Professional Caring and Ethical Practice Study Guide for the CCRN

Caring Practices

Nurses are responsible for respectfully caring for patients. These caring practices can be defined in numerous models as well as nursing training. Review the following implications regarding caring nursing practice.

AACN® Synergy Model

The AACN Synergy Model, as described previously in this study guide, was created to guide nursing practices as well as patient and family interactions to promote a cohesive, compassionate, and therapeutic environment. A section of this model focuses on caring practice. In this section, subjects such as patient empowerment, skilled nursing care, patient dignity, nurturing care, and inner strength are defined in different levels to promote the best patient outcomes.

There are three levels of caring practice, levels 1, 3, and 5. Each level builds upon the last.

• Level 1 focuses on the nurse providing a safe environment for the patient and supporting the patient’s basic needs.
• Level 3 grows to include compassionate care and kindness from the nurse. At this level, death may be accepted as an outcome of therapy, and ensuring peaceful and dignified death preparation may be part of the nurse’s responsibility.
• Level 5 identifies a nurse that is fully engaged in patient care and can interpret or anticipate the patient’s and their family’s needs. Nurses at this level provide comfort, dignity, and safety and have a great respect for both the patient and his or her family.

Nursing Responsibilities

Following the AACN Synergy Model, nursing responsibilities vary greatly from patient to patient. However, all nurses must practice basic care responsibilities for all patients. These include ensuring patient safety, minimizing harm or pain to the patient and decreasing the incidence of medical errors. Nurses must also serve as frequent problem solvers to assess breakdown in the patient/healthcare staff relationship and improve overall outcomes.

Safe Passage

Hospitalized patients trust healthcare providers to keep them safe while in their care. Nurses must help to facilitate this safety of practice. Nurses are responsible for administering medications appropriately, to the right patient, at the right time, via the right route, and with the right dose. This should be followed by documentation of the event. Nurses should prevent infection by performing thorough handwashing and infection control measures.

Maintaining open communication with the patient and their family is essential to safe care practice as well as taking the time to assess patient needs and wishes. Safe passage and transition through different care measures is also a large part of nursing care, as families and patients often need guidance through these events.

Pain Management

Many patients will have concerns regarding their pain management. Supportive and caring treatment can help make patients comfortable. All patients have the right to pain management. Nurses must provide care in the least invasive, least painful ways possible.

Nurses can implement measures to reduce and treat pain throughout a patient’s care. Implementation of an interdisciplinary team can help provide balance in the patient’s care. Nurses should follow facility protocols, evidence-based practice, and guidelines to ensure that therapies are maximized. Pain should be assessed frequently, usually every 2-4 hours to ensure proper management. Communication of goals, identification of potentially painful events, providing appropriate pain control, and providing emotional support should be part of daily nursing care.

Medication Errors

Medication errors are one of the most common adverse events that occur in hospital systems. They account for around 7000 annual deaths and occur in approximately 20% of medication administrations. Nurses must be extra cautious of this and follow appropriate protocols in place to help avoid error.

Some common, and important, standards have been defined to help reduce these types of errors. Nurses should avoid all use of medical abbreviations or symbols (PRN, HS, QID, etc.). Handwritten orders should be written legibly and/or questioned if not legible. Nurses should avoid taking verbal orders when possible. If needed, verbal orders should be repeated back to the provider to ensure clear communication. Electronic medical records and order tracking should be used to ensure medication double checks and reduce error. Nurses should use institutional medication administration procedures such as medication barcoding and scanning. Nurses should be aware of similarly named medications and clearly mark these to prevent confusion.

Problem Solving

Nurses are always solving problems. Patients will present problems, providers will present problems, and internal conflicts or concerns will present problems. Nurses must navigate these situations to provide the best care. Nurses are also responsible for trying to anticipate and prevent problems from occurring.

Several problem-solving strategies exist. Problems that arise must be solved as promptly as possible to prevent continuance or recurrence of that problem. Nurses must identify the issue, collect data regarding that concern, identify important concepts, consider possible actions and their reasons, and ultimately make a decision. When a conclusion is decided, remember it must be the most ethical and moral decision and benefit the patient.

Patient and Family Rights

Patients and families have a right to be involved in their care. Nurses can help to facilitate this by maintaining open communication and providing access to appropriate resources.

Advance Directives

Advance directives are available for all patients. Federal and state laws protect a patient’s right to have self-determination in their healthcare. This allows patients to participate in the decision making of therapy as well as end of life care. Advance directives also allow patients to nominate a durable power of attorney to make decisions for them if they become incapable of doing so.

One part of an advance directive includes a do-not-resuscitate (DNR) order. Patients with terminal illness, old age, or other conditions may wish to not have extensive resuscitative measures in the event of imminent death. Patients and families should be educated thoroughly on what DNR means so they can determine the best option for the interest of the patient. Palliative care teams and hospice care teams may be involved in this education and/or decision making.

Death and Dying

When treatment options seem to be ending, death and dying become important nursing concerns. Patients of all ages are entitled to a dignified, respectful death. Nurses will need to provide appropriate interventions to improve patient comfort, pain control, and sustaining reasonable last wishes in patient care. Guiding patients and their families through this process can be difficult, but with the proper care it can be a relatively positive experience.

Family Support

While patients frequently receive the care they need when going through the dying process, a key element is often excluded—family support. Families may feel that they are underprepared for their loved one’s death. Nurses may be responsible for providing comfort and information to the families during this tough time.

Before death, nurses should attempt to stay with the patient, quietly allowing them to navigate their emotions and actively listen to conversations. Platitudes and reassuring cliches should be avoided. Nurses should remember that all families and family members will grieve differently and to avoid judgement regarding the family’s actions or emotions. Therapeutic touch and gentle care should be given to the patient. The nurse can encourage the family members to do the same. Several support groups exist for families in similar situations. Provide families with these resources as indicated to help them find support both during and following the dying process.

At the time of a patient’s death, reassure the family that the patient is being well cared for in the most comfortable manner. Express compassionate personal feelings regarding the loss of the patient and encourage family members to do so. Nurses should communicate their and the patient’s actions out loud to help the family understand the process of dying. Patients may experience death rales, Cheyne-Stokes respirations, reflexive movements, and other unusual actions that may need to be explained. Use the support of facility clergy or spiritual guidance staff and notify family if/when death becomes imminent. Ultimately, the nurse should respect the family and attempt to satisfy their needs during this time.

Following death, allow family members to say goodbye to the patient. Do not rush or force the family out of the room immediately following death. Use the patient’s name to be respectful to the patient and their family. Assist in making arrangements with facilities for burial or alternate arrangements for caring of the body. Encourage grieving and expression of emotions following the death. Maintain open communication and provide facilitation of appropriate resources.

Grief

Elisabeth Kübler-Ross was a famous writer who wrote several pieces of literature on death and dying. One of her most popular works defined the five stages of grief a person will work through in the event of a significant loss. The stages of grief are denial, anger, bargaining, depression, and acceptance. Not every person will travel through the five stages, but almost everyone will experience at least two of the defined stages.

The denial stage is usually the first stage in the grieving process. During this stage, the griever will deny or be resistant to the fact of the loss. This may impair their decision-making skills and worsen their comprehension of the situation.

In the anger stage, reality becomes more clear and the griever may become angry. This emotion can be reflected in their words or their actions. Some may react with violence, and appropriate restraint measures should be implemented to ensure the safety of the griever and others around them.

Bargaining occurs when the griever tries to propose trades to improve the outcome of the loss. This may be a bargaining chip with a spiritual power or an attempt to change care providers or treatment plans.

In the depression stage, the griever begins to accept the loss and becomes submissive to the negative outcomes regarding the loss. Patients may be overwhelmingly sad, withdrawn, or tearful.

Grieving people will often fluctuate between the previously defined stages, sometimes going through stages multiple times. Eventually, grief lessens as the griever comes into acceptance of the loss. Grievers and families at this time can begin to return to normal daily activities and continue life despite the great loss they experienced. With acceptance, they are able to think about and remember their loved one without great pain.

Communication

Communication is one of the most, if not the most, essential skills needed for good nursing care. Without communication, breakdown in continuity of care, increased medical error, and poor patient/staff relationships occur. Communication with patients and their families can be therapeutic or non-therapeutic. The goal of the nurse is to maximize therapeutic communication to ensure a caring environment.

Therapeutic Communication

The essence of therapeutic communication is respect for the patient and the family. All verbal and non-verbal communication is meaningful and should be used in a caring and compassionate way. Nurses should practice active listening and avoid a too-quick response.

Some ways to improve therapeutic communication include introducing yourself to the patient and their family, using open-ended questions to help identify needs, acknowledging comments, allowing for silence when appropriate, asking for clarification when needed, and repeating statements to ensure understanding. Nurses should be empathetic, considerate, and patient. Nurses should answer patients’ questions, validate their responses, and acknowledge patients’ emotions and concerns.

Non-Therapeutic Communication

The opposite of therapeutic communication is non-therapeutic communication. Non-therapeutic communication can occur both verbally and non-verbally. It can break a nurse-patient relationship and create a sense of uneasiness or mistrust. Common missteps in non-therapeutic communication include using meaningless clichés, providing unwanted or inappropriate advice, asking for explanations for patient behaviors, agreeing instead of accepting and responding to a patient, devaluing the patient, directly disagreeing, arguing with the patient, and providing inappropriate responses to patient statements.