NSE 101 (COMS) Final Exam Review - PDF

WEEK 1: Chp 1, 2, 3 =================== [Chapter 1: Introduction ] -------------------------------------- **Scholarly writing:** - - - - - [Chapter 2: Reading and Comprehension] -------------------------------------------------- **Dialectic Note Taking:** Dialectic just means a dialogue---a discussion between two (or more) voices trying to figure something out. **[Pre-reading: ]** 1. 2. 3. 4. 5. 6. **[Critiquing a text:]** Evaluating in a constructive way to explore and understand the material you're working with. **Main point/summary:** Critiquing flow, accuracy (evidence & support), clarity, significance, consistency/ does it wander at any point **Tone -** Refers to the **attitude** or **approach** an author takes toward the subject matter. Is the text's tone and language appropriate? Ex. Academic words = Formal tone, Slang = Informal tone (bombaclaat) **Presence of jargon -** Refers to the use of specialized or technical language that is specific to a particular field, discipline, or community (May be difficult to understand by others outside a given field). Ex. Nurse uses medical terms **Emotion/Objectivity -** Based on purpose, **specific way emotions, feelings or thoughts are conveyed** through words, body language, or facial expressions. (Ex. Joy, Sadness) **Response -** How did you respond to the piece? Did you like it? Did it appeal to you? Could you identify with it? **Cultural Context -** Cultural context is a fancy way of asking who is affected by the ideas and who stands to lose or gain if the ideas take place. **Effective reading skills:** ![](media/image7.png) [Chapter 3: Information Literacy] --------------------------------------------- **Information Literacy:** Having the skills to competently evaluate various types of knowledge. -Being able to determine whether the information you are reviewing is **high quality**, **reliable**, and **relevant** to your practice. **Search Operators:** Tools to help you optimize your searches. **Operator** **Definition** -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **AND** In capital letters, AND is used to **combine terms** so that your search reveals sources that have both terms in it. Ex. nursing AND compassion **OR** In capital letters, OR is used to **combine more than one keyword** that you are interested in, but both words won't necessarily be in the articles together. Ex. youth OR adolescents OR teenagers **NOT** In capital letters, NOT is used to **filter out certain keywords** that you are not interested in. Ex. "dance therapy" NOT "hip hop" NOT ballroom **TRUNCATION (\*)** Use the **asterisk/star** at the end of a word if you are interested in **variations of the word**. Involves shortening of the word. Ex. **Educat**\* → This will find results for \"education,\" \"educator,\" \"educational,\" \"educating,\" etc. **QUOTATIONS MARKS (")** Use quotation marks surrounding phrasing to group words together so that individual words are not found separately. **[Evaluating Quality (CRAAP):]** **C: Currency -** The timeliness of the information. **R: Relevance -** The importance of the information for your needs. **A: Authority -** The source of the information. **A: Accuracy -** The reliability, truthfulness, and correctness of the content. **P: Purpose/point of view -** The reason the information exists. **[Sources: ]** **Peer-Reviewed Resources:** Experts have anonymously reviewed, critiqued, and recommended (or not recommended) an article for publication **Popular Sources:** Popular sources are intended for a more general audience and range from entertainment magazines to well-researched investigative articles from the New York Times. These sources usually do not have a specific structure and rarely contain references. (Ex. New York Times) **Grey Literature:** Sources of information that are not formally published through traditional means and are often not peer reviewed. These are typically excluded from databases, making the information difficult to locate. **Primary Sources:** Direct, firsthand sources of information or data. In nursing, primary sources are typically research articles. **Secondary Sources:** one step removed from the primary source of information and discuss, interpret, analyze, consolidate, or otherwise rework information from primary sources. (Ex. Reviewed Literature) In the nursing context, some examples are websites of CNO, CNA, RNAO **Wikipedia: NOT CONSIDERED ACCEPTABLE RESOURCES -** Due to **egalitarianism** (Billed as a public encyclopedia for everyone) [WEEK 2: Chp 4, 5] ============================== [Chapter 4: Types of Writing] ----------------------------------------- **[Types of Writing]** [Descriptive:] This type of writing usually does not include your personal opinion or critique. Rather, it focuses on a summary of what the authors said. [- Steps:] \- You describe or write a summary of a text you have read \- Consider the reason why you are writing the summary and the audience you are writing for \- Do some pre-reading \- Document the main/supporting points in point form \- Write the summary which is a general overview of the text and excludes minor details *What to keep in mind:* \- Use complete sentences \- Neutral tone \- Paraphrase in your own words \- Avoid **anthropomorphism** (attribution of human characteristics, behaviors, or emotions to animals, objects, or non-human entities). [Reflective] \- Think deeply and critically -First person, hence the reflectiveness [- Steps:] \- **Look Back** --- recall a situation that was meaningful to you \- **Elaborate** --- describe situation from both objective and subjective \- **Analyze** --- examine how and why the situation happened the way it did \- **Revise** --- consider how and why your practice should remain the same and how it should be changed \- **New Trial/Perspective** --- what will you do differently? [Analytical] \- Detailed examination of multiple elements [- Steps:] \- Start with a question or debate \- Review the literature \- Begin your analysis \- Opposing viewpoints \- Themes/categories in the literature \- Present what is known about the topic in a concise and informative manner \- Articulate your process of inquiry and examine the concept or issue closely \- Offer analytical commentary to reflect on issues [Persuasive] \- Convince, Motivate, or Move readers [- Steps:] \- Choose a topic that you feel passionate about \- Read and prepare \- Begin with engaging introduction \- Begin with most important points \- Identify opposing points of view \- Write a conclusion that leaves the reader with a strong impression [Critical] \- Involves critical thinking when you start breaking down your topic to develop discussion points. [- Steps:] \- Demonstrate concise and comprehensive understanding of the issue \- Identify strengths and limitations of the issue \- Synthesize and connect ideas, arrive at your own conclusions \- Evaluate and critique texts related to the topic *What to keep in mind:* \- Adopt the language used in original source \- Clearly and concisely argue one point at a time [Editorial] \- Sharing educated opinion -Often involves persuasive writing as It is sometimes referred to as an opinion or perspective piece (IT IS STILL A EDITORIAL AND NOT OPINION,PERSPECTIVE, PERSUASIVE PIECES, ONLY POSSESSING SUCH COMPONENTS) \- Steps: \- Choose a specific topic that is current, timely and controversial \- Consider the audience and tailor your language \- Your purpose statement should identify clearly your opinion /resolution / suggestion for change \- Choose a side and state your opinion early on so the reader knows what to expect *What to keep in mind:* \- Professional tone \- Clear and simple language \- Catchy title that emphasizes main point \- Do your research and make sure facts are correct \- Present idea constructively [Literature Writing:] Summarizing what is known about a particular topic based on your examination of existing scholarly sources. 1. \- Identify your topic and the number of texts to be included \- Search the literature \- Take notes while reading and critique the text \- Construct a short annotation for each text \- Briefly comment on the text \- Include a bibliographic citation 2. \- Narrow and define your topic \- Search the literature \- Take notes about the main points of the article and critique the text \- Decide how to structure your review (based on chronological order, methodology, theory etc...) \- Use topic sentences in each paragraph [Chapter 5: The Fundamental of Writing] --------------------------------------------------- **Audience, Reader, Purpose (purpose statement), Point Of View** [- Audience] \- Audience is the person or group that you are trying to influence \- Your instructor is alway the reader but not always the audience \- Tailor content and style of writing to audience [- Purpose/Purpose statement] \- Purpose will guide your writing process \- **Verbs** in your guidelines can help determine the purpose of your writing \- Writing an effective and scholarly purpose statement \- Consider the audience and write it clearly and concisely \- Choose your verbs purposefully \- Use present tense and avoid future tense \- Write it with confidence, avoid words like think and believe \- Use pronouns consistently \- Use first or third person POV [- POV] \- The perspective used when writing a text \- First person --- I, our and we (anthropomorphism needs to be avoided --- giving non-human object a humanistic character) it is scholarly \- Second Person --- You, your --- used to address one or more readers \- Third Person --- She, he, they, it --- used to eliminate subjectivity \- Consistency of pov needs to stay the same \- Choice of POV is influenced by the purpose and audience \- Watch out for gendered assumptions [Tones of Writing] \- Identifies a writers attitudes towards a subject or audience \- Types: \- **Informal** --- tends to be more relaxed, unofficial way of writing \- **Conversational** --- tends to informal, fun and engaging \- **Professional** --- tends to be formal, respectful and serious \- **Scientific** --- tends to be impersonal, objective, derived from facts \- **Ironic** --- to be subtle, humorous and dispassionate \- **Critical** --- tends to expose oppression and power inequalities \- **Rhetorical** --- tends to be persuasive and simplistic \- **Political** --- tends to overtly convey an ideology or belief **Sentence and Paragraph Construction** \- Construct paragraph and sentences with intention \- Sentences should be no longer than three lines \- Paragraphs should be at least 3-8 sentences \- Paragraphs should be about ½ to ¾ of page in a double spaced paper **Common Writing Errors** \- **Anthropomorphism** --- giving a humanistic characteristic to a non-human **Clear and Complex Language** \- Words that lead to lack of clarity: \- Mentioned --- implies something was briefly referred to \- Several --- refers to three of something rather than couple which is two \- Proves --- unless it is proven use words like indicates or suggests \- Correlates --- words refers to relationship between two things use "corresponds" or "associated with" instead [- Language to avoid] \- **Jargon** --- refers to language, abbreviations or terms used by specific groups \- **Colloquial phrasing** --- familiar, everyday slang \- **Cliches** --- descriptive expression that are not understood due to overuse **Respectful and Inclusive Language** \- Labels are words and phrases that describe and categorize people in ways that are demeaning \- Denotation - is the dictionary or literal definition \- Connotation - cultural meaning or feeling or idea Commonly Confused Words \- Accept means to agree / except means only or but \- Affect means to create change / effect means and outcome or result \- Are is a conjugated verb to be / our indicate possession and follow pronoun we **Other Grammar and Style Tips** [- Common grammar errors] \- Contraction use --- it's (should be "it is") \- Excessive modifiers/descriptors --- very, quiet, extremely \- Semicolon use --- ; \- Omission of listing comma --- listing 2 or more \- Comma splice --- two independent clauses joined with a comma \- Run on sentences \- Verb form or verb tense error --- the nurse "speaked" \- Wrong preposition --- gave instructions for (should be gave instructions to) \- Apostrophe error - ' [WEEK 3: CHP 6, 7] ============================== [Chapter 6: Writing Process & Pre-writing] ------------------------------------------------------ - 1.PREWRITING/BRAINSTORMING: Generate and begin to develop ideas to write about. As a starting point, read the writing assignment, determine what is required, and what you will focus on. You may need to conduct research during this phase. 2.OUTLINING A STRUCTURE OF IDEAS: Determine the paper's overall organizational structure and create an outline to organize these ideas. This phase usually involves elaborating on the initial ideas. 3.WRITING A ROUGH DRAFT: Use the work completed in the prewriting and outlining phases to develop a first draft. It should cover the ideas that you brainstormed and follow the organizational plan that you laid out. 4\. REVISING: Review the draft and reshape its content to ensure it **flows smoothly.** This stage involves moderate and sometimes major changes: adding or deleting paragraphs, phrasing the main point differently, expanding on an important idea, reorganizing content, etc. 5\. EDITING: Review the draft again to make changes that improve style and adherence to standard writing conventions. For example, you may replace a vague word with a more precise one, or correct errors in grammar and spelling. Once this stage is complete, the writing process is finished and your work is ready to share with others. - - - - - - [QUALITIES OF A THESIS:] SPECIFICITY PRECISION ARGUABILITY CONFIDENCE DEMONSTRABILITY ------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Must concentrate on a specific area of a topic.** Choose a broad subject, and then narrow it down until you pinpoint a specific aspect. **Must be precise enough to allow for a coherent argument and to remain focused on the topic.** **Must present a relevant and specific argument.** A factual statement is generally not considered arguable. A thesis statement should contain an opinion or point of view that can be supported with evidence. **You should be confident in your argument.** **Provide reasons and examples for your opinion.** You can rely on personal observations to do this, or you can consult outside sources to support your opinion. **Writing and Revising a Thesis Statement** - - - - - - - -Outlining is a useful pre-writing tool once you are at the stage where you know your topic well or at least know the areas you want to explore. It provides a map of what your paper will look like, including its components. [- Two Types] - [-Develop an outline with a format of an introduction, 3 body paragraphs and a conclusion \| Example:] **Introduction** - - - **Body paragraphs** - - - - - **Conclusion** - - - [Chapter 7: Drafting & Writing A Paper ] ---------------------------------------------------- - +-----------------------+-----------------------+-----------------------+ | INTRO | BODY | CONCLUSION | +=======================+=======================+=======================+ | -Piques the | -Includes several | -Reinforces the main | | audience's interest, | paragraphs with a | idea or thesis | | conveys what the | topic sentence in | statement and leaves | | paper is about (i.e., | each paragraph that | the audience with a | | the main idea), and | states the main idea | feeling of | | motivates readers to | of the paragraph and | completion. | | keep reading. | connects the idea to | | | | the thesis statement | | | -Provides the thesis | or the main idea of | | | statement, if one is | the paper. | | | applicable or | | | | required, to present | -Supporting sentences | | | the controlling idea | in each paragraph | | | of the entire piece | develop or explain | | | of writing. | the topic sentence. | | | | Depending on the type | | | | of writing (e.g., | | | | reflective, | | | | persuasive), these | | | | may be specific | | | | facts, examples, | | | | anecdotes, or other | | | | details that | | | | elaborate on the | | | | topic sentence. | | +-----------------------+-----------------------+-----------------------+ **[Writing the first draft (Refer below):]** - - - - [TOPIC SENTENCES: ] -Helps you **introduce a paragraph.** The job of the topic sentence is to **control the development and flow of the information** contained in the paragraph. It **shapes the specific topic of the paragraph and how you present it to readers. Often, but not always, the paragraph's first sentence.** **[Characteristics of a good topic sentence:]** - - - - - - +-----------------------------------+-----------------------------------+ | GOOD SUPPORT | BAD SUPPORT | +===================================+===================================+ | Is relevant and focused (sticks | Lacks a clear connection to the | | to the point). | point that it's meant to support. | | | | | Is well developed. | Lacks development. | | | | | Provides sufficient detail. | Lacks detail or gives too much | | | detail. | | Is vivid and descriptive. | | | | Is vague and imprecise. | | Is well organized. | | | | Lacks organization. | | Is coherent and consistent. | | | | Seems disjointed (ideas don't | | Highlights key terms and ideas. | clearly relate to each other). | | | | | | Lacks emphasis on key terms and | | | ideas. | +-----------------------------------+-----------------------------------+ **TRANSITION WORDS:** **Move from one idea to another.** Rather than leaping to a new idea, a transition weaves thoughts together. Transitions signal the order of ideas, highlight relationships, unify concepts, let readers know what's coming next, or remind them about what's already been covered. **[Sentence level transitions:]** -Words that indicate **similarity** include: **also, similarly, and likewise.** -Words that indicate **contrast (difference)** include: **despite, on the other hand, in contrast, and yet.** -Words that indicate **examples** include: **for instance, for example, specifically, and to illustrate.** -Words that indicate **cause and effect** include: **therefore, so, and thus.** Words that indicate **additional support** include: **also, besides, equally important, and additionally.** **[Paragraph level transitions:]** -**Signposts** are **words or phrases that indicate where you are in the process of organizing an idea.** They might indicate that you are introducing a new concept, summarizing an idea, or concluding your thoughts. Can be at the beginning or end of paragraphs. They may include words like: first, then, next, finally, in sum, and in conclusion. Ex. The first problem with this practice is... -Give a hint about what's coming in the next paragraph or section. **Forward-looking sentences** at the end of paragraphs can help provide a transition and prepare your readers for the next paragraphs. Don't leave your readers hanging by introducing a completely new or unrelated topic. Ex. Walking has positive effects on physical health, but it also offers other benefits. -Rather than concluding a paragraph by looking forward, you might instead begin a paragraph by looking back. **Backward-looking sentences** at the beginning of paragraphs can be helpful as a review. Ex. While the physical benefits of walking are great, the benefits of walking for mental health cannot be overlooked. **ORGANIZATION OF IDEAS:** - - - - - - - - - - - - - - **Writing Conclusions** \- Final chance to make an impression on your readers\ - **The Recency Effect** --- they're remembering the most recent information they've encountered - - - [Week 4: Chp 9 ] ============================ Chapter 9: Academic Integrity and Style Rules (APA 7th Edition) --------------------------------------------------------------- - \(a) One-inch margins on all four margins with left justification; \(b) Double spaced text; \(c) Times New Roman 12 font; \(d) Page numbers in top right corner starting on the title page; \(e) "Indent first line of every paragraph 0.5 in"; \(f) One space after each sentence. \(g) In addition, the title of your paper should appear on the first line of the text of your paper (APA, 2020). As per APA, this title should be "title case, bold, and centered" ![](media/image1.png) Example of title page: Name, University, Course code/course name, Instructor, Date - -**Your own ideas** and **identify** when you are **incorporating the work and ideas of others.** - **Plagiarism**: Integrating another person's ideas and intellectual material into your writing without giving them credit or citing them. - - - - - [Citing another persons ideas] -Within a paragraph, you only have to cite the authors **once**, **IF** it is clear that the other sentences are still being paraphrased (APA, 2000). However, it has to be clear when a sentence is paraphrased and when a sentence is your own original idea. **Narrative citation:** Ex. APA (2020) **Parenthetical citation:** Ex. (APA, 2020) If you are including **multiple references within parentheses**, list them in **alphabetical order**, and **if** by **the same author**, **list in chronological order** (APA, 2020). For example: It has been found that hand hygiene with hand gel is the best measure for infection prevention (Barjarow, 2017, 2019; Matilada & Barsowitz, 2018). L**etter notations**: Distinguish **2 different citations that have the same author and same year** (APA, 2020), such as: Reading prior to lecture has been correlated with better grades (Lapum 2017a, 2017b). \- Rank the sources in the order they appear in your reference section. When including **direct quotations**, you must **add page numbers**. For example: According to Schultz (2005), "In the overwhelmingly White world of professional tennis, Serena Williams and her older sister Venus are frequently represented in the tradition of Black pride and heritage" (p. 339). **Ellipses \[...\]**: Use ellipses to show you\'ve left out words or phrases that aren\'t necessary. If you remove part of a sentence that ends with a period, use \[....\]. Ex. **Original**: \"Nursing is a challenging, rewarding, and highly respected profession.\" - **Brackets \[ \]**: Use brackets to change words, add details, or fix verb tense in a quote. Ex. **Original**: \"He enjoys working with patients.\" **With Brackets**: \"\[The nurse\] enjoys working with patients.\" **\[sic\]**: Use **\[sic\]** when the original quote has a spelling or grammar mistake. It shows the mistake isn't yours. **With \[sic\]**: \"Nurseing \[sic\] is a rewarding career.\" **Quotation Marks**: Use **" "** for direct quotes and **' '** for quotes inside other quotes. **Citing Authors**: When citing in parentheses, include the last names and year (e.g., Smith & Jones, 2023). If you mention authors in the text, just note the year the first time (unless you switch to a new paragraph or cite similar authors). [In text Citation types] **A work by one author or two authors** - [One author\ ]- Chang (2018) emphasized that "engaging in weight-bearing exercise consistently is one of the single best things women can do to maintain good health" (p. 49).\ - Chang (2018) pointed out that weight-bearing exercise has many potential benefits for women. [Two authors\ ]- As Garrison and Gould (2019) pointed out, "It is never too late to quit smoking. The health risks associated with this habit begin to decrease soon after a smoker quits" (p. 101). \- It was found that the health risks associated with smoking begin to decrease soon after a smoker quits (Garrison & Gould, 2019). [Two or more works by the same author and year] - \- Rodriguez (2019a) \.... Additionally, Rodriguez (2019b) warned... [Works by authors with the same last name\ ]- Include each author\'s initial (first name) in citation (in text or in parentheses) - loss. \- According to two leading researchers, the rate of childhood obesity exceeds the rate of adult obesity (K. Connelley, 2019; O. Connelley, 2019). \- Studies from A. Wright (2017) and C. A. Wright (2018) confirmed the benefits of diet and exercise on weight [A work by three or more authors] \- Authors last name with "et al"\ **Narrative Citation**: **Smith et al. (2019)** demonstrated that technology integration enhances nursing practices. **Parenthetical Citation**: Technology integration enhances nursing practices **(Smith et al., 2019)**. \- When you are shortening multiple sources that have both the same last name of the first author and the same year, this can create confusion \- An example of confusion \- Ballo, G., Marque, T., Illiana, C., & Manna, J. (2021) \- Ballo, G., Leung, S., Chen, S., & Titan, P. (2021) \- In this case write out as many authors names need to differentiate \- Ballo, Marque, et al. (2021) **Other In-Text Citation Types** [A work authored by an organization] - [A work with no listed author] - - - - [Primary and Secondary Sources\ ]- When the source refers to another source, this latter source is considered a primary source. It is preferable to track down the primary source and reference it.\ - Use "as cited in\..." \- Rosenhan (1972) reported\... (as cited in Spitzer, 2020). [Two or more works cited in one reference] -At times, you may provide more than one citation in a parenthetical reference, such as when you are discussing related works or studies with similar results. -List authors alphabetically based on authors last name -Separate with semicolon Ex. Some researchers have found serious flaws in the way Rosehan's study was conducted (Dawes & Adams, 2001; Spitzer, 1975). [Electronic Sources] -Author, date, page number [Online sources without page numbers:]\ -Include paragraph number\ -Precede paragraph number w abbreviation (para) **Narrative Citation**:\ **Smith (2023)** states that mindfulness can improve overall well-being (para. 4). **Parenthetical Citation**:\ Mindfulness can improve overall well-being (Smith, 2023, para. 4). [If a source does not have numbered paragraphs:] **Narrative Citation**:\ **Johnson (2022)** discusses the benefits of exercise in the section titled \"Health Benefits.\" **Parenthetical Citation**:\ The benefits of exercise are well documented (Johnson, 2022, \"Health Benefits\"). \- If source has no listed author or no date use source title and abbrev n.d. in parentheses Ex. It has been... ("Cell Phones and Cancer," n.d.). - - **Creating a Reference Pages: APA Style** - - - - - [Reference page samples] **Journal Articles: APA FORMATTING\ **- The author or authors' names\ - Publication year\ - Article title (in sentence case, without quotation marks or italics)\ - Journal title (in title case and in italics)\ - Volume number (in italics) and issue number not italicized (in parentheses)\ - Page number(s) where the article appears - \- DeMarco, R. F. (2010). Palliative care and African American women living with HIV. *Journal of Nursing Education*, *49*(5), 1--4. https://doi.org/10.1041/rev0000129 [- Journal Article without a DOI] Acheampong, D., Wagner, J., Johns, C., & Macalli. (2019). Rethinking school lunches: A review of recent literature. *American School Nurses' Journal*, *47(2)*, 1123--1127. https://journals.sagepub.com/home/nas [Journal Article, in press or advanced online publication] -Available online w no volume/issue - [- A Magazine Article] - \- Marano, H. E. (2020, March 10). Fast food. *Eating Nutritious 43*(2), 58. https://eatingnutritious/42 [- Editorials]\ - After title, include (Editorial) \- Jones, J. (2009, January 31). Food police in our schools \[Editorial\]. *Rockwood Gazette*, *34*(5), 209.[https://doi.org/10.1277/109874040404] [- Blogs ] -Blog posts are cited similar to a magazine, but they will include a URL as DOI are not available Adebayo, L. (2020, January 11). Paleo diet. *Healthy* *Eating*. [[https://blogs.healthyeating/paleodiet2]](https://blogs.healthyeating/paleodiet2) [WEEK 5: Chp 8] =========================== [Chapter 8: Revising and Editing a Paper] ----------------------------------------------------- **[Revision]** **Revise to Improve Organization:** Look at the **flow of ideas** throughout your paper as a whole and within individual paragraphs. -Each section reinforces your main idea/thesis. **Revise to Improve Cohesion:** -Involves **deleting unnecessary material or rewriting parts of the paper** so that the out-of-place material fits in smoothly. -Integrating necessary material when using sources. **Creating unity:** -**Following your outline closely** should help you stay focused on your purpose and not drift away from the main idea/thesis. -Arranged in an order that makes logical sense. **Revise for Style & Tone:** **Creates the voice of your paper** (Must be consistent) -Maintain gender neutrality **[Editing ]** -Spelling, grammar, spacing, and punctuation Must Edit (Refer back to OER for examples): -Sentences that begin with "There is..." or "There are..." -Sentences with unnecessary modifiers. -Sentences in the passive voice. Sentences with passive voice verbs often create confusion because the subject of the sentence does not perform an action. Sentences are clearer when the subject performs the action and is followed by a strong verb. -Sentences with deadwood phrases that add little to the meaning. Be careful using phrases such as: in terms of, with a mind to, on the subject of, as to whether or not, more or less, etc. You can usually find a more straightforward way to state your point. -Sentences with constructions that can be shortened. -Sentences that are overly emphatic. You can still convey a strong meaning without overusing words. **[Ensuring Writing is clear and concise:]** - - - - - - - - **Feedback (Giving and receiving):** Listen to the writer: what kind of feedback are they asking for? ---------------------------------------------------------------------------------------------------------- Be kind and respectful Comment on important issues first Use "I" statements to help focus on your own reactions instead of shitting on them Ex. I'm confused.... Ask questions to clarify what the author means Offer advice based on your own experience Explain what is incorrect rather than making the writer sound like you Correct errors **Creating and Refining a title:** - - - - - WEEK 6: Chp 2 ============= Chapter 2: Therapeutic communication and interviewing ----------------------------------------------------- **Therapeutic communication:** Foundation of the nurse-client relationship **The Client Interview:** \- Primary source --- client - to Collect subjective data \- Secondary source --- family and friends **Preparing for the Interview:** \- Must maintain privacy and confidentiality \- Clients have the right to have their personal health information kept private (PHIPA, 2004) \- Disclosure of personal health information \- Child abuse and neglect \- Elder abuse when living in a retirement or a long term care home in Ontario \- Must report to CNO, if you observe or a client discloses a nurse who poses a serious risk of harm to patients **Self Reflection Prior to Interview** \- Awareness of your own emotional state \- Minimizing unintentional miscommunication \- Self reflecting \- How are you feeling \- What is occupying your thought \- In what ways are you physically expressing your emotions and thoughts \- How is your health and well-being \- What is the environment surrounding you **Beginning the Interview** \- Introducing self and addressing the client how they want to be addressed \- Hello, I am Jennifer Lapum, I am your registered nurse today. My pronouns are she/her. How would you like me to refer to you? \- What pronouns do you use? \- Identify purpose of encounter \- Okay, today, I am here to learn about your health. It will involve asking you some questions and take about 20 minutes [Types of Interviewing Questions] \- **Close-ended questions** --- direct questions that you ask when you are seeking precise information. Are **objective** since you are getting **factual information** (Ex. data, facts, observations). \- Do you smoke? \- Have you been tested for tuberculosis? \- What year were you born? \- Do you take medications as directed \- When did your rash start \- **Open-ended questions** --- invite the client to share descriptive answers, open up their experience (Subjective data) \- What was going on in your life when you first started feeling depressed? \- Tell me about when you first started smoking \- How have you been feeling in the past week? \- Tell me about the challenges you are having with your medication regimen? \- **Probing questions** --- allows you to gather more subjective data, **more broader** than open ended questions \- Tell me more \- How did that affect you? \- When talking about your health, you said 'don't cross the bridge till you come to it,' can you tell me what you mean by that? \- You said that you have been doing 'well' since your partner's death, but I noticed that you are teary eyed as you are speaking about them. Can you talk a bit about that? **Communication Strategies** \- Clear and simple language \- Active listening by facilitation and paraphrasing \- Silence \- Empathetic responses \- Honest by avoiding false reassurance \- Unconditional positive regard by avoiding questions that begins with why \- Permission statements \- One question at a time \- Vocal qualities \- Work collaboratively [Non-Verbal Communication Strategies] \- Facial expressions, hand gestures, eye contact, body language \- Positioning \- Aligning with verbal behaviors \- Physical touch **- SURETY MODEL** \- S - sit at an angle to the client \- U - uncross arms and legs \- R - relax \- E - eye contact \- T - touch \- Y - your intuition **Culture Considerations** \- People are cultural beings \- Culture is deeply embedded \- Culture is socially transmissible \- Cultural safety is important \- Relational inquiry approach to culture \- Tell me about your culture \- Tell me about a typical day for you \- Tell me about what is important to know about your culture in order to care for you best \- How can I provide care to you that is culturally safe **Developmental Considerations** \- Chronological age and developmental stage **- Young children** \- 5 years and younger which includes infants (under one year of age), toddlers (1-2 years of age), and preschoolers (3-5 years of age). \- Use combo on verbal and non-verbal \- Infant enjoy hearing humans **- Older children and adolescents** \- Older children 6-12 years of age and \- Adolescents 13-17 years of age \- Address them first rather than care partner \- Covey acceptance and understanding \- Open and non-judgmental **- Adults and older adults** \- Adults 18 years of age and older \- Younger use adolescent techniques \- Older adults 65 years and older \- Avoid assumptions about health \- Inclusive communication if care partner is present **[Additional Considerations:]** **Language discordance (Language barrier)** \- Speak directly to the client using simple language \- Use pictures or paper and pen to write \- Incorporate care partner \- Sometimes use of interpreter is needed \- Consider using a translating app such Google translate **Emotions** \- Important to make clients feel comfortable and open up about their emotions \- Acknowledge clients emotions and provide space for them to experience the emotions **Violence and trauma** \- Best to use a trauma-informed approach with all clients \- Introducing who you are and why you are there. \- Explaining each step of what you are doing. \- Asking permission to touch. \- Giving the client options on what topic to discuss first. **Hearing and visual impairment** \- Minimize background noises and distractions \- Speak clearly and slightly louder voice **Intellectual impairment (Literally slow)** \- Consider how each client can best participate in communication \- Speak in a positive tone and avoid speaking slower **Substance impairment (Ability affected by substance)** \- Maintain a non-judgmental attitude and convey unconditional positive regard \- Speak clearly and in short sentences **Escalation** \- When clients spiral out of control \- Attend to your own safety **- De-escalating communication strategies:** \- Acknowledge and value how the client feels and be non-judgmental. \- Avoid downplaying or judging how the client feels. \- Engage in active listening to understand the situation and explore the reason for the escalation. \- Offer genuine interest, concern, and empathy. \- Remain calm and do not allow your voice or non-verbal communications to demonstrate rising emotions. \- Recognize the client's self-determination and collaborate with them on how to address the issue. \- Maintain your safety, but do not act afraid. \- Maintain your professionalism and do not take the situation personally. Inappropriate communication from the client \- Inappropriate touching and harassing language [- Strategies to respond:] \- If applicable, ensure your personal safety. Depending on the situation, this may involve moving toward the doorway or having it in your sight, leaving the room, or calling for help. \- Acknowledge the language/behavior and clearly let the client know that it is inappropriate, do so in a professional and non-judgmental manner. \- Remind the client that as a nurse you only engage in professional relationships with clients and families. \- Ask the client if their language has something to do with the effects of their health or illness. [WEEK 7:] ===================== **Describe an Inclusive Approach to Communication Within Health Assessment** ============================================================================ - [Inclusive health assessments are based on four key principles:] 1. 2. 3. 4. Health Assessments with clients: **Indigenous Clients** **Black clients** ---------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- understand the cultural experiences that affect their health Be mindful - Try to break down any potential or apparent barriers with consistent acceptance, friendliness, genuine care, and patience. recognize their trauma experiences. Be aware of your own biases/assumptions about Blackness. - Being willing to learn from the client creates an equitable environment for healing. Use inclusive and anti-racist communication respect the knowledge that Black clients bring to health assessments. uphold their self-determination. - prioritize the client's right to make decisions for themselves. Reflect on your own bias and assumptions **4 Concepts of culture:** [Cultural Sensitivity] - [Cultural Competency] - [Cultural Humility] - [Cultural Safety] - - - **Racist** **Anti-racist** ------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ Believes in racial hierarchy and/or takes no action to dismantle it. Believes in racial equality and acts to dismantle racism. Believes that social problems are rooted in groups of people based on race. Believes that social problems are rooted in both power and policy and acts to challenge these. Permits racial inequities to exist and doesn't actively do anything to change them. Actively works to confront power and policy that maintains racial inequities. **Types of racism:** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - WEEK 8: THE COMPLETE SUBJECTIVE HEALTH ASSESSMENT ================================================= **[The Complete Subjective Health Assessment (Health History)]** \- **Subjective** --- based on personal feelings or opinions/client shares \- **Objective** --- based on facts/you observe \- **Primary Source** --- client \- **Secondary Source** --- family/friends \- **Considerations of the Subjective Health Assessment** (Potential factors that influence quality of information gathered) \- **Developmental Stage:** The patient's age, cognitive abilities, and level of development significantly impact how information is gathered. Ex. **Children** may not be able to articulate their symptoms clearly, so you might rely more on parents or caregivers for subjective information, and you may need to observe behavioral cues. \- **Care Partners:** The involvement of care partners---such as family members, caregivers, or others in the patient\'s life---is crucial for gathering a comprehensive understanding of the patient's health. \- **Influencing Factors:** Socioeconomic and cultural factors, language barrier, etc **Categories of the Subjective Health Assessment** **[- Demographic and Biographical Data]:** **Basic identifying details** about the patient that help create a clear record of who they are. \- Name/Contact Information and Emergency Information \- Questions and Statements \- What is your full name? \- What name do you prefer to be called by? \- What is your address? \- What is your phone number? \- Who can we contact in an emergency? What is their relationship to you? What number can we reach them at? *[- Birthdate and Age]* \- Questions and Statement \- What is your birthdate \- What is your age [- Gender] \- Questions and Statements \- Tell me what gender you identify with. \- Not everyone uses a gender pronoun, but if you do, what gender pronouns do you use? (If the person asks you to use a pronoun that you are not familiar with, it is okay for you to respectfully respond, "I am not familiar with that pronoun. Can you tell me more about it?") [- Allergies] \- Questions and Statements \- What languages do you speak \- What language do you prefer to communicate in? (verbally or written?) [- Relationship Status] \- Questions and Statements \- Tell me about your relationship status \- Avoid questions such as "Are you married" or "Do you have a boyfriend?" or "Do you have a wife?" [- Occupation / School Status] \- Questions and Statements \- What is your occupation? \- Where do you work? \- Do you go to school? [- Resuscitation Status --- Full resuscitation, DNR] **- Main Health Needs (Reasons for Seeking Care)** \- Presenting to a clinic or a hospital emergency or urgent care (first point of contact) \- Tell me about what brought you here today \- Probes --- tell me more, how is that affecting you [- Already admitted, and you are starting your shift] \- Tell me about your main health concerns today \- Probes --- tell me more, how is that affecting you **- The PQRSTU Assessment:** Framework used in healthcare to help assess and document pain or other symptoms from the patient\'s perspective. \- **Provocative**--- What makes your pain worse? What makes your breathing worse? \- **Palliative**--- What makes your pain feel better? What makes your nausea better? \- **Quality**--- What does the pain feel like? What does the itching feel like \- **Quantity**--- How bad is your pain? How bad is the itching \- **Region**--- Where do you feel the pain? (point to where you feel the pain) \- **Radiation**--- Does the pain move around? Do you feel the pain elsewhere \- **Severity**--- How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst you have ever experienced \- **Timing**--- When did the pain start? What were you doing when the pain started? Where were you when the pain started? Is the pain constant or does it come and go? If the pain is intermittent, when did it last occur? How long does the pain last? \- **Treatment**--- Have you taken anything to help relieve the pain? Have you tried any treatments at home for the pain? \- **Understanding**--- What do you think is causing the pain? **[- Current and Past Health]** \- Current Health \- Questions and Statements \- Are there any other issues affecting your current health [- Childhood Illnesses] \- Questions and Statements \- Tell me about any significant childhood illnesses that you had. \- When did it occur? \- How did it affect you? \- How did it affect your day-to-day life? \- Were you hospitalized? Where? How was it treated? \- Who was the treating practitioner? \- Did you experience any complications? \- Did it result in a disability? [- Chronic Illnesses] \- Questions and Statements \- Tell md about any chronic illness you currently have or have had \- Acute Illnesses, Accidents, or Injuries \- Obstetrical Health **[- Mental Health and Mental Illnesses]** \- Tell me about your mental health \- Tell me about the stress in your life \- How does stress affect you \- How do you cope with stress \- Have you experienced a loss in your life or a death that is meaningful to you \- Have you had a recent breakup or divorce \- Have you recently lost your job or been off work \- Have you recently had any legal issues \- Have you purchased any weapons \- POINTS OF CONSIDERATION --- avoid assumption based on their appearance, facial expression, or their capacity to Function **[- Functional Assessment]**: Evaluates a person's ability to perform essential daily activities and assess their overall ability to function independently. [- Nutrition] \- Tell me about your diet [- Elimination] \- How often do you urinate each day [- Sleep and Rest] \- Tell me about your sleep routine [- Mobility, Activity, Exercise] \- Tell me about your ability to move around [- Violence and Trauma] \- Many clients experience violence, can you tell me about any violence or trauma in your life [- Relationships and Resources] \- Tell me about the most influential relationships in your life [- Intimate and Sexual Relationships] \- I always ask clients about their intimate and sexual relationships. To start, tell me about what you think is important for me to know about your intimate and sexual relationships [- Substance use and abuse] \- When did you first start? If you used to use, when did you quit [- Environmental Health and Home/Occupation/School Health] \- Tell me about your home? Do you have any concerns about safety in your home or neighborhood? [- Self Concept and Self Esteem] \- Tell me what makes you who you are [- Other iADL] (Instrumental Activities of Daily Living \| Ex. paying bills) \- Tell me about how you take care of yourself and manage your home **[- Preventative Treatments and Examination]** \- What are the ways that are most important for you to optimize your health? [- Medications] \- Do you have the most current list of your medications? [- Examination and Diagnostic Dates] \- When was the last time you saw your primary care provider or nurse or specialist? [- Vaccinations] \- Can you tell me about your immunization status? \- If the client's immunization are not up to date or you noted vaccine hesitancy, you may ask \- Can you tell me the reasons that your immunizations are not up to date? \- Can you tell me why you are hesitant to receive immunization? **[- Family Health]** \- Tell me about the health of your blood relatives \- Do they have any chronic or acute diseases \- Have any of your blood relatives died? \- If so, do you know the cause of death? \- And at what age did they die? \- Tell me about the health status of those you live with \- Has anyone been sick recently \- If so, do you know the cause \- What symptoms have they had \- Have you been around anyone else who was sick recently? **[- Cultural Health]** [- Cultural background] -Assessing the current and past health of a client's family is important because diseases sometimes have a genetic component. \- "I am interested in your cultural background as it relates to your health. Can you share with me what is important about your cultural background that will help me care for you?" \- "Tell me more." \- "How does that affect your health and illnesses?" \- "Is there anything else you want to share about how these factors act as resources in your life?" **Interventions/Actions based on normal, abnormal, and critical findings** [- Normal] \- are findings that are not of concern and expected for a client's age, developmental stage, and sex. [- Abnormal] \- are findings of concern because they are not normal and not consistent with a client's age, developmental stage, and sex. [- Critical] \- are findings that require prompt and immediate action to prevent clinical deterioration or intervene when a client is deteriorating [WEEK 9: DOCUMENTATION] =================================== - Should document ALL phases of the **nursing process** (Assessment, Diagnosis, Planning, Implementation, Evaluation) **including**: -Assessments, history, and observations of client's health status (normal and abnormal) -Diagnostics, planning, and interventions (care, treatment, services, and health teaching) -Evaluations of care, treatment, and services provided, noting how the client responded, and any necessary follow-up [Components of documentation included in client chart will depend on area of care and institution] Ex: -Cardiac care vs labour and delivery unit\ -Across hospitals, out-patient clinics, primary care settings, long-term care [Information and Communication Technologies (ICT):] -Documentation can be facilitated using ICT -Allow "electronic capture, processing, storage, and exchange of information -Umbrella term used to describe technology-based tools that nurses use in a clinical environment, including electronic record (ICT can be referred to as an umbrella term) -Will be expected to use ICT to support interprofessional communication with the client and other providers and to inform client care and clinical decision-making **Reasons for Documentation:** \- Have a legal obligation \- Must adhere to the practice standard Documentation, Revised 2008 (CNO) 1. -Communicates clinical information about client including data related to their state of health and illness -Documentation record is a **vehicle of communication** within the healthcare team -By documenting, healthcare team knows any assessments, interventions, and responses -Allows for **continuity of care** for the client -Allows for HCP to incorporate information in clinical judgment and decision making 2. -Involves partnering with other HCP and clients to prevent and minimize unsafe acts, reduce harm and respond accordingly -Actions to achieve client safety must involve timely, clear, and comprehensive documentation -\> communicate common understanding between HCPs about client -Facilitates effective decision making -Include directives and care plans related to client safety (bed rails, assistive devices) -Documentation of medication administration, to prevent likelihood of duplicate administration -Alert HCP to findings that require interventions 3. -Involves constant reflection and commitment to working toward best outcomes associated with healthcare systems that are safe, effective, client-centered, timely, efficient, and equitable -Chart audits and reviews help with evaluation of standards associated with high quality care and its appropriateness -Can help identify needed changes in practice and foster evidence-informed approaches -For ex. High rates of fall incident report, may prompt in-service or training sessions surrounding falls 4. -Can influence provincial and federal funding 5. -Must consider legal aspects of documentation -Client record: legal document that provides evidence of the assessments conducted on the client and services provided -May be subpoenaed for proceedings in cases related to negligent practice, coroner's inquests, violence, child welfare, and criminal offenses ▪ May take place years after taking care of client, documentation is the only way to recall events ▪ "IF ITS NOT DOCUMENTED, IT WASN'T DONE" 6. -Health care providers may review documentation as part of research ▪ nurse-sensitive indicators/outcomes, which will lead to evidence-informed practice 7. -Review of client records can provide insight into specific populations and clinical health issues ▪ may provide information related to transmission of diseases and epidemics, effectiveness of interventions, or complications with certain populations 8. -Important in cases that involve violence -May be used as source of evidence in legal proceedings -Incorporate direct quotes and place them in quotation marks, even if it contains profanity and obscenity -Images may also be allowed to document cases of physical and sexual violence ▪ In cases of bruising, swelling, lacerations, and/or contusions, use a measurement tool as a point of reference \- Consult institutional policies about photography and record keeping **Documentation Components** (**vary** between institutions and practice settings) **- Admission** (Register them into the healthcare facility) **sheet** -First item you see, will vary between institutions -Client name, age, DOB, gender, contact information, admission date, reason for admission, next of kin and/or emergency contacts -Identifies and highlights in red any known allergies -May include other health issues, list of current medication, personal items, list of client valuables, advance directives **- Progress notes/interdisciplinary notes** -Free-text entry space that allows for open-ended documentation -Many members of the interdisciplinary team may write notes in the same section ▪ There may be specific section for physician or nursing notes -Include record of assessment and care (health status, responses to interventions) **- Referrals and consultations** -HCPs document expertise about client's healthcare status/condition and advice related to the plan of care -Format similar to progress notes (also open ended) **- Diagnostic, laboratory, and therapeutic orders** \- Healthcare providers provide orders related to diagnostic tests, sometimes referred to as "physician orders" or "doctor orders." -Diagnostic tests (ultrasound, X-ray) -Laboratory orders (blood, urine) -Therapeutic orders (medication, diet, mobility) **- Medical administration record (MAR)** **-** List of all medications that are ordered ▪ Medication name, dose, route, frequency, date the medication was ordered, and the date it will expire o Details any considerations for administration ▪ Minimum apical heart rate before administration -Any client allergies highlighted in red -AS THE NURSE, Must document date and time, and sign and initial the MAR, when you prepare and provide any medication -May include space for noting the client\'s apical pulse or temp. -**eMARs** helpful by providing notifications ▪ timing of medication to prevent missed doses (ensuring that medications are given at the correct times) ▪ when medication is about to expire ▪ when a new medication is ordered -Some drugs like narcotics require special documentation and witnessing protocols b/c of potential for illicit use ▪ Consult institution for policies related to documenting, dispensing, administration, and disposal **Flow sheet and graphic record** -Commonly completed by nurses -Documentation of physiological data ▪ Vital signs, pain, weight -Outline routine documentation related to hygiene, mobility, nutrition, and use of restraints -Allow HCP to observe trends in data over time and recognize cues that require intervention **Kardex/summary sheet** -Summarize important information that should inform your daily care of the client and must be continually updated during each shift. -Must be continually updated during each sheet -If written, can be done in pencil b/c it requires frequent updating ▪ IT IS NOT A LEGAL DOCUMENT WHEN WRITTEN IN PENCIL -Any info on Kardex must also be in permanent health record ▪ A stamp on the top with the client's name, hospital identification number, and date of birth. ▪ Treating physician, client's age, preferred gender, and diagnoses. ▪ Allergies, resuscitation status, and required safety precautions. ▪ Emergency contact information. ▪ Medications. ▪ Therapeutic orders (e.g., turning, ambulation, mobility aids, diet, dressing changes). ▪ Tests and procedures. ▪ Hygiene (e.g., if and how often they can have a shower or bed bath). ▪ Dressing and wound care instructions. **- Nursing care plan** -Nursing diagnoses -Plan of care based on specific goals **- Operative procedures** -Physician uses this form to document the specific details of procedure and any complications **- Consent forms, resuscitation forms, and healthcare directives** -Includes all completed consent forms for procedures, completed and signed resuscitation forms, and information about any healthcare directives such as a legal document (power of attorney for personal or financial care) **- Discharge plan and summaries** -Information about preparation and teaching related to discharge -Must be written in clear and non-medicalized language (no presence of jargon) that the client can understand -Step-by-step instructions that the client should follow when they are discharged [o includes:] ▪ Education about their condition or disease. ▪ A list of medications including the name, dose, route, and frequency as well as adverse effects to watch for. ▪ Guidance surrounding nutrition in terms of the client's diet (i.e., what they should eat, how often, what they should avoid). ▪ Information about mobility and mobility aids, such as specific goals in terms of activity and exercise (amount and frequency), and information about aids such as crutches or a cane and how to use them. ▪ Access to resources in the community such as homecare, rehabilitation, and meal-delivery services. ▪ Information about when to seek healthcare if the client experiences specific symptoms, adverse effects, or complications, and appointments related to follow-up care. ▪ Finally, this form documents the date/time of discharge and how the client is getting home (e.g., transportation and whether they are accompanied by someone). **- Critical incident reports** -May be required to report and submit **forms related to specific incidents** -Regulation 965 of the Public Hospitals Act (1990): ▪ Critical incident: any **unintended event that occurs when a patient receives treatment in a hospital**, (a) that **results in death, serious disability, injury, or harm to the patient**, and (b) **does not result primarily from the patient's underlying medical condition or from a known risk inherent in providing treatment** -Need to inquire about workplace policies about critical incident reporting ▪ In ON, hospitals are "required to report all critical incidents related to medication/IV fluids" (Ontario Ministry of Health and Long Term Care, 2011) -Important to ensure patient safety by clarifying how the incident occurred and inform changes in practice so that unsafe acts are less likely in the future **- Workload measurement tools** -May be required -Common ones: GRASP or other systems developed in-house -Allow organizations and leaders to monitor client care needs (number of care hours required) and nurse staffing requirements -Used for quality improvement, secure funding, and decision making concerning allocation of nurses -Usually completed at the end of shift -May involve electronic tracking of the amount of time spent with each client performing tasks such as measuring vital signs, administering medications, caring for wounds, etc **- More on incident reporting (As a nursing student)** -Must refer to your university department and clinical placement office with regard to policies about what type of incidents must be reported **Electronic Documentation Systems** \- Clinical documentation increasingly being recorded, either partially or completely, using electronic documentation systems \- Occurs via computerized devices (computer, laptop, tablet, smartphone) \- Sign in with username and password -Beneficial security feature compared to paper charting b/c it identifies who enters the client's record and restricts who enters the system -Help protect client's privacy in comparison to written records \- Common electronic documentation system include **electronic medical records** (EMR) and **electronic health records** (EHR) **-EMR:** used and sometimes built for a single organization or practice, with a focus on collection of medical data (e.g. specific to physicians) ▪ used in the practices and clinics of primary care providers that do not connect to systems outside those organizations **- EHR:** developed with I**NTEROPERABILITY** (exchange, interpret, and use data seamlessly) as a key function ▪ all providers who use the same health information system can access and exchange information across organizations and providers (Ex. share info across hospitals, specialists, pharmacies, labs). -many prefer EHRs **- Purpose and vision of EHR** Aim: **FACILITATE SEAMLESS CARE FOR CLIENTS** by providing a way to capture and access real-time client data -Improve interprofessional communication, coordinate among providers, and foster effectiveness and efficiency in care -Help eliminate gaps in care that can arise from the inability to share information across institutions and/or geographic boundaries -Provide access to longitudinal and comprehensive health records of clients, along with document and other clinical tools to support care provision by individual HCPs and teams o IT IS LEGIBLE COMPARED TO PAPER o Documentation is automatically inserted in the next available space, so no empty space is left **- Commonly used EHR vendors** o Numerous types of EHRS -Vary in FUNCTIONALITY , LOOK, FEEL, USABILITY -Healthcare organizations purchase an EHR system from a vendor based on their needs, capacity, and type of care provision ▪ Acute, public health, long-term care, primary care o Common ones: EPIC, Cerner, Meditech, Allscripts o May have their own ▪ Electronic Patient Record System by University Health Network in Toronto o PointClickCare in long-term care facilities o Given the variability, what is most important for clinical documentation is to **recognize the components of EHRs that are common across different types of systems** **- Common components of EHRs** -Digitized versions of paper chards, include similar information as paper charts -b/c they're electronic, they have functions that allow for data entry, viewing, and exchange of various types of client information (health history, progress notes, diagnostic and laboratory results, therapeutic orders) **- Structured data elements vs. unstructured data elements** o A KEY DIFFERENCE IN CLINICAL DOCUMENTATION IS THAT THE TECHNOLOGICAL CAPACITY OF EHR ALLOWS FOR STRUCTURED DATA TO BE EASILY AGGREGATED AND ANALYZED **o Structured data elements** ▪ Built-in templates/structures that guide HCPs when entering data ▪ Require to fill out specific fields (**vital signs, medication dose**), often by selecting a system-provided option ▪ In context of EHR, structured data can have inherent meaning and can be used in meaningful ways in other functions of EHR (trending data, triggering warnings, reminders) ▪ Example 1: nurse enters value of 140/80 in the HER entry data field EHR recognizes 140 as systolic and 80 as diastolic in mmHg ▪ Example 2: nurse begins to document wound assessment When the nurse begins to type wound odor, there is a suggestion in a drop-down menu (no odor, increasing malodour, foul odor) **-Unstructured data elements** ▪ Free-text entry sections that allow open-ended documentation of client data ▪ Include: progress notes, nurses' notes, given the narrative nature ▪ Involve same principles used for paper charts (communication, accountability, security) ▪ Due to technological limitations, unstructured info cannot currently be used in a meaningful way ▪ EHRs are unable to summarize or identify trends in these data ▪ Area of emergent research and methods are being developed to allow systems to understand unstructured narrative data ▪ Example 1: nurse enters a note: "The client described walking for twenty minutes a day with no shortness of breath. The client uses a cane to support their balance." Does not have a way of understanding the meaning of any data entered in this field (whether it relates to mobility, nutrition, allergies) **- Status of EHR** -EHR deployment, maturity, and use varies among organizations, provinces, and territories -Important to note that EHRs are not simple replacements of paper records -Affect workflow significantly in terms of how nurses work, document, and manage information **- Principle of Documentation** \- You are LEGALLY required to complete documentation \- 3 standard statements related to documentation: [Communication] ▪ Nurses ensure documentation presents an accurate, clear, and comprehensive picture of the client's needs, nurse's interventions and the client's outcomes ▪ Comprehensive documentation consists of **subjective** (what the client says) and **objective** (what you observe) data. **STRUCTURED** and **UNSTRUCTURED** ▪ A complete record includes all phases of the **NURSING PROCESS**: assessment, plan of care and intervention, evaluation ▪ **Must document with full legal name, signature, initials, and title (Designations)** **▪ Must be legible (can be read and understood by others w/ permanent ink)** ▪ Use abbreviations and symbols **depending on the organization** [Accountability] ▪ Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete **▪ Use 24 hour clock** ![](media/image8.png) ▪ **Date and time** of documentation should reflect the TIME OF YOUR DOCUMENTATION ENTRY When documenting vital signs, medication administration, or other procedures, note down WHAT TIME THE TASK WAS PERFORMED ▪ must document promptly after an assessment or providing care do not wait until the end of shift, and NEVER DOCUMENT PRIOR TO CARE if not possible to document promptly, identify it as late entry, include the time you are documenting "Late entry. Assessment and care provided at XX." ▪ Documentation must be arranged from WHAT HAPPENED FIRST to WHAT HAPPENED LAST ▪ **Do not leave empty space** If insufficient space, write a word, or draw a line and continue Draw a line to fill in any space after your signature and designation ▪ Only document your own observations and actions except in cases where you are the designated recorder, such as during code situations ▪ **If an error is made, draw a line through the error and initial it** In EHR, you can add additional note referencing the error [Security] ▪ Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standards(s) and legislation ▪ You and any other HCP have access to the client record, if you are involved in the care ▪ Clients and their substitute decision make have the right to view and/or acquire a copy of their health record, unless there is a compelling reason not to do so You and the HCP team may decide not to if it infringes on client's treatment and/or recovery Must document when a client views the record or if the decision was made to not permit the client to do so ▪ You are responsible for securing the client's record so that the only people that can access it are those involved in the patient care Keep written records in a secure location Never leave a chart open or unattended, return the chart to a secure location ▪ If you need to mention another client while documenting in a client's record, USE THE OTHER CLIENT'S INITIALS ▪ Don't share your login information with anyone else, replace your p/w regularly, sign out when you're done **- Privacy, Confidentiality, and Security** \- Federal and provincial/territorial legislation governs privacy rights related to the protection of personal information \- 2 federal laws enforced by Privacy Commissioner of Canada 1. ▪ Relates to how the government protects **privacy of a person's information** ▪ person's right to access and correct personal information that the government collects, uses, and discloses 2. ▪ Applies to private-sector organizations that collect, use, and disclose personal information \- As an HCP or student nurse, familiarize with 2004 **Personal** **Health Information Protection Act (PHIPA)** ▪ Legislates the collection use and disclosure of personal health information by information custodians [The following definitions used in the PHIPA are important:] **▪ Personal Health Information** Identifying information about an individual in oral or recorded form that relates to physical or mental health, provision of health care, a plan of service, donation of body parts or bodily substance, payments or eligibility of healthcare, health number, substitute decision makers, any records held by health information custodian **- Health Information Custodians** Anyone involved in delivering healthcare services and in control of personal health information \- Legislation requires protection and confidentiality of client\'s personal health information. \- Data should not be shared with those not involved in the client\'s care. \- Paper charts must be safeguarded from inappropriate access, electronic charts use usernames and passwords for added security. \- PHIPA (2004) applies to health information custodians (e.g., healthcare providers) and recipients of health information (e.g., insurance companies). \- Healthcare organizations, including hospitals, must comply with PHIPA (2004) by ensuring accuracy, currency, and protection of personal health information. \- Use of personal health information is restricted to the healthcare team involved in the client\'s care. \- Consent is required for the collection, use, and disclosure of personal health information o Implied consent is assumed if the client has been informed about the collection, use, and disclosure of personal health information. o Expressed consent (verbal or written) is required for sharing information outside the healthcare team, with exceptions **- Disclosure exceptions** (Times when sharing your info without asking for your consent is allowed) [o Disclosure to other individuals working in the healthcare system] ▪ When it is not possible to obtain consent from client in a timely manner and there is reasonable need for care ▪ To ask for a custodian to receive funding ▪ If misconduct is reported to suspected, an investigation can be carried out with patient consent [o Disclosure to public health authorities] ▪ May disclose info to public health authorities if the disclosure is made for the purpose of the Health Protection and Promotion Act ▪ In cases of suspect child abuse, disclosure to Children's Aid Society [o Disclosure for proceedings] ▪ Info can be shared for legal proceedings if it has been subpoenaed (legal document that **orders someone** to do something) [o Disclosure for research] ▪ Info can be shared for research if it has been approved by the organization's research ethics board [o Disclosure for planning and management of a health system] ▪ Purpose of analysis or compiling statistical information related to the management, evaluation, or monitoring of allocation of resources or planning for all/part of health system, including delivery [o Disclosure to a health data institute] ▪ May be disclosed to an approved health data institute for analysis of the management, evaluation and monitoring **- Who owns the client record?** -Client have the right to access their own personal health information -1992: supreme court of Canada ruled that the client owns the contents of health records and has the right to receive the full copy despite the institution/physician owning it ▪ Except in situations where it may harm the client **Methods of Documentation** \- Organize nurse's notes, a.k.a. progress notes \- Decision which method may depend on organization, otherwise it is a personal preference \- 3 main methods: [Charting by exception] ▪ Not commonly used, some units find it helpful ▪ Involves when a finding is not normal ▪ If a client's activities/assessment findings are outside the norms of the specific settings' list of normal ranges/activities ▪ Example: normal finding may be no signs of infection on an incision, only document if client exhibits signs of infection [Narrative] ▪ Chronological documentation ▪ Storied format, sequential order ▪ Example: When client's symptoms first started, what they did to treat them and how they responses to the treatment ▪ Involves: who (who was involved), what (what happened), when (when did it happen) how (how did client respond) ▪ Example: 8-year-old client fell off bike. Client's mother indicated that he experienced a loss of consciousness for about 20 seconds, was confused when he awoke, and got a headache within 20 minutes. She brought him to the emergency, and arrived within 30--40 minutes of the fall. [Nursing process] -Used to inform documentation in which the nurse focuses on the client's issue/concern/problem, followed by the plan and action to address the issue, and an evaluation of how the client responded. [Potential Approaches to the Nursing Process method:] - - - - ![](media/image4.jpg) **Future of Documentation** **- Role of the client** **-** Clients should play a role in documentation and have access to their personal health information. -Some healthcare providers resist client access, reflecting a historical paternalistic approach. -Shifting towards a client-centered model recognizes clients as experts in their own health ▪ it make sense for clients to have access to their own health data \- New technologies enable personal health records (PHRs) owned and held by patients. -National EHR systems are increasingly supporting clients\' open access to their health records. \- The change reflects a broader move towards acknowledging clients\' ownership of their health data **- Data literacy** -Data literacy for clients is a crucial aspect of moving forward in healthcare. -Data literacy refers to a person\'s ability to read and understand relevant healthcare information -Clients\' growing desire for access to their health records necessitates a focus on data literacy -Hospitals and laboratory testing services offer direct portals for clients to access their information -Data should be recorded in ways easily interpreted by clients -Healthcare providers need training to assist clients in understanding the data they access -Enhancing data literacy ensures clients can make informed decisions about their health information **- EHR documentation** -Most health systems will likely transition primarily or exclusively to EHR documentation. [-Implications for nurses/Reasons more moving towards usage of EHR:] ▪ Need for flexibility and adaptability to learn and use various EHR systems in different practice settings. ▪ Navigating and using EHRs extends beyond documentation, including interpreting EHR dashboards. ▪ EHRs are incorporating artificial intelligence for data-driven decision-making. Data documented in EHRs supports building algorithms for predicting aspects of clinical care or client outcomes. Quality of artificial intelligence systems depends on the accuracy, completeness, and consistency of documentation in the EHR. \- Nurses play a crucial role in ensuring high-quality and consistent documentation practices for effective care provision. \- The use of EHRs and artificial intelligence highlights the need for ongoing training and skill development among nurses **- Artificial intelligence** -Healthcare providers should be aware of biases inherent in artificial intelligence (AI). -AI programs are created by individuals with inherent biases, and if present, these biases can be systematized into the algorithm. -AI should be viewed as a clinical aid to supplement rather than replace the healthcare provider\'s own clinical judgment. -The Canadian Medical Protective Association (CMPA) emphasizes the importance of recognizing and addressing biases in AI systems used in healthcare. \- This underscores the need for healthcare providers to critically assess and interpret AI-generated information in conjunction with their professional expertise WEEK 11: Communication and Indigenous Health ============================================ Define racism and its impact on the health and well-being of Indigenous peoples: - - - - - Reflect on positionality in relation to anti-racist communication approaches: - - Explore cultural safety and humility in relation to communication: - - Reflect on promoting self-determination of Indigenous Peoples through communication strategy: - - - - WEEK 12: Chp 1, 3 ================= Chapter 1: Communication Theory ------------------------------- Define communication. - Describe the types of communication. - - - - Differentiate models of communication. - - -Communication as a linear, **one-way process** in which a sender intentionally transmits a message to a receiver (Focuses on the **Sender and the Message)** -Emphasizes **clarity and effectiveness**, but it also acknowledges that there are barriers to effectively sending communication. Barriers such as **Noise:** anything that interferes with a message being sent between participants in a communication encounter. **Environmental noise:** Any physical noise present in a communication encounter. **Semantic noise:** Refers to an interference that occurs in the encoding and decoding process resulting in different interpretations of what is being communicated (e.g., lack of understanding, clarity, and confusion of words and meanings). - - - -Communication as a process in which participants alternate positions as sender and receiver and generate meaning by sending messages and receiving **feedback** within physical and psychological contexts. \- Rather than illustrating communication as a linear, one-way process, this model incorporates feedback, which makes communication a **more interactive, two-way process.** (More interaction focused) [Involves:] **Physical context:** includes the environmental factors in a communication encounter. **Psychological context:** includes the mental and emotional factors in a communication encounter - Communication as a process in which communicators generate social realities within social, relational, and cultural contexts. -Considers both parties as **communicators** (you are simultaneously a sender or receiver) They communicate to - *Construct realities*: - - - - [Involves many contexts such as: ] - - - [Explain the significance of trauma-informed, relational practice, and anti-racist approaches to communication.] [Trauma-informed approach] -Creates a **safe space** for clients to engage in conversation and fosters control and choice. It **does not require the client to disclose trauma.** However, it creates a space in which the client may feel safe to speak about trauma, if relevant, at their own pace. involves integrating an understanding of the need for: - - - -Can be used as one part of therapeutic communication. It involves emphasizing confidentiality, identifying the interview purpose, letting the client set the pace of the interview and shaping it based on their needs, and engaging in collaborative intervention so that the client is in control and empowered. [Relational Inquiry approach] \- Attends to the **broader social context** in which clients and their support systems are situated. Also, as the nurse, you should be aware of yourself and how you influence, and are integrally connected to, the client and the healthcare system Involves the following elements of communication: - - - [ ] [Anti-racist approach] -Active process of changing attitudes, beliefs, practices, and policies with the goal of dismantling systemic hierarchy and oppressive power. An anti-racism approach involves: - - - - Describe ineffective communication. - Reflect on professional communication in nursing. - [Chapter 3: Interpersonal Communication] ---------------------------------------------------- **Interpersonal Communication** \- The process of exchanging messages between people whose lives **mutually influence** one another -refers to **communication between two or more people** on a personal level, where the focus is on the exchange of thoughts, feelings, and ideas. -**Goal oriented** **-Structed by social norms/expectations** \- Involves 2 or more people who are **interdependent** o communication you engage in with family, friends, peers \- Builds, maintains, and evolves relationships; foundational to many aspects **Interprofessional communication** o Communication that occurs among members of a client care team, who belong to (but are not limited to) various professional groups Interprofessional communication refers to communication **between professionals from different fields or disciplines working** together in a collaborative setting. It typically occurs in healthcare, education, business, or other sectors where people from different professional backgrounds interact and collaborate to achieve common goals. -**Goal oriented** \- Communication among members of a client care team, includes members of various professional groups o May involve nurse, clients, families, and other HCPs **[- Interprofessional communication involves verbal, written, and non-verbal]** **- Verbal communication** o Conversations between 2 or more members of the interprofessional teams, or over the telephone **- Written communication** o Commonly includes documentation notes in a chart (progress notes, physician orders, MAR, diagnostic reports, referral letters, and discharge notes; faxes, emails, texts) **- Non-verbal communication** o Meaning and interpretation conveyed through body language (facial expressions, eye contact, body position, and gestures o Must be aware of body language as it aligns with verbal language **- Types of Communication** o Client/unit rounds where an interprofessional group discuss client's status and plan of care o In-person/phone conversation in which providing a client update and consulting another HCP on a plan of action o Discussion that occur among HCPs while providing client care o Calling a taxi for a client's family member is not interprofessional because it DOES NOT INVOLVE THE HEALTHCARE TEAM **Interprofessional Communication and Collaboration** \- Interprofessional communication is a fundamental component of **interprofessional collaboration** o Fosters effective teamwork among the client care team o Optimize client outcomes, ensuring that clients are safe throughout the healthcare system o Canadian Interprofessional Health Collaborative: National Interprofessional Competency Framework \| As per below (4) : ![](media/image12.png) **▪ 6 interdependent competency domains to achieve the goal of interprofessional collaboration** Defined as the "knowledge, skills, attitudes, and values that shape the judgements essential for interprofessional practice:" o 1. Interprofessional communication o 2.Patient/client/family/community-centred care o 3. Role clarification o 4. Team functioning o 5. Interprofessional conflict resolution o 6. Collaborative leadership First 2 competencies have a strong influencing role in all healthcare situations Framework contributes to an effective healthcare team functioning, focused on communication and collaboration **Interprofessional communication in interprofessional collaboration supports the 5 other competency domains** HCPs must be able to "communicate with each other in a collaborative, responsive, and responsible manner" o Each HCP is responsible for engaging in effective communication in the specific clinical and interprofessional context in **respectful, explicit, and clear way** o Important to actively respond to everyone's perspectives **- Strategies for effective interprofessional communication** **o Establish teamwork communication principles** ▪ A clear set of communication principles and procedures is important for HC teams that work closely together and depend on each other ▪ Fosters open and creative discussions, recognition and appreciation of each person's role and contribution, and transparency in decision-making **o Actively listen to other team members** ▪ Active listening involves closely attending to what another person is saying and responding to them based on what they said **o Communicate to ensure common understanding of care decisions** ▪ Each HCP is responsible for communicating clearly as well as clarifying discussion or a written order or care plan when it is unclear **o Develop trusting relationships with clients/families and other team members** ▪ Trust among HCP is important to communication ▪ Building trust begins with your interactions with each other ▪ Important to engage with others in respectful ways and provide time for discussion ▪ Important to be honest, ▪ Aim to be knowledgeable on the topic, and if not, open up the discussion in a way that addresses this and allows for learning opportunity **o Effectively use information and communication technology to improve interprofessional client/community-centred care** ▪ Information and communication technology (telephones, computers, and software programs) can facilitate communication ▪ Computer-based documentation systems will commonly be used to document assessments and plans of care \- Consistent execution of successful communication requires attentive listening, administrative support, and collective commitment **- Other principles of interprofessional communication:** o Speak clearly with appropriate vocal intonation and at a moderate pace o Simple and clear language o Maintain eye contact and show confidence o Be efficient o Incorporate adequate, relevant and timely information o Engage in active listening, ask questions to clarify o Speak up o Seek clarification if needed until concern about patient is addressed o Put client first ▪ Remind interprofessional team members that decisions and actions affect client and client should be the focus of discussions o Show respect in communication patterns **Factors Influencing Interprofessional Communication** \- Several factors that can influence interprofessional communication in positive/negative ways, which may have positive or negative effects on HCPs and client outcomes [- Divided into 3 categories:] 1. ▪ Noisy, have many moving parts ▪ Beeping machines, overhead announcements ▪ Cause sensory overload, which clients and families are often unfamiliar with 2. ▪ Involves a lot of information and dynamic and complex clinical situations that require high level of acuity ▪Can be Intense, with life-threatening conditions, death, uncertainty, dear, and anxiety -- lead to work overload ▪ Influence dynamic nature and intensity of interprofessional conversations Hierarchical relationships that exist in interprofessional teams and imbalances of power/ideas can also affect how individuals communicate and interpret conversations COMMUNICATE CLEARLY, COMPASSIONATELY, SYSTEMATICALLY 3. ▪ Each group of HCPs has their own culture ▪ May not align with other HCPs ▪ Ex. Nurses must be descriptive, embed narrative elements in communication vs other HCPs that are taught to be more concise and efficient ▪ Reflect on how to tailor communication to the person/group, while still communication your POV as a nurse [▪ Ineffective communication:] Disrespectful Failure to communicate concern Failure to communicate rationale for an action/decision Unclear/incomplete communication or miscommunication Ineffective conflict resolution on a plan of care **Conflicts in an Interprofessional Environment** \- State of serious opposition between two or more perspectives that influences thinking and actions \- Conflict emerges when one individual's behaviours impede another individual's interests/goals, resulting in negative emotions such as fear, anger, and frustration \- Different perspectives will inevitably arise \- Many HCPs may have different disciplinary perspectives that inform their understanding of a situation, and may have different priorities in terms of client care \- Communication can become problematic when perspectives/priorities contradict each other \- Conflict is more likely if interprofessional communication is sub-optimal and ineffective [- Other factors:] o Lack of respect for others' perspective o Differences in values, age, gender, education, ethnicity, culture o Elements related to professional roles (responsibilities, power, and scope of practice) [- Strategies:] o ANALYZE THE SITUATION BEFORE CONFLICT EVEN STARTS ▪ Better to prevent! **o Client-centered approach to frame discussions** ▪ ensures that the focus is on client as a whole person ▪ patient is cared for in ways that respect their "autonomy, voice, self-determination, and participation" in their own care **o Use evidence-informed approach to make decisions** ▪ Help critically engage in discussions that are informed by the evidence **o Be open to hearing varying perspectives** **o Engage in self-reflection** **o Engage in respectful discussions** **o Reflect on all perspectives** **o Share your own perspective and rationale** **- Point of Consideration:** o Interprofessional communication can be optimized using client-centred perspective and evidence-informed approach o Should be guided by discussions that are centred on the client's wellbeing and incorporate best possible evidence for each client \- Interprofessional conflict prevention and management require action at both individual and systemic levels. \- Interpersonal dynamics are crucial, but contextual and organizational factors also play a significant role. o In nursing, team members often face environments with emotions like frustration, burnout, dissatisfaction, and a sense of being undervalued. \- Healthcare organizations need to be assessed for their support of collaboration and conflict resolution, as well as their impact on emotional well-being. \- Considerations include communication processes, team dynamics, decision-making practices, accountability culture, and workload distribution. \- The Registered Nurses\' Association of Ontario (RNAO, 2012) provides specific recommendations for organizations, covering organizational structures, leadership support, staffing, communication, and professional aspects, to prevent and reduce interprofessional conflict. **Harassment and Communication** \- Effective **intraprofessional and interprofessional communication** and interactions are essential to effective work environment and safety in healthcare \- **Civility:** key component of effective communication and interactions o Particularly important b/c of the stressful and complex nature of healthcare environments and decision making o Involves treating others with respect, listening to their perspectives, considering their feelings within an encounter, and respective differences o Also seeking common ground when needed o Involves engaging in authentic, respectful, and inclusive ways o Fosters feeling of belonging and community even when there is conflict/differences in perspectives \- **Incivility:** serious issue in teamwork o Involves **covert** (subtle) or **overt** disrespect of another person ▪ Ex. Discourtesy, eye rolling, gossiping, rude comments, name calling, complaining, and physical actions (violence) ▪ Cause emotional and physical harm ▪ Conflict management strategies and communication training **- Bullying and harassment** o Type of incivility addressed to a specific person o **Harassment:** type of discrimination based on religion, race, age, sex, and disability **o Typically repetitive behaviours and harm or humiliate another person** ▪ Also includes serious one-time incidents of unwanted verbal and/or physical behaviour o Forms of harassment and bullying include: physical (unwelcome touching) or non-verbal (eye-rolling and other facial/bodily expressions) and verbal behaviours (demeaning, humiliating, belittling language, hurtful teasing/jokes, name-calling, slurs, insults, and criticism as opposed to critique) o Also include: purposefully ignoring someone, not helping, continuous assigning of difficult workload o Interprofessional or interprofessional conflict does not equate to incivility or harassment o Workplace conflicts can arise from strong opposing views, and constructive criticism or feedback, even from supervisors or peers, is not necessarily incivility or harassment o Some uncivil behavior may not constitute harassment or bullying but should still be addressed (Government of Canada, 2015) o Bullying or harassment may not always be immediately recognized, and not everyone engaging in such behavior may be aware of it o Personal issues, such as stress, financial concerns, or anger management problems, can contribute to workplace conflicts and incivility. o Stress associated with the healthcare environment can be a risk factor for such behaviors. o Regardless of the cause, every individual has the right to a workplace free from all forms of incivility, including bullying and harassment. \- Professional nursing associations play a crucial role in addressing and managing workplace bullying and harassment \- All nurses should actively address workplace violence and take on leadership roles to bring about change \- Nursing has a historical legacy as an oppressed group, stemming from its subordinated position to the medical community and gendered work perceptions \- Oppressed group behavior can lead to horizontal violence, where members of the same group exhibit violence towards each other in response to external dominant power \- Horizontal violence arises when members of an oppressed group feel subjugated and powerless against a dominant group, leading to internal conflicts \- Awareness of this dynamic is essential in the effort to create workplaces that are free from and intolerant to violence. **- Why is it important to understand incivility, violence, harassment, and bullying?** o Violence, harassment, and bullying are identified as occupational health and safety hazards that are underreported and often unrecognized o As a nursing student, we need to be aware of what incivility, harassment, and bullying are and how to deal with them ▪ Behaviours are not always conscious choices ▪ Self-reflection and awareness are important first steps ▪ Being a victim

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