Professional Caring and Ethical Practice Study Guide for the CCRN

Response to Diversity

Diversity occurs in every hospital. Nurses must respond appropriately to the diverse situations, cultures, and patients they interact with to provide the most comprehensive care.

AACN® Synergy Model

Nurses must be able to recognize several diverse situations and treat patients of all different backgrounds. The AACN Synergy Model defines levels of responding to diversity.

• In Level 1, nurses can assess diversity with standard questionnaires. At this level, nurses then provide care based on personal beliefs and past experiences.

• At Level 3, nurses begin to seek information about the diverse background of the patient and become active in incorporating the patient’s needs into their care.

• At the highest level, Level 5, the nurse actively incorporates and investigates all levels of diversity regarding the patient. This allows the nurse to present alternate options for therapy based on cultural/diversity requests, anticipate the needs of the patient, and integrate the patient’s diversity when applicable.

Cultural Competence

Cultural competence is the ability to communicate and understand people of all different cultures. Nurses must be culturally competent to provide individualized patient care. Nurses must have a good understanding of their own cultural views and values. They should then develop an appreciation for the diversity of others and how others’ views differ from their own. They should never assume that cultural generalizations apply to the individuals. Intercultural dynamics become important in cultural competence as well. Having an understanding of communication strategies, differences, and behaviors plays into this.

Many institutions have their own culture. Recognizing this can help to identify where institutional values lie and how to navigate this through patient care. Ultimately, the cultivation of cultural competence lies in how the nurse can adapt patients’ service to the diversity of their life. This allows for connection and contact between cultures and promotes holistic patient care.

Jehovah’s Witnesses

Jehovah’s Witnesses are fairly well-known in the medical community for avoiding or banning the use of blood transfusions or blood products due to religious beliefs. Patients in critical care may require therapies that include transfusion of these products to sustain life. Nurses must be thorough in their assessment of the patient’s needs and address the needs of the family regarding this procedure.

Nurses should provide factual information regarding the need for the blood product/transfusion without passing judgment on the patient or their family. They should also allow the patient and their family to voice their concerns regarding this treatment plan. Nurses should never assume that patients will refuse a blood transfusion for themselves or family members based solely on religious belief.

Many hemoglobin-based blood substitutes (fractions from red blood cells, white blood cells, platelets, and plasma) can be used without violating the traditional Jehovah’s Witnesses religious beliefs. These substitutes may be considered if other therapies are dismissed as inappropriate for the patient.

Hispanic Patients

Hispanic populations are traditionally Catholic. They often request support from a Catholic priest throughout their healthcare stay. Family is also extremely important to many Hispanic families, and nurses may see an influx of visitors during the patient’s hospital stay. Nurses should be mindful of the patient’s support network and be tactful in explaining facility and/or unit restrictions on visitors and visiting hours.

Some Hispanic patients and families will have language barriers that prevent congruent communication. Use hospital-based translators to facilitate communication of therapies and ensure patient and family understanding of the care being provided. Hispanic culture traditionally sees time as more flexible than Americans. Having appropriate communication avenues will also help to facilitate communication regarding the timing of testing and other interventions.

It is important to note the family dynamic when working with a patient from a Hispanic culture. Many Hispanic families are patriarchal in nature, and family members may wait for the father or other males to make decisions for the patient, regardless of the patient’s age. Other patients and families may act or be indecisive with medical decision making to show respect for the medical team’s proposed plan. Women and children may dismiss or not speak up for their needs, and nurses may have to anticipate these to provide appropriate care.

Middle Eastern Patients

Middle Eastern patients have many specific cultural beliefs when it comes to decision making, religious practice, and medical care. In this culture, segregation among men and women is common. Men are often valued as the primary decision makers for the care of the women and children. Men are not to see women in “indecent” dress, which usually reduces the ability for male nurses to care for female patients due to cultural views. On the other hand, female nurses may be viewed as “indecent” due to their interactions with male patients and be ignored or not respected in their medical intelligence or recommendations. Family members may stand closely to each other and staff members as well due to culturally decreased need for personal space. Open communication techniques and cultural competence can be used in these situations, if needed, to help promote therapeutic patient care.

Dietary restrictions are another consideration when caring for Middle Eastern patients. Many Middle Eastern patients do not eat pork or animals killed in non-ritualistic fashions. They may prefer to have vegetarian or kosher meals, and these options should be made available to them. Language barriers may trigger the need for a hospital-trained interpreter. Attempt to use interpreters of the same sex when possible to respect the cultural divide between men and women in this population.

Emotional displays of grief in this culture are considered respectful to the dead. Allow family to grieve openly and provide resources as appropriate to assist the family through difficult times. Caregivers may also present small gifts or treats to the staff. Accepting large compensation or gifts from patients is often against hospital policy, so politely explain this to the family with gratitude toward the gesture.

Asian Patients

Another population that often presents a variety of cultural differences is the Asian population. Nurses and providers are often viewed with respect and are expected to maintain an authoritative relationship with the patient and family. Clear, direct communication can be expected. Use a hospital-trained interpreter as needed for bridging language barriers.

Males tend to be the decision makers for the family and should be included in medical planning. Asian patients may not question or disagree with recommended measures as culturally, this is viewed as disrespectful. If there is a concern about the understanding of an instruction or procedure, encourage the family to express their understanding by repeating the instructions.

Many Asian patients will avoid eye contact as a sign of respect. Outward emotions of grief or affection are usually suppressed. This may make the patient or family appear unengaged or flat, when it is part of their cultural demeanor. Many patients and/or families will also hide the fact that they are ill as they feel ashamed that this is occurring or do not want others to know.

Complementary therapies may be requested or performed. Some Asian families may use traditional healing techniques such as cupping, pinching, or pressure application that can lead to bruising. Instead of rushing to the assumption of abuse, question families regarding their home health care and means of complementary therapies as a way of comfort/healing. Herbal therapy is also common in this culture.

Facilitation of Learning

Learning is a part of growing. Nurses must participate in learning and help teach others to grow professionally.

AACN Synergy Model

The AACN Synergy Model branches to include the facilitation of learning. The facilitation of learning is the ability to teach patients, family members, community members, and other healthcare professionals. Nurses must go through a needs assessment and prepare content thoroughly to meet the needs of the learning objectives.

The three levels of the AACN Synergy Model focus on the differences between just delivering content and understanding that content.

• In Level 1, nurses are able to deliver previously planned content without fully assessing the audience’s learning style or readiness.

• In Level 3, the nurse is able to take the teaching objectives further to individualize treatment to patient and/or family needs. There is an understanding of the variety of methods in which to teach as well as the learning styles that exist.

• Level 5 expands on the first two levels to include full understanding and appreciation for teaching methods, learning styles, and readiness learning assessments. The patient and family, the audience, and the other healthcare professionals are taken into high consideration when creating and delivering the content designed for them.

Teaching and Learning

Several components play into teaching. In order to teach, nurses must first have an understanding of the information they wish to portray. They must also have a basic understanding of their audience to ensure transfer of the teaching in a way they too will understand. Finally, assessing the success of the teaching will help to understand if the information was learned by the audience. Using pre- and post-learning assessments, defined goals, measurable objectives, and carefully designed lesson plans can maximize both teaching and learning.

The Lesson Plan

Creating a lesson plan for an audience is not an easy task. Several components must be addressed in order to create a comprehensive learning program. Nurses must begin with setting goals for the teaching to be done. This is followed by creating measurable objectives to assess the learning being done. Finally, the content or course will be created to address both the goals and objectives. Nurses should keep in mind that each lesson plan should only focus on one or two topics to avoid confusion or information overload. After the teaching is completed, return to the measurable objectives to ensure that the goal of the learning has been met.

After the lesson plan has been developed and taught, one must assess the learner outcomes to ensure that appropriate and successful teaching has taken place. These assessments can be done via survey, feedback forms, examinations, or return presentations regarding the material taught. Educators should also be open to any concerns or criticisms regarding their teaching and use that to build improved teaching tactics in the future.

Teaching Approaches

People learn in a variety of ways. Nurses must be able to tailor teaching approaches to fit the needs of their intended audience. Material for educational workshops will be designed completely differently than bedside patient education.

Several types of teaching styles exist. When educating large groups of people, lectures may be the chosen format of teaching. Smaller groups of people may prefer to engage in hands-on workshops or discussion groups. Individual learners may benefit most from one-on-one instruction with targeted goals to meet the needs of the learner. Finally, computer programs or online modules may help to reach more remote or independent learners.

Videos and supplemental handouts/reading assignments can be useful across all of these settings to help solidify learning. Remember that any written documents for the general public should not exceed a sixth to eighth grade reading level. Documents for healthcare workers may be written at a higher level.

Learning Styles

Educators must also factor in the learners’ learning styles. Four primary learning styles exist: visual, auditory, reading/writing, and kinesthetic. Knowing the types of learners in the audience can help to tailor material to improve teaching outcomes. If lecturing to a large group of people, consider using several learning styles within the presentation to address the needs of all the learners.

• Visual learners learn best by seeing and reading. Powerpoint presentations, videos, written handouts, pictures, charts, and diagrams are beneficial to this type of learner.
• Auditory learners learn through listening and talking. Discussion groups, verbal explanations, audiotapes, and question/answer sessions are beneficial to this type of learner.
• Learners with a reader/writer preference benefit from the ability to write down instructions, read handouts, take notes, and highlight important documents.
• Kinesthetic learners learn best with hands-on activities, handling supplies or equipment, and exploring situations without extensive verbal or written instruction.

Adult Learning

Adult learners, while they exhibit different learning styles, have additional needs to ensure a productive teaching/learning experience. Most adult learners have prior knowledge and experience regarding education. Some may be eager to learn more, while others may be resistant due to previous events. Specific strategies can improve the educators’ ability to reach all the adult learners. These strategies include being goal-oriented, educating practically, using problem-solving exercises that build on previous knowledge and experience, maintaining a goal-focused and organized presentation, providing opportunities for active involvement, allowing for differing opinions and discussion, validating the learners’ concerns, providing the relevance of information and relating it to real-life events, clearly stating objectives, and maintaining respect for the learners.

Patient and Family Learning

Patients and families will also require various types of education throughout their hospital stay. Nurses should assess a patient and their family’s needs frequently. Some families may prefer to have handouts or videos, while others wish to have more hands-on learning opportunities.

One-on-one instruction is often beneficial when working with families; however, it can be costly and time intensive. Patients and their families may be requested or invited to attend group instruction events for skills learning activities. These activities are extremely useful when trying to teach a large number of patients and family members how to perform the same specific tasks. Many institutions offer short skills lessons on CPR, birthing preparation, car seat safety, childhood safety, medical equipment teaching, and others. Group activities may provide opportunities for families to ask numerous questions or to get information from others they would not have otherwise received with one-on-one instruction.

Nurses must also consider the patient and family’s readiness to learn prior to delivering education. Many patients and families will have barriers to successful learning, especially in critical care environments. Physical restrictions such as dexterity changes, weakness, immobility, and injury may prevent patients from learning certain skill sets. Language and cultural barriers may limit the family’s ability to understand instruction or to complete prescribed therapies due to preconceived notions regarding those therapies. Mental or emotional lability may reduce the ability of the patient or the family to comprehend the teaching being given.

Nurses should also consider what the patient and the family knows prior to delivering teaching. This assessment allows for a more thorough understanding of where the learner is in their ability to learn as well as prevents the nurse from teaching over or under the learner’s current knowledge.

Teaching Policies and Changes

Many nurses and nurse educators are responsible for teaching policy changes and quality improvement objectives. Education in these areas must be developed quickly and accurately to ensure compliance with the programs created. There is usually a multi-step process when policies are changed within a facility. Nurses should disseminate pre-information building up to the final decision so all staff are kept up to date and have the opportunity to pose questions or concerns regarding the upcoming changes. Policies and changes can be taught through a variety of media. Changes in delivery of medical care are often taught best in hands-on workshops or demonstrations. Posters, handouts, emails, and other forms of written communication can also be used to disseminate this information. If hands-on demonstrations are unavailable, videos and simulations may be used instead. Provide several teaching approaches to reach all of the intended learners.

Bloom’s Taxonomy

Bloom’s taxonomy is an outline of the necessary behaviors for effective learning. Three types of learning exist under this outline: cognitive, affective, and psychomotor. Each has their own categories of skills to recognize or master to achieve learning.

In cognitive learning, the learner must be able to understand the following categories: knowledge, comprehension, application, analysis, synthesis, and evaluation. In nursing testing, NCLEX-style questions focus on the higher levels of cognitive learning, starting with application and advancing to evaluation. While knowledge and comprehension are important, to test the true knowledge and learning one must be tested on the application of that learning to real-life scenarios.

Affective learning can occur slower than cognitive learning. In affective learning, behaviors and values are recognized throughout the knowledge process. Learners must be able to receive the information and accept the need to learn, respond to the information and take an active part in learning, value the information and understand how to become independent with that knowledge, organize values to understand how knowledge has improved the outcomes, and finally internalize those values to accept that knowledge as a part of one’s individual priorities. The culmination of affective learning is to become adherent to the knowledge throughout life and be self-reliant with the skills learned.

Finally, in psychomotor learning, the goal of learning is to achieve independence in the knowledge and presentation of skills learned. Learners must progress step by step through the motor skills necessary to create independence. These skills are perception, set, guided response, mechanism, complex overt response, adaptation, and origination. It allows the learner to learn tasks, willingly perform tasks, follow directions, complete specific task goals, display competence, modify skills as needed, and creatively solve problems using the skills learned.