record (chart or client record) is a formal, legal document evidencing client care.

• Charting, documenting, or recording is the act of recording client information.

• Documentation is written or printed proof for authorized persons, legally required for continuity of care.

Purposes of Documenting and Reporting

• Communication among healthcare professionals for continuity of care and patient safety.
• Planning client care with individualized care plans.
• Auditing health agencies for compliance.
• Research using documented data for evidence-based practice.
• Education for nursing students and healthcare professionals.
• Reimbursement by accurately reflecting care provided.
• Legal documentation for protection during disputes.
• Healthcare analysis for trends, outcomes, and quality improvement.

Documentation System Methods

• Integral for:
  • Accurate communication
  • Maintaining legal records
  • Support clinical decision making

Source-Oriented Medical Record (SOMR)

• Traditional format.
• Departments/providers document observations, interventions, and outcomes in designated sections.

Problem-Oriented Medical Record (POMR)

• Established by Dr. Lawrence Weed in the 1960s.
• Organizes data by patient problems, unlike source-oriented records.
• Begins with a problem list.

Four Basic Components of POMR

• Database: Includes history, physical examination, and lab results.
• Problem List: Derived from the database, serves as an index.
• Plan of Care: Three categories: diagnostic, therapeutic, and patient education.
• Progress Notes: SOAP format details ongoing care and updates.

SOAP Format

• Structured method for POMR documentation.

Elements of SOAP

• S - Subjective data: Patient symptoms, feelings, perceptions (chief complaint, history).

• Example is "The patient reports experiencing sharp chest pain radiating to the lift arm for the past two hours".

• O - Objective data: Observable and measurable facts (physical exam, diagnostics).

• Example is "Blood pressure is 150/90 mmHg, heart rate is 95 bpm, and an ECG shows ST-segment elevation.”

• A - Assessment: Interpretation and analysis of data (diagnosis or differential diagnosis).

• Example is "The patient is experiencing symptoms indicative of acute myocardial infarction (heart attack).”

• P - Plan: Proposed plan of action (tests, treatments, education).

• Example is “Administer aspirin and nitroglycerin, perform a cardiac catheterization, and admit the patient to the ICU for monitoring and further treatment.”

• SOAPIE format extends SOAP with Intervention and Evaluation components.

Additional components in SOAPIE

• I - Intervention: Specific actions and treatments (medications, procedures).
• Example is "Administered 325 mg of aspirin and 0.4 mg of nitroglycerin sublingually. Initiated intravenous access and started a heparin drip."
• E - Evaluation: Patient's response to interventions and changes in condition.
• Example is "The patient's chest pain decreased from 8/10 to 3/10, and repeat ECG shows reduced ST-segment elevation.

Nursing Handover

• Essential for clinical jobs.
• Improves continuity of care, reduces workload, and betters patient outcomes.
• Information shared includes patient history, current condition, and future plans.

Qualities of a Good Nursing Handover

• Focused
• Concise
• Timely
• Complete
• Organized

Dangers of Inadequate Nursing Handover

• Delays in patient care.
• Increased medical errors.
• Lack of immediate updates.
• Poor tracking of patient needs.
• Problems from using two systems.

Benefits of Handover in Nursing

• Maintains data integrity
• Patient safety
• Patients likely to receive best care

Impact of Handover

• Reduces avoidable harm
• Reduces patient history repetition
• Supports clinical decision-making
• Reassures relatives
• Reduces stress
• Reduces review time
• Maintains records

Barriers To Effective Nursing Handover

• Complex transfer cause incomplete information
• Shifting responsibility relies on the team communication methods and culture
• Poor organisation dictates efficiency

Overcome Handover Barriers by

• Supportive culture
• Consistent method

Key Principles of Clinical Handover

• Focused

• Concise

• Timely

• Complete

• Organised

• Effective handover requires setting boundaries and consistency.

• It should be consistent in method, process, and outcome.

• It should be private to protect patient confidentiality.

• It should be understood by the team.

Nursing Process

• Method of caring with systematic, patient-centered and goal-oriented nursing.

Objectives of the Nursing Process

• Identify patient needs

• Prioritize care

• Maximize strengths

• Resolve problems

• Apply health promotion

• Documentation of this process is the accurately recording of relevant nursing skills.

Six Phases of the Nursing Process

• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation

Assessment

• Collection and communication of patient data.
• Includes information to implement effective care.
• Sources include patient, family, records, medical history, and tests.

Types of Assessment

• Initial: Performed after admission.
• Focused: Gathers data about a specific problem.
• Emergency: Identifies life-threatening problems through crisis assessment.
• Time-lapsed: Compares current status with baseline data.

Assessment Skills

• Observation
• Interviewing (directive, nondirective)
• Physical examination (inspection, palpation, percussion, auscultation)

Assessment Activities

• Determine priorities
• Cluster data
• Establish data base

Activities of Nursing Diagnosis

• Interpret and analyze patient data.
• Identify patient strengths and health problems.
• Formulate and validate nursing diagnoses.
• Prioritize nursing diagnoses.
• Detect and refer significant signs and symptoms.

Parts of Nursing Diagnosis

• Problem: Clear and concise statement.
• Etiology: Identifies physiological, psychological, social, spiritual, and environmental factors.
• Defining characteristics: Subjective and objective data.

Types of Nursing Diagnosis

• Actual: Validated by presence of characteristics.
• Risk: Vulnerability to develop a problem.
• Possible: Suspected problem.
• Wellness: Transition to a higher level of wellness.
• Syndrome: Cluster of nursing diagnoses.

Nursing Planning

• Formulating guidelines to resolve nursing diagnoses and develop the client's care plan.

Activities of Planning Phase

• Identify expected patient outcome.
• Select evidence-based nursing interventions.
• Communicate the plan of care.

Stages of Planning

• Initial: Developed by the admitting nurse.
• Ongoing: Updated by the nurse to keep the plan up to date.
• Discharge: Carried out by the nurse working with patient and family.

Critical Elements of Planning

• Establishing priorities
• Setting goals and developing expected outcomes
• Planning nursing interventions
• Documenting

Implementation

• Doing and documenting specific nursing actions to carry out interventions.

Types of Interventions

• Direct: Actions through interaction.
• Indirect: Actions away from client.

Nursing Care Plan

• Expected outcomes
• Client problems (nursing Diagnosis)
• Interventions

Types of Interventions

• Dependent
• Independent
• Collaborative

Evaluation in nursing

• Judgement of effectiveness of care to meet goals based on client's behavioral responses.

• Involves measuring how well the clients are achieved.

• Occurs whenever nurse interacts with patient.

Determining status of outcomes

• Systematic & ongoing outcomes need to be considered
• Identify factors that contribute to success and to failure
• If indicated you can modify the plan of care

Possible Evaluations

• Outcomes are not met (continue the plan)
• Outcomes are not met (modify the plan)
• Outcomes are met ( terminate the plan)

Factors to consider that affect outcomes

• Facilitators
• Barriers