Not only do these diagnostic tests affect adults, but body measurements can also provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process. Explore how you could effectively gather information and encourage parents and caregivers to be proactive about their health and weight.

For this Assignment, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values. 

Adult Assessment Tools or Diagnostic Tests.

The assigned Assessment Tool/Diagnostic Test is Colonoscopy

THE QUESTION:

• Description how the assessment tool or diagnostic test you were assigned is used in healthcare.
  • What is the purpose of Colonoscopy?
  • How is Covid Colonoscopy conducted?
  • What information does it gather?
• Based on your research, evaluate the test or the tool’s validity and reliability, and explain any      issues with sensitivity, reliability, and predictive values. Include references in appropriate APA formatting.

When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.

Not only do these diagnostic tests affect adults, but body measurements can also provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process. Explore how you could effectively gather information and encourage parents and caregivers to be proactive about their health and weight.

For this Assignment, you will consider the validity and reliability of different assessment tools and diagnostic tests. You will explore issues such as sensitivity, specificity, and positive and negative predictive values. 

Adult Assessment Tools or Diagnostic Tests.

The assigned Assessment Tool/Diagnostic Test is Colonoscopy

THE QUESTION:

• Description how the assessment tool or diagnostic test you were assigned is used in healthcare.
  • What is the purpose of Colonoscopy?
  • How is Covid Colonoscopy conducted?
  • What information does it gather?
• Based on your research, evaluate the test or the tool’s validity and reliability, and explain any      issues with sensitivity, reliability, and predictive values. Include references in appropriate APA formatting.

2

PLEASE USE THIS PICOT, OBJECTVE, AND STATEMENT BELOW TO CPMPLETE THE ATTACHED TEMPLATE

Question 1: PICOT

P= The research will use secondary research conducted within the last 10 years.

I= A systematic research review method will be applied to provide a review of the existing research regarding the topic.

C= Comparison between the mortality rates between active smokers and non-smokers who quit smoking before age 4

O= Determine impacts of smoking on mortality rates of individuals.

T= The time needed for the research is one and half months to complete an adequate review of existing research.

Question 2: Objective

Determine the risks of smoking and advantages of ceasing the habit.

Statement

Due to the persistence of the smoking behaviors within the contemporary society, there is an increase in awareness regarding the hazardousness of the behavior. The research aims at increasing advocacy against by incorporating various research results regarding adverse health impacts of smoking to provide a more generalizable result for reducing smoking behaviors, especially among the young populations.

Directions

1. Introduction: Provide an overview of what will be covered in the assignment. Introduction should include general statements on scope of practice, competencies, and leadership, and identification of the purpose of the assignment. 
2. APN Scope of Practice: Research the Nurse Practice Act and APN scope of practice guidelines for the state in which you intend to practice after graduation. (Example: Students who intend to practice in California must research the California Nurse Practice Act and relevant Board of Registered Nursing regulations, such as obtaining a DEA number, and prescriptive requirements).  Describe the educational, licensure, and regulatory requirements for that state in your own words. Identify whether your state allows full, limited, or restricted NP practice. Discuss NP prescriptive authority in your state. Provide support from at least one scholarly source. Source may be the regulatory body that governs nursing practice in your state. (Students who intend to practice in California, include the use of written standard procedures that guide nurse practitioner practice in the state and physician supervision ratios).
3. Nurse Practitioner (NONPF) Core Competencies: Review the NONPF Core Competencies. Describe two competency areas you believe to be personal strengths and two competency areas in which you have opportunities for growth. Discuss two scholarly activities you could do during the master’s program to help yourself achieve NP competencies. Provide support from at least one scholarly source. Source may be NONPF Core Competencies document provided via the link in the week 2 readings. 
4. Leadership Skills: Analyze three leadership skills required to lead as an NP within complex systems. Describe two strategies you could use to help you develop NP leadership skills. Provide support from at least one scholarly source. Textbooks are not considered scholarly sources. 
5. Conclusion: Provide a conclusion, including a of what you discussed in the assignment. 

Creating Your Professional Identity

Competency

• Determine the attributes that help form the professional nurses’ identity.
• Apply principles of professional identity and professionalism.

Scenario

As a nursing student, you have a vision of your core values and expectations as a professional nurse. In this assignment, create a plan to guide you as you form your professional identity.

Instructions

This formation will include the following:

• Describe the meaning of nursing professionalism identity
• Identify the most important professional identity characteristics/attributes
• Explain how you will adapt these characteristics/attributes in the clinical setting
• Reflect on your educational journey and describe how this shaped your professional identity.
• Create your goals for continued professional identity formation during your career as a nurse.
• Provide stated ideas with professional language and attribution for credible sources with correct APA citation, spelling, and grammar.

Week 5: Endocrine Case Study

The purpose of this assignment is to apply the principles of pharmacology to support evidence-based prescribing practices for the management of common diseases of the endocrine system. This assignment allows students to use clinical practice guidelines to guide treatment decisions for common patient scenarios in the clinical setting.  

Course Outcomes 

This assignment enables the student to meet the following course outcomes: 

· CO 1: Identify the most commonly prescribed agents in the major drug classes. (POs 1, 2) 

· CO 2:  Make appropriate evidence-based therapeutic treatment decisions for individual patients utilizing drugs from the major drug classes.(POs 1, 2) 

· CO 3: Apply knowledge of pharmacokinetics, pharmacodynamics and pharmacogenomics in prescribing patient treatment. (POs 1, 2) 

· CO 4: Distinguish internal and external environment factors affecting drug action, reaction, efficacy, and interaction. (POs 1, 2) 

· CO 5: Identify client indicators of therapeutic, ineffective, adverse responses and side effects to drug therapy. (POs 1, 2) 

Due Date 

· The Late Assignment Policy applies to this assignment.  

· The assignment title is due by Sunday 11:59 p.m. MT of Week 5.  

Total Points Possible 110  

Preparing the Assignment

· Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions. 

· There are three patient cases presented in this assignment.  You are to use the following to answer the questions.

· When you click on the resource links, the links will open in a new window so you will be able to navigate between the resources and the quiz.  

· American Diabetes Association. (2020). Figure 9.1 [Graph]. Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers. https://clinical.diabetesjournals.org/content/38/1/10 (Links to an external site.)  (Links to an external site.)  

· Rosenthal, L., Burchum, J. (2021). Lehne’s pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.

You will be presented with a patient case and then a series of questions. This assignment is completed in a quiz format; however, it is not an exam and you are encouraged to use your textbook and course materials. There are 12 questions worth 9 points each and an attestation question worth 2 points for a total of 110 points.  

· Review the case information and then answer each required question with a succinct, informative answer.

· Answers should be one to five sentences in length.

· Some questions may require a short one-sentence answer, whereas others require a five-sentence answer for a complete explanation.

· Consider the most common and obvious answer.

· A scholarly reference is required for answers where a source such as textbook or clinical practice guideline is used to develop your response.

· Feedback is provided immediately after completing this assignment only.  The feedback provided is general and non-specific to protect the integrity of this assignment due to the unfortunate nature of answer sharing among many students. 

Lockdown browser is not required and there are no keyed correct answers to review. Course faculty will post assignment feedback for your review in the gradebook when grading is complete. There is no time limit for this assignment. It needs to be completed in one sitting and should be completed at the time it is begun as your answers may not be saved to return to it later. 

When you are ready to begin this assignment, click the “Take the Quiz” button near the bottom of this page.

Take the Quiz

RESEARCH ARTICLE

Critical care nurses’ communication

experiences with patients and families in an

intensive care unit: A qualitative study

Hye Jin Yoo 1 , Oak Bun Lim

1 , Jae Lan ShimID

2*

1 Department of Nursing, Asan Medical Center, Seoul, South Korea, 2 College of Medicine, Department of

Nursing, Dongguk University, Gyeongju, South Korea

* [email protected]

Abstract

This study evaluated the communication experiences of critical care nurses while caring for

patients in an intensive care unit setting. We have collected qualitative data from 16 critical

care nurses working in the intensive care unit of a tertiary hospital in Seoul, Korea, through

two focus-group discussions and four in-depth individual interviews. All interviews were

recorded and transcribed verbatim, and data were analyzed using the Colaizzi’s method.

Three themes of nurses’ communication experiences were identified: facing unexpected

communication difficulties, learning through trial and error, and recognizing communication

experiences as being essential for care. Nurses recognized that communication is essential

for quality care. Our findings indicate that critical care nurses should continuously aim to

improve their existing skills regarding communication with patients and their care givers and

acquire new communication skills to aid patient care.

Introduction

Critical care nurses working in intensive care units (ICUs) care for critically-ill patients, and

their work scope can include communicating with patients’ loved ones and care givers [1]. In

such settings, nurses must make timely judgments based on their expertise, and this requires a

high level of communication competency to comprehensively evaluate the needs of patients

and their families [2,3]. The objective of nurses’ communication is to optimize the care pro-

vided to patients [4]. Therapeutic communication, a fundamental component of nursing,

involves the use of specific strategies to encourage patients to express feelings and ideas and to

convey acceptance and respect. In building an effective therapeutic relationship, a focus on the

patient and a genuine display of empathy is required [5]. Empathy is the ability to understand

and share another person’s emotions. To convey empathy towards a patient, one must accu-

rately perceive the patient’s situation, communicate that perception to the patient, and act on

the perception to help the patient [6]. Effective communication based on empathy not only

contributes greatly to the patient’s recovery [3,5–7], but also has a positive effect of improving

job satisfaction by nursing with confidence [8] In contrast, inefficient communication leads to

PLOS ONE

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OPEN ACCESS

Citation: Yoo HJ, Lim OB, Shim JL (2020) Critical

care nurses’ communication experiences with

patients and families in an intensive care unit: A

qualitative study. PLoS ONE 15(7): e0235694.

https://doi.org/10.1371/journal.pone.0235694

Editor: Liza Heslop, Victoria University,

AUSTRALIA

Received: January 21, 2020

Accepted: June 21, 2020

Published: July 9, 2020

Copyright: © 2020 Yoo et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript.

Funding: This work was supported by the Dongguk

University Nursing Academy-Industry Cooperation

Research Fund of 2018.The funder had no role in

study design, data collectionand analysis, decision

to publish, or preparation of the manuscript

Competing interests: The authors have declared

that no competing interests exist.http://orcid.org/0000-0002-7795-0149https://doi.org/10.1371/journal.pone.0235694http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09https://doi.org/10.1371/journal.pone.0235694http://creativecommons.org/licenses/by/4.0/

complaints and anxiety in patients and can also lead to other negative outcomes, such as

extended hospital stays, increased mortality, burnout, job stress, and turnover [9,10].

Therefore, communication experiences need investigation since effective communication is

an essential for critical care nurses. Nurses use curative communication skills to provide new

information, encourage understanding of patient’s responses to health troubles, explore

choices for care, help in decision making, and facilitate patient wellbeing [11]. Particularly,

patient- and family-centered communication contributes to promoting patient safety and

improving the quality of care [12,13]. However, communication skills are relatively poorly

developed among critical care nurses compared to nurses in wards and younger and less expe-

rienced nurses than in their older and more experienced counterparts [3,7,14–16]. This calls

for an examination of the overall communication experiences of critical care nurses.

To date, most studies on the communication of critical care nurses have been quantitative

and have evaluated work performance, association with burnout, and factors that hinder com-

munication [2–4,7]. A qualitative study has examined communications with families of ICU

patients in Korea [17], while an international study has identified factors that promote or hin-

der communication between nurses and families of ICU patients [16,18]; however, few studies

have been conducted on participant-oriented communication (including patients and fami-

lies). Nurses’ communication with patients and their families in a clinical setting is complex

and cannot be understood solely on the basis of questionnaire surveys; therefore, these com-

munication experiences must be studied in depth.

This study explored critical care nurses’ communication experiences with patients and their

families using an in-depth qualitative research methodology. This study will help to enhance

communication skills of critical care nurses, thereby improving the quality of care in an ICU

setting.

Materials and methods

Design

This study employed a qualitative descriptive design using focus-group interviews (FGIs) and

in-depth individual interviews and was performed according to the consolidated criteria for

reporting qualitative research (COREQ) checklist [19]. An FGI is a research methodology in

which individuals engage in an intensive and in-depth discussion of a specific topic to explore

their experiences and identify common themes based on the interactions among group mem-

bers [20]. Individual in-depth interviews were also conducted to complement the content

identified in FGIs and further explore the deeper information developed based on experiences

at the individual level.

Participants

Sixteen critical care trained nurses providing direct care to patients in an ICU of a tertiary hos-

pital in Seoul were included in this study. The purpose of this study and the contents of the

questionnaire were explained to them, and they voluntarily agreed to participate and complete

the questionnaire. The exclusion criteria were as follows: 1) nurses with a hearing problem; 2)

nurses with less than 1 year of clinical experience; and 3) nurses diagnosed with psychiatric

disorders.

Snowball sampling—in which participants recruit other participants who can vividly share

their experiences regarding the topic under investigation—was used. Six participants for the

first FGI, six for the second FGI, and four for the individual in-depth interviews were

recruited. All participants were women (mean age = 29.0 years old; mean nursing experi-

ence = 4.5 years). Their characteristics are listed in Table 1.

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Data collection

Developing interview questions. The interview questions were structured according to

the guidelines developed for the focus-group methodology [21]: 1) introductory questions, 2)

transitional questions, 3) key questions, and 4) ending questions. The questions were reviewed

by a nursing professor with extensive experience in qualitative research and three critical care

nurses with more than 10 years of ICU experience (Table 2). These questions were also used

for individual face-to-face in-depth interviews.

Conducting FGIs and individual interviews. The two FGIs and four individual inter-

views were conducted between July 20, 2019 and September 30, 2019. The FGIs were moder-

ated by the principal female investigator and were conducted in a quiet conference room

where participants were gathered around a table to encourage them to talk freely. The FGIs

were audio-recorded with the participants’ consent, and the recordings were transcribed and

analyzed immediately after. Similar content was observed from the two rounds of FGIs, and

we continued the discussion until no new topics emerged.

To complement the FGIs and verify the results of the analysis, we also conducted individual

interviews of four participants. One assistant helped in facilitating the interviews and took

notes. The duration of each interview was about 60–90 minutes.

Ethical considerations and investigator training and preparation. This study was

approved by the institutional review board of the Asan Medical Center (approval no. 2019–

0859). Prior to data collection, participants provided written informed consent and were

informed in advance that the interviews would be audio-recorded, their participation would

remain confidential, the recordings and transcripts would only be used for research purposes,

the data would be securely stored under a double lock and would be accessed by the investiga-

tors only, and personal information would be deleted upon the completion of the study to

eliminate any possibility of a privacy breach. The collected data were coded and stored to be

accessed by the investigators only to prevent leakage of any personal information.

The authors of this study are nurses with more than 10 years of ICU experience and a deep

understanding of critical care. The principal investigator took a qualitative research course in

Table 1. Participant characteristics.

No. Sex Age (years old) Intensive care unit experience (months) Marital status Highest Educational Level

1 F 28 30 Single University

2 F 27 30 Single University

3 F 27 29 Single University

4 F 29 27 Single University

5 F 27 24 Single University

6 F 26 24 Single University

7 F 26 22 Single University

8 F 26 22 Single University

9 F 26 22 Single University

10 F 26 20 Single University

11 F 27 20 Single University

12 F 26 20 Single University

13 F 29 40 Single University

14 F 37 168 Married Master’s

15 F 38 180 Married Master’s

16 F 39 188 Married Master’s

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graduate school and has conducted multiple qualitative studies to enhance her qualitative

research experience.

Data analysis

We utilized Colaizzi’s [22] method of phenomenological analysis to understand and describe

the fundamentals and meaning of nurses’ communication experiences with patients and fami-

lies. Data analysis was conducted in seven steps: 1) Recording and transcription of the in-

depth interviews (all authors read the transcripts repeatedly to better understand the partici-

pants’ meaning); 2) Collection of meaningful statements from phrases and sentences contain-

ing phenomena relating to the communication experiences in the ICU. We extracted

statements overlapping with statements of similar meaning—taking representative ones of

similar statements—and omitted the rest; 3) Searching for other interpretations of participant

statements using various contexts; 4) Extraction of themes from relevant meanings and devel-

opment of a coding tree, with the meanings organized into themes; 5) Organization of similar

topics into a more general and abstract collection of themes; 6) Validation of the collection of

themes by cross-checking and comparing with the original data; 7) After integrating the ana-

lyzed content into one technique, the overall structure of the findings was described.

During data analysis, we received advice on the use of language or result of analyzing from

a nursing professor with extensive experience in qualitative research and had the data verified

by three participants to establish the universality and validity of the identified themes.

Establishing precision

The credibility, fittingness, auditability, and confirmability of the study were evaluated to ana-

lyze our findings [23]. To increase credibility, we conducted the interviews in a quiet place to

Table 2. List of interview questions.

Question

Type

Questions

Introductory What kind of care do you provide to your patients and their families as an ICU nurse?

Transitional As an ICU nurse, how is your communication with your family now?

Key What is your primary focus when communicating with patients and their families?

Do you have memorable experiences in your communication with your patients’ families?

a) If so, what were these experiences?

b) How do you feel about those experiences?

Do you have your own strengths in communicating with patients and their families?

a) If so, what are their advantages?

b) What role do your strengths play in communication?

c) What is the impact of communication on nursing?

Have you ever faced difficulties in communicating with patients’ families?

a) If so, please specify them.

b) What is the impact of these communication difficulties on your patients and their families?

c) How do these communication difficulties affect nursing?

Have you made any personal effort to communicate effectively with patients and their families?

a) If so, what have you done specifically?

b) How does the effort/s you have made affect your communication with patients and their

families?

Do you need hospital or external help to improve communication with your patients and their

families?

a) If so, what specific help do you need?

b) How do you feel about the changes in communication style with patients and families when

support and help are provided?

What does communication with the patients and their families mean to the nurse?

Ending Is there anything you would like to add?

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focus on participants’ statements and help participants feel comfortable during interviews; to

establish the universality and validity of the identified themes, data verification was performed

by three participants. To ensure uniformity in data, participants who could provide detailed

accounts of their experiences were selected, and the data were collected and analyzed until sat-

uration was achieved (i.e., no new content emerged). To ensure auditability, the raw data for

the identified themes were presented in the results, such that the readers could understand the

decision-making process. To ensure confirmability, our preconceptions or biases regarding

the participants’ statements were consistently reviewed to minimize the impact of bias and

maintain neutrality.

Results

After analyzing the communication experiences of 16 critical care nurses, three major themes

emerged: facing unexpected communication difficulties, learning through trial and error, and

recognizing communication experiences as being essential for care. The results are summa-

rized in Table 3.

The results of this study are schematized based on Travelbee’s Human-to-Human Relation-

ship Model [24,25] (Fig 1), which suggests that human-to-human interaction is at a develop-

mental stage. In this study, communication between patients and their families and

experienced nurses in ICUs promotes human-to-human connections, leading to a genuine

caring relationship through interaction, empathy, listening, sharing, and respect, which are all

therapeutic communication skills.

Theme 1: Facing unexpected communication difficulties

Nurses experienced more difficulties in communicating with patients and their families and

caregivers than in performing essential nursing activities (e.g., medication administration, suc-

tion, and various mechanical operations) The communication difficulties they experienced

were either nurse-, patient- and family-, or system-related. Distinct problems in an ICU are

related to urgency; for example, hemodynamically unstable patients or patients with respira-

tory failure or those suffering from a cardiac arrest may be prioritized.

Nurse-related factor: True intentions were not conveyed as wished. Although nurses

intend to treat patients and their families with empathy, they frequently lead one-way conver-

sations when pressed for time in the ICU. In addition, their usual way of talking, such as their

dialect and intonation, can sometimes be misunderstood and cause offense. Participants expe-

rienced difficulties communicating their sincerity to patients and their families.

“Oftentimes, I only say what I have to say instead of what the caregivers really want to know

when I’m pressed for time to convey my thoughts and go on to the next patient to explain

things to the other patient.” (Participant 2)

“I usually speak loudly, and I speak in dialect; so, things I say are not delivered gently. . .I

try to be careful because my dialect can seem more aggressive than the Seoul dialect; but it’s

not easy to fix what I have used for all my life at once.” (Participant 3)

Nurse-related factor: Hesitant to provide physical comfort. Participants were not famil-

iar with using non-verbal communication. The participants realized the importance of both

verbal communication and physical contact in providing care, but the application of both

these communication styles was not easy in clinical practice.

“I want to console the caregivers of patients who pass away; but I just can’t because I get

shy. I feel like I’m overstepping, and when I’m contemplating whether I can really speak to

their emotions, the caregiver has already left the ICU in many cases.” (Participant 6)

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Table 3. Critical care nurses’ communication experience with patients and their families.

Sub-category Category Theme

Theme 1: Facing unexpected communication

difficulties

In critical care, communication with patients and their

family is burdensome

1.1. True intentions not conveyed as wished Nurse-related

Misunderstanding because of the linguistic characteristics

of a nurse (e.g., dialect, voice tone, etc.)

Impatience/lack of care for patients and caregivers

ICU nurses need both verbal and nonverbal

communication skills

1.2. Hesitant to provide physical comfort

Nonverbal communication is unfamiliar

Not sure how to effectively provide nonverbal

communication

Patient in ventilator feels frustrated because he or she

cannot speak

1.3. Mechanical ventilation hindering communication

with the patient

Patient- and family-related

Difficulty understanding because the patient is on a

ventilator and thus cannot speak

Ventilator interferes with the communication between

nurse and patient

ICU patient’s caregiver is sensitive 1.4. Caregivers’ negative responses to nurses

Normal communication is impossible owing to caregivers’

aggressive attitude

As an ICU nurse, I have no choice but to respond to the

conversation

I have not learned properly about communication in the

clinic

1.5. Lack of experience and a mismatch between

theory and practice

System-related

Communication is the most difficult task for less

experienced, young nurses

The scheduled visit time in the intensive care unit is when

most communication occurs

1.6. Intense visiting hours in limited time

One-way conversation with the caregiver in a short period

Life-dependent care is a priority in the intensive care unit 1.7. Urgent workplace that deprioritizes

communication

Insufficient time to talk with patients and caregivers owing

to heavy workload

Nurses are hurt by distrustful patients and caregivers 2.1. Fundamental doubts about the nursing profession Theme 2: Learning through trial and error

Difficulty in nursing because of trauma from patients and

caregivers

Follow senior nurses and learn practical communication 2.2. Finding out which communication style is better

suited for patients and their families

Explains the patient’s daily life in detail

Communication is indispensable to nursing 2.3. Knowhow learned through persistent effort

Studying the lack of communication by searching books

and videos

Understand the anxiety and difficulties experienced by the

critically ill and their caregivers

3.1. Empathy garnered through various clinical

experiences

Theme 3: Recognizing communication

experiences as being essential for care

Nurse’s words have the power to make the patients and

their families cry or laugh

Listening as an intensive care nurse is more important than

talking

3.2. The power of active listening

Nurse empathy strengthens patients and caregivers and

enhances their feelings of control

Patients and caregivers are easy to reach 3.3. Mediator between physicians, patients, and

caregivers

(Continued)

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“I’m really bad at physical contact even with my close friends; but I’m even worse when it

comes to patients and caregivers. Because of my tendency, there are times when I hesitate to

touch patients while providing care.” (Participant 7)

Patient- and family-related factor: Mechanical ventilation hindering communication

with the patient. Mechanical ventilators were the greatest obstruction to communication in

ICU. Although it is normal for patients on a mechanical ventilator to lose the ability to speak,

patients and their families did not understand how mechanical ventilators work and were frus-

trated that they could not communicate freely with the patient. Participants expressed diffi-

culty in communicating with patients in ways other than verbal communication as well.

“Patients who are on mechanical ventilation can’t talk as they want and do not have enough

strength in their hands to write correctly; so, even if I try to listen to them, I just can’t

Table 3. (Continued )

Sub-category Category Theme

Nurses use words that are easy to understand

Nurses convey sincerity to others with respect and

understanding

3.4. Expressing warmth and respect

Nurses’ heartfelt expressions promote trust

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Fig 1. Summary of communication experiences encountered by intensive care unit nurses.

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understand what they are saying. You know in that game where people wear headphones play-

ing loud music and try to communicate with one another—words completely deviant from the

original word are conveyed. It just feels like that.” (Participant 9)

“Patients on mechanical ventilation and who thus cannot communicate are the most diffi-

cult. The patient keeps talking; so, it hinders respiration—the ventilator alarm keeps going off,

the stomach becomes gassy, and the patient has to take the tube off and vomit later. No matter

how much I explain, there are patients or caregivers who tell me that the tube in the throat is

making [it] hard [for them] to breathe or [they] ask me to take it off just once and put it back

on, and these patients are really difficult. There is no way to communicate if they cannot accept

mechanical ventilators even if I explain.” (Participant 8)

Patient- and family-related factor: Caregivers’ negative responses to nurses. It was also

burdensome for nurses to communicate with extremely stressed caregivers and loved ones,

especially when patients were in a critical state. Despite the role of nurses in helping patients

during health recovery, caregivers’ negative responses to nurses, such as blaming them and

speaking and behaving aggressively, intimidated the participants and ultimately discouraged

conversations.

“I can manage the patients’ poor vital signs by working hard but communicating with sensi-

tive caregivers who project their anxiety about the patient’s state onto nurses doesn’t go as I

wish, so, it’s really difficult and burdensome.” (Participant 6)

“When the patient is in a bad state, caregivers sometimes want to not accept it and project

their feelings onto the nurses, and in such cases, there are no words that can console them.

Even approaching the caregivers is a burden, and I get kind of intimidated.” (Participant 5)

System-related factor: Lack of experience and a mismatch between theory and prac-

tice. Participants have learned the importance of communication during training; however,

they had trouble appropriately applying the learned concepts in their workplace. Participants

in this study were in their 20s and 30s, with limited life and social experiences, and felt the gap

between theory and practice in communicating with patients and families in ICU.

“Talking to the patient or caregiver was the most challenging thing when I was new. . .it is

impossible for nurses with not much life experience to communicate skillfully.” (Participant

10)

“It would be nice if the real-world conversation proceeds in the way shown in our textbook;

but it doesn’t in most cases. So, it is more practical to observe and learn from what other nurses

do in the actual field.” (Participant 2)

System-related factor: Intense visiting hours in limited time. The 30-minute ICU visit-

ing period is the only time when patients and families can talk to one another. Although nurses

are well trained to care for the patients to the best of their ability, caregivers distrust the nurses’

ability to care for patients since caregivers only have a limited amount of visiting time, thus

hindering effective communication. Some participants even experienced mental trauma fol-

lowing short but unforgettable interactions with caregivers.

“. . .the caregiver browbeat me and intimidated me for doing so. This gave me a mental

trauma for visiting hours. . .I didn’t know how to start a conversation and the visiting hours

were really stressful for me.” (Participant 3)

“The caregivers don’t stay in the ICU for 24 hours; so, once they begin to doubt our nursing

practice, we cannot continue our conversation with them. . .” (Participant 11)

System-related factor: Urgent workplace that deprioritizes communication. The ICU

is a unit for treating critically-ill patients; therefore, ICU nurses were more focused on tasks

directly linked to maintaining patients’ health, such as stabilizing vital signs, than on commu-

nication. Participants frequently encountered emergency situations, in which they could not

idly stay around to communicate with one patient because another required immediate

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assistance, i.e., they faced a reality in which they had to prioritize another patients’ health over

communication with one.

“. . .I’m really pressed for time when the patient keeps writing things I can’t understand

with their weak hands. . .I don’t have time to spare even if I want to listen to them.” (Partici-

pant 12)

“Vital signs are the utmost priority in [the] ICU. I’m on my feet the entire shift and don’t

even have time to go to the restroom. . .During early ICU treatment, there are a lot of emer-

gency situations; so, communication is way down in the priority list.” (Participant 5)

Theme 2: Learning through trial and error

The negative experiences arising from communicating with various individuals sometimes

forced nurses to think twice about their vocation; however, due to a sense of responsibility,

they tried to engage in therapeutic communication and to overcome difficulties.

Fundamental doubts about the nursing profession. Experiencing unfriendly and con-

frontational conversations with patients and caregivers was intolerable for participants. These

experiences were shocking enough to make them fundamentally question their decision to

choose and stay in the nursing profession.

“I felt so disappointed and frustrated when patients or caregivers bombard[ed] rude com-

ments at me with complete disregard of what I have done over a long period. . .I can’t sleep

well at night and my values as [a] nurse are shaken from their root.” (Participant 14)

“It becomes so difficult the moment communication fails and mutual trust is lost. Maybe I

could survive if this is just with one patient or caregiver; but the afterimage lingers with me persis-

tently while I’m working. . .I came to think whether I could continue nursing.” (Participant 7)

Finding out which communication style is better suited for patients and their fami-

lies. Nurses learned how to resolve communication-related difficulties that they encountered

from their seniors and mentors and tried to communicate better from their position at the

nursing station.

“A senior nurse of mine was talking to a caregiver who was really concerned, and she was

using affirmations like ‘Oh, really’ and ‘I see’ with a relaxed facial expression, and the caregiver

would spill her heart out to her. That’s when I thought that empathy is to express responses to

what the other person is saying.” (Participant 10)

“I can feel that I am able to bond with patients’ families when I tell them about the patient’s

daily living, such as how much the patient had slept, eaten, and whether the patient was not in

pain, during visiting hours.” (Participant 13)

Knowhow learned through persistent effort. Nursing activities, such as taking vital signs

and performing aspiration and intravenous injection, are learned over time; however, it is

impossible to acquire therapeutic communication skills without personal effort and interactive

experiences in the field.

“I’m reading a book about conversation and am learning about how to express empathy and

understand other people. . .Nursing skills are developed and improved over time; but it’s not easy

to enhance communication without personal effort or change in perception.” (Participant 16)

“Communication is an indispensable part of nursing. If you want to provide high-quality

care, you need to enhance your communication skills first.” (Participant 15)

Theme 3: Recognizing communication experiences as being essential for

care

Nursing and communication are inseparable. Although communication is a challenge while

caring for ICU patients, therapeutic communication is important for the patients’ and their

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families’ overall wellbeing. In an ICU, communication based on empathy and experience is a

significant component that helps patients perceive their illnesses more positively.

Empathy garnered through various clinical experiences. Since participants met many

patients and their families in the ICU, they were able to communicate. Participants understood

patients’ discomfort and learn why it was difficult for them to communicate and to comfort

and assure unease families who could not observe the patient’s condition. However, it was a

necessary communication method in the ICU. Participants realized the value and importance

of their words.

“. . .his endotracheal tube was touching his throat and was so uncomfortable: his mouth

was dry, he couldn’t talk, and his arms were tied; so, he thought the only way to communicate

was to use his legs and that’s why he was kicking. I felt really sorry. . .” (Participant 7)

“I gave a little detailed explanation to the caregiver during visiting hours and she thanked

me overwhelmingly. I feel that, because this is the ICU, patients and caregivers can be encour-

aged and discouraged by the words of the medical professionals.” (Participant 9)

The power of active listening. Although the ability to handle tasks promptly is important,

listening to patients amid the hectic work schedule in the ICU is also an important nursing

skill. Critical care nurses realized that listening to patients and caregivers without saying any-

thing is also meaningful and therapeutic.

“I was listening to the caregiver the entire duration of the visiting hour. . .She said that she

just had to open up to someone to talk about her frustrations, and that my listening to her was

a huge consolation for her.” (Participant 12)

“While listening to the caregiver and showing empathy every day at the same time, I was

able to witness that the caregiver who had been aggressive and edgy changed in a way to trust

in and depend on the nurse more.” (Participant 16)

Mediator between physicians, patients, and caregivers. Participants were at the center

of communication, serving as the bridge connecting physicians to patients and patients to

caregivers. They served as mediators, explaining the doctors’ comments to the caregivers, and

providing details regarding the patients’ state to families. Participants helped maintain a close

and balanced relationship between the doctor, the patients, and their families by conveying

messages not effectively communicated by the doctor or patients.

“Caregivers would not ask any questions to the doctor in the ICU and would ask me instead

once the doctor is gone. They would ask, ‘what did the doctor say?’ and ask me for an explana-

tion.” (Participant 4)

“The patients can’t say everything they want; so, as nurses, we are the mediators between

patients and caregivers. . .Tell[ing] the family about things that happened when they were not

around the patient is meaningful.” (Participant 14)

Expressing warmth and respect. Participants have experienced sharing emotions with

the patient’s family as well as with the patient during disease improvement and exacerbation.

In particular, sincere actions, such as staying with the families of patients who died or those

whose condition was deteriorating, led to more genuine relationships, as respect for human

life was expressed.

“When patients whom we have spent a long time [with] are about to pass away, we cry for

them and we stay beside them in their final moments. . .Showing respect for a person’s final

moments of life and expressing our hearts is meaningful, and it is something critical care

nurses must do.” (Participant 16)

“When the patient’s state worsened and. . .his daughter was sobbing next to him. . .I softly

touched her shoulder, and she really thanked me. As I saw the patient’s family grieve, I just

expressed how I felt, and, fortunately, my intention was well conveyed” (Participant 4)

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Discussion

This study evaluated critical care nurses’ communication skills and experiences with patients

and their caregivers. Based on the two FGIs and four individual in-depth interviews, three

themes have been identified: 1) facing unexpected communication difficulties; 2) learning

through trial and error; and 3) recognizing communication experiences as being essential for

care

For theme 1, we examined nurse-, patient-, family-, and system-related (i.e., pertaining to

hospital resources and education) factors. Theme 1 can be considered as the communication

involving human-to-human interaction, as mentioned in Travelbee [24,25], that takes place at

an incomplete stage. First, critical care nurses struggled with balancing their heavy workload

and communicating with patients and their families. In Korea, an ICU nurse, on an average,

cares for two to four patients, which is higher than in some other countries, wherein an ICU

nurse cares for one or two patients at the most; thus, the Korean work environment for ICU

nurses is more stressful [26]. This limits the amount of time nurses may have to communicate

and interact with their patients and caregivers. Misunderstandings are also common owing to

the patients’ inability to speak while intubated and to use of regional dialects. Patients and

caregivers want to hear specific and comprehensible information from health professionals

regarding the treatment procedures in the ICU [17,27]. However, previous studies [4,28] have

reported that critical care nurses experience communication difficulties due to high mental

pressure due to work, time constraints, and the inability to use their own language; these are

consistent with our findings. As nurses are required to interact with patients having various

needs, they need to learn how to communicate verbally and nonverbally in a sophisticated

manner [27], and hospital managers should implement practical communication programs in

the ICU.

Communication between nurses and their patients in the ICU is also often adversely

affected by the therapeutic environment, such as patient emergencies and the use of mechani-

cal ventilation [27,28]. Mechanical ventilators are one of the greatest obstacles to communica-

tion. Although they are essential for critically-ill patients who are incapable of spontaneous

breathing, they affect their ability to speak [29]; therefore, these patients need to employ other

strategies for communication, such as using facial expressions and lip movements, which

make communication extremely difficult [27,30]. Our participants strived to understand the

needs of critically-ill patients through verbal and nonverbal communication, such as writing

and body language. However, when the intentions were not conveyed properly, some patients

responded aggressively, hindering respiratory treatment and ultimately prolonging treatment.

This is in line with many previous findings [29,31,32] indicating that patients’ failure to effec-

tively express their needs to nurses or their family members triggers negative emotions. In

addition, participants had trouble interacting with caregivers who were extremely tense and

sensitive. According to Lee and Yi [17], families of critically-ill patients experience fear and

anxiety regarding the patients’ health state and strive to save the patient. Thus, nurses must

consider this when addressing vulnerable patients and their families and must actively identify

and resolve causes of discomfort in patients on mechanical ventilation (i.e., by using appropri-

ate analgesics/sedatives and removing the ventilator). Further, considering a systematic review

revealing that electronic communication devices enable efficient communication with criti-

cally-ill patients through touch or eye blinks [33], Korea should also keep abreast with techno-

logical advances in communication technology.

Concerning theme 2, as participants experienced emotional exhaustion from being misun-

derstood or unfairly criticized by patients and their families, they contemplated and doubted

the occupational values of nursing. Park and Lee [7] found that higher job satisfaction for ICU

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nurses is associated with better communication. This is consistent with our participants’ doubt

for choosing the nursing profession. However, instead of giving up on this profession, they

closely observed the effective communication skills of more experienced nurses, actively

learned about therapeutic communication through books and videos, and applied their learn-

ings during practice. Similar results were reported by Park and Oh [3] that patient-centered

communication competency among critical care nurses was the highest when a biopsychoso-

cial perspective, focused on delivery of factual information, was followed and the lowest in the

therapeutic alliance domain, which is required for performing cooperative care with patients.

Therapeutic communication provided by nurses to patients and their families in the ICU effec-

tively diminished their psychological burden and fostered positive responses from families

[34]. Currently, ICUs implement a systematic education system for nurses that focuses on

therapeutic techniques, such as hemodynamic monitoring, mechanical ventilation care, aspi-

ration, and extracorporeal membrane oxygenation; however, they lack a program targeting

effective therapeutic communication with patients and caregivers. The communication diffi-

culties experienced by nurses will persist without this additional program; thus, its implemen-

tation is critical to improve patient satisfaction and nursing quality of care. Further, instead of

coercing unilateral effort from critical care nurses, nurse managers should pay attention to

nurses’ emotional wellbeing and promptly develop systems to offset potential burnout, such as

voluntary counseling systems or measures to “refresh” nurses.

Concerning theme 3, participants learned that communication is a challenging but essential

aspect of critical care. The concept of communication resonates through Travelbee’s model

[24,25]. Getting to know another human being is as important as performing procedures. A

nurse must establish a rapport with the patient and the patient’s caregivers, otherwise he or she

will not know the patient’s needs. As a place where life-and-death decisions are made, the ICU

induces anxiety in critically-ill patients and their caregivers. Hence, nurses should fully empa-

thize with patients and their caregivers [4,5,17].

Travelbee [24,25] emphasized the relationship between the nurse and the patient by estab-

lishing the Human-to-Human relationship model, which gives meaning to disease and suffer-

ing based on empathy, compassion, and rapport building. In addition, it presents concepts,

such as disease, hope, human-to-human relations, communication, interaction, patient’s

needs, perception, pain, finding meaning, therapeutic use of communication, and self-actuali-

zation. The participants cultivated empathy and active listening skills when speaking with

patients and their families, and, as they spend more time doing so, their quality of care and

nonverbal communication skills (such as eye contact, soft touch, and tears) improve and

became more genuine. Our findings are consistent with the meaning of human-centered care

suggested by Jang and Kim [35], which involves paying close attention to and protecting

patients’ lives, deeply empathizing with patients from a humanistic perspective, and being sin-

cere. The experience of nursing, including active interaction, has a positive impact on estab-

lishing the roles and caring attitudes of professional nurses [36], which is significant for critical

care nurses. Patient-family-centered care, which has been confirmed to positively promote

critically-ill patients’ recovery worldwide [1], is possible when nurses engage in therapeutic

communication with patients and their families through dynamic interactions [34,37]. There-

fore, critical care nurses and nurse managers should pay attention to communication and

develop an effective communication course that can be applied in clinical practice. To do this,

first, it is necessary to hire appropriate nursing personnel for active therapeutic communica-

tion with the patients and their families in an ICU. Second, continuous, and diverse educa-

tional opportunities should be provided to critical care nurses, along with policy strategies. For

example, at the organizational level, it is necessary to develop manuals on how to deal with dif-

ficult situations by gathering challenging communication cases from actual clinical practice.

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Simulation education for communication is an important component of the nursing

curriculum.

Limitations

First, this study included a small number of participants; however, we ensured that the maxi-

mum data was collected from these participants. Second, specific information was collected

from only those nurses who provided direct care in the ICU of a general hospital in a large city

in Korea. The homogeneity and dynamics of the focus groups may have resulted in congruent

opinions. Third, because the experiences of nurses from only one hospital were analyzed, cau-

tion should be exercised in generalizing our results and applying them to other hospitals in

Korea. Therefore, follow-up studies with larger sample sizes and more representative partici-

pants are warranted.

Conclusion

This qualitative study explored critical care nurses’ communication skills and experiences with

patients and caregivers from various perspectives. Although these nurses felt discouraged by

the unexpected communication difficulties with patients and their families, they recognized

that they could address these difficulties by improving their communication skills over time

through experience and learning. They realized that empathy, active listening, and physical

interaction with patients and their families enabled meaningful communication and have

gradually learned that effective communication is an indispensable tool in providing nursing

care to critically-ill patients.

Supporting information

S1 File. COREQ checklist and coding tree.

(DOCX)

Acknowledgments

The authors would like to thank all the participants for their time and contribution in this

study.

Author Contributions

Conceptualization: Hye Jin Yoo, Jae Lan Shim.

Data curation: Hye Jin Yoo, Jae Lan Shim.

Formal analysis: Oak Bun Lim, Jae Lan Shim.

Funding acquisition: Jae Lan Shim.

Investigation: Hye Jin Yoo, Oak Bun Lim.

Methodology: Hye Jin Yoo, Jae Lan Shim.

Resources: Oak Bun Lim.

Supervision: Jae Lan Shim.

Validation: Hye Jin Yoo, Oak Bun Lim, Jae Lan Shim.

Writing – original draft: Hye Jin Yoo.

Writing – review & editing: Jae Lan Shim.

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PLOS ONE | https://doi.org/10.1371/journal.pone.0235694 July 9, 2020 15 / 15https://doi.org/10.4040/jkan.2018.48.3.323https://doi.org/10.4040/jkan.2018.48.3.323http://www.ncbi.nlm.nih.gov/pubmed/29968688https://doi.org/10.1111/wvn.12146http://www.ncbi.nlm.nih.gov/pubmed/26860230https://doi.org/10.5935/0103-507X.20160027http://www.ncbi.nlm.nih.gov/pubmed/27410408https://doi.org/10.4040/jkan.2015.45.2.280http://www.ncbi.nlm.nih.gov/pubmed/25947190https://doi.org/10.1016/j.hrtlng.2009.12.009http://www.ncbi.nlm.nih.gov/pubmed/20561863https://doi.org/10.1186/s13054-016-1483-2https://doi.org/10.1186/s13054-016-1483-2http://www.ncbi.nlm.nih.gov/pubmed/27756433https://doi.org/10.1111/nicc.12141http://www.ncbi.nlm.nih.gov/pubmed/25583405https://doi.org/10.4040/jkan.2019.49.4.423https://doi.org/10.4040/jkan.2019.49.4.423http://www.ncbi.nlm.nih.gov/pubmed/31477672https://doi.org/10.1016/j.ijnurstu.2018.08.010http://www.ncbi.nlm.nih.gov/pubmed/30227279https://doi.org/10.1371/journal.pone.0235694

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Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 

To Prepare

· Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

· Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.

· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

· Please Note:

· All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.

· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

· You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.

· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.

· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

· Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

· Dress professionally and present yourself in a professional manner.

· Display your photo ID at the start of the video when you introduce yourself.

· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

·

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

Personal Philosophy of Nursing

This information is also found in the Student Handbook.

Develop a personal philosophy focusing on the central concerns of nursing. The fundamental elements are to be included; others may be chosen if desired. Use at least two references to support your point of view. One reference must be research based from a nursing journal.

A philosophy of nursing is by its very nature, a very individualized, personal statement based on subjective life experiences and adoption of particular world views. As such, the grading of this project will rest solely on the “depth and breadth” of the philosophical inquiry guided by the questions. Total points possible for this project are 15. This is not a simple exercise. Put thought into this. It is your personal philosophy of nursing. Please answer the questions below: Personal Knowing 1. Examine your personal beliefs and baccalaureate nursing education.

(Write an overall introduction of your personal beliefs about being a baccalaureate prepared nurse). Ontological Questioning 2. To develop a personal philosophy of nursing: one must focus on the central concerns of the discipline. This would include, for example, the nature of human beings and the life process. From the perspective of nursing, attempt to answer the following questions which reflect the fundamental elements of nursing and any others you may choose to incorporate:

a. What is society – of whom is it composed, and what is the nature of the relationships among its constituents including self in the role of the nurse? Where do you, as a professional nurse, fit into the picture and landscape of community? b. What are your central beliefs about the individual person, and that individual’s potential? The individual’s ability to learn, change, and heal? The family? The community? Your role as a professional nurse in these processes and relationships? c. What constitutes the environment? How do human beings and the environment interact? What contextual importance does it have for the focus of the discipline of nursing. d. What is your view(s) of health? Is it a continuum? A unidirectional phenomenon? A state? A process? Achieved/maintained alone or in unison with others? e. How do illness and wellness relate to health? f. What is the central reason for the existence of nursing and your calling to it? g. Who is the recipient of your nursing call? h. How does self-discovery and knowledge development occur in nurse-client relationships.Empirical Knowing 3. From the perspective of a philosopher’s concern with knowledge, Epistemological attempt to answer the following questions that reflect the Questioning essential elements of the scientific discipline of nursing: a. What do you believe is the nursing process? b. From what cognitive base does the professional nurse operate? Critical thinking? Problem-solving methodology? c. How do you implement the nursing process as you define it? What is necessary in the application of knowledge? d. How is the theory base for nursing derived? e. What is the theoretical framework for the profession? Is there room for diversity of thought, or is unity conceptual? Ethical and Esthetic 4.From the philosopher’s concern with ethics and esthetics, attempt Knowing to answer the following questions reflecting the valuation elements of nursing:

a. What are the essential rights and responsibilities of the professional nurse? b. What are the essential rights and responsibilities of the recipient of nursing care? c. How do your beliefs about nursing guide the research, education, administration and practice components of your role as a professional nurse? d. What are the governing ethical principles in the delivery of nursing care and the conduct of nursing research? e. What are your beliefs about the educational requirements and the focus of education for the practice of the profession? f. What are your beliefs about the teaching-learning process? g. What do you believe is needed for your continued development of esthetic knowing or responsiveness in nurse-client interactions?

Student:________________________________________________Date___________________

Criteria	3	2	1	0
Personal Knowing	Personal philosophy of nursing written from a generalist nurse perspective	Written from a specialty nurse perspective	Vague references to nursing	Paper does not address nursing
Ontological Questioning	Includes all questions and provides an in-depth reflection of self	Includes all questions but there is no in-depth reflection of self	Not all questions answered	Does not include
Empirical Knowing	Includes all questions and provides an in-depth reflection of self	Includes all questions but there is no in-depth reflection of self	Not all questions answered	Does not include
Ethical and Esthetic Knowing	Includes all questions and provides an in-dept reflection of self	Includes all questions but there is no –in-depth reflection of self	Not all questions answered	Does not include
APA	0 mistakes	1 -2 mistakes	3-4 mistakes	More than 4 mistakes

Comments: Total:________________________

___________________________________________________ ________________________

Faculty Signature Date

An ongoing challenge for advanced practice registered nurses (APRNs) has been changing state legislation that allow APRNs to practice to the fullest extent to which they were academically prepared. For this discussion question, contact the Board of Nursing (BON) in your state or access your BON online. Examine laws that govern APRNs in your state. Consider the following: do APRNs in your state have prescriptive authority; is there legislation in place that allows them to practice autonomously; and finally, if a bill has been passed and adopted, which legislator introduced the bill and who were the strongest advocates for the bill? Then post an initial response that addresses the following:

Explain how the lack of autonomy for APRNs impact patients in rural populations? As a health care professional in an advocacy role, what resources could you utilize to guide you in changing policies that impact APRNS in your state? Include in your discussion the type of stakeholders and collaborative partners you would seek to guide or assist you on this cause. initial 400 APA words, makeup 2 replies to 2 students 200 words each.

Nursing Reflection Assignment

Florence Nightingale was a leader in nursing whose writings led to the foundation of many of our current nursing philosophies and theoretical models. Although there have been significant changes in our society and health care since her era, one can identify evidence of her writings and practice in current nursing practice.

For this assignment, read “Nightingale’s Environmental Theory” published by Margaret Hegge in Nursing Science Quarterly 26(3), 211-219. The article can be accessed on the D’Youville College Library website. In this article, Dr. Hegge describes the environmental theory from Nightingale’s experiences. In your writing, please address the following topics:

Introduction to the main topic of the paper.(Begin with “The purpose of this paper is to…..” and then discuss the main points of the paper)

Describe Nightingale’s Theory.

Explain the current (actual or potential) environmental problem faced by patients or communities. Be sure that the problem is within the past 5 years and show the impact of the environment on the health problem. Discuss political influences, policy issues, and legal influences on the problem. Examples of current environmental problems include: Covid 19, Flint Water Crisis, Air pollution etc.

Compare and contrast one other discipline (e.g., PT, OT, Pharmacy, Social Work, Nutrition etc.) with nursing in examining the problem.

Discuss stakeholders and resources involved in examining the problem

Discuss outcomes. How will you measure the success of the solutions you propose?.

General directions for submitting assignment:

Use subheadings for each topic following the grading rubric.

The paper should be detailed with evidence.

APA format should be used including a title page, and references. You will lose credit if you do not follow APA format. See the APA documents for how to format the title page

To access the article for the assignment, go to the D’Youville College Library website (click to access). (Links to an external site.)Once there, in Spartan Search:

Type “Nightingale’s Environmental Theory Hegge.”

Click “Full Text.”

Under “Tools” in the right column, click “Article as PDF.”