Health Disparities: Understanding and Addressing Inequalities in Health and Healthcare, Study Guides, Projects, Research of Nursing

Download Health Disparities: Understanding and Addressing Inequalities in Health and Healthcare and more Study Guides, Projects, Research Nursing in PDF only on Docsity! JM7/17 NR222: Exam 2 Study Guide (Units 3, 4, and 5) Health disparity A particular type of health difference that is closely linked with social, economic, and environmental disadvantage. Health disparity • The second goal, eliminating health disparities, addressed the continuing problems of access to care; differences in treatment based on race, gender, and ability to pay; and related issues such as urban versus rural health, insurance coverage, Medicare and Medicaid reimbursement for care, and satisfaction with service delivery. (Edelman text book Unit 1 Foundations for Health Promotion Ch. 1 Objectives for Promotion and Prevention pg. 6) • Health disparities is an umbrella term that includes disparities in health care. It was defined by Healthy People 2020 as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage, and “health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender, age, mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion (U.S. Department of Health and Human Services, 2011) • Addressing health literacy and providing culturally sensitive health education are critical to reducing health disparities and achieving health equity. Health disparities are systematic, potentially avoidable health differences that adversely affect socially disadvantaged groups. Groups affected are those with characteristics such as race/ethnicity, skin color, religion, language, or nationality; socioeconomic resources or position; gender, sexual orientation, or gender identity; age; physical, mental, or emotional disability or illness; geography; political or other affiliation; or other characteristics that have been linked historically to discrimination or marginalization [(Braverman et al., 2011) Edelman text book Ch. 10 Health Education pg. 217] • Health Disparities and Health Care: Health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases, and related complications. On the other hand, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. [Fundamentals Ch. 9 Cultural Awareness Pg. 102] JM7/17 • Poor access to health care is one social determinant of health that contributes to health disparities. Access to primary care is an important indicator of broader access to health care services. A patient who regularly visits a primary care provider is more likely to receive adequate preventive care than a patient who lacks such access. The 2013 National Healthcare Disparities Report (AHRQ, 2013a) revealed that African Americans, Asians, and Hispanics are less likely than non-Hispanic Whites to see a primary care provider regularly. • A similar disparity in access to care exists in other disadvantaged groups. Less care is available or accessible to people in low and middle- income groups compared with people in high-income groups. Uninsured people ages 0 to 64 are less likely to have a regular primary care provider than those with private or public insurance (AHRQ, 2013a). Research suggests that some subgroups of the LGBT community have more chronic health conditions & a higher prevalence & earlier onset of disabilities than heterosexuals • In addition to the poor access to health care, a large body of research shows that health care systems and health care providers can contribute significantly to the problem of health disparities. More than a decade ago, reports by the Institute of Medicine (IOM 2001, 2010) defined quality health care as care that is safe, effective, patient centered, timely, efficient, and equitable or without variation in outcomes as determined by stratified outcomes data. Although the U.S. health care system has improved in most of these areas since the IOM reports were published, the focus on the equity has lagged behind (Mutha et al., 2012). Inadequate resources, poor patient-provider communication, a lack of culturally competent care, fragmented delivery of care, and inadequate access to language services all compromise patient outcomes (NQF, 2012). As a result, many disparities in health care and health outcomes remain. • Disparities in access to care, quality of care, preventive health, health education, and available resources to enable self-management when patients are outside of the health care setting contribute to poor population health. Health disparities are also very costly. Recent analysis estimates that 30% of direct medical costs for Blacks, Hispanics, and Asian Americans are excess because of health inequities and that overall the economy loses an estimated $309 billion per year because of the direct and indirect costs of disparities Health equity The accomplishment of the highest level of health for all people. Health equity JM7/17 • African Americans – African-Americans have the highest mortality rate of any racial and ethnic group for all cancers combined, contributing in part to a lower life expectancy for both African-American men and women. Care of the body after death depends on the African- American's country of origin and degree of American acculturation. The presence of large extended family groups, including the church family, is common at time of death. The mourning period is relatively short, with a memorial service and a public viewing of the body or a wake before burial. Organ donation and autopsy are allowed. • Hispanics – Hispanic youths ages 2 to 19 are more likely to be overweight or obese than the non-Hispanic White or Black youths of the same age, which places them at a greater risk of developing a number of chronic diseases such as type 2 diabetes, high blood pressure, and asthma. Honoring family values and roles is essential in providing care and making decisions at the end of life. People in Hispanic and Mexican-American cultures often use special objects such as amulets or rosary beads, alternative healing practices (folk medicine), and prayer. Grief is expressed openly. Religious and spiritual rituals (predominantly Catholic) are essential at the end of life. Death is often believed to be the will of God • Asian Americans – Asian Americans generally have lower cancer rates than the non- Hispanic white population, but they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Whites, or non-Hispanic Blacks. • Jewish- If the family practices Orthodox Judaism, determine if members from the Jewish Burial Society are coming to the facility before preparing the body. A family member often stays with the body until burial. Usually the burial occurs within 24 hours but not on the Sabbath. Some but not all types of Judaism avoid cremation, autopsy, and embalming • Arab Americans - , Arab women frequently do not have breast examinations, mammograms, and cervical cancer screening because of religious and cultural beliefs about modesty. Define/give examples of culture, acculturation, cultural competency, values, ethnicity, transcultural nursing • Culture is associated with norms, values, and traditions passed down through generations. It also has been perceived to be the same as ethnicity, race, nationality, and language. A more contemporary view of culture acknowledges its many other facets such as gender, sexual orientation, location, class, and immigration status. • acculturation Process of adapting to and adopting a new culture • Cultural competency is defined by the National Institutes of Health (2015) as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Developing cultural competency allows systems, agencies, and groups of professionals to function effectively to understand the needs of groups accessing health information and health care and thus help eliminate health care disparities and ultimately health disparities. • Value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. Inevitably you will work with patients and JM7/17 colleagues whose values differ from yours. To negotiate differences of value, it is JM7/17 important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours. • ethnicity - Shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics • transcultural nursing - Distinct discipline developed by Leininger that focuses on the comparative study of cultures to understand similarities and differences among groups of people. Cultural knowledge, cultural skills, cultural encounters, cultural desire • cultural knowledge Obtaining knowledge of other cultures; gaining sensitivity to, respect for, and appreciation of differences. • cultural skills Communication, cultural assessment, and culturally competent care. • cultural encounters Engaging in cross-cultural interactions; refining intercultural 1311communication skills; gaining in-depth understanding of others and avoiding stereotypes; and managing cultural conflict. • Cultural desire: The motivation and commitment to caring that moves an individual to learn from others, accept the role as a learner, be open to and accepting of cultural differences, and build on cultural similarities. 1st step to achieve cultural competence • Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. • Cultural competency is defined by the National Institutes of Health (2015) as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Goals of health education The goal of health education is to help individuals, families, and communities achieve, through their own actions and initiative, optimal stages of health. Health education facilitates voluntary actions to promote health. Another important goal of health education is improving literacy. (Edelman Textbook Ch. 10 Health Education Goals pg. 217) Through health education, individuals can learn to make informed decisions about personal and family health practices and to use health services in the community. (Edelman Textbook Ch. 10 Health Education pg. 218) Patient education in Planning stage: After determining the nursing diagnoses that identify a patient’s learning needs, develop a teaching plan, determine goals and expected outcomes, and JM7/17 • What are the learner’s needs for health promotion, risk reduction, or health problems? • What does the person already know and what skills can the person already perform that are relevant to the health needs? • Is the learner motivated to change any unhealthy behaviors? • What are the barriers to and facilitators of health behavior change? Development of expected learning outcomes. (Determine the expected learning outcomes of a health education intervention) The nurse answers the following questions: • What broad public health and social goals guide the proposed educational program? • What are the participant’s learning goals? • What does the learned need to know, do, and believe to progress through the behavior change process? Program goals: The program goals of a health education project reflect the desire to facilitate improvement in some health problem or social living condition. Program goals are broad statements on long-range expected accomplishments that provide direction; they do not have to be stated in measurable terms (Miller & Stoeckel, 2011) Learning goals: Learning goals are best established when the student and the nurse work together. These goals reflect the health behavior or health status change that the person will have achieved by the end of an educational intervention. Learning goals relate to the program goals. Learning objectives: Learning objectives indicate the steps to be taken by the individual toward meeting the learning goal and may involve the development of knowledge, skill, or change in attitude. Objectives are most useful when stated in behavioral terms and when they contain these components: the learner and a precise action verb that indicates what the learner will be able to do; the conditions under which the task is performed; and the level of performance expected (Bastable & Doody, 2008). Learning objectives guide the selection of content and methods and help narrow the focus of a teaching plan to more achievable steps; they also aid in setting standards of performance and suggesting evaluation strategies. The Development of the Teaching Plan, Content To select appropriate content for a health education program. The nurse considers what information, skills, and attitudes need to be taught and the level of learning to be achieved. Content is divided into three domains: Cognitive, psychomotor, and affective. Cognitive learning refers to the development of new facts or concepts and building on or applying knowledge to new situations. Example: Patient Dan will correctly select food choices based on this diabetic meal plan (measurable). Psychomotor learning involves developing physical skills from simple to complex actions. Example: Patient Dan will demonstrate proper technique and dosage when giving an insulin injection to himself. (measurable) JM7/17 Affective learning alludes to the recognition of values, religious and spiritual beliefs, family interaction patterns and relationships, and personal attitudes that affect decisions and problem- solving progress. Example: Patient Dan will verbalize the importance of checking his blood glucose level before each meal and at bedtime. (measurable) To learn or change a health behavior, a person may need to acquire new information, practice some physical techniques, and clarify the ways in which the new behavior may affect relationships with others. The nurse’s role is to select a combination of content from the three domains that is appropriate to meet the behavioral objective. To find samples of content for a teaching plan, the nurse researches resource materials, such as books, teaching guides, journal articles, pamphlets, and flyers created by nonprofit agencies and professional organizations. The nurse is careful about giving students materials with technical vocabulary that is too complex for the audience. Implementing the teaching Table 10-2 (pg. 224 Edelman Ch. 10 Health Education) Domain of Learning: Cognitive (thinking). Teaching strategies – Lecture, One-to-one instruction, Discussion, Discovery, Audiovisual or printed materials, Computer-assisted instruction. Domain of Learning: Affective (feeling). Teaching strategies – Role modeling, Discussion, Role playing, Simulation gaming. Domain of Learning: Psychomotor (acting). Teaching strategies – Demonstration, Practice, Mental imaging. Evaluation of expected outcomes Examples of desired outcomes for the following learning domains: Cognitive (thinking) – Describes and/or explains information relevant to the behavior change. Affective (feeling) – Expresses positive feeling, attitudes, values toward changing the behavior. Psychomotor (acting) – Demonstrates performance of skills related to the behavior change. Evaluating the teaching – learning process. The teacher can evaluate the learning, or measure achievement of learning objectives, in all domains using written or oral testing, demonstrations, observation, self-reports, and self-monitoring. Teaching methods for one domain may overlap those for another domain. Teaching is directed toward one or more of three learning domains: Cognitive, psychomotor, and affective. Examples of appropriate teaching strategies for each domain and the expected JM7/17 outcomes in relation to behavior change are summarized in Table 10-2 page 224. (Edelman. Ch. 10 Health Edu. Pg. 224 & pg. 225) Assessing health literacy: What is it and when to assess regarding education Assessing health literacy: What is it and when to assess regarding education What is it? Health Literacy Definition by The World Organization (WHO, 2015) = The cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. Health literacy pertains not only to a patient’s ability to read and comprehend health-related information, but to having the skills to problem solve, articulate, and make appropriate health care decisions as well (Ingram. 2011). People most likely to be at risk minority populations, immigrant populations, people of low income, and people with chronic mental and/or physical health conditions. For example, approximately half of Medicare/Medicaid recipients read below the fifth-grade level (National Network of Libraries of Medicine, 2014). [Potter. Fundamentals Ch. 25 Patient Education Health Literacy pg. 344 & pg. 345] Functional illiteracy – The inability to read above a fifth-grade level (is a major problem in America today). Results from a 2015 survey by the U.S. Department of Education, National Institute of Literacy (U.S. Department of Education, 2015) found that 32 million American adults had below-basic levels of literacy. Older adults, men, people who did not speak English before entering school, people living below the poverty level, and people without a high school education tended to have lower health literacy scores. [Potter. Fundamentals Ch. 25 Patient Education Health Literacy pg. 344 & pg. 345] To compound the problem, the readability of printed health education material is often above the patient’s reading level, which can lead to misinterpretation and prevent patients from asking for help (Gargoum and O’keeffe. 2014; Protheroe et al., 2015). This discrepancy results in unsafe care. Health literacy is one of the most important predictors of health outcomes. Studies have shown that patients with low literacy levels are 1.5 to 3 times more likely to experience adverse health outcomes and an increased risk for hospitalization than those with higher literacy levels (Kasabwala et al., 2012). To ensure patient safety, all health care providers need to ensure that information is presented clearly and in a culturally sensitive manner (TJC, 2015a). Both the American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient education materials be written at the sixth-grade level or lower (Kasabwala et al. 2012). [Potter. Fundamentals Ch. 25 Patient Education Health Literacy pg. 344 & pg. 345] When to assess regarding Education? Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient’s health literacy before providing instruction. Assessing health literacy is challenging, especially in busy clinical settings where often there is little time to conduct a thorough health literacy assessment. However, all health care providers need to identify problems and provide appropriate education to people who have special health literacy needs (TJC, 2015a). Research shows that many Americans read and understand information that is 3 to JM7/17 • Responding: Requires active participation through listening and reacting verbally and nonverbally • Valuing: Attaching worth and value to the acquired knowledge as demonstrated by the learner's behavior • Organizing: Developing a value system by identifying and organizing values according to their worth • Characterizing: Acting and responding with a consistent value system; requires introspection and self-examination of one's own values in relation to an ethical issue or particular experience Psychomotor Learning Psychomotor learning involves acquiring motor skills that require coordination and the integration of mental and physical movements such as the ability to walk or use an eating utensil (McDonald, 2014). The simplest behavior in the hierarchy is perception, whereas the most complex is origination. Psychomotor learning includes the following: • Perception: Being aware of objects or qualities through the use of sensory stimulation • Set: Readiness to take a particular action; there are three sets: mental, physical, and emotional • Guided response: Early stages of learning a particular skill under the guidance of an instructor that involves imitation and practice of a demonstrated act • Mechanism: Higher level of behavior in which a person gains confidence and proficiency in performing a skill that is more complex or involves several more steps than a guided response • Complex overt response: Smoothly and accurately performing a motor skill that requires complex movement patterns • Adaptation: Motor skills are well developed and movements can be modified when unexpected problems occur • Origination: Using existing psychomotor skills to create new movement patterns and perform them as needed in response to a particular situation or problem Teaching methods for developmental capacity (i.e. how to teach a toddler vs adolescent) Box 25-3 Teaching Methods Based on Patient's Developmental Capacity Infant • Keep routines (e.g., feeding, bathing) consistent. • Hold infant firmly while smiling and speaking softly to convey sense of trust. • Have infant touch different textures (e.g., soft fabric, hard plastic). Toddler • Use play to teach procedure or activity (e.g., handling examination equipment, applying bandage to doll). JM7/17 • Offer picture books that describe story of children in hospital or clinic. • Use simple words such as cut instead of laceration to promote understanding. Preschooler • Use role play, imitation, and play to make learning fun. • Encourage questions and offer explanations. Use simple explanations and demonstrations. • Encourage children to learn together through pictures and short stories about how to perform hygiene. School-Age Child • Teach psychomotor skills needed to maintain health. (Complicated skills such as learning to use a syringe take considerable practice.) • Offer opportunities to discuss health problems and answer questions. Adolescent • Help adolescent learn about feelings and need for self-expression. • Use teaching as collaborative activity. • Allow adolescents to make decisions about health and health promotion (safety, sex education, substance abuse). • Use problem solving to help adolescents make choices. Young or Middle Adult • Encourage participation in teaching plan by setting mutual goals. • Encourage independent learning. • Offer information so adult understands effects of health problem. Older Adult • Teach when patient is alert and rested. • Involve adult in discussion or activity. • Focus on wellness and person's strength. • Use approaches that enhance patient's reception of stimuli when they have a sensory impairment (see Chapter 49 ). • Keep teaching sessions short. Learning environment Learning Environment (Potter. Fundamentals Ch. 25 page 342) Factors in the physical environment where teaching takes place make learning either a pleasant or a difficult experience (Bastable, 2014). The ideal setting helps a patient focus on the learning task. The number of people included in the teaching session; the need for privacy; the room temperature; and the lighting, noise, ventilation, and furniture in the room are important factors when choosing the setting. The ideal environment for learning is well lit and has good ventilation, appropriate furniture, and comfortable temperature. JM7/17 A darkened room interferes with a patient’s ability to watch your actions, especially when demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes a patient too uncomfortable to focus on the information being presented. It is also important to choose a quiet setting. A quiet setting offers privacy; infrequent interruptions are best. Provide privacy even in a busy hospital by closing cubicle curtains or taking the patient to a quiet spot. Family caregivers often need to share in discussions in the home. However, patients who are reluctant to discuss the nature of the illness when others are in the room benefit from receiving education in a room separate from household activities such as a bedroom. Teaching a group of patients requires a room that allows everyone to be seated comfortably and within hearing distance of the educator. Make sure that the size of the room does not overwhelm the group. Arranging the group to allow participants to observe one another further enhances learning. More effective communication occurs as learners observe others’ verbal and nonverbal interactions. Considerations for postponing teaching Considerations for postponing teaching (Potter. Fundamentals Ch. 25 page 341 and 342) Physical Capability. The ability to learn often depends on a patient’s level of physical development and overall physical health. To learn psychomotor skills a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. Any condition (e.g., pain or fatigue) that depletes a person’s energy also impairs the ability to learn. For example, a patient who spends a morning having rigorous diagnostic studies is unlikely to be able to learn later in the day because of fatigue. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. As you work with a patient, assess energy level by noting the patient’s willingness to communicate, the amount of activity initiated, and responses to questions. Temporarily stop teaching, if the patient needs rest. You achieve greater teaching success, when patients are physically able to actively participate in learning. Family health Family Health (Potter. Fundamentals Ch. 10 pg. 122 and 128) JM7/17 Noncompliance- what is it Noncompliant, a negative term that suggests that the individual has not followed their instructions. Naturally health professionals want people to choose the recommended course of action, but each individual has the right to choose not to follow advice. Enlisting the individual’s partnership or cooperation rather than compliance achieves better results Considerations for adult learners Teaching adults differs from teaching children. Adults are able to reflect on their current situation critically but sometimes need help to see their problems and change their perspectives. Because adults become independent and self-directed as they mature, they are often able to identify their own learning needs (Billings and Halstead, 2012). Learning needs come from problems or tasks that result from real-life situations. Although adults tend to be self-directed learners, they often become dependent in new learning situations. The amount of information you provide and the amount of time you spend with an adult patient varies, depending on the patient's personal situation and readiness to learn. An adult's readiness to learn is often associated with his or her developmental stage and other events that are occurring in his or her life. Resolve any needs or issues that a patient perceives as extremely important, so learning can occur. Adults have a wide variety of personal and life experiences. Therefore patient learning will be enhanced if they perceive the information to be relevant and are asked to use past experiences to solve real-life problems (Billings and Halstead, 2012). Furthermore, you make education patient centered by developing educational topics and goals in collaboration with the adult patient. Adult patients ultimately are responsible for changing their own behavior. Assessing what an adult patient currently knows, teaching what the patient wants to know, and setting mutual goals improve the outcomes of patient education (Bastable, 2014). Stages of grief Denial- The person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person cannot yet bear. Anger- The person expresses resistance or intense anger at God, other people, or the situation. Bargaining- The person cushions and postpones awareness of the loss by trying to prevent it from happening. Depression-The person realizes the full impact of the loss. Acceptance-The person incorporates the loss into life. Family life cycle stages Understanding family developmental stages and attributes enables you to provide nursing care to a patient, the family as a whole, and individuals within the family structure. TABLE 10-1 Stages of the Family Life Cycle Family Life-Cycle Stage al Process of Transition: Key Principles, ly Status Required Unattached young adult “Accepling parent-ollspring sepasation ion to family of origin Developing intimate peer relationships Establishing self in work Joining of families through martiage: newly mattied couple ‘Committing to new system Forming macital system Realigaing rel ianships with extended fami sand friends to include spouse Family with young children Family with adolescents “Accepting new generation of members into system Increasing flexibility of family boundaries to include ren’s independence ‘Adjusting marital system to make space for children ‘Taking on parental roles Family with young adults Launching children and moving on. rom and entries into fa ult relationships between grown children and their parents 1g telationships to include in-laws and grandchileleen Dealing with dis ies and death of parents (grandparents) Family without children amily in tater life From Duvall EM, lr BC: Marriage and family development, ed 6, Boston, 2005, A “Maintaining flexibility Acceping shilling, of generational roles & Bacon, Printed and electroni Refocusing on career issues and new ocr opportunities Refocusing on partner and marriage issues cational activities Maintaining own or couple functioning and interests in Une face of physiological dectine; exploring new familial and social role options system for wisdom and experience of o ing for them older generations without Dealing with retirement Dealing with loss of spouse, siblings, and other peess and preparation for own death; life review, in which one jences and de expe ms ly reproduces by permission af Pearson Education, Upper Saddle River, NJ JM7/17 What is happening with the population of homeless families? Homelessness- is a complex social and economic problem that continues to persist and grow. • Homelessness could be defined as a lack of fixed, regular, and adequate nighttime residence resulting from extreme poverty and/or unsafe or unstable living environments. • Estimated that 42% of the homeless population are African American, 39% are White, 13% are Hispanic, 4% are Native American, and 2% are Asian (National Coalition for the Homeless, 2009 ). Homeless Persons • Characteristics – Transience of instability of place – Instability or absence of connections to family – Instability or absence of housing – More homeless families, adolescents, and veterans • Causes of homelessness – Families and Persons Become Homeless due to both structural and personal factors alone or in combination lead to lack of resources to secure and/or maintain housing. – Changing housing markets – Lack of employment opportunities for undereducated – Inadequate support for persons with mental illness – Poverty – Substance abuse • Health concerns and care issues – Basic survival issues – Respiratory and infectious diseases – Dental and vision problems – Mental health concerns (substance/drug abuse) • Barriers to care – Access – Affordability – Lack of transportation – Poverty Values clarification- steps, definitions and application Values clarification is a method for discovering one’s values and the importance of these values (Raths et al., 1978). Values clarification does not tell a person how to act, but it helps people recognize what values they hold and evaluate how those values influence their actions. ● Essential to the interactional process JM7/17 conveys specific meaning through a combination of words. The most important aspects of verbal JM7/17 communication are presented in the following paragraphs. Metacommunication- Metacommunication is a broad term that refers to all factors that influence communication. Awareness of influencing factors helps people better understand what is communicated. For example, a nurse observes a young patient holding his body rigidly, and his voice is sharp as he says, “Going to surgery is no big deal.” The nurse replies, “You say having surgery doesn't bother you, but you look and sound tense. I'd like to hear more about how you're feeling.” Awareness of the tone of the verbal response and the nonverbal behavior results in further exploration of the patient's feelings and concerns. Non-Verbal Communication- Nonverbal Communication includes the five senses and everything that does not involve the spoken or written word. Nonverbal aspects of communication such as voice tone, eye contact, and body positioning are often as important as verbal messages. Thus nonverbal communication is unconsciously motivated and more accurately indicates a person's intended meaning than spoken words. When there is incongruity between verbal and nonverbal communication, the receiver usually “hears” the nonverbal message as the true message. All kinds of nonverbal communication are important, but interpreting them is often problematic. Sociocultural background is a major influence on the meaning of nonverbal behavior. In the United States, with its diverse cultural communities, nonverbal messages between people of different cultures are easily misinterpreted. Because the meaning attached to nonverbal behavior is so subjective, it is imperative that you verify it. Assessing nonverbal messages is an important nursing skill. Clarifying Clarifying- To check whether you understand a message accurately, restate an unclear or ambiguous message to clarify the sender's meaning. In addition, ask the other person to rephrase it, explain further, or give an example of what the person means. Without clarification you may make invalid assumptions and miss valuable information. Despite efforts at paraphrasing, sometimes you do not understand a patient's message. Let the patient know if this is the case: “I'm not sure I understand what you mean by ‘sicker than usual.’ What is different now?” Factors in effective communication: Listening, reciprocity, silence, humor, touch, space Effective Communication: Listening- Active listening means being attentive to what a patient is saying both verbally and nonverbally. It facilitates patient communication. Inexperienced nurses sometimes feel the need to talk to prove that they know what they are doing or to decrease anxiety. It is often difficult at first to be quiet and really listen. Active listening enhances trust because you communicate acceptance and respect for a patient. Several nonverbal skills facilitate attentive listening, using the acronym SOLER : S—Sit facing the patient. This posture conveys the message that you are there to listen and are interested in what the patient is saying. O—Open position (i.e., keep arms and legs uncrossed). This position suggests that you are “open” to what the patient says. A “closed” position such as crossing arms conveys a defensive attitude, possibly provoking a similar response in the patient. L—Lean toward the patient. This position conveys that you are involved and interested in the interaction. JM7/17 E—Eye contact—Establish and maintain intermittent eye contact to convey your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying. R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates a lack of interest and a feeling of discomfort to the patient. Silence- It takes time and experience to become comfortable with silence. Most people have a natural tendency to fill empty spaces with words, but sometimes these spaces really allow time for a nurse and patient to observe one another, sort out feelings, think about how to say things, and consider what has been communicated. Silence prompts some people to talk. It allows a patient to think and gain insight.In general, allow a patient to break the silence, particularly when he or she has initiated it. Silence is particularly useful when people are confronted with decisions that require much thought. For example, it helps a patient gain the necessary confidence to share the decision to refuse medical treatment. It also allows the nurse to pay particular attention to nonverbal messages such as worried expressions or loss of eye contact. Remaining silent demonstrates patience and a willingness to wait for a response when the other person is unable to reply quickly. Silence is especially therapeutic during times of profound sadness or grief. Touch- Touch is one of the most potent and personal forms of communication. It expresses concern or caring to establish a feeling of connection and promote healing. Touch conveys many messages such as affection, emotional support, encouragement, tenderness, and personal attention. Comfort touch such as holding a hand is especially important for vulnerable patients who are experiencing severe illness with its accompanying physical and emotional losses. Students initially may find giving intimate care to be stressful, especially when caring for patients of the opposite gender. They learn to cope with intimate contact by changing their perception of the situation. Since much of what nurses do involves touching, you need to learn to be sensitive to others' reactions to touch and use it wisely. It should be as gentle or as firm as needed and delivered in a comforting, nonthreatening manner. Sometimes you withhold touch for highly suspicious or angry persons who respond negatively or even violently to you. Humor- Humor is an important but often underused resource in nursing interactions. It is a coping strategy that can reduce anxiety and promote positive feelings. It is a perception and attitude in which a person can experience joy even when facing difficult times. It provides emotional support to patients and professional colleagues and humanizes the illness experience. It enhances teamwork, relieves tension, and helps nurses develop a bond between people who laugh together. Patients use humor to release tension, cope with fear related to pain and suffering, communicate a fear or need, or cope with an uncomfortable or embarrassing situation. The goals of using humor as a health care provider are to bring hope and joy to a situation and enhance a patient's well-being and the therapeutic relationship. It makes you seem more warm and approachable. Use humor during the orientation phase to establish a therapeutic relationship and during the working phase as you help a patient cope with a situation. Zones of Space (proxemics) Territory and Personal Space- Territoriality is the need to gain, maintain, and defend one's right to space. Territory is important because it provides people with a sense of privacy, identity,