CHAPTER 3: NURSING AS AN ART

A. Caring
 Nursing is a science and art
 Nursing as an art – caring, compassion(ate), understanding, communicating, and loving in
caring for patients
 ETSAC – Education, Theory, Service, Autonomy, Code of Ethics
 Science – it includes all the knowledge (nursing process, assessment, etc.)
 Art – described to be how you are going to develop a bond or relationship with your patient

 Nursing as a form of aesthetic knowledge (art), where the nurse make use of his/her internal
creative resources
 Transformation, performance, creativity – visible through actions, behaviors, attitudes and
interactions (Chinn & Kramer, 1999)
 The artistic of caring, verbal and non-verbal, forms unique relationship between the nurse and
interlocutor (Contreras Ibachache, 2019)
 Traditional media – painting, sculpture, film, dance – ‘’only works of art’’ (Porter, 2010)

2 Key areas:
 Formal communication of art – they refer to;
 Theoretical System of Knowledge
- establishes and guides caring in nursing
- enhances the skills, knowledge, and attitude that is required in a certain profession
- nursing (vs caregiving) – is an intentionally established altruistic process – to help others in
their life processes, in sickness, health, and death
 Scientific Evidence in Nursing
- Reached with established different forms of introduction of care as it is enacted in everyday
life
 Studies conducted qualitative and/or quantitative methodology
 Websites about theories, philosophy and nursing models
 Narrative forms: research, criticism, editorials reported by scientific journals
 Literature – a process of communication, creative collective process, comprehensive and
practical format for projects
 Scientific literature – pieces of nursing art

 The expression of the individual and artistic communication – how individual and artistic
characteristic of a nurse is being communicated
 Jean Watson
- The relationship implied by human care is a transpersonal relationship
- A union between the nurse and the person
 Personal and unique
- Based on life experiences, individual beliefs, and self-exploration
- Allows nurses to see and integrate themselves into the entirety of the act of care
- Ex. Nurse enters a hospital room; the act of greeting a patient

Final considerations
- ‘’Art of nursing is difficult to explain and conceptualize’’
 - We are certain of having opportunities to make our art known to others
- Scientific communications or personal expressions of care
- For everyday in each moment in our professional task, we are exemplifying our art – which
has the potential to understand the human experience in its totality

Caring Practice Models

5 major types of nursing care delivery systems:
 Total patient care – case method (nurse provides all care to the patient); clear
communication
 Functional nursing – task-based nursing (nurse will be assigned based from different tasks)
 Team nursing – or modular nursing – involves collaboration of different nurses to perform or
provide the needs of our patient
 Primary nursing – nurse assumes 24/7 accountability for their primary patients
 Care management – RN case manager supervises the care of the patient

6 CS of caring – purpose is to ensure that patients are looked after with care and compassion by
competent workers who communicate well, to make changes that improve care and commit to
delivering all day everyday

 Care
- Core characteristic of nursing as a profession
- Improves the health of the whole community
 Compassion
- ‘’To suffer together’’
- Sympathetically (sympathy – you are able to identify, to see, to recognize that your client and
other people is having certain kind of distress or suffering) being aware of the distress of
others and having the desire to alleviate it
- Based on empathy (being able to assess and recognize that the other person is having distress
– characterized to be putting your shoes into others), respect, and dignity
- Central to how people perceive their care – how you intelligently present your kindness is
seen by your patient; they can feel it
- Described as intelligent kindness
 Courage
- Enables us to do the right thing for clients
- Bravery – to speak-up when we have concerns
- Have the personal strength and vision to innovate and to embrace new ways of working
 Commitment
- Public look to healthcare workers
- Looking after one’s own health and maintaining code of conduct and to provide the best
possible guidance and care for clients
- To improve the care and experience of patients
 Communication
- Central to successful caring relationships and effective team work
- Being a good listener and clear record-keeping
- Reporting and monitoring of patient records and other documentation
 Competence
- Set of demonstrable characteristics and skills that enable and improve the efficiency or
performance of a job – skillful and knowledgeable
 - Ability to understand an individual’s health
- Based on research and evidence
 Evidence – necessary to update your knowledge and skills regularly, as well as knowing your
limits as nurse

When caring of clients: the nurse’s ultimate role

 Eriksson’s (2018)
 Nurses who are present in the caring situation see and observe the person’s suffering and
understand that they are responsible for acting in the person’s best interest
 If nurses encounter the patient face to face in a presence of love, it can alleviate the patient’s
suffering (Kasen, 2002)
 Self-awareness and values clarification is the key of patient care
- To fully view the patient as a unique individual and invite him/her to a caring relationship
- Requires self-knowledge, and awareness of one’s approach to the patient
- Be responsible for nursing based on patient needs
- Self-reflection – create an awareness of nursing and caring, ethical inner values in caring

B. Communication
- Process of creating, interpreting, and negotiating meaning
- Verbal, nonverbal, textual; aural, visual, or physical
- Learned behavior; collective practice
- A process in which people affect one another though the exchange of information, ideas, and
feelings
- One important factor for success in nursing
- Ability to communicate and connect with clients, help build relationships and provide a
higher level of care

 2013 – 440,000 people die each year from preventable medical errors (miscommunication)
 Preventable medical errors – 3rd leading cause of death in the US
 2012, 2013, 2014 – data communication as one of the top 3 leading causes of sentinel events
– related to communication, patient safety event unrelated to patient’s illness or condition
resulting to death or permanent harm

 Increases in nursing communication

- Facilitate positive patient outcomes (lessened hospital stay, prolonged life span, etc.)
- 2014 – program to enhance and standardize communication
- Results of effective communication (nursing communication literatures) – increased recovery
rates, a sense of safety and protection, improved levels of patient satisfaction, and greater
adherence to treatment options
 Linear, interactional, and transactional – most well-known models of communication
 Development of communication that emphasizes on different parts of communication process

 Linear model
- Developed by Shannon and Weaver in 1948
- Specific point to the endpoint
- Describes how a sender or speaker transmits a message to the receiver or listener
- Sender or speaker – source of the message
- Message – consists of sounds, words, or behaviors
 - Channel – the pathway for communication
- Receiver or listener – target or recipient of the message
- Noise – obstacles in the communication process
 Interactional model
- More dynamic view of communication – 2 channels between the sender and receiver
- Communication as an ongoing process
- Fields of experience – how environment, experiences, culture and eve heredity influence how
a sender constructs a message
- Limitation – an individual can be a sender and a receiver but cannot do it simultaneously
 Transactional model
- Places more emphasis on the field of experience
- Inhabit a shared field of experience
- The overlap between these communicators includes culture, language and the environment
- Messages will influence the responses or subsequent messages; interrelated – connected and
built upon one another
- People are viewed as dynamic communicators
- Messages are interdependent – subsequent group of messages are dependent on those
messages prior

Peplau’s interpersonal relations theory

4 Stages:

 Orientation
- The nurse engages the patient in treatment
- Patients are able to ask questions and receive information
- Helps patients develop trust and where first impression about the nurse and other healthcare
workers begin to evolve
 Identification
- The patient and the nurse begin to work together
- ‘’Working phase’’
- Interactions provides the basis for understanding, trust, and acceptance as patient becomes an
active participant in care/treatment
 Exploitation
- The patient takes advantage of all services that are being offered
 Resolution
- Patient’s needs are met and he/she moves toward full independence

Comfort communication model

- Built around the fundamental principles of interaction adaption theory
- Established as early as 2012; not linear guide, algorithm, protocol, or rubric for sequential
implementation
7 basic communication principles:

 C – connect
- Involves activities like sharing difficult information with patient/family
- Employs narrative clinical practice
- Prioritizes person-centered messages
 - Proliferates health literacy (degree to which the individuals have the capacity to obtain,
process and understand basic information that are needed to make appropriate health-
decisions) messages and actions
 O – options
- Integrates cultural/spiritual awareness into nursing practices
- Seeks communication accommodation with all patients and their caregivers
- Practices health literacy strategies with patients and caregivers to achieve shared
understanding
- Secures effective communication tools and resources
 M – making meaning
- Examines the meaning of suffering
- Integrates mindfulness in the delivery of care
- Seeks and delivers communication that is responsive to meeting patient care goals
 F – family caregivers
- Practices family-centered care to serve caregivers of care recipients
- Gains an understanding of family communication
- Seeks pathways to help caregivers access information and resources for patient care
- Offers unique attention to caregivers
 O – openings
- Understanding the importance of navigating privacy boundaries for patients and their
family/friend/caregivers
- Introduces alternatives to curative-only care when patient status changes
 R – relating
- Engages uncertainty and certainty as patients and families advance in disease and plans of
care change
- Pursues goals of care conversations with patients and families
- Invites patients to provide feedback and evaluation of communication
 T – term
- Collaborates with interdisciplinary partners and team members
- Practices inter-professional patient care (collaboration between different professions taking
care of the client)
- Participates in peer-to-peer learning and improvement in health literacy practices
- Shares resources and information to ensure that team needs are met

Therapeutic communication
- Communication strategies that supports a patient’s feelings of well-being
- Goal – to help a patient feel cared for and understood; establish a relationship in which the
patient feels free to express any concerns
Types:
 Non-verbal – non-spoken
- Ways in which beings convey information about their emotions, needs, intentions, attitudes,
and thoughts without the use of verbal language
- Include facial expression, gestures, paralinguistic (loudness or tone of the voice)
 Verbal – spoken
- Use of words to convey a message
- Some forms of verbal communication are written and oral communication
Therapeutic Communication Techniques:

 Using silence
 Accepting
 Giving recognition
 Offering self
 Giving broad openings
 Offering general leads
 Placing the event in time or sequence
 Making observations
 Encouraging description of perceptions
 Encouraging comparison
 Restating
 Reflecting
 Focusing

 Affirm desired behaviors – let your patient know that you are aware of his/her efforts
 Ask for clarification – you are not confident that you understand your patient correctly
 Ask open-ended questions – helps you capture your patient’s thoughts and perceptions
 Confront – you have established trust with your patient
 Encourage formulation of an action plan – your patient needs to create a good habit

Non-therapeutic Communication Techniques:

 Giving reassurance
 Rejecting
 Approving or disapproving
 Agreeing or disagreeing
 Giving advice
 Probing
 Defending
 Requesting an explanation
 Indicating the existence of an external source of power
 Belittling feelings expressed

Helping relationship
- One of the parties intends to promote the growth, development, maturity, or improved
functioning of the other; parties may be either individual or groups
- A therapeutic nurse-patient relationship – a helping relationship based on mutual trust and
respect
- Includes effective communication and information-sharing – will assist the nurse in
understanding the patient’s preferences regarding their environment and enabling them to feel
safe

 Therapeutic relationships are focused on the client’s needs, experiences, feelings, and ideas
3 phases:

 Orientation
- Begins when the nurse and client meet and ends when the client begins to identify problems
to examine
 Working
2 sub phases:
 Problem identification
- Client identifies the issues causing problems
 Exploitation
- Nurse guides the client to examine feelings and responses to develop better coping skills

 Termination
- Final stage in nurse-client relationship that begins when the problems are resolved, and ends
when the relationship is ended

Helping relationship: stages

 Establishing a working relationship
 Identifying client problems
 Heling clients create goals
 Encourage client exploration and action
 Termination

Communication and the nursing process

- Communicating is a fundamental skill in nursing used from point of admission to point of
discharge
- Effective use of communication benefits the nurse-patient relationship and contributes to
overall well-being and accelerating the process of treatment
- Essential part of nursing process
- Delicate and complex art that requires good understanding of interplay between factors

C. Teaching
- In education, teaching is the concerted sharing of knowledge and experience; the provision of
stimulus to the psychological and intellectual growth of a person by another person or artifact
(IGI Global, 2019)

Teaching as an art of nursing

- Patient education is a significant part of a nurse’s job
- Education empowers patients to improve their health status
Role of nurses in patient education
- Effective patient education; admission to discharge
- Teaching the client about self-care (directly related to their current condition)
- Prevent relapse – unhealthy habits, ignoring management of medical condition
 Teaching approaches
- Nurses’ teaching approach vs teaching methods; directive vs non-directive
 - Effective educator concentrates on the tasks and uses teaching approaches according to
learner’s needs along with change over time
 Telling
- Used when teaching is needed in a limited information – anxious clients
- Nurse outlines the tasks that the client needs to perform
- No opportunity for feedback
 Participating
- Nurses and client set objectives and become involved in the learning process together
- Nurse guides client on pertinent information
- Opportunity for discussion, feedback, mutual goal setting, and revision of teaching plan
- Ex. parent and nurse for a child with leukemia

Health promotion
- Process of helping people improve their health to reach an optimal state of physical, mental
and social well-being
- Health promotion activities help clients maintain or enhance their present of levels of health;
motivate people to act positively
- Goal – achieve appropriate lifestyle choices
- Passive or active
 Passive strategies – individuals gain from the activities of others without acting themselves
 Active strategies – individuals adopt specific health programs, require patients to be actively
involved to improve their present and future levels of wellness while decreasing the risk of
disease

Disease prevention
- Actions to reduce or eliminate exposure to risks that might increase the chances that an
individual or group will incur disease, or premature death
- Risk factors for disability – mutable (you can change it) or unmutable (you cannot change it)
- Goal – to identify the health problems for which preventive efforts can result in more
appropriate utilization of health services and improvements in health status
- Lifestyle and personal behavior in improving personal health status
- Extent of effectiveness of health care interventions and behavior change
- Need for individuals and family units – accept personal responsibility for own health

Health restoration and maintenance

 Health maintenance
- Guiding principle in health care that emphasizes health promotion and disease prevention
- Help a person to maintain their current good health
- Involves helping clients achieve and continue enjoy optimal health
- Benefits – feel energetic and happy – body will be in better shape and feel really good
 Health restoration
- Induction of a return to a previous state
- To restore back to its original functioning
 Rehabilitation
- Process of restoring ill or injured people to maximum and functional levels of wellness
- Goal – help people return to their previous level of health or to the highest level they are
capable of
- Begins in the hospital but will eventually lead clients back out into the community for
treatment and follow-up

 Several studies present the art of nursing practice includes showing up, staying, and helping
patients, connecting to patients, intuitive caring, and making a difference in the lives of both
patients and nurses
 ‘’… As a filed grounded in compassion and direct patient care, the art of the nursing
profession is more important than the science. And this is where the so-called calling comes
into play.’’ (Bettencourt, 2014)