Week 1- Chapter 3

Week 1- Chapter 3 Nursing has responded to the health care needs of society, influenced over time because of economic, social, and cultural factors. Nursing in Canada is rooted in the traditions of nursing that developed in New France (Jeanne Mance) Florence Nightingale revolutionized nursing as an acceptable profession for women as lay nurses in the late 1800s and early 1900s. -English Nurse in Turkey during the Crimean War. The development of a system of nursing education in Canada emerged from the early nursing sisterhoods and from schools of nursing associated with hospitals. 1874…First Canadian Nursing School opened with a hospital diploma program- University of Alberta 1881…The School for Nurses at Toronto General Hospital- Mary Agnes Snively 1894…Nursing school opened in Medicine Hat, Alberta 1896…3-year course, 84 hours of practicum, medical staff taught the nurses for 119 hours 1898…Victorian Order of Nurses 1909…CNA became a full-fledged member of ICN 1930…Approximately 330 schools of nursing in Canada 1942…The University of Toronto was first in Canada to approve a degree in nursing 1982…CNA approved baccalaureate test entry to practice with the target date of 2000 2019…Graduate degrees for nurses and need for research is on the rise Baccalaureate entry-to-practice requirements have been fully implemented in English-speaking Canada- Alberta • • • • • • • • 1617…Mme Hebert 1629…Port Royal in Acadia 1639…Hotel-Dieu de Quebec opened…Quebec’s first Hospital 1641…Jeanne Mance founded in a hospital in Montréal 1738…Sisters of Charity (Grey Nuns) 1844…Grey Nuns journey to St. Boniface, Manitoba 1859…Grey Nuns journey to Lac Ste. Anne, Alberta 1885…Sisters of St. John the Divine arrive at Moose Jaw and return to Toronto to establish the first surgical hospital for women The ranks of the profession are moving toward gender balance and increased diversity that reflects the Canadian population. 1 Weir Report (1932) Concern about the quality of nursing education and exploitation of nursing students! Led to a report that confirmed insufficient classroom instruction and a lack of variety in clinical experience across Canada’s nursing schools! Recommended nurses be taught in schools and not in hospitals Week 1- Chapter 5 Nursing Priority= Assess Highest Risk The nursing process is the fundamental problem-solving process by which new situations are assessed, plans are developed, and interventions are performed and evaluated. Emergence of Theory Florence Nightingale’s work is considered an early theoretical and conceptual model for nursing. Nursing science Is a unique body of knowledge about the practice of nursing. Nursing science has evolved within a historical and social context. -Much of the early theorizing about nursing practice was specifically designed to guide nursing curriculum development so that nursing education would be focused on the knowledge unique to nursing care. Concept- Example: Anxiety Conceptualization- the process of formulating concepts. Example: Framing behavioural patterns as anxiety related. Operational Definition- A description of concepts, can be applied to decision making in practice. Example: Differentiation and measurement of state and trait anxiety. Nursing Process ADPIE • Assessment • Nursing Diagnosis • Planning • Intervention • Evaluation Profession Exists to provide service to others: altruistic 2 Self-regulation (obligation to public) Code of ethics (relationships with colleagues and patients) Advanced specialized body of knowledge that is based on high level of education and is continually developed Has autonomy over a specific jurisdiction and mandate i.e. protecting public and supporting excellence in practice International, national, and provincial members Nursing Organizations International Council of Nurses- 130+ national associations- advancing profession, promoting well-being and strong health policies Canadian Nurses Association- 13 jurisdictions- leadership for regulation and program accreditation for protecting public, code of ethics, certification specialties College of Alberta and Registered Nurses Association- 30,000+ members; standards of practice, continuing competence and licensing regulation, education and consultation. Health Professions Act United Nurses of Alberta Theory- A purposeful set of assumptions or propositions about concepts. Example: Social determinants of illness. Explains, predicts, prescribes concept connections! We accept and test connections through research “BLUEPRINT” Theorizing and other ways of knowing Nurses ways of knowing are explicit and tacit Explicit ways of knowing is the formal information gained from written words, maps or symbols Tacit knowledge is the knowledge gained from experience, interaction and the acquisition and combination of skills Carper four patterns of knowing has been widely taken up in nursing 3 1) 2) 3) 4) Empirics- the scientific, objective Ethics- choosing justifying, moral duty Esthetics- interpreting the patient’s behavior in regard to relationships Personal- knowledge of self and an awareness of others in relationships Concepts Concept: describes our ideas about objects or events ‘person’- biological, psychological, social and spiritual entity THEORY Grand – abstract- need testing- cannot direct actions Middle-Range – links concepts in situations (admin., clin., teaching) Descriptive- tentative expectations and predictions of consequences *Prescriptive- explanations and consequences (naming actions) Relationship of Theory to Nursing Practice Nursing knowledge is theoretical and practical. Theories provide direction to nursing research. Generate nursing knowledge for use in practice Can direct how to use nursing process Are adaptable to different clients and all care settings Nursing theory and nursing research build nursing’s knowledge base. Conceptual Frameworks • Goal is to understand how effective nurses systematically organize knowledge about nursing to understand an individual patient’s situation. Cannot be confirmed or disproved through research- proposed ideas • Frameworks and models sought to depict theoretical structures that would enable a nurse to grasp a clinical situation within the larger context of available options. Often referred to as Nursing Theories Nursing conceptual frameworks include those for understanding both the person as the nurse’s patient and the nurse’s role in relation to that patient. 4 Nursing theorists based their conceptual frameworks on various ways of thinking about human behaviour and experience. Some framed their ideas within theories of human behaviour, such as needs, interaction, or systems, and others drew their primary inspiration from what they observed in excellent nursing practice. Although each framework may have been an attempt to organize nursing knowledge and systematic reasoning processes in a different way, each was aiming for a very similar ideal of excellent decision making in nursing practice. • Although nursing theoretical frameworks are no longer considered useful as prescriptive models for practice, they help conceptualize nursing’s interests and identify researchable nursing problems. Metaparadigm Concepts • Nursing • Health • Client or Person • Environment/situation Ways of Knowing • Empirical science- Facts “water boils at 100 degrees Celsius.” • Ethical, personal, aesthetic, and sociopolitical knowledge- can’t fully measure emotional states and feelings. • Critical thinking • Nursing Diagnosis -NANDA's list is recognized by many nurses as a system that relies entirely upon an agreement about what constitutes average wellness and illness experiences. Clinical Judgement - decisions made on patient-nurse interaction Nurses’ understanding of the role of science has changed as more complex forms of science have been articulated by philosophers of science; science is no longer limited to simple relationships such as cause and effect but instead provides strategies for understanding increasingly complex relationships and phenomena. • Nursing knowledge derives from, in addition to science, various sources that include aesthetics, personal knowing, sociocultural understanding, and ethics. 5 Which statement about nursing is true? A) B) C) D) It is a discipline that has its own unique science. Is not a true science but rather an art. It is a discipline that is still trying to create its own theories. It has a number of theories that are interrelated. Week 2- Chapter 1 Health conceptualizations and determinants influence the nature and scope of professional practice. Definitions of Health Historically- health is the absence of disease Now- physical, emotional, mental, spiritual health Promoting health is a foundation of Nursing practice “A resource for everyday life that is influenced by circumstances, beliefs and determinants of health.” “A state of complete physical, mental and social well-being, and not merely the absence of disease.” “The extent to which an individual or group is able, on the one hand to realize aspirations and satisfy needs: and, on the other hand, to change or cope with the environment. Health is, therefore seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, as well as physical capacities.” World Health Organization (WHO), 1984 Disease- an objective state of ill health Illness- a subjective (perceived) experience of ill health 3 Recent Approaches to Health 1)Medical -medical intervention restores health (WWII) 2) Behavioural -Lalonde Report shifted approach - “further improvements in the environment, reductions in self-imposed risks, and a greater knowledge of human biology.” Lalonde Report, 1974 -Places the responsibility for health on the individual. -Became victim BLAMING approach 6 3) Socioenvironmental Approach -Health Promotion, Health tied to Social and Environmental Structures - Hancock & Perkins, 1985 -WHO 1984 Determinants of Health • Income and social status- MOST IMPORTANT • Social support networks • Education • Employment and working conditions • Physical environments • Biology and genetic endowment • Personal health practices and coping skills • Gender • Culture • Social environments • Healthy child development • Health services The Ottawa Charter -WHO, 1986 -identifies five major categories of health promotion strategies: 1) building healthy public policies 2) creating supportive environments 3) strengthening community action 4) developing personal skills 5) reorienting health care services Jakarta Declaration -WHO, 1997 -1st to be held in a developing country and involving the private sector 7 -empowerment of women, social security, respect for human rights + social relations Bangkok Charter -WHO, 2005 -Health inequalities within and between countries, global environmental change, and globalization Toronto Charter -~1990s, recognized inequalities in Canada’s Healthcare System, -Social Determinants of Health: Indigenous status, Early Life, Education, Employment and Working Conditions, Food Security, Gender, Health Care Services, Housing, Income, Social Safety Net, Social Exclusion, and Unemployment and Employment Security. Poverty- is the greatest threat to health • Low birth weight children 43% higher incidence in poor neighborhoods • Children in poverty more likely to have chronic diseases • Lack of material resources • Higher levels of psychosocial stress Health Literacy involves functional, interactive, and critical abilities needed to exert control over life events and circumstances that influence health experience and health status. Canada is a leader in ever-changing views of health and health determinants. Health Promotion VS. Disease Prevention Health Promotion= “directed toward increasing the level of well-being and selfactualization.” Ottawa Charter- “the process of enabling people to increase control over and improve their health.” (WHO, 1986) -addresses health issues in context. -supports a holistic approach -requires a long-term perspective -is multisectoral 8 -draws on knowledge from social, economic, political, environmental, medical, and nursing sciences, as well as from first-hand experiences. Disease Prevention- action to avoid illness Primary Prevention -protects against a disease before signs occur. -Immunization, reducing risk factors: reducing inactivity, smoking, and exposure to air pollution. Secondary Prevention-promote early detection of a disease once pathogenesis has occurred. -Preventive screening for cancer, Blood Pressure Screening, Blood Glucose Screening. Tertiary Prevention- activities directed towards minimizing residual disability and helping people to live productively with limitations. Convalescence of disease! -Cardiac Rehabilitation program after a myocardial infarction. (heart attack) Why was the Ottawa Charter important? A) It identified prerequisites for health. B) It identified recommendations for federal funding. C) It identified nursing standards of practice. D) It identified the need for interprofessional education At what are health promotion activities aimed? A) Providing protection against disease B) Increased well-being C) Avoiding injury and illness D) Teaching clients to learn to live with limitations Week 2- Chapter 2 Medicare is a key component of Canada’s social safety net. All levels of government play a major role in co-funding national health insurance and setting health care policy in accordance with the Canada Health Act. (1984) The Canada Health Act forbids extra billing and user fees + it articulates the 5 principles of: 1)Public administration- non-profit 9 2)Comprehensiveness- covers all medically necessary hospital and physician services 3)Universality- negates discrimination 4)Portability- insured residents can access healthcare services in another province or territory 5)Accessibility- reasonable access to healthcare facilities and providers Escalating costs, technological innovations, and consumer expectations challenge the health care system in efforts to deliver innovative, efficient, and quality care. Equality, equity, access, interdisciplinary approaches, communication, and continuity of care challenge the health care system. The primacy of primary health care (PHC) and home care is aligned with the reforming health care environment and cost-effectiveness. Sufficient, diverse, and qualified human health resources are essential for a culturally competent workforce attending to a culturally safe Canadian health care system. Enhancing the health of Canada’s Indigenous peoples is a significant challenge to society and to the health care system. -Nurses must continually seek out information and evidence to remain responsive to providing quality, culturally competent, and safe care. Federal Jurisdiction/ Government -Set and administer Health Care Act principles -Sets and administers national principles -Assists in financing of health care services through transfer payments -Delivers health services for First Nations and Inuit people, veterans, federal inmates, and RCMP -Provides national policy and programming to promote health and prevent disease Provincial Jurisdiction -develop and administer its own health care Insurance Plan -Manage, finance, and plan insurable health care services and delivery, in alignment with CHA principles -Determine organization and location of hospitals or long-term care facilities; mix of health providers, and amount of money dedicated to health care services 10 -Reimburse physician and hospital costs; some rehabilitation and long-term care services, usually on the basis of co-payments with individual users The Romanow Commission (2002) -Medicare is sustainable and must be preserved because it represents core values of Canadians. -Creating a new diagnostic service fund -Building information technology infrastructure -Improving access -Ensuring and measuring quality -Improving and expanding primary health care -Strengthening and expanding home care -Offering catastrophic drug coverage -Creating a national health council responsible for indicators and performance measures The Kirby Report (2002) Health care is a basic right ……… BUT • Medicare system is not sustainable • Need for stronger private sector involvement • Shifting funding for hospitals to a service-based model • Granting more responsibility to regional health authorities • Reforming primary health care • Offering a health care guarantee to Canadians Primary Health Care (PHC)- extends beyond Primary Care to include health education, nutrition, maternal and child health care, family planning, immunizations, and control of locally endemic diseases • Philosophy and model from improving essential healthcare services with emphasis on health promotion • 4 pillars: 1) 2) 3) 4) Teams Access (street works) Information (digital age) Healthy living (DoH, LOP) 11 Care continuity Primary Care (PC)- focuses on personal health services! Settings for Health Care Delivery Institutional sector: • Hospitals • Long-term care facilities • Psychiatric facilities • Rehabilitation centers Community sector • Public health • Physician’s office • Community health centers and clinics • Assisted living • Home care • Adult day support programs • Community and voluntary agencies • Occupational health • Hospital and palliative care • Parish nursing 2017-2027 • Home care (6 billion) • Mental health (5 billion) Levels of Health Care • Level 1: Health Promotion • Level 2: Disease and Injury Prevention • Level 3: Diagnosis and Treatment • Level 4: Rehabilitation • Level 5: Supportive Care 12 Challenges in Health Care • Cost accelerators: age is a contentious issue & consumer involvement has become a focal area • Equality and quality: EIP & Culture & PROs are trending To whom does medicare in Canada provide healthcare? A) Permanent residents, new immigrants, and citizens of the country B) Permanent residents, temporary residents, and citizens of the country C) Permanent residents, visitors, and citizens of the country D) Permanent residents, refugees, temporary residents and citizens Which of the following statements is true about primary health care and primary care? A) They are similar concepts, which refer to the care patients receive with specific focus on the diagnosis and treatment B) They are similar concepts that are centered on promotive, preventive, curative, rehabilitative and supportive care C) They are different concepts where primary healthcare looks beyond primary care D) They are opposing concepts and the distinction between primary healthcare and primary care is difficult to understand What are the five levels of healthcare? A) Health promotion, disease and injury prevention, primary healthcare, rehabilitation, palliative care B) Health promotion, disease and injury prevention, diagnosis and treatment, rehabilitation, supportive care C) Illness prevention, diagnosis and treatment, palliative care, acute care, rehabilitation D) Disease and injury prevention, primary health care, supportive care, health promotion, laboratory diagnostic services Week 3- Chapter 12, 13, and 14 Critical thinking is a process acquired through learning and experience. • Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than rapidly and carelessly adopting solutions. 13 Following a procedure step by step without adjusting to a patient’s unique needs is an example of basic critical thinking. In complex critical thinking, a nurse learns that problems may have alternative and perhaps conflicting solutions. The critical thinking model combines a nurse’s knowledge base, experience, competence in nursing process, qualities, and standards to explain how nurses make clinical judgements that are necessary for safe, effective nursing care. • In diagnostic reasoning, the nurse collects patient data and then logically develops a clinical judgement, such as a nursing diagnosis. • When a nurse faces a clinical problem or situation and chooses a course of action from several options, the nurse is making a clinical decision. -Clinical learning experiences are necessary for nurses to acquire clinical decision-making skills. -Nurses improve their clinical decision making by knowing their patients and including them in the decision-making process. -Clinical decision making involves judgement that includes critical and reflective thinking and action, as well as the application of scientific and practical knowledge. The nursing process is a blueprint for patient care that involves both general and specific critical thinking competencies in a way that focuses on the patient’s unique needs and desired health outcomes. Sound information literacy skills help nurses locate, retrieve, evaluate, and apply research findings and are essential to thinking critically. The use of intellectual standards during assessment ensures that the database of information is complete. Professional standards for critical thinking refer to ethical criteria for nursing judgements, scientific and practice criteria to be used for evaluation, and criteria for professional responsibility. 14 Case-based learning complements, but cannot replace, clinical experience in learning to think critically. • Reflective writing gives nurses the opportunity to define and express clinical experiences in their own words. • Drawing a concept map enables nurses to obtain a broader and more complex understanding of their patients’ complex health care needs. The nursing process employs critical thinking to identify, diagnose, and treat patients’ responses to health and illness. Nursing assessment involves the collection and verification of data and the analysis of all data to establish a database about a patient’s perceived needs, health problems, and responses to those problems. • By interpreting cues, the nurse forms an inference, which then enables the nurse to identify meaningful clusters of information. • To conduct a comprehensive assessment, nurses use a structured database format or a problem-oriented approach. • Open-ended questions encourage patients to describe their health histories in detail, whereas closed-ended questions may elicit only limited responses by the patient. An interview includes three phases: orientation, working, and termination. • Once a patient provides subjective data, the nurse considers exploring the findings further by collecting objective data. • Written data statements are descriptive, concise, and complete; they do not include inferences or interpretative statements. To form a nursing judgement, nurses critically assess a patient, validate the data, interpret the information gathered, and look for diagnostic cues that will lead them to identify the patient’s problems. • NANDA International has developed a common language that enables all members of the health care team to understand a patient’s needs. • The analysis and interpretation of data requires nurses to validate data, recognize patterns or trends, compare data with healthful standards, and then form diagnostic conclusions. 15 • The absence of defining characteristics of a proposed diagnosis suggests that the nurse reject that diagnosis. Four types of nursing diagnoses exist: those for actual disorders, those concerning risk for disorders, wellness diagnoses, and those for health promotion. • A nursing diagnosis is written in a two-part format, including a diagnostic label and an etiological or related factor. • The “related to” factor of the diagnostic statement assists nurses in individualizing a patient’s nursing diagnoses and provides direction for their selection of appropriate interventions. • The presence of risk factors indicates that an at-risk nursing diagnosis applies to a patient’s condition. • Concept mapping is a visual representation of a patient’s nursing diagnoses and their relationship with one another. • Nursing diagnostic errors occur through errors in data collection, in interpretation and analysis of data, in clustering of data, or in the diagnostic statement. During planning, nurses determine patient-centred goals, set priorities, develop expected outcomes of nursing care, and develop a nursing care plan. • Priority setting helps nurses anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems exist. Goals and expected outcomes provide clear direction for the selection and use of nursing interventions and provide focus for evaluation of the effectiveness of the interventions. • In goal setting, the time frame depends on the nature of the problem, etiology, overall condition of the patient, and treatment setting. • A patient-centred goal is singular, observable, measurable, time-limited, mutual, and realistic. • An expected outcome is an objective criterion for goal achievement. • Care plans and critical pathways increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another. The Nursing Interventions Classification (NIC) taxonomy provides a standardization to assist nurses in selecting suitable interventions for patients’ problems. Correctly written nursing interventions include actions, frequency, quantity, and method, and they specify the person who is to perform them. 16 • Consultation and collaboration increase nurses’ knowledge about a patient’s problem and help nurses learn skills and obtain the resources needed to solve the problem. Implementation is the step of the nursing process in which the nurse provides direct and indirect nursing care interventions to patients. • Clinical guidelines or protocols are evidence-informed documents that guide decisions and interventions for specific health care problems. • During the initial phase of implementation, nurses reassess the patient to determine whether the proposed nursing action is still appropriate for the patient’s level of wellness. • To anticipate and prevent complications, and thereby create a culture of patient safety, nurses identify risks to the patient, adapt interventions to the situation, evaluate the benefit of a treatment in relation to the risk, and initiate risk-prevention measures. • To implement nursing interventions successfully, the nurse must use appropriate cognitive, interpersonal, and psychomotor skills. Counselling is a direct care method that helps patients use problem solving to recognize and manage stress and to facilitate interpersonal relationships. Preventive nursing actions include assessment and promotion of the patient’s health potential, application of prescribed measures (e.g., immunizations), health teaching, and identification of risk factors for illness, trauma, or both. A concept map provides a visually graphic way to understand the relationship between a patient’s nursing diagnoses and interventions. Evaluation is a step of the nursing process that allows nurses to determine whether nursing interventions are successful in improving a patient’s condition or well-being. • During evaluation, the appropriateness of the intervention should be assessed, as should the outcome. • Evaluation involves two components: an examination of a condition or situation and a judgement as to whether change has occurred. • Evaluation findings are positive when desired outcomes are met; this enables nurses to conclude that their interventions were effective. • In comparing the patient’s actual responses (e.g., behaviours and physiological signs and symptoms) to nursing interventions with expected outcomes established during planning, the nurse determines whether goals of care are met. At this time, the nurse should also determine whether the goals, outcomes, or both were realistic. 17 • Evaluative measures are assessment skills or techniques that nurses use to collect data for evaluation. • To interpret evaluative findings, the nurse should examine the expected outcome, assess the patient’s actual behaviour or response, compare the expected outcome with the actual behaviour or response, and judge the degree of agreement between the two. • The evaluative process may result in changes in a patient’s nursing diagnoses, priorities, and interventions. Week 4Chapter 1: Health and Health Care in Canada Classifications of Health Conceptualizations: -Health as Stability: Health is defined as the maintenance of physiological, functional and social norms, and encompasses views of health as a state, as a process, as adaptation and as homeostasis -Health as actualization: Health is defined as the actualization of human potential. Scholars and researchers who adhere to this definition often use the terms health and wellbeing interchangeably. -Health as actualization and stability: Both actualization and stability concepts are incorporated in the definition of health as the realization of human potential through goaldirected behavior, competent self-care and satisfying relationships with others, while adapting to meet the demands of everyday life and maintaining harmony with the social and physical environments -Health as a Resource: The definition of health as a resource or asses emerged in the Ottawa Charter for Health Promotion (WHO 1986) and includes capacities to fulfill roles, meet demands and engage in the activities of everyday life. -Health as Unity: Health is defined as reflecting the whole person as process and is synonymous with self-transcendence or actualization. Historical Approaches to Health in Canada 18 -Medical approach: represents a stability orientation to health, dominated western thinking for most of the twentieth century. IT emphasizes that medical intervention restores health. Health problems are primarily defined as Physiological risk factors: physiologically defined characteristics that are precursors to or risk factors for disease. FOCUSSING ON TREATMENT! -Behavioral approach: Lalonde Report! Shifts emphasis from a medical to behavioral approach to improve health. Health determinants were lifestyle, environment, human biology and organization of health care. This Health field Concept was iwdely used. Focused on Behavioral risk factors such as smoking -Socioenvironmental approach: Lalonde report challenged 1980’s; victim blaming. Socioenvironmental approach came out, tied closely to social structures such as poverty. WHO produced a discussion paper identifying the social conditions that influence health. Ottawa Charter Prerequisites for Health: -peace -shelter -education -food -income -stable ecosystem -sustainable resources -social justice -equity Ottawa Charter 5 Major strategies to promote health: -Building Healthy public Policy -creating supportive environments -strengthening community action -developing personal skills -reorientation health services - 19 Important Declarations and Charters Jakarta Declaration: on health promotion, WHO 1997. -emerged from 4th international conference on health promotion -the first to be held in a developing country and to involve private sector -affirmed WHO Ottawa charter prerequisites for health -priorities for action: promoting social responsibility for health in public and private sectors, consolidating and expanding partnerships for health to all levels of gov and private sector; increasing community capacity and empowering the ind. Securing adequate infrastructure for health promotion Bangkok Charter: Health promotion in a globalized world, 2005 -affirmed health as a human right and emphasized mental and spiritual well-being as important elements -Identified critical factors influencing health: increasing inequalities within and between countries, global environmental change and urbanization etc Toronto Charter: social determinants of heatlh! HOW TO NURSE CHAPTER 1: INTRODUCTION TO RELATIONAL INQUIRY IN NURSING PRACTICE 1. Components of relational inquiry 2. Limitations of an individualist approach to nursing practice 3. The connections among patient/family well-being, nurse wellbeing and the well-being of the health care system 4. Relational conceptualizations of people, families and communities 5. A pragmatic approach to knowledge development and its implications for learning ow to nurse as a relational inquirer WHAT IS A RELATIONAL INQUIRY APPROACH TO NURSING PRACTICE? Relational: The complex interplay of human life, the world, and nursing practice. Relational Practice: involves highly reasoned, skilled action. 20 Relational inquiry requires: a thorough and sound knowledge base, sophisticated inquiry and observational and analytical skills, strong clinical skills including clinical judgement, decision making skills and clinical competencies, and a particular way of being. Relational Consciousness: grounded in the assumption that people are relational beings who are situated in and constituted through social, cultural, political and historical processes and communities. co Intrapersonally: consider what is going on within all the people involved Interpersonal: you notice what is gong on between people Contextually: you consider what is going on around the people and situation: structures and forces that are ingluencing the situation and shaping the intrapersonal and interpersonal Relational consciousness: -sensitizes us to the relational complexities that affect what happens at the point of care -firescts attention toward the relational transactions that are occurring within and among people and contexts -enables us to be very intentional and consciously choose how to act in response to these complexities and transactions WHY A RELATIONAL INQUIRY APPRAOCH TO THE NURSING PRACTICE? -it is consistent with the realities of contemporary nursing situations -aimed toward patient well being, nurse well-being and system well-being; it recognizes the way in which those elements are integrally connected. -a relational inquiry approach increases nurses ability to affect well-being 21 RELATIONAL PRACTCE • Adapted with permission of Sherry Dahlke • Learning objectives 1) Review and discuss definitions of relational practice and relational inquiry 2) Explore the theoretical support for relational 3) Discuss the 5 C’s of relational inquiry • ‘We’ are a product of relationality c’s of Relational inquiry: • Context • Critical lens • Compassion • Curious • Page 15, para 4: 3 key points Intrapersonal Interpersonal Context -what structures & forces are at play here? (turmoil from external: policies & DoH) • Theories that inform Relational Inquiry Hermeneutic phenomenological lens- how people make meaning of their life situations • How people interpret life situations Critical lens • Do men and women differ • Do rich and poor people differ • Do Chinese, British, and Canadian people differ • Relational inquiry: focusing attention & acting • Being conscious OR mindfully aware An inquired pays attention to: • How people, situations, places connect and shape each other 22 • How am I being present, responding and relating in a real situation • Inform & form our practice responsively to reality we are facing If we don’t do this we get stuck • • • • What is happening at the point of care, right here? What social transactions are taking place, right here? Consider the relevant in the moment to inform action Choosing how to act, given these ‘right here’ things relational inquiry Ways of being in the world with others and with ourselves Being Compassionate Sharing suffering: being in solidarity, doing with another Suffering humbles us, brings us up short, stops us in our tracks, something surpassing which inspires a mix of fear and awe and admiration, something which both strikes us down and draws us near (p. 104) Be in relation with • relational inquiry Ways of being in the world with others & ourselves Being Curious: paths of knowing and not knowing We do bring our expert knowledge to our work with people and families We do not act as if we know nothing We do not act as if we know everything • relational inquiry Ways of being in the world with others & ourselves Being Committed: to pledge and to promise 1) Identifying your values and concerns as a nurse What is the priority here? What cations am I obligated to take? What authority will I follow? 2) Asking: Did my actions match my values and concerns? • relational inquiry 23 Ways of being in the world with others & ourselves Being Competent (knowledge and skills) Performing work without harm to patients Evaluating the effects of our performance Competence is bigger than knowledge and skill (intrapersonal) Competence is shaped by realities at work (context) Following VS questioning protocols (interpersonal) • relational inquiry Ways of being in the world with others & ourselves Being Corresponding: being in harmony/in sync with Paying attention to meaning, concerns, life situations of people and families Relating to people and families in a way that is meaningful to them • How am I responding to the patient or family? • Am I treading lightly and respectfully into the person’s space? Family Health- Class 8 Week 4 Learning objectives 1. Define and describe family from a relational perspective 2. Compare and contrast three models of care that shape family nursing: family centered care 3. Explain how relational inquiry can enhance your effectiveness as a nurse caring for diverse people and families in any care context 4. Explore events situations that can influence the health of the family 24 • What do we mean by Family? 3 potential ways to define family • Biologically, legally, or as a social network with personally constructed ties and ideologies • -Set of relationships that the patient identifies as a network of individuals who influence each other’s lives, regardless whether or not there are actual biological or legal ties. • Each person’s definition of who or what constitutes family. What does a family do for us? • Seen as an individual BUT…. • Experience that you matter and that others matter • Experience being valued and how to value others • Experience being loved and loving others • Experience a sense of belonging and connection to something more than yourself • Are cared for and supported when you go through life threatening of life-altering situations Relationality Family Forms • Nuclear: traditional mother father and children • Extended: includes other relatives; grandparents, aunts, uncles etc • Step: one child from previous relationship of a parent • Blended: both parents bring in children from previous relationship to a joint relationship • Lone-parent: single parent • LGBTQ Family diversity Attention 3 models of care health care system (context) 25 • FCC 50s and 60s: Family is constant in a child’s life, whereas health care providers and systems fluctuate and are temporary • Respecting and honoring differences in families • Collaborating in care • Sharing information and providing support • Ensuring flexibility in access to services PCC: the evolution of a disease in an individual PFC: the person with the disease identifies health concerns Patient participation and involvement Collaborative patient Calgary Family Assessment Model (CFAM) • Structural assessment who & who matters • Internal and external relationships • Contexts: income, education, where you are from, SRO, living environment Developmental assessment stages require you to adjust, change and adapt • i.e: stages of family life cycle and expected tasks • Functional assessment how they interact and behave toward each other • Normal everyday activities • Expressive common. Problem solving, roles, influences, beliefs • Alliance/coalitions • ECOMAP • “Questions to ask the family (pg. 319, table 19.2) and interventions (318-320) a relational and collaborative model Who should we focus on? • Family as context- Individual is client; family is a resource or stressor: we treat the individual (FCC) • Family as patient – Each individual member is the client and if all are treated, we treat the family (PCC, PFC) 26 • Family as systems- individuals and the family unit, e.i CM • Family as component of society- family interacts as a unit with other social intuitions to exchange or receive services • relational inquiry, perhaps {interpersonal + context} Must dos ask us to ….. 1. How is family being scripted (by you, social norms, contect) 2. How aligned are your family practice actions to the specific needs of patients and families 3. Scrutinize family nursing theories/models 4. See family in every nursing care picture 5. Scrutinize particular health care setting as limiting or supporting responsive family nursing practice Relational inquiry • Letting be and change • Knowing who and what… capacities, challenges, contextual constraints • - recognize and acknowledge family ‘caregiving work’ • Self-observation • - participating consciously and intentionally- self knowing • -join family and their roller coaster • Staying in sync • -walking alongside the family • -asking what support a family might need/include family in the NCP • Following the lead of families • -scrutinizing knowledge vs. family experience…. Curious, uncertain • Join family on their roller coaster! What affects family health? Beliefs, values, practices, i.e. functional expressions 27 Health of another family member Larger context – environment, economy [politics], SES WEEK 5- GLOBAL PERSPECTIVE AND GROWTH AND DEVELOPMENT Growth and Development • Growth encompasses the physical changes across a person’s lifespan and are continuous and complex. • Growth and development are synchronous processes that are interdependent in the healthy individual. • Growth and development are based on timing and sequence of developmental tasks. • Developmental processes include sociocultural, biological, and psychological factors. • An organized, systematic approach ensures that a care plan will meet the needs of the client. Growth : Quantitative • Growth encompasses the physical changes across a person’s lifespan and are continuous and complex. • Growth and development are synchronous processes that are interdependent in the healthy individual. • Growth and development are based on timing and sequence of developmental tasks. • Developmental processes include sociocultural, biological, and psychological factors. • An organized, systematic approach ensures that a care plan will meet the needs of the client. 28 Development: Qualatative • A progessive and continuous process of change leading to increased skill and capacity to function • The result of complex interactions between biological and environmental influences • Qualitative in nature, difficult to measure • Has certain predicatable characteristics (simple to complex, general to specific, cephalocaudal) Developmental Age Periods • Prenatal – conception to birth • Infancy – birth to 12 to 18 months • Early Childhood – 1 to 6 years • Middle Childhood – 6 to 12 years • Adolescence – 12 to 19 years • Young to Middle Adulthood – 20 to 65 years • Older Persons or Late Adulthood – over 65 years Factors affecting Growth and Development -genetic, environmental and interacting factors! • Heredity • Temperament • Family • Peer group • Health environment • Nutrition • Rest, sleep, and exercise • Living environment 29 • Political and policy environment • Life experiences • Prenatal health • State of health Developmental Theories • Provide a framework for examining, describing, and appreciating human development. • All theories have value in understanding patient/client situations. • Nurses need to know when a theory applies and when it does not • Help nurses assess and treat a patient's response to illness. • Accurate assessment is necessary. • Thorough analysis and interpretation are needed for accurate conclusions. • Types of developmental theories: • Organicism • Psychoanalytic • Psychosocial • Mechanistic • Contextualism Organicism -has it’s theoretical focus on the organism itself -development is a result of biologically driven behaviour and the person’s adaptation to the environment -included in this tradition are the following theories of development: • • • -biological -cognitive -moral 30 Biophysical Developmental Theories • These theories describe and explain how our physical bodies grow and change. • The changes that occur as a newborn infant grows into adulthood can be quantified and compared against established norms. Cognitive Developmental theories • Part of the organicism tradition because development originates within the organism • Focus on reasoning and thinking processes • Mental processes affect certain types of emotional behaviour • Piaget!!!!!! • Kohlberg • Gilligan (will not focus on) Piaget’s Theory of Cognitive Development • Examines how people learn to think and make sense of their world • Four stages • Sensorimotor (birth to 2 years): infant touching and feeling things to learn! • Preoperational (2 to 7 years of age): symbols, mental images; play for expression and symbols! Parallel play: two kids next to each other play with the same toys, but not together. Pre-operational thinking: associated play, coordinated play: cause and effect type thinking • • Concrete operations (7 to 11 years of age): planning what they want to do in advance without doing it- pre planning! Grades 1-2 to 4-5. When you start guiding children’s behaviours, bringing in privileges • Formal operations (11 years to adulthood) : start thinking abstractly- can give them theoretical/ abstract questions! Pro’s and cons thinking. Major incorporation with decision making! Real decision making considering their care. Summarized nicely in Table 21-2 31 Piaget’s Theory of Moral Development • Moral development goes through a series of successive stages, just as cognition and learning do. • Three stages of development • Premoral stage: young children, only for personal benefit! • Conventional stage: when they begin to see moral decisions based on their internalization and surroundings: “I want mommy and daddy to think I’m a good boy. I don’t want Ms. Brandy to be mad at me.” -going to behave accordingly to environment • Autonomous stage: Understanding human rights and moral rules. Following rules/ laws but changing and pushing a little bit. Recognizing there are societal expectations, have a moral monologue on what’s right or wrong, but autonomous about it. Psychoanalytic and Psychosocial Theory • Describes development from personality, cognitive, and behavioural perspectives • Havighurst (focus on) • Erikson (focus on) • Sigmund Freud • John Bowlby • Patricia Crittenden Erik Erikson • Individuals need to accomplish one task before moving on to another. • Mastering one task before the next is necessary for success in life. • -Eight stages of life (Summarized well in Table 21-5_ • Stage 1: Trust versus mistrust (birth to 1 year) • Stage 2: Autonomy versus sense of shame and doubt (1 to 3 years) 32 • Stage 3: Initiative versus guilt (3 to 6 years) • Stage 4: Industry versus inferiority (6 to 11 years) • Stage 5: Identify versus role confusion (adolescence) • Stage 6: Intimacy versus isolation (young adulthood) • Stage 7: Generative versus self-absorption and stagnation (middle adulthood) • Stage 8: Integrity versus despair (old age) • Psychoanalytic and Psychosocial Theories • Robert Havighurst • Series of essential developmental tasks arising from predictable internal and external pressures • Tasks that you need to do/ accomplish before doing the next. 33 Conception through adolescence Conception • From the moment of conception, human development proceeds rapidly. • Intrauterine life • First trimester: most dangerous/ susceptible bc a lot of things are developing! • Second trimester: most of fetal organs developed; 24 weeks, if baby is born can survive 34 • Third trimester: gain weight! -Paternal factors can have impacts too! Transition from Intrauterine to Extrauterine Life • Physical changes: a lot of physical changes, cardio and resp. system to allow babies to adapt to extra uterine life! • Psychosocial changes: bonding! • Health risks: ABC’s, temp. regulation Shaken baby syndrome, SIDs Newborn: birth- 28 days • Physical changes: original weight loss, but should regain after 2 weeks, keep gaining; eyesight gets better, sleeps a lot; better coordinating, hands to mouth improves. Mostly reflex • Cognitive changes: • Psychosocial changes: • Health risks: infection! • Health concerns: • Screening: metabolic disorders. 48 hours. • Circumcision Infant 28 days- 12 months • Physical changes: by 5 months, doubles, a year triple • Cognitive changes • • Language Psychosocial changes • Separation- 9 months age, after object permanence • Play • Trust! 35 • • • Health risks • Sudden infant death syndrome (SIDS) • Accidental injury- primary cause of death ☹ • Child maltreatment Health concerns • Nutrition • Immunizations • Sleep These skills don’t really advance at the same rate! Toddler 12 months – 3 yrs • Physical changes • Cognitive changes • Language: 3-4 sentences towards end of toddler stage. Short and simple! 50 words. • Psychosocial changes • Recognize that they have some autonomy- start wanting to exert it • Where you start to give choice! 2 options type thing. Limited. • Recognizes themselves as human beings, but don’t understand from other points of views. • Health risks • • Injury Health concerns • Nutrition- tansiting to foods Preschooler 3- 5 • Physical changes: doing a lot more, running, jumping, coordination has improved a lot! Hold pens, drawing, more independence • Cognitive changes 36 • • Language: speaking over 2000 words! Speaking in full sentences, carry on conversations • Thinking and learning limited by attention span • Erikson’s unitive vs. guilt! • Let child take initiative- but support them when they fail • Guilt develops in child if you respond badly to failed initive Psychosocial changes • Play • Health risks • Injuries- mostly poisoning • Health concerns • Nutrition- picky eaters • Sleep- through night, in own beds • Vision- getting better, closer to 20 20 • School-Age Child • Physical changes • Cognitive changes • • Language development Psychosocial changes • Moral development • Peer relationships • Sexual identity 37