Nur1 230 Fundamentals of Canadian Nursing PDF Free

KOZIER ERB BERMAN SNYDER FRANDSEN
BUCK FERGUSON YIU STAMLER
FUNDAMENTALS OF
KOZIER ERB
BERMAN SNYDER
CANADIAN NURSING
FRANDSEN BUCK CONCEPTS, PROCESS, AND PRACTICE 4TH ED I TI ON
FERGUSON YIU
STAMLER
FUNDAMENTALS OF
CANADIAN NURSING
CONCEPTS, PROCESS, AND PRACTICE
4TH EDITION
www.pearsoncanada.ca
ISBN 978-0-13-419270-3
9 0 0 0 0
9 780134 192703
Fundamentals of Canadian Nursing
Concepts, Process, and Practice
Fourth Canadian Edition
A01_KOZI2703_04_SE_FM.indd 1 03/03/17 3:30 PM

Fundamentals of Canadian Nursing
Concepts, Process, and Practice
Fourth Canadian Edition
Barbara Kozier, MN, RN
Glenora Erb, BScN, RN
Audrey Berman, PhD, RN

Professor
Dean, Nursing
Samuel Merritt University
Oakland, California
Shirlee J. Snyder, EdD, RN

Former Dean and Professor, Nursing
Nevada State College
Henderson, Nevada
Geralyn Frandsen, EdD, RN

Professor of Nursing
Maryville University
St. Louis, Missouri
Madeleine Buck, RN, BScN, MSc(A)

Assistant Professor
Ingram School of Nursing
McGill University
Clinical Associate
McGill University Health Centre
Linda Ferguson, RN, BSN, MN, PhD

Professor
College of Nursing
University of Saskatchewan
Lucia Yiu, RN, BSc, BA, MScN

Associate Professor
Faculty of Nursing
University of Windsor
Lynnette Leeseberg Stamler, PhD, RN, FAAN

Professor and Associate Dean for Academic Programs
College of Nursing
University of Nebraska Medical Center
(formerly of University of Saskatchewan)

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ISBN-13: 978-0-13-419270-3
10 9 8 7 6 5 4 3 2
Library and Archives Canada Cataloguing in Publication
Kozier, Barbara, author
Fundamentals of Canadian nursing : concepts, process,
and practice / Barbara Kozier [and eight others].—Fourth
Canadian edition.
Originally published under title: Fundamentals of nursing, the

nature of nursing practice in Canada.
Includes bibliographical references and index.
ISBN 978-0-13-419270-3 (hardback)
1. Nursing—Canada—Textbooks. 2. Nursing—Textbooks.
I. Title.
RT41.K69 2017 610.73 C2016-904384-3
A01_KOZI2703_04_SE_FM.indd 4 16/06/17 9:32 AM

Contents
Preface xiv
Canadian Reviewers xviii
UNIT 1 T H E F O U N D AT I O N O F N U R S I N G I N C A N A D A 1
Chapter 1 Chapter 4 Chapter 6

Historical and Nursing Philosophies, Accountability and Legal
Contemporary Nursing Theories, Concepts, Aspects of Nursing 85
Practice 1 Frameworks, and Relationship between Nurses
Historical Nursing Practice 2 Models 51 and the Law 86
Contemporary Nursing Practice 7 Contractual Arrangements
What Is Philosophy? 52
Roles and Functions of the Nurse 12 in Nursing 89
Philosophy’s Three Primary
Nursing as a Profession 14 Areas of Potential Tort Liability
Areas of Inquiry 52
Factors Influencing Contemporary in Nursing 90
World Views and Paradigms 53
Nursing Practice 16 Selected Legal Aspects of Nursing
Philosophy in Nursing 53
Nursing Organizations 17 Practice 97
Concepts and Theories 54
Legal Protections in Nursing
Overview of Selected Nursing
Chapter 2 Theories 56
Practice 99
Nursing Education Reporting Crimes, Torts, and Unsafe
Practices 101
in Canada 23 Chapter 5
Legal Responsibilities of Nursing
Nursing Education 24 Values, Ethics, and Students 102
Types of Educational Programs 25 Advocacy 66
Nursing Associations and Their Influence Values 67
on Education 27 Ethics 72
Issues Facing Nursing Education 29 Ethical Decision Making 75
Selected Ethical Issues
Chapter 3 in Nursing 76
Nursing Research in Nursing and Advocacy 79
Canada 35 Enhancing Ethical Practice 80
Nursing Research 36
UNIT 2 C O N T E M P O R A R Y H E A LT H C A R E I N C A N A D A 106
Chapter 7 Chapter 8 The Nurse’s Role in Health

Promotion 130
Health, Wellness, Health Promotion 120 The Nursing Process and Health
and Illness 106 Development of Health-Promotion Promotion 131
Concepts of Health, Wellness, Initiatives in Canada 121 Promoting Canadians’ Health 135
and Well-Being 107 Strategies for Population Health
Models of Health and Wellness 108 (1994) 123 Chapter 9
Health-Promotion Models 111 Defining Health Promotion 125 The Canadian Health Care
Sites for Health-Promotion
Health Care Adherence 113
Activities 126
System 140
Illness and Disease 113
Pender’s Health-Promotion Model 126 History 141
What Makes Canadians
The Transtheoretical Model: Stages of Rights and Health Care 142
Healthy? 114
Health Behaviour Change 128 Categories of Health Care 143
Summary 116

vi Contents
Types of Health Care Organizations Chapter 12 Community Health Nursing Practice 249
and Care Settings 146 The Community Health Nurse as a
Factors Impacting the Health Care
Individual Care 203 Collaborator 252
System 151 Concept of Individuality 204 Community Health Nursing
Contemporary Frameworks for Self-Concept 205 Competencies 254
Care 155 Concept of Holism 212 Focus on Trends in Community
Models for the Delivery Applying Theoretical Frameworks Health Nursing 256
of Nursing 156 to Individuals 216
Chapter 15
Chapter 10 Chapter 13 Rural and Remote
Environmental and Global Nursing Care of Health Care 262
Health Nursing 160 Families 223 Definition of Rural 263
Environment and Health 161 What Is “Family?” 224 Rural Health: Place, Space,
Global Health versus International Family Nursing 224 and Time 263
Health: What Is the Development of Family Elements of a Rural Health
Difference? 164 Nursing 226 Framework 263
Theories of Development 167 Canadian Families: A Demographic Health of Rural Residents 265
Globalization 168 Snapshot 227 Special Concerns in Rural and Remote
Sustainable Development Understanding Families 231 Aboriginal Communities 269
Goals 168 How Does the Family Affect Health Care Delivery 270
Major Issues in Global the Illness? 234
Health 170 Nursing Care of Families 234 Chapter 16
Nurses and Global Health 174 Evaluating Nursing Care of Complementary and
Families 240
Chapter 11 Alternative Health
Safe Cultural Caring 181 Chapter 14 Modalities 279
Canada’s Cultural Mosaic 182
Community Health Basic Concepts 280
Definitions and Concepts Related to Nursing 246 Complementary and Alternative Health
Modalities 281
Culture 187 What Is Community Health
Nursing Role in Complementary and
Considerations for Culturally Safe Nursing? 247
Alternative Health Modalities 290
Nursing Practice 187 Community Health Nursing in the
Providing Culturally Safe Context of Canadian Health
Care 194 Care 248
UNIT 3 L I F E S PA N A N D D E V E L O P M E N TA L S TA G E S 294
Chapter 17 Preschoolers (4 to 5 Years) 318 Moral Development 355

School-Age Children (6 to 12 Years) 321 Spirituality and Religion 355
Concepts of Growth and Adolescence (12 to 18 Years) 323 Promoting Healthy Aging 355
Development 294 Planning for Health Promotion 358
Factors Influencing Growth and Chapter 19
Development 295 Young and Middle
Stages of Growth and Development 296 Adulthood 331
Growth and Development Theories 296
Young Adults (20–40 Years) 332
Applying Growth and Development
Middle-Aged Adults (40 to 65 Years) 337
Concepts to Nursing Practice 305
Chapter 18 Chapter 20
Development from Older Adults 344
Characteristics of Older Adults in
Conception through Canada 345
Adolescence 308 Attitudes toward Aging 346
Conception and Prenatal Gerontological Nursing in Canada 346
Development 309 Care Settings for Older Adults 347
Neonates and Infants Theories of Aging 347
(Birth to 1 Year) 310 Psychosocial Aging 352
Toddlers (1 to 3 Years) 315 Cognitive Abilities and Aging 354

Contents vii
UNIT 4 INTEGRAL ASPECTS OF NURSING 364
Chapter 21 Chapter 23 Computer Technology and Informatics

in Nursing 485
Clinical Reasoning and The Nursing Process 411 How Nurses Are Currently Using
Critical Thinking 364 Overview of the Nursing Process 412 Technology 489
Critical Thinking 365 Assessing 412 Using Evidence-Informed Nursing
Critical Thinking: Definitions and Diagnosing/Analyzing 428 Practice in ICT 491
Purposes 365 Planning 436 Roles in Nursing Informatics 491
Techniques in Critical Thinking 367 Implementing 448 How Technology Influences Humans
Clinical Reasoning 369 Evaluating 450 and How Humans Influence
Attitudes That Foster Critical Thinking 369 Nursing Process Summarized 456 Technology 492
Standards of Critical Thinking 371 Workflow or Nursing Practice
Applying Critical Thinking to Nursing
Chapter 24 Process 493
Practice 371 Documenting and Consumers’ Health Informatics and
Developing Critical Thinking Attitudes Reporting 460 Online Information Access 494
and Skills 374 Professional Issues 495
Ethical and Legal Considerations 461
Conclusion 496
Purposes of Client Records and
Chapter 22
Documentation 462 Chapter 26
Caring and Documentation Systems 462
Communicating 381 Documenting Nursing Activities 470 Teaching and
Professionalization of Caring 382 General Guidelines for Learning 500
Nursing Theories on Caring 382 Documentation 472 Teaching 501
Types of Knowledge in Nursing 384 Reporting 476 Learning 502
Caring in Practice 385 Conferring 478 Nurse as Educator 506
Communicating 385
The Helping Relationship 396
Chapter 25 Chapter 27
Group Communication 398 Nursing Informatics Leading, Managing,
Communication and the Nursing and Technology 482 and Delegating 522
Process 400 Definition of Nursing Informatics 483 Nurse as Leader 523
Communication among Health Care Informatics Fundamentals: Data, Nurse as Manager 526
Professionals 405 Information, and Knowledge 484 Nurse as Delegator 529
Nurse and Physician Standardized Languages 485 Change 531
Communication 406
UNIT 5 N U R S I N G A S S E S S M E N T A N D C L I N I CA L ST U D I E S 537
Chapter 28 Male Genitals and Inguinal Area 621 Implementing 689

The Anus 625 Pharmacological Pain
Health Assessment 537 Management 691
Physical Health Assessment 538 Chapter 29 Nonpharmacological Pain
General Survey 545 Vital Signs 629 Management 700
The Integument 547 Evaluating 703
Body Temperature 630
Head 555
Pulse 637
Eyes and Vision 555 Chapter 31
Respirations 648
Ears and Hearing 558
Blood Pressure 651 Hygiene 710
Nose and Sinuses 567
Oxygen Saturation 662 Skin 711
Mouth and Oropharynx 567
Feet 725
The Neck 572 Chapter 30 Nails 729
Thorax and Lungs 574
Cardiovascular and Peripheral Vascular Pain Assessment and Mouth 730
Systems 586 Management 668 Hair Care 738
Eyes 744
Breasts and Axillae 594 The Nature of Pain 670 Ears 747
Abdomen 598 Physiology of Pain: Nociception 673 Nose 748
Musculoskeletal System 599 Factors Affecting the Pain Supporting a Hygienic
Neurological System 605 Experience 676 Environment 748
Female Genitals and Inguinal Lymph Pain Assessment 679
Nodes 610 Planning 686

viii Contents
Chapter 32 Chapter 34 Chapter 35

Safety 761 Infection Prevention Skin Integrity and
Factors Affecting Safety 762 and Control 875 Wound Care 930
Assessing 764
Health Care–Associated Infections 877 Skin Function and Integrity 931
Diagnosing 766
Types of Microorganisms Causing Wounds or Altered Skin Integrity 932
Planning 767
Infections 877 Wound Healing 933
Implementing 767
Body Defences against Infection 878 Heat and Cold Applications 961
Evaluating 785
Pathophysiology of Infection 882 Care of Specific Common Wound
Chapter 33 The Clinical Spectrum of Infection 882 Etiologies 966
Infection: An Imbalance between Pressure Injury 966
Medications 792 Microorganisms and Defences 882 Skin Tears 972
Key Concepts in Pharmacology 793 The Chain of Infection 883 Moisture-Associated Skin Damage 976
Effects of Drugs 795 Breaking the Chain: Prevention and Lower Extremity Ulcers 977
Drug Misuse 797 Control of Health Care–Associated
Actions of Drugs in the Body 797 Infections 887 Chapter 36
Factors Affecting Medication Action 799 Routine Practices and Additional Caring for Perioperative
Routes of Administration 800
Medication Order 802
Precautions 910 Clients 983
Practical Considerations for
Systems of Measurement 806 Implementation of Precautions 918 Types of Surgery 984
Methods of Calculating Dosages 807 Nursing Responsibility for Infection Preoperative Phase 986
Administering Medications Safely 811 Prevention and Control 919 Intraoperative Phase 998
System Factors Related to Medication Occupational Health Issues Related Postoperative Phase 1000
Safety 811 to Infection 922
Enteral Medications 819 Roles of the Infection Control
Parenteral Medications 824 Practitioner 924
Topical Medications 858 Infection Prevention and Control Is a
Inhaled Medications 867 Shared Responsibility 925
UNIT 6 P R O M O T I N G P H Y S I O L O G I C A L H E A LT H 1021
Chapter 37 Chapter 39 Vegetarian Diets 1143

Altered Nutrition 1144
Sensory Perception 1021 Activity and Assessing 1145
Components of the Sensory-Perceptual Exercise 1057 Diagnosing 1155
Process 1022 Normal Movement 1059 Implementing 1158
Sensory Alterations 1022 Factors Affecting Body Alignment Evaluating 1176
Factors Affecting Sensory and Activity 1067
Function 1024 Exercise 1069 Chapter 41
Assessing 1025 Effects of Immobility 1073 Fecal Elimination 1183
Diagnosing 1027 Assessing 1079 Physiology of Defecation 1184
Planning 1027 Diagnosing 1082 Factors that Affect Defecation 1186
Implementing 1027 Planning 1082 Fecal Elimination Problems 1189
Evaluating 1032 Implementing 1084 Bowel Diversion Ostomies 1192
Using Body Mechanics 1084 Assessing 1194
Chapter 38 Evaluating 1118 Diagnosing 1197
Sleep 1038 Planning 1197
Physiology of Sleep 1039 Chapter 40 Implementing 1200
Normal Sleep Patterns and Nutrition 1123 Evaluating 1214
Requirements 1041 Essential Nutrients: Macronutrients 1124
Factors Affecting Sleep 1043 Essential Nutrients: Micronutrients 1127 Chapter 42
Common Sleep Disorders 1044 Energy Balance 1128 Urinary Elimination 1219
Assessing 1047 Factors Affecting Nutrition 1130 Physiology of Urinary Elimination 1220
Diagnosing 1048 Nutritional Variations Throughout the Factors Affecting Voiding 1222
Planning 1049 Lifespan 1133 Altered Urine Production 1224
Implementing 1050 Standards for a Healthy Diet 1140 Altered Urinary Elimination 1225
Evaluating 1053

Contents ix
Assessing 1227 Factors Affecting Respiratory and Factors Affecting Body Fluid, Electrolytes,
Diagnosing 1236 Cardiovascular Functions 1274 and the Acid–Base Balance 1335
Planning 1236 Alterations in Function 1278 Disturbances in Fluid, Electrolyte, and
Implementing 1241 Assessing 1281 Acid–Base Balance 1337
Evaluating 1260 Diagnosing 1287 Assessing 1346
Implementing 1290 Diagnosing 1352
Chapter 43 Evaluating 1320 Planning 1352
Oxygenation and Implementing 1354
Chapter 44
Circulation 1265 Evaluating 1383
Physiology of the Respiratory

Fluid, Electrolyte, and
System 1266 Acid–Base Balance 1325
Physiology of the Cardiovascular Body Fluids and Electrolytes 1326
System 1270 Acid–Base Balance 1334
UNIT 7 P R O M O T I N G P S Y C H O S O C I A L H E A LT H 1391
Chapter 45 Spiritual, Religious, and Faith Coping 1443

Development 1419 Assessing 1444
Sexuality 1391 Spiritual and Religious Care in Diagnosing 1445
Development of Sexuality 1392 Contemporary Context 1420 Planning 1445
Sexual Health 1397 Spiritual and Religious Practices Affecting Implementing 1447
Factors Influencing Sexuality 1401 Nursing Care 1422 Evaluating 1451
Sexual Response Cycle 1402 Spiritual Health and the Nursing
Altered Sexual Function 1404 Process 1425 Chapter 48
Effects of Medications on Sexual Assessing 1426 Loss, Grieving, and
Function 1406
Assessing 1406
Diagnosing 1427 Death 1456
Planning 1427
Diagnosing 1408 Implementing 1428 Loss and Grief 1457
Planning 1408 Evaluating 1429 Assessing 1460
Implementing 1408 Implementing 1461
Evaluating 1412 Chapter 47 Dying and Death 1462
Chapter 46
Stress and Coping 1435
Concept of Stress 1436
Spirituality 1417 Models of Stress 1438
Spirituality and Related Concepts 1418 Indicators of Stress 1441
Glossary 1484
Answers and Explanations for NCLEX-Style Practice Quizzes 1524
Appendix A
Laboratory Values 1587
Appendix B
Vital Signs 1594
Index 1595

About the Canadian
Editors
Madeleine Buck
Madeleine Buck is an Assistant Professor and Director of the Bachelor of Science (Nursing) pro-
gram at the McGill University Ingram School of Nursing. She is also a clinical associate at the McGill
University Health Centre and consultant at the TANWAT Hospital in Njombe, Tanzania. Her 38-year
career in nursing has provided her with opportunities to work in acute and critical care, community
health, and educational settings. She teaches in the undergraduate and graduate nursing programs at
McGill, principally in the areas of acute care and illness management. She is involved in international
work and leads McGill Nurses for Highlands Hope, which works with a group of Tanzanian nurses
and peer health educators in dealing with the HIV/AIDS pandemic in the Highlands of Tanzania.
With her nursing students in the McGill Global Health Masters stream, she works to foster collab-
oration and development of nursing education and practice relationships, including implementing
nursing best practices in low-resourced settings in Tanzania. As with previous editions, half of her
royalties from the publication of this book will go toward supporting sustainable nursing projects ori-
ginating from the Tanzanian Highlands Hope Nurse network.
Linda Ferguson
Linda Ferguson, RN, BSN, MN, PhD (Alberta), is Full Professor at the College of Nursing,
University of Saskatchewan. Her undergraduate, master’s, and PhD studies were in the field of nurs-
ing, and she has a postgraduate diploma in Continuing Education. She has worked extensively in
the field of faculty development in the College of Nursing and the University of Saskatchewan. At
the University of Saskatchewan, she has taught educational methods courses at the undergraduate
(nursing and physical therapy), post-registration, and master’s levels for the past 25 years, and nursing
theory and philosophy in the master’s and PhD programs. Her research expertise is in the area of
qualitative research, with a particular focus on nursing education and workplace learning in profes-
sional practice. Her research has focused on mentorship and preceptorship, continuing education
needs of precepting nurses, teaching excellence, interprofessional education, and the process of devel-
oping clinical judgment in nursing practice and mentorship. She is past president of the Canadian
Association of Schools of Nursing and currently serves as a member of the Board of Governors of
the University of Saskatchewan.
Lucia Yiu
Lucia Yiu, RN, BScN, BA (Psychology, Windsor), BSc (Physiology, Toronto), MScN (Administration,
Western Ontario), is an Associate Professor in the Faculty of Nursing, University of Windsor, and an
Educational and Training Consultant in community nursing. She has authored various publications
on family and public health nursing. Her practice and research interests include multicultural health,
international health, experiential learning, community development, breast health, and program plan-
ning and evaluation. She has worked overseas and served on various community and social services
committees involving local and district health planning. Lucia was a board member for various com-
munity boards related to children’s mental health; community health centres; quality assurance; status
of women, equity, and diversity; occupational health, employment equity, and breast cancer. She is
currently a board member with CARE working with international educated nurses.

xii About the Canadian Editors
Lynnette Leeseberg Stamler

Lynnette Leeseberg Stamler began her nursing career with a BSN from St. Olaf College,
Northfield, Minnesota, USA. Her interest in patient teaching began within that program and inspired
her to complete an MEd degree from the University of Manitoba. Although she has worked in many
areas of nursing, she has always gravitated toward clinical areas where the relationship with patients
and families is essential—such as rehabilitation, long-term care, dialysis, and VON (visiting nursing).
After teaching in a diploma program at Red River College in Winnipeg, she completed her PhD in
nursing from the University of Cincinnati, where she was their third graduate. She has since taught
at the University of Windsor, Nipissing University/Canadore College Collaborative BSN program,
the University of Saskatchewan, South Dakota State University, and, currently, the University of
Nebraska Medical Center. She has been very active in the Canadian Association of Schools of Nursing
(CASN), serving as Treasurer and the first elected President who was not a Dean or Director. She is
also active in Sigma Theta Tau International. Her research and international work have focused on
aspects of education, from patient to health to nursing. In this spirit, she began work on Canadian
nursing textbooks, recognizing that this is one way to influence the next generation of nurses. She has
served as an accreditation site visitor. In 2011, her work was recognized when she was inducted as an
International Fellow in the American Academy of Nursing, one of eight Canadian nurses to hold that
distinction at that time.

Dedication
Madeleine Buck dedicates this edition to the Highlands Hope Umbrella,
an organization that brings together community, professional, and volunteer networks to
address the challenge of HIV-AIDS and related social problems in the Njombe region of
the Southern Highlands of Tanzania. The knowledge, skill, creativity, and dedication of
nurses, nursing students, and other members within the “umbrella” are truly commendable.
Linda Ferguson dedicates this edition to those nurses in professional practice

who contribute their knowledge and expertise to nursing students in teacher-led groups and
preceptored relationships across Canada. Their substantive and tacit knowledge of nursing
and their enthusiasm for the profession are inspiring to students, faculty, clients, and their
nursing colleagues.
Lucia Yiu dedicates this edition to her daughters, Tamara, Camillia, and Tiffany;
and especially to her students and nursing colleagues who have inspired her to strive for
excellence in nursing.
Lynnette Leeseberg Stamler dedicates this edition to the many

nurses who have taught and inspired her throughout her life to “pay it forward” to the nurses
of tomorrow. Together, we daily move mountains.
Audrey Berman dedicates this tenth edition to everyone who ever played a
part in its creation: to Barbara Kozier and Glenora Erb who started it all and taught me
the ropes; to the publishers, editors, faculty authors, contributors, reviewers, and adopters
who improved every edition; to the students and their clients who made all the hard work
worthwhile; and to all my family and colleagues who allowed me the time and space to make
these books my scholarly contribution to the profession.
Shirlee Snyder dedicates this edition to her husband, Terry J. Schnitter, for his
unconditional love and support; and to all of the nursing students and nurse educators she
has worked with and learned from during her nursing career.
Geralyn Frandsen dedicates this edition to her husband and fellow nursing
colleague Gary. He is always willing to answer questions and provide editorial support. She
also dedicates this edition to her children Claire and Joe and future son-in-law, John Conroy.

Preface
As the scope and pace of nursing and allied health know-
ledge continue to grow exponentially, one must ask what is
Organization
truly “fundamental” for a nurse to know and understand in For this fourth edition, we present seven units containing in
order to practice knowledgeably, morally, ethically, accurately, total 48 chapters—one less than our last edition, as we have
sensitively, and compassionately in both today’s and tomor- merged the chapter on “Self-Concept” (Chapter 45 in the
row’s health care delivery system. Within the context of the 3rd edition) with “Individual Care” (Chapter 12 in this edi-
current and future health care system, the fourth edition of tion). The material presented in this publication addresses
Fundamentals of Canadian Nursing: Concept, Process, and Practice foundational and fundamental knowledge and skills required
provides undergraduate nursing students with the fundamentals for a person entering the nursing profession. Building on the
strengths of our previous editions, we enhanced many features
they will require as they embark on their nursing careers. This
to ensure that our textbook is relevant and informative to
textbook aims to provide students with a broad and solid foun-
nurses across the country.
dation of knowledge about the health of individuals, families,
communities, and populations. Also included are the issues Unit 1—The Foundation of Nursing in Canada
that client populations face at varying points in time, as well (Chapters 1–6) introduces the nature of the nursing pro-
as the nursing care that is possible in health and illness situa- fession, from the history of nursing to its current practice,
tions, whether clients are situated at home, in the community, education, and research. Each chapter has been updated since
at a clinic, at an extended or palliative care facility, or in an our previous edition to reflect evolving trends and emer-
acute care setting. We hope that this text will serve as a “go to” ging issues, such as changes to nursing practice standards, the
increasing role of nurses as research consumers, the influx of
resource for students and practising nurses working in a wide
internationally educated nurses, moral distress in the work of
range of settings.
nurses, and the role of social media in nursing and health care,
With the goal of providing a fundamental understanding
among many other topics.
of what is required for contemporary professional nursing
practice in Canada, we built on the first three editions to Unit 2—Contemporary Health Care in Canada
ensure that we thoroughly addressed needed skills, such as (Chapters 7–16) includes discussions on health care practice
communication, critical thinking, clinical reasoning, decision in today’s multicultural environments. Concepts of health,
making, use of the nursing process, development of inter- illness, and wellness are addressed as well as the role nurses
personal and interprofessional relationships, teaching, leading can play in health promotion from an individual, family,
community and global perspective. This unit addresses foun-
and managing change, use of technology, and application
dational concepts related to Canada’s health care system and
of primary health care principles. We placed high import-
specific issues related to rural and remote health care, includ-
ance on such concepts as caring, wellness, health promotion,
ing Northern nursing.
disease prevention, complementary and alternative health
modalities, rural health, environmental and global health, Unit 3—Lifespan and Developmental Stages
multiculturalism, growth and development, nursing theories, (Chapters 17–20) describes concepts of growth and develop-
nursing informatics, nursing research and education, ethics, ment and outlines the various developmental stages and their
accountability, and advocacy. Furthermore, we highlighted specific health needs throughout the lifespan. Particular atten-
tion has been given to the issues facing the very young and
basic nursing care for clients across the lifespan from hospi-
older adults.
tal to community settings in the culturally diverse Canadian
health care system throughout. In all areas, we integrated the Unit 4—Integral Aspects of Nursing (Chapters
most recent literature and clinical best-practice guidelines. 21–27) describes the fundamental nursing tools required for
To ensure that our text reflects “pan-Canadian” issues practice, including critical thinking, clinical reasoning and
and practices, we enlisted reviewers and contributors from decision making, caring and communicating, the nursing pro-
across the country, representing different geographical per- cess, documenting and reporting, teaching and learning, and
spectives. We expended every effort to ensure that the level of leading and managing change. These tools provide a founda-
specificity and readability is appropriate for beginning nursing tion for competent nursing care.
students. We believe that this text will also provide a strong Unit 5—Nursing Assessment and Clinical
foundation for advanced nursing studies. Enjoy! STUDIES (Chapters 28–36) provides fundamental knowledge

Preface xv
to guide comprehensive health assessment, including vital ●● An emphasis on Clinical Reasoning—A discussion about
signs, and addresses integral components of care in relation the importance of clinical reasoning and the similarities
to pain assessment and management, hygiene, safety, medi- and differences between clinical reasoning and critical
cations, infection prevention and control, skin integrity and thinking now appear. “Clinical Reasoning” questions
wound care, and caring for perioperative clients. appear in several chapters to encourage readers to consider
Unit 6—Promoting Physiological Health the clinical context as a major factor in determining the
(Chapters 37–44) discusses such physiologic concepts as sen- specific priorities and approach to nursing care.
sory perception; sleep; activity and exercise; nutrition; fecal ●● REINSTATED Glossary of Key Terms—Previously, our
elimination; urinary elimination; fluid, electrolytes, and acid– glossary of key terms was available online; based on feed-
base balance; and oxygenation and circulation. back from users, we have reinstated the glossary as part of
Unit 7—Promoting Psychosocial Health the text so that users have ready access to such an import-
(Chapters 45–48) covers a wide range of areas that affect ant feature.
one’s health. Sexuality, spirituality, stress and coping, and loss, ●● The latest evidence in the “Evidence-Informed Practice”
grieving, and death are all areas that a nurse should consider (EIP) boxes—A thorough review of the literature was con-
to care effectively for a client. ducted for each chapter. Emphasis was placed on including
Following the book chapters is a Glossary in which key the results of systematic reviews and meta-analyses to
terms are defined. Two Appendices are provided near the ensure the highest level of evidence is contained in the
end of the book. They summarize important information chapters. The EIP boxes highlight Canadian studies.
about laboratory values, formulae, and vital signs.
●● A focus on the role of all Registered Nurses in clinical
leadership as a means of providing high-quality and safe
patient care.
What’s New in the 4th Edition ●● A focus on changes in the regulation of nurses in Canada,
including reference to the NCLEX-RN examinations for
●● NEW approach with adoption of a broader, less prelicensure.
scriptive approach to nursing diagnoses. This new edition
●● UPDATED all relevant national consensus guidelines relat-
encourages students and nurses to use their knowledge,
ed to nursing care are included in the relevant chapters.
experience, and critical thinking skills to generate diagnoses
or analyses. ●● ENHANCED Rationales for Nursing Care—All Skill
instructions and Clinical Guidelines were reviewed and
●● Inclusion of the Canadian Association of Schools of
revised to ensure that a rationale is provided for each rec-
Nursing Competencies Domains from the Nursing
ommendation to promote clarity and understanding.
Education Competencies Framework (CASN, 2014).
●● ENHANCED Pan-Canadian Perspective—Reviewers and
●● A stronger focus on the roles of nurses in interprofessional
contributors were selected from across Canada to ensure
collaboration in patient care.
that the textbook provides a relevant and comprehensive
●● A focus on “Environmental and Global Health Nursing”—A perspective on nursing care and issues facing nurses across
whole chapter is devoted to this important and fascinating the country.
topic.
●● ENHANCED Level of foundational knowledge—We took
●● All national patient safety consensus recommendations care to sustain the broad knowledge base provided by this
from Safer HealthCare NOW!, the Canadian Patient foundational “fundamentals” text; however, the depth and
Safety Institute, and Accreditation Canada have been inte- specificity of certain topics were updated and augmented
grated into relevant chapters. where required throughout the text.
●● Emphasis on continuity of care—To ensure that continu- ●● ENHANCED images and photos—Over 50 new colour
ity of care and home care considerations are addressed we photos have been added, mostly in the Skill boxes, to
have featured “Continuity of Care” segments in relevant enhance clarity and ensure that the most up-to-date equip-
chapters. ment appears.
●● Inclusion of Strength-Based Nursing model (Gottlieb,
2013) as a way to address patient care as well as nursing
leadership.

xvi Preface
Resources and Supplements

Student Resources CPRNE and NCLEX style. TestGen also allows for the
administration of tests on a local area network, to have the
Clinical Reference Cards
tests graded electronically, and to have the results prepared in
Each copy of the book is accompanied by a series of Clinical electronic or printed form.
Reference Cards, which are intended to serve as a handy refer-
PowerPoint Slides illuminate and build upon key concepts in
ence when engaged in clinical work. The contents include brief
the text.
summaries of such topics as the normal ranges of vital signs for
An Image Library provides electronic files of all the fig-
various age groups, common laboratory values, the Glasgow
ures, photos, and tables in the book.
Coma Scale, and the “10 Rights” of medication administration.
Online Resources Learning Catalytics
MyNursingLab Learning Catalytics is a “bring your own device” assessment

and classroom activity system that expands the possibilities
for student engagement. Using Learning Catalytics, you can
A revised MyNursingLab accompanies the new edition
deliver a wide range of auto-gradable or open-ended questions
of the text. MyNursingLab features a wealth of self-study
that test content knowledge and build critical thinking skills.
material and practice questions, including NCLEX-style quiz-
You can also manage student interactions by using
zes. Additional resources, such as Procedure Reviews and
Learning Catalytics to automatically group students for dis-
Skills Checklists, have been thoroughly reviewed and updated
cussion, teamwork, and peer-to-peer learning. Throughout
for the new edition.
the course, Learning Catalytics complements your instruction
by capturing student feedback and offering a range of data to
assess student understanding.
Instructor Resources Over 200 Canadian NCLEX-style questions are currently
The following instructor supplements are available for down- available through Learning Catalytics, including selected end-
load from a password protected section of Pearson’s online of-chapter questions from the new edition of Fundamentals of
catalogue: catalogue.pearsoned.ca. Navigate to your book’s Canadian Nursing.
catalogue page to view the complete list of available supple-
ments. See your local sales representative for details and
access. Learning Solutions Managers
The Instructor’s Manual includes lecture outlines and
Pearson’s Learning Solutions Managers work with faculty and
additional material to help instructors design effective classes
campus course designers to ensure that Pearson technology
for their students. The Instructor’s Manual includes unique
products, assessment tools, and online course materials are
Classroom and Clinical Activities geared towards students in
tailored to meet your specific needs. This highly qualified team
both degree (BScN) and diploma (PN) programs.
is dedicated to helping schools take full advantage of a wide
A Testbank is available in both Word and TestGen for-
range of educational resources, by assisting in the integration
mats. Pearson’s TestGen computerized Testbank is a powerful
of a variety of instructional materials and media formats.
program that enables instructors to view and edit existing
Your local Pearson Education sales representative can provide
questions, create new questions, and generate quizzes, tests,
you with more details on this service program.
examinations, or homework by searching and selecting ques-
tions in each chapter by a number of attributes including

Preface xvii
Acknowledgments
We wish to extend our sincere thanks to the many talented and ●● The two people who revised the end-of-chapter test ques-
committed people involved in the development of this fourth tions to make them NCLEX compliant: Joanne Jones,
edition. We are especially grateful to: Thompson Rivers University; and Elizabeth Brownlee,
●● The students and colleagues who provided valuable sug-
Northern College of Applied Arts and Technology.
gestions for developing this edition, in particular users who ●● The expert guidance and ongoing support from the editor-
alerted us to new practices or region-specific variations in ial and production teams at Pearson Canada: Kimberley
practice. Veevers, Daniella Balabuk, John Polanszky, Jessica Mifsud,
●● The Canadian contributors, who worked diligently to pro-
Avinash Chandra, Rohini Herbert, and many others who
vide content in their areas of expertise. worked scrupulously behind the scenes to help realize this
project.
●● The Canadian reviewers, who provided critical appraisal to
strengthen this text (listed on pages xviii). Madeleine Buck
●● The editors and contributors of the U.S. tenth edition for
Linda Ferguson
setting high standards for the book.

Canadian Reviewers
Catherine Linner Christine Castagne Ken Kustiak
St Clair College Memorial University of Grant MacEwan
Newfoundland
Manon Lemonde Jane Tyerman
University of Ontario Institute of Jacquie Bouchard Trent University
Technology Northern Lakes College
Paula Crawford
Katharine Hungerford Sharon Cassar George Brown
Lambton College Seneca College
Sandy Madorin
Joanne Gullison Crystal O’Connell-Schauerte Georgian College
New Brunswick Community Algonquin College
Amy Horton
College
Deborah Van Wyck Western University
Chris Sanders Dawson College
Monica Gola
Western University
Mary Anne Vanos York University
Shari Cherney Sheridan College
Diane Browman
George Brown College
Sharon Chin John Abbott College
Gail Orr Nipissing University
Kimberly Morency
Loyalist College
Margaret Verkuyl University of Manitoba
Heidi Holmes Centennial College
Dawn Inman-Flynn
Conestoga College
Nancy Flemming University of Prince Edward Island
Dwayne Pettyjohn Confederation College
Andrea Leatherdale
Camosun College
Jackie Bishop Centennial College
Karla Wolsky Centennial College
Lethbridge College

1
UNIT 1
Chapter The Foundation of

Nursing in Canada
Historical and
Contemporary
Nursing Practice*
Updated by
Professor and Associate Dean for Academic Programs
College of Nursing, University of Nebraska Medical Center
N
LEARNING OUTCOMES
After studying this chapter, you will be able to urses have traditionally
1. Discuss the range of people who provided nursing care in different composed the largest por-
periods in Canadian history. tion of health care workers
2. Compare different settings in which nursing care has been in Canada. As such, they have enabled
provided by Canadian nurses. and participated in shaping the Canadian
3. Explain the usefulness of nursing history for understanding current health care system and have made a sig-
practice issues. nificant impact on the health of individu-
4. Analyze the influence of changing social, political, and economic als, families, and communities. Although
conditions over time. public surveys identify nurses as the most
5. Describe the scope and standards of nursing practice. trusted of health care providers, gloomy
forecasts of massive nursing shortfalls
6. Outline the expanded nursing career goals and their functions.
persist. Nurses perceive their work as
7. Examine the criteria of a profession and the professionalization
being undervalued, while others deem
of nursing.
it too expensive in the face of persistent
8. Explain the functions of national and international nurses’
cost-cutting measures and concerns over
associations.
the viability of government-supported
health care and medical care. At the same
time, nurses struggle to articulate what
they actually do (Nelson & Gordon, 2006).
Nursing policymakers, educators, and
union leaders are challenged with defin-
ing and defending a unique role for nurses
among other health care professionals
and within a rapidly changing health care
*The author acknowledges the work of Drs. Jayne Elliott and Cynthia Toman in the
historical section. system (Villeneuve & MacDonald, 2006).
M01_KOZI2703_04_SE_C01.indd 1 17/03/17 10:37 AM

2 UNIT ONE The Foundation of Nursing in Canada
Historical Nursing Practice with other female workers. Analyzing nurses as agents
of the state allows us to ask in what ways they did (and
do) enable and influence larger social, political, and
In the past, Canadian nurses were on the front lines economic agendas through their participation in systems
during cholera, influenza, and polio epidemics, as they of health care. Knowledge of how nursing developed in
were for more recent outbreaks of contagious diseases, specific contexts or sets of circumstances permits nurses
such as the severe acute respiratory syndrome (SARS) to better understand their present situation and, particu-
outbreak in 2003 (MacDougall, 2007). They served in larly, to see how contemporary concerns might relate to
military medical units during the South African War, larger social-structural conditions.
World Wars I and II, the Korean War, and the Gulf War, Before the establishment of training schools in
leaving a rich heritage for Canadian nurses who continue Canada, women provided most of the nursing care either
to play important roles in international conflicts. Nurses for family members and acquaintances or for strangers in
and their work were critical to the rapid expansion in their communities. Some took on these roles as charitable
the number and size of hospitals, and nurses continue acts of kindness; others, self-identifying as nurses in the
to facilitate the spread and acceptance of medical tech- pretraining era, developed midwifery practices or hired
nology both within and outside hospitals. Since the late themselves out as “monthly” nurses to care for women in
nineteenth century, public health nurses have provided their homes for a month after childbirth (Young, 2004).
essential health and medical care to isolated populations First Nations women provided much-needed help to new,
in both rural and urban centres, a legacy taken up by white settler societies as they spread across the frontier—
street nurses caring for people on new frontiers. a history too long ignored because the skilled medical
As these situations suggest, nursing takes place within care provided by these women, particularly in midwifery
broad cultural, sociopolitical, and economic contexts and childhood diseases, was critical to the very survival
that also influence both its practitioners and its prac- of these new communities. Women who were members
tice. Nursing evolved similarly in most Western nations, of religious groups were also early skilled caregivers, dat-
partially shaped by societal events and such changes as ing back to the first group of European nuns who arrived
industrialization, urbanization, wars, cycles of economic in 1639 in what is now Quebec, with a mission to provide
depression and expansion, and the women’s movement. care for the bodies and souls of both settlers and native
Developments in scientific and technological knowledge inhabitants. These women cared for the sick and desti-
and the consolidation of Western medicine have changed tute where they landed (see figure 1.1) but many soon
conceptualizations of health and illness, as well as the followed the new immigrants west and founded hospitals,
meanings associated with them. Historical research con- some of which have survived into the present.
tributes to nursing knowledge in two main ways: (a) It
develops in-depth analyses of these complex relation-
ships, and (b) it creates enhanced understandings of the
past that inform both present and future situations.
Early historians of nursing focused primarily on
Hôtel Dieu, Quebec. From Gibbon, J., Mathewson, M. (1947). Three Centuries of Canadian
questions about professionalization, education, and lead-
ership, tending to see their history as a steady march of
progress through time. Although indebted to these writ-
ers who have preserved vast amounts of source material,
historians since the 1980s have examined the profes-
sion more critically—paying closer attention to issues
that complicate and add greater complexity to their
analyses. It is important, for example, to understand
who was considered a “nurse” and what nursing work
encompassed in a particular historical period. Answers
Nursing. Toronto: Macmillan Co. of Canada
to these questions are contingent on who was available

to work as a nurse, what status or value society attributed
to nurses’ (and women’s) work, and how nurses were
compensated for that work within a specific timeframe.
Inclusion of gender, race, ethnicity, and class in histori-
cal analyses raises important questions about the social
arrangements and relationships of power that shaped
who was included or excluded as a nurse. Although, for
the most part, nurses have worked as subordinates within
health care systems, they often held positions of privi- FIGURE 1.1 Arrival of the first three Augustinian sisters in
lege, increased social status, and respect in comparison Quebec, 1639.
M01_KOZI2703_04_SE_C01.indd 2 27/02/17 10:37 AM

Chapter 1 Historical and Contemporary Nursing Practice 3
Library and Archives Canada

FIGURE 1.2 Nuns at prayer, along with their patients, at an early Hotel Dieu hospital.
By the late nineteenth century, immigration, grow- Revolution in Quebec during the 1960s, in reaction
ing urbanization, and changing concepts around the to the hegemony of the church over French-Canadian
transmission and treatment of diseases contributed to society, brought in a period of rapid secularization with
the push for formally trained nurses. Early Canadian closer government control over institutions, eroding the
towns and cities were plagued by inadequate sanitation nuns’ authority within their institutions and shifting
and sewage systems. Waves of infectious diseases, such nursing education into the public sphere (Charles, 2003;
as typhus, influenza, and smallpox, regularly devastated Paul, 2005; Violette, 2005) (Figure 1.2). Both systems
both immigrant and native populations (Cassel, 1994). built on religious and cultural ideals of respectable femi-
Wealthy patrons initially established hospitals during the ninity that integrated contemporary ideas about scien-
late nineteenth century as philanthropic institutions that tific thinking with womanly, selfless devotion to duty and
served the increasingly visible “sick poor.” Measures to service.
improve and protect the delivery of food and water sup- The first official training school was established
plies, a gradual acceptance of germ theory in disease in St. Catharines, Ontario, in 1874 by Dr. Theophilus
transmission, and the availability of anesthesia all helped Mack. Over the next decades, the number of nurses
to increase confidence in the idea of scientific medi- rose dramatically from only 300 at the turn of the
cine. Although cures for many illnesses often lagged far twentieth century to 20 000 by the end of World War I
behind identification of causes, perceptions of increased (McPherson, 1996). Student nurses formed the major
therapeutic efficacy predisposed the better-off classes portion of the hospital workforce until the 1940s, with
to choose care in medical institutions over treatments the expectation that they would become self-employed
(including surgeries) in their homes. Hospital adminis- as private duty nurses outside the hospital on graduation.
trators increasingly relied on these paying patients to The apprenticeship training system was the predominant
offset the costs of caring for the poor (Gagan & Gagan, model of nursing education in both large and small
2002). Significantly, the advent of trained nurses lent hospitals across the country until the 1970s. Several
both efficiency and respectability to this shift toward universities did offer combined programs whereby it was
hospital care. possible to earn a degree in nursing, such as the first
Two main influences have shaped formally pre- degree program established at the University of British
pared nursing in Canada. The British system, associ- Columbia in 1919.The focus of these programs was
ated primarily with Florence Nightingale during the often on preparing nurses to be supervisors, educators,
mid-nineteenth century, has attracted the most historical and public health nurses.
attention, even if her vision for an independent nurs- Nursing became one of the few respectable opportuni-
ing force complementary to, and not dependent on, ties for paid work available to women in the first half of the
hospital administration was never fully realized. French- twentieth century. The vast majority of student placements
Canadian religious communities, which also contrib- in nursing schools were reserved for young, white women
uted significantly to the development of trained nurses, whose families could afford to do without their financial
blended religious and work life to own and manage hos- contribution, at least for the duration of their training.
pitals and training schools across the country. The Quiet Two men appear in the 1899 graduating class of Victoria
M01_KOZI2703_04_SE_C01.indd 3 27/02/17 10:37 AM

Library and Archives Canada/Canadian Nurses Association fonds
©Library and Archives Canada. Reproduced with the permission of Library and Archives Canada.
FIGURE 1.3 Ottawa General Hospital graduation 1912.
General Hospital in Halifax (Nursing Education in Nova

Scotia, n.d.), but men, in general, have remained vastly
underrepresented in the ranks of an occupation strongly
tied to the concept, promoted sometimes by nurses them-
selves, that nursing is women’s work (McPherson, 1996).
Despite the Canadian Nurses Association’s official policy
of nondiscrimination, in place since the 1940s, few black FIGURE 1.4 Aboriginal nurse with a patient at Blood Hospital,
nurses gained entrance to training programs until the Cardston, Alberta.
1970s (McPherson, 1996). In British Columbia, a few
nursing students of Asian background were admitted dur-
ing the late 1930s for the explicit purpose of nursing Poor health status (and subsequent rejection) of wartime
among their own ethnic communities. And in 1954, Jean recruits because of preventable and treatable illnesses
Cuthand Goodwill became the first Aboriginal woman in contracted in childhood, the devastating impact of the
Saskatchewan to graduate from nursing school, but again, influenza epidemic (1917–1918), and a high rate of tuber-
not until the 1970s was a concerted effort made to recruit culosis and venereal diseases among returning World War I
First Nations and Inuit students into nursing (McBain, soldiers in 1918 fuelled demands for increased government
2005) (see Figures 1.3 and 1.4). responsibility in matters of health. Specially trained nurses
Various professionalization movements throughout were dispersed into schools and homes across Canada,
the twentieth century also intensified debates over who in both urban and rural districts. Nurses, as women, met
was, or could become, a nurse. In the early decades, nurs- gendered expectations that they were the ideal people to
ing leaders attempted to distance skilled nursing work from bring the new “gospel of good health” to mothers and
domestic caregiving and midwifery. Following a success- their families. By helping to spread new scientific theories
ful campaign by physicians to gain control over medical of health, including those on social and mental hygiene,
practice, nurses sought to establish control over nursing nurses were responsible for Canadianizing new immigrants
through the standardization of educational curricula and through the promotion of white, middle-class, urban-based
the legal authority to credential graduates of recognized ideals of health, which they found that their clients some-
hospital-based training programs. Most provinces brought times could not, or would not, meet.
in nurse registration between 1910 and 1922, thus sepa- The Victorian Order of Nurses was founded in
rating trained nurses from others who used the title nurse 1897, but other organizations, such as the Margaret Scott
(Mansell, 2003). Newfoundland and Labrador nurses Nursing Mission in Winnipeg, the Alberta District Nursing
obtained registration in 1954, Northwest Territories nurses Service, the Newfoundland Outport Nursing and Industrial
in 1975, and Yukon nurses in 1992. Association (NONIA), and the Medical Service to Settlers
During the first half of the twentieth century, most in Quebec, emerged to meet these public health needs.
nurses worked in private duty after graduation, but chang- Several provincial divisions of the Canadian Red Cross
ing concepts in public health provided other opportunities. Society began outpost programs in isolated parts of their
Women’s groups were instrumental in pushing for reform, territories (Elliott, 2004; McKay, 2007; Penney, 1996;
particularly in maternal and child health, and initiated many Richardson, 1998; Rousseau & Daigle, 2000). The federal
services that provincial health authorities later took over. health department did not regularly supply nursing stations
M01_KOZI2703_04_SE_C01.indd 4 27/02/17 10:37 AM

Victorian Order of Nurses Canada

FIGURE 1.5 Three patients of Victorian Order of Nurses
(VON) cared for in their own homes. The VON still provides
community and home care services across Canada.
and nurses to First Nations and Inuit populations in the War (1899–1902), but they were not officially part of
sub-Arctic and Arctic regions of the country until after the Canadian military. With the formation of the first
World War II (McPherson, 2003; Meijer-Drees & McBain, permanent nursing service as part of the Canadian
2001). Together, these nurses brought much-needed health Army Medical Corps (CAMC) in 1904, civilian nurses
care to areas underserved by physicians, and they often became fully integrated into the Canadian armed forces
found they needed to undertake such tasks as midwifery, as soldiers, enlisting as lieutenants with the specially
stitching of wounds, or teeth pulling, for which they had created officer’s rank and title of nursing sister, serving
received little training (see Figures 1.5, 1.6, 1.7, and 1.8). under the supervision of higher-ranked matrons. During
Several small groups of civilian nurses volun- 1944, Matron-in-Chief Elizabeth Smellie became the
teered with the Canadian militia during the Northwest first woman in the world to rise to the rank of a full
Rebellion (1885), with the Northwest Mounted Police
during the Klondike Gold Rush (1898), and with the
British Expeditionary Force during the South African Gibson, J., Mathewson, M. (1947). Three Centuries of Canadian Nursing.
Gibson, J., Mathewson, M. (1947). Three Centuries
of Canadian Nursing. Toronto: MacMillan
Toronto: MacMillan
FIGURE 1.6 Well-baby clinic in Manitoba. FIGURE 1.7 District nurse at Old Pendryl Cottage, Alberta.
M01_KOZI2703_04_SE_C01.indd 5 27/02/17 10:37 AM

Wilberforce Red Cross Outpost & Historic House
University of Ottawa
FIGURE 1.9 Canadian civilian nurses with the British
Expeditionary Force in South Africa (1899–1902).
FIGURE 1.8 Red Cross Nurse Gertrude Leroy Miller discharg-

ing a patient from the nursing outpost at Wilberforce, Ontario,
in the 1930s.
colonel. Initially, nursing sisters were the only women to

serve in the military, and they readily filled every avail-
able position in the Canadian armed forces throughout
both World Wars—even creating long waiting lists to get
into the military. Canadian military nurses served with
the North Atlantic Treaty Organization (NATO) forces
in Europe during the 1950s and with the Allied Forces
during the Korean War (1950–1953), as well as with
peacekeeping forces during the 1990s and beyond.
At least 3141 nursing sisters served during World
War I and 4079 during World War II. They called them-
selves soldiers and understood their work as winning the
FIGURE 1.10 World War I Nursing Sister Mabel Lucas
war through the salvage of damaged men. They actively Rutherford (left) and three colleagues in their dress uniforms.
sought opportunities to move closer to the front lines,
readily accepting increased risk and danger as part of
the job. In both wars, some died as a result of enemy
action and military-related illnesses and accidents; two
were prisoners of war under the Japanese army in Hong
Kong for almost 2 years during World War II; others
were torpedoed, bombed, or strafed—and survived to
talk about the experiences. Some of them left personal
accounts of these experiences; some questioned the
contradictory values of caring and saving lives while
working in organizations designed for the destruction
of lives. The armed forces placed high value on the
knowledge and skills of nurses, reluctantly moving them
forward as they demonstrated better outcomes for the
soldiers under their care than less-trained personnel

could achieve. The military was adamant, however, that
nurses were temporary—only for the duration of the
war, regardless of what nurses preferred with regard to
their military careers (Toman, 2007) (see Figures 1.9, FIGURE 1.11 World War II Nursing Sister Dorothy Macham
1.10, and 1.11). attending to a wounded soldier.
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During the 1930s, the private duty market for nurses

shrank because of both an oversupply of graduate nurses Contemporary Nursing
and the widespread economic depression that left at least
30% of the Canadian population unemployed. A boom
Practice
in hospital construction and the growing use of medical
An in-depth study of contemporary nursing practice
technologies, among other factors, increased the need for
includes a look at selected definitions of nursing, a frame-
nurses again, precipitating a nursing shortage that contin-
work for the Canadian health system, the goals of the
ued into the 1970s. The nursing leadership campaigned
nurse within this system, the acts that legislate health
to move nurses’ training into educational institutions and
care and nursing practice, and the scope and standards
gradually weaned hospital administrators from depending
of practice. This chapter will concentrate on definitions
on student labour, opening up further employment oppor-
and the goals and roles of nursing. Currently, four legis-
tunities for graduate nurses within hospitals. Although
lated categories of nursing exist in Canada: (a) Licensed
hospitals soon became the preferred employer for nurses,
(Registered) Practical Nurses, (b) Registered Nurses, (c)
the shortage was so great that hospitals had to make sub-
Registered Psychiatric Nurses, and (d) Nurse Practitioners
stantial changes in the workplace to attract new students
(Extended Class). Each has a scope of practice legislated
for training and married nurses back into the workforce.
within a province or territory. For the Canadian health
Due to nursing shortages, Nursing Assistants (CNAs) were
care system, see Chapter 9, and for legal issues, see
created to assist RNs in hospitals.
Chapter 6.
Changes in medical and surgical therapeutics were
central forces in defining the nature and scope of nursing
practices. By accepting delegated medical tasks, nurses
have been instrumental in facilitating the spread and Definitions of Nursing
acceptance of many technologies that range from ther- To understand what nursing is, we must first define the
mometers in the early twentieth century, through routine word. Many definitions exist, some of which misrepresent
blood tests in the 1940s and 1950s, to the complex sys- the complex knowledge and skill of professional nursing.
tems of medical monitoring in place today (Sandelowski, Common dictionary definitions, for example, still refer to
2000; Toman, 2001). An increasingly specialized nursing the nurse as “a person, usually a woman, trained to care
workforce has resulted in a hierarchical relationship for the sick” (Cayne, 1988). Today, however, many men
among nurses and between nurses and lesser-skilled aux- are choosing to become nurses, and nurses also provide
iliary workers, whose positions emerged initially to help preventive and health-promoting care to well clients.
address the shortage of trained nurses. This section provides several definitions of nursing, and
Each of these issues lies within a body of histori- Chapter 4 provides other definitions created by nursing
cal research that offers alternative perspectives through theorists.
which we can question who and what is determining In 1860, Florence Nightingale described nursing as
today’s nursing practice. On the one hand, the wider the “use of fresh air, light, warmth, cleanliness, quiet
socioeconomic and political milieu has shaped nurses and the proper selection and administration of diet”
and their work; on the other hand, nurses have partici- (Nightingale, 1938, p. 8). She considered a clean, well-
pated in shaping the health care system and the role of ventilated, and quiet environment essential for recovery
nursing within it. Curiosity about the roots of the nursing from illnesses. Often considered the first nurse theorist,
profession has merit in itself, but many would argue that Nightingale raised the status of nursing through educa-
the value of nursing history lies in its relevance to cur- tion. Nurses were no longer untrained housekeepers but
rent issues in professional practice. Much more research persons educated in the care of the sick.
is needed, for example, on the history of registered Virginia Henderson was one of the first modern
psychiatric nursing programs and how the baccalaureate nurses to define nursing. In 1960, she wrote: “The unique
degree as entry to practice has affected perceptions of function of the nurse is to assist the individual, sick or
nursing work among nurses themselves and the wider well, in the performance of those activities contributing
society. Hospital-based training and work environments to health or its recovery (or to peaceful death) that he
tried to standardize nurses, nurses’ knowledge, and nurs- would perform unaided if he had the necessary strength,
ing care, creating the illusion of a homogeneous nurs- will, or knowledge, and to do this in such a way as to
ing workforce while devaluing the vast diversity among help him gain independence as rapidly as possible”
people performing nursing work. A more critical analysis (Henderson, 1966, p. 3). Like Nightingale, Henderson
of the roles of gender, class, race, and ethnicity, and the described nursing in relation to the client and the client’s
way these factors have worked to include or exclude environment. Unlike Nightingale, Henderson saw the
those wanting to enter the profession, is necessary to nurse as concerned with both well and ill individuals,
understand who became nurses in Canada and how acknowledged that nurses interact with clients even when
these influences still shape who become nurses in today’s recovery may not be feasible, and mentioned the teach-
multicultural health care context. ing and advocacy roles of the nurse.
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Professional nursing associations have also examined Recipients of Nursing

nursing and developed their definitions of it. In 1987,
the Canadian Nurses Association (CNA) described nurs- Nurses work with many and varied recipients of care.
ing practice as a dynamic, caring, helping relationship in The recipients can be individuals, families, groups, com-
which the nurse helps the client to achieve and maintain munities, and populations. Even when planning and
optimal health (CNA, 1987). Many countries have cho- implementing care to various recipients, it is important
sen to use the International Council of Nurses (2015) for the nurse to recognize that these recipients live within
definition: a larger society—for instance, individuals are connected
to families, groups live in the community, and multiple
Nursing encompasses autonomous and collab- communities exist within a given population. Groups are
orative care of individuals of all ages, families, collections of individuals with a shared goal or purpose,
groups and communities, sick or well and in and communities may be defined by geography, culture,
all settings. Nursing includes the promotion of or other characteristics.
health, prevention of illness, and the care of ill, In this book, we have generally identified the recipi-
disabled, and dying people. Advocacy, promotion ent of care as the individual (see Chapter 12). We have,
of a safe environment, research, participation in however, also provided some beginning information on
shaping health policy and in patient and health families and working with families in providing nursing
systems management, and education are also key care (see Chapter 13). When referring to individuals who
nursing roles (ICN, 2015b). are receiving nursing care, the literature refers to them
as consumers, patients, residents, or clients and by other
In the latter half of the twentieth century, a number terms. A consumer is an individual, a group of people,
of nurse theorists developed their own theoretical defini- or a community that uses a service or commodity. People
tions of nursing. Theoretical definitions are important who use health care products or services are consumers
because they go beyond simplistic common definitions. of health care.
They describe what nursing is and the interrelationship A patient is a person who is waiting for or undergo-
among nurses, nursing, the environment, the client, and ing medical treatment and care. The word patient comes
the intended client outcome—health. See Chapters 4 from a Latin word meaning “to suffer” or “to bear.”
and 23. Several themes are common to all the various Traditionally, the person receiving health care has been
definitions of nursing (see Box 1.1). called a patient. Usually, people become patients when
Caring is described as the “essence of nursing” they seek assistance because of illness or for surgery.
(Leininger, 1984). It is a complex concept that has mul- Some nurses believe that the word patient implies pas-
tiple aspects: affective, cognitive, and ethical. Research sive acceptance of the decisions and care of health care
to explore the meaning of caring in nursing has been professionals. Additionally, with the emphasis on health
increasing because nursing, more than any other profes- promotion and prevention of illness, many recipients of
sion, has “the distinction of being responsible for the nursing care are not ill persons. Moreover, in addition
caring that clients receive in the health care system” to caring for patients, nurses interact with family mem-
(Miller, 1995, p. 29). Details about caring are discussed in bers and significant others to provide support, informa-
Chapter 22. See also Watson’s assumptions of caring in tion, and comfort. See Evidence-Informed Practice for a
Box 4.2 in Chapter 4 (see page 59). recent study with patients in a hospital setting.
For the reasons mentioned above, nurses also refer
to recipients of health care as clients. A client is a person
who engages the advice or services of another who is
BOX 1.1 THEMES COMMON TO DEFINITIONS qualified to provide this service. The term client presents
Although several different definitions of nursing have the receivers of health care as collaborators in the care,
been made over the years, they do share some that is, as people who are also responsible for their own
common themes: health. Thus, the health status of a client is the respon-
• Nursing is caring. sibility of the individual that is met in collaboration with
• Nursing is an art. health care professionals. In this book, we have generally
used the term patient to describe the individual admitted
• Nursing is a science.
to an acute care facility or otherwise seeking care, the
• Nursing is client centred.
term resident for an individual cared for in a long-term
• Nursing is holistic. care facility, and the term client to describe recipients of
• Nursing is adaptive. nursing care in other settings. The topics discussed in
• Nursing is concerned with health promotion, health this book are often equally applicable to clients, patients,
maintenance, and health restoration. and residents. When this is the case, readers may see ref-
• Nursing is a helping profession. erences to more than one recipient of care in the same
paragraph.
M01_KOZI2703_04_SE_C01.indd 8 02/03/17 1:01 PM

include immunizations, prenatal and infant care, and pre-

EVIDENCE-INFORMED vention of sexually transmitted infections.
PRACTICE RESTORING HEALTH Restoring health focuses on the
Pain experienced by patients has long been studied, but ill client, and it extends from early detection of disease
no clear consensus has been reached on the results of the through helping the client during the recovery period.
studies or the proposed strategies. In this study, all eligible Examples of nursing activities focused on restoring health
patients in the clinical areas of cardiology, medicine, and include the following:
surgery in 12 hospital units were visited within a 4-hour
period to assess their pain experience. Of the 65% who • Providing direct care to the ill person, such as adminis-
responded, 70.4% indicated they had pain at that time. tering medications, baths, and specific procedures and
Although the duration, anatomic location, and severity of treatments
pain varied across the patients, almost all (92%) indicated
that hospital staff had assessed their pain within the previ- • Performing diagnostic and assessment procedures, such
ous 8 hours. Gender and age differences were noted in the as measuring blood pressure and examining feces for
responses. The study patients also indicated that their pain occult blood
interfered with their activities, to varying degrees. Although • Consulting and working collaboratively with other
this study did not consider the problem of memory in that
health care professionals about client problems
it only asked for the pain experience “right now,” it is clear
that pain remains a multifactorial experience that is difficult • Teaching clients about recovery activities, such as exer-
to describe and treat. cises that will accelerate recovery after a cerebrovascular
CLINICAL IMPLICATIONS: Health care organizations accident (stroke)
that desire to create a culture where pain assessment • Rehabilitating clients to their optimal functional level
and treatment are expected and valued will need to following physical or mental illness, injury, or chemical
first acknowledge that pain is a real issue for many addiction
patients.
CARING FOR THE DYING This area of nursing practice
Source: Jabusch, K. M., Lewthwaite, B. J., Mandzuk, L. L., Schnell-Hoehn, K. N.,
& Wheeler, B. J. (2015). The pain experience of inpatients in a teaching hospital: involves comforting and caring for people of all ages who
Revisiting a strategic priority. Pain Management Nursing, 16(1), 69–76. are dying. It includes helping clients be as comfortable as
possible until death and helping the support people cope
with death. Nurses carrying out these activities work in
homes, hospitals, and extended care facilities. Some agen-
cies, called hospices, are specifically designed for this purpose.
Scope of Nursing See Chapter 48 for further discussion.
Nursing practice involves four areas: (a) promoting health
and wellness, (b) preventing illness, (c) restoring health, and
(d) caring for the dying. Within each of these areas, nurses
Nursing Numbers and Settings
seek to articulate and follow best practices in terms of the Canada has four categories of regulated nurses: (a) reg-
care they provide. Various chapters of this book relate to istered nurses (RNs), (b) licensed (registered) practi-
each of the areas of nursing practice. The Registered Nurses’ cal nurses (LPNs/RPNs), (c) Nurse Practitioners (NPs),
Association of Ontario has led the way in developing a (d) registered psychiatric nurses (RPNs) (see Box 1.2 for
series of best practices documents (see the Weblinks section definitions of each category of regulated nurses). The
in this chapter). Reference to appropriate best practices docu- Canadian Institute for Health Information reported that
ments can be found in the chapters throughout the book. Canada had a supply of 415 864 regulated nurses in
2015. Of these, RNs numbered 296 731 practical nurses
PROMOTING HEALTH AND WELLNESS “Wellness is a
113 367 and psychiatric nurses 5766. The RN num-
process that engages people in activities and behaviors that
bers include 4353 nurse practitioners (NPs) (Canadian
enhance quality of life and maximize personal potential”
Institute for Health Information [CIHI], 2016). The
(Anspaugh, Hamrick, & Rosata, 2003, p. 490). Nurses pro-
acute care hospital remains the primary practice set-
mote wellness in clients who are healthy as well as those
ting. In 2014, approximately 63.3% of RNs, 47.2% of
who are ill. This promotion may involve individual and
LPNs/RPNs, and 38.8% of NPs worked in hospitals.
community activities to enhance healthy lifestyles, such as
The remainder worked in clients’ homes; community
improving nutrition and physical fitness, preventing prob-
agencies, including long-term care facilities; ambulatory
lematic drug and alcohol use, smoking cessation, and pre-
clinics; and nursing practice centres (CIHI, 2016). The
venting accidents and injury in the home and workplace.
CIHI also noted that the supply of RNs declined by 1%
See Chapters 8 and 14 for further discussion.
in 2014 but increased by 1.2% in 2015; the numbers of
PREVENTING ILLNESS The goal of illness-prevention LPNs and RPNs had slower growth. In addition, per-
programs is to maintain optimal health by preventing haps as a function of the aging of the “baby boomer”
disease. Examples of nursing activities that prevent illness generation, fewer (30 897) new nurses registered for the
M01_KOZI2703_04_SE_C01.indd 9 02/03/17 9:35 AM

BOX 1.2 DEFINITIONS AND ROLES first time, compared with those who allowed their reg-
istration to lapse (22 534). This pattern may has strong
OF CATEGORIES OF NURSES
significance for future health care delivery in Canada.
Registered nurses (RNs, including NPs) work both autono- Figure 1.12 shows nurses in a variety of settings.
mously and in collaboration with other health care providers Nurses have different degrees of nursing autonomy
to coordinate health care, deliver direct services, and sup- and nursing responsibility in the various settings. They
port clients in their self-care decisions and actions in health,
may provide direct care, engage in health teaching for
illness, injury, and disability in all stages of life. RNs are cur-
diverse individuals and groups, serve as nursing advo-
rently regulated in all 10 provinces and three territories.
Nurse practitioners (NPs) are RNs with additional educates and agents of change, and help determine health
cational preparation and experience. NPs may order and policies affecting consumers in the community and in
interpret diagnostic tests; prescribe pharmaceuticals, medi- hospitals.
cal devices, and other therapies; and perform procedures. The CNA maintains that an individual’s health
NPs are currently regulated in all 10 provinces and three affects the quality of that person’s life. Health is influ-
territories. enced not only by the health care system but also by
Registered psychiatric nurses (RPNs) work both autono- human biology, lifestyle choices, and the environment.
mously and in collaboration with clients and other health With this in mind, the CNA advocates a framework to
care team members to coordinate health care and provide provide direction for the Canadian health care system
client-centred services to individuals, families, groups,
that includes (a) the conditions of the Canada Health Act
and communities. RPNs focus on mental and develop-
and (b) the principles of primary health care.
mental health, mental illness, and addictions while inte-
grating physical health into their care. RPNs are currently The Canada Health Act (1984) lists the conditions
and recognized in the four western provinces (Manitoba, or national standards that provincial and territorial
Saskatchewan, Alberta, and British Columbia) and the terri- health insurance plans must respect to be able to receive
tory of Yukon. federal cash contributions: public administration, acces-
Licensed practical nurses (LPNs) work independently sibility, comprehensiveness, universality, and portability.
or in collaboration with other members of a health care The CNA believes that these conditions are essential to
team. LPNs assess clients and work in health promotion Canada’s health care system.
and illness prevention. They assess, plan, implement, and
evaluate care for clients. LPNs are currently regulated in all 1. Public administration means that federal, provincial, and
10 provinces and three territories. territorial health insurance programs should be non-
profit programs operated by public authorities who are
Source: Excerpt from Regulated Nurses: 2014. Copyright © by Canadian Institute for
Health Information. Used by permission of Canadian Institute for Health Information. appointed by government.
© Elena Dorfman/Addison Wesley/Pearson Education, Inc.
FIGURE 1.12 Nurses practise in a

variety of settings. Clockwise from
left: Pediatric nursing, operating
room nursing, geriatric nursing, home
nursing, and community nursing.
M01_KOZI2703_04_SE_C01.indd 10 27/02/17 4:38 PM

2. Accessibility means that Canadians have reasonable options for accessing health care services by (a) acting
access to essential health care services, with no financial as an entry point for clients into the health care system,
barriers, such as user fees, to impede this access. (b) providing nursing care and treatment for health prob-
3. Comprehensiveness means that federal and provincial or lems, (c) helping clients identify and use health resources,
territorial health insurance together should cover the both formal and informal, and (d) acting as a source of
full continuum of health care services for all Canadians, health information for clients (CNA, 1995).
including health promotion, the prevention of disease Nurses increase public participation in planning and
and disability, the treatment of disease and disability, making decisions about health care by (a) involving cli-
restoration, rehabilitation, and support. ents in decisions about their own health, (b) encouraging
clients to take action for their own health, (c) involving
4. Universal coverage means that all Canadians are entitled
clients in identifying their own health care needs, (d)
to essential health care services, regardless of gender,
involving clients in planning, using, and evaluating their
culture, income, language, education, marital status,
own health care services, and (e) encouraging and using
or age.
community development approaches (CNA, 1995).
5. Portability means that Canadians should be covered
equally for health care services wherever they are in
Canada (Canada, House of Commons, 1984). (See Health Promotion
Chapter 9 for more information on Canada’s health In keeping with a health-system focus that helps clients
care system.) stay well, nurses are able to play a leadership role in
health promotion and initiate health education and other
activities that assist, promote, and support clients as they
Primary Health Care strive to achieve their highest possible level of health.
Primary health care is essential (promotive, preventive, Health promotion implies a commitment to dealing
curative, rehabilitative, and supportive) care that focuses with challenges to health, including reducing inequities,
on preventing illness and promoting health. It is both a extending the scope of prevention, and helping people
philosophy of health care and an approach to providing cope with their circumstances. In keeping with the prin-
health care services. Primary health care has been adopted ciples of primary health care outlined above, it means
by the World Health Organization (WHO) and by Canada fostering public participation, strengthening community
as the key to a healthy society. Clients of primary health health services, and coordinating public health policy.
care can be individuals, families, groups, communities, and Moreover, it means creating environments conducive to
populations (CNA, 2005, 2012; WHO, 1982). health, in which people are better able to take care of
themselves and to offer one another support in solving
PRIMARY CARE AND PRIMARY NURSING Primary
and managing collective health problems.
health care should not be confused with primary care or
Health status is influenced by social norms; cultural
primary nursing. Primary care is provider driven and is the
values; economic and environmental conditions and
entry point to the health care system. Primary nursing is
policies; and life practices, such as food and exercise
a system of delivering nursing services whereby a nurse
choices, the following of safety precautions, and the
is responsible for planning the 24-hour care of a specific
problematic use of tobacco, alcohol, and other sub-
patient. Both these concepts are illness-oriented concepts.
stances. Health-promotion initiatives must be widely
For more information on primary health care and primary
targeted, beginning with the very young, and extending
care, see Chapter 14.
throughout the lifespan. Nurses must provide leadership
for health promotion and addressing the determinants
of health (CNA, 2009). This guiding should be done
The Role of the Nurse through positive role modelling and personal demon-
The goal of nursing is to improve the health of clients stration of healthy life practices, as well as by assisting,
through partnerships with clients, other health care pro- promoting, and supporting clients, individuals, groups,
viders, related community agencies, and government. and communities through nursing interventions so that
Nursing practice involves a variety of roles, including they understand and achieve the highest possible level
direct care provider, educator, administrator, consultant, of health.
policy adviser, and researcher. The principles of primary In cooperation with clients, with each other, with
health care apply to nurses in all these roles (CNA, 2005). professionals from other sectors, and with governments,
Nurses are encouraged to examine their own practice nurses coordinate client care and strive to integrate health
and places of work in light of the pillars of the Canada care services. Nurses participate with clients in designing
Health Act and the principles of primary health care public health policies and will continue to do so to achieve
(CNA, 2005, 2012). health for all. Nurses will continue to work with clients and
To ensure that Canadians have reasonable access other health care providers to implement the principles of
to essential health care services, nurses provide more primary health care (CNA, 2005, 2012).
M01_KOZI2703_04_SE_C01.indd 11 27/02/17 10:37 AM

Nurse Practice Acts Differences in the regulation of professionals in

Canada can often be traced to the differences in provin-
Nurse practice acts, or legal acts for professional nursing cial and territorial legislation. Usually, licensed practical
practice, regulate the practice of nursing in Canada and nurses (LPNs), who are called registered practical nurses
other countries. Because health is a provincial/territo- (RPNs) in Ontario, and registered psychiatric nurses are
rial responsibility, each province and territory in Canada regulated under legislation separate from that for reg-
has its own act for each of the regulated nursing groups. istered nurses. Some provinces regulate more than one
Although nurse practice acts differ in various jurisdic- profession in a single legislative act. Nonregulated work-
tions, they all have a common purpose—to protect the ers such as care aides also work in the health care system.
public. See Chapter 6 for additional information on See Chapter 6 for more information on legislation.
scopes of practice and nurse practice acts.
One of the ways that the public is protected is through
regulation of the profession. The primary purpose of Nursing Practice Standards
regulation is to “assure the public that they are receiving Nursing practice standards are mandatory for a self-
safe and ethical care from competent, qualified registered regulating profession. “A standard is a desired and
nurses” (CNA, 2007b, p. 1). Professions can be regulated achievable level of performance against which actual per-
in one of two ways: (a) by the government or (b) by the formance can be compared. Standards for nursing
profession itself. In Canada, in all the provinces and ter- practice reflect the philosophical values of the profes-
ritories, self-regulation is in place for registered nurses, sion, clarify what the registered nursing profession expects
licensed or registered practical nurses, and registered psy- of its members, and inform the public of the minimal
chiatric nurses. In some jurisdictions, it is the professional level of acceptable practice of registered nurses. These
association that is the self-regulatory body, whereas in standards apply to every setting and provide a benchmark
other jurisdictions, it is a specific and separate regulatory for the basic level of safe registered nursing practice. . .”
body. Self-regulation means that the provincial and territo- (Saskatchewan Registered Nurses’ Association [SRNA],
rial governments delegate to professional bodies, through 2007, p. 4). Each jurisdiction and regulatory body compiles
legislative acts, the power to determine who may enter and its own nursing standards in conjunction with the legisla-
remain in the profession and under what circumstances. tion governing nursing practice in that jurisdiction for that
Self-regulation is a privilege granted by governments to group of nurses (e.g., licensed practical nurses, registered
professional or regulatory organizations. One way in which practical nurses, registered psychiatric nurses, nurse practi-
nurses in Canada are regulated is through title control. tioners) (see Chapter 6).
“The use of such titles as ‘registered nurse,’ ‘RN,’ and
‘nurse’ is protected by legislation. Only individuals who
are currently registered with a nursing regulatory body
may use these titles” (CNA, 2007b, p. 1). Similarly, prac- Roles and Functions
tical nurses and psychiatric nurses in Canada have title
protection. Nurse practitioners are also regulated by the of the Nurse
provincial and territorial regulatory bodies.
Nursing associations, including the International Nurses assume a number of roles when they provide care for
Council of Nurses, the CNA, and the provincial and ter- clients. Often, nurses carry out these roles concurrently. For
ritorial professional regulatory associations work together example, the nurse may act as a counsellor while providing
to develop frameworks for regulatory matters, such as physical care and the health education aspects of that care.
standards of practice, scope of practice, and continuing The roles required at a specific time depend on the needs
competence. Standards of practice “reflect the values of the of the client and the aspects of the particular environment.
nursing profession, clarify what the profession expects Some of the roles of nurses are described below.
of its members, define the expectations of the public or
employers, and provide a benchmark below which per-
formance is unacceptable” (CNA, 2001, p. 6). The scope
Caregiver
of practice refers to the activities that RNs are educated The caregiver role has traditionally included those activi-
and authorized to perform as set out in legislation and ties that assist the client physically and psychologically
complemented by standards, guidelines, and policy posi- while preserving the client’s dignity. The required nurs-
tions of provincial and territorial nursing regulatory bod- ing actions may involve full care for the completely
ies (CNA, 2007a, p. 13). Continuing competence, as defined dependent client, partial care for the partially dependent
by the CNA and the Canadian Association of Schools client, and supportive–educative care to assist clients in
of Nursing (CASN), is “the ongoing ability of a nurse to attaining their highest possible level of health and well-
integrate and apply the knowledge, skills, judgment and ness. Caregiving encompasses the physical, psychosocial,
personal attributes required to practice safely and ethi- developmental, and spiritual levels. A nurse may provide
cally in a designated role and setting” (CNA, 2004, p. 1). care directly or delegate it to other caregivers.
M01_KOZI2703_04_SE_C01.indd 12 02/03/17 9:36 AM

Communicator clinical care, if it is not helping a client return to health.

Technological changes, changes in the age of the client
Communication is integral to all nursing roles. Nurses population, and changes in medications are just a few of
communicate with clients and their support people, other the changes nurses deal with daily. See Chapter 27 for
health care professionals, and people in the community. additional information about change.
The quality of a nurse’s communication is an important
factor in nursing care. The nurse must be able to com-
municate clearly and accurately so that a client’s health Leader
care needs are met. (See Chapters 6 and 22.)
The leadership role can be employed at different levels:
individual client, family, groups of clients or colleagues,
Educator or the community. Effective leadership is a learned pro-
cess requiring an understanding of the needs and goals
As a health teacher, the nurse helps clients learn about that motivate people, the knowledge to apply the lead-
health and the health care procedures they need to ership skills, and the interpersonal skills to influence
perform to restore or maintain health. In collaboration others. All nurses are leaders and participate in both
with the client, the nurse determines the client’s learning informal and formal leadership roles. The leadership
needs and readiness to learn, sets specific learning goals role of the nurse is discussed in Chapter 27.
and teaching strategies, implements teaching strategies,
and evaluates learning. Nurses also teach other health
care providers to whom they delegate care, and they Manager
share their expertise with other nurses and health care
professionals. See Chapter 26 for additional details about Every nurse manages the nursing care of individuals,
the teaching and learning processes. families, or communities. The nurse manager, a formal
leadership role, also delegates nursing activities to ancil-
lary workers and other nurses, and supervises and evalu-
Client Advocate ates their performance. Managing requires knowledge
about organizational structure and dynamics, authority
A client advocate acts to protect the client. In this role, and accountability, leadership, change theory, advocacy,
the nurse may represent the client’s needs and wishes delegation, supervision, and evaluation. See Chapter 27
to other health care professionals, such as relaying the for additional details.
client’s request for information to a member of the
health care team. They also assist clients in exercising
their rights and help them advocate for themselves. See Case Manager
Chapter 5.
Nurse case managers work with multidisciplinary health
care teams to coordinate care, measure the effectiveness
Counsellor of case management plans, and monitor outcomes. Each
agency or unit specifies the role of the case manager.
Counselling is the process of helping a client recognize
and cope with stressful psychological or social problems,
develop improved interpersonal relationships, and pro- Research Consumer
mote personal growth. It involves providing emotional,
intellectual, and psychological support. In contrast to the Nurses often use research to improve client care. In a
psychotherapist, who counsels individuals with identified clinical area, nurses need to (a) have some awareness
problems, the nurse counsels primarily healthy individu- of the process and language of research, (b) be sensi-
als who are experiencing normal adjustment difficulties. tive to issues related to protecting the rights of human
The nurse focuses on helping the person develop new subjects, (c) participate in the identification of significant
attitudes, feelings, and behaviours, rather than on pro- researchable problems, and (d) be a discriminating con-
moting intellectual growth. The nurse encourages the sumer of research findings (see Chapter 3).
client to look at alternative behaviours, recognize the
choices, and develop a sense of control.
Expanded Career Roles
Nurses are fulfilling expanded career roles, such as those
Change Agent of nurse practitioner, clinical nurse specialist, nurse mid-
The nurse acts as a change agent when assisting clients wife, nurse administrator, nurse educator, and nurse
to make modifications in their own behaviour. Nurses researcher, that allow greater independence and auton-
also often act to make changes in a system, such as omy. See Box 1.3.
M01_KOZI2703_04_SE_C01.indd 13 27/02/17 10:37 AM

BOX 1.3 SELECTED EXPANDED CAREER ROLES FOR NURSES

NURSE PRACTITIONER prenatal and postnatal care and manages deliveries in
normal pregnancies. The midwife practises in association
A nurse practitioner is a registered nurse who has an advanced
with a health care agency and can obtain medical services
education and is a graduate of a nurse practitioner program.
if complications occur.
Nurses can be primary health care nurse practitioners who
work with clients of all ages or can specialize in a single area or
NURSE ADMINISTRATOR
client age group.
The nurse administrator manages client care, including the
CORE COMPETENCIES delivery of nursing services. The administrator may have a
1. Professional Role, Responsibility, and Accountability middle-management position, such as nurse manager or
a. Clinical Practice supervisor, or a more senior management position, such as
director of nursing services. The functions of nurse adminis-
b. Collaboration, Consultation, and Referral
trators include budgeting, staffing, and planning programs.
c. Research The educational preparation for nurse administrator positions
d. Leadership is at least a baccalaureate degree in nursing and frequently a
2. Health Assessment and Diagnosis master’s or doctoral degree.
3. Therapeutic Management
NURSE RESEARCHER
4. Health Promotion and Prevention of Illness and Injury
(CNA, 2010) Nurse researchers investigate nursing problems to improve
nursing care and to refine and expand nursing knowledge.
CLINICAL NURSE SPECIALIST They are employed in academic institutions, teaching hospi-
The clinical nurse specialist is a registered nurse or registered tals, and research centres. Nurse researchers usually have
psychiatric nurse who has an advanced degree or expertise in a advanced education at the doctoral level.
specialized area of practice (e.g., gerontology, oncology, mental
health, primary health care) and provides direct client care, edu- NURSE EDUCATOR
cates others, consults, conducts research, and manages care. Nurse educators are employed in nursing programs, at
educational institutions, and in hospital or institutional
NURSE MIDWIFE
(e.g., long-term care) staff education. Many have advanced
The nurse midwife is a registered nurse who has completed degrees in nursing or education.
a program in midwifery and is certified. The nurse gives
Nursing as a Profession current knowledge. Although not all professional orga-

nizations use the same criteria for identifying a profes-
sion, most include that a profession has a formal base of
Nursing is acknowledged as a profession. A profession knowledge, requires significant educational preparation
has been defined as an occupation that requires extensive to be admitted to the profession, maintains control over
education or a calling that requires special knowledge, the standards by which new applicants are evaluated,
skill, and preparation. A profession is generally distin- uses the knowledge for the direct benefit of the public,
guished from other kinds of occupations by (a) its require- is self-regulating, and maintains a code of ethics (Ross-
ment of prolonged, specialized training to acquire a body Kerr, 2003). See Chapter 5 for more information on the
of knowledge pertinent to the role to be performed, and codes of ethics for nursing.
(b) an orientation of the individual toward service, either
to a community or to an organization. The standards of
education and practice for the profession are determined
by the members of the profession, rather than by outsid-
Criteria of a Profession
ers. The education of the professional involves a com- BODY OF KNOWLEDGE As a profession, nursing is estab-
plete socialization process, more far-reaching in its social lishing a well-defined body of knowledge and expertise.
and attitudinal aspects and its technical features than is A number of nursing conceptual frameworks (discussed
usually required in other kinds of occupations. in Chapter 4) contribute to the knowledge base of nurs-
Self-regulation is based on the belief that the profes- ing and give direction to nursing practice, education, and
sion of nursing has the special knowledge required to ongoing research.
set standards of practice and to assess the conduct of its Increasing research in nursing is contributing to
members through peer review. As members of the nurs- nursing practice and nursing knowledge. In the 1980s,
ing profession, nurses are bound by the ethical values increased federal funding and professional support
of the profession to base their practice on relevant and helped establish centres for nursing research. Most early
M01_KOZI2703_04_SE_C01.indd 14 27/02/17 10:37 AM

research was directed to the study of nursing education. Socialization to Nursing

In the 1960s, studies were often related to the nature of
the knowledge base underlying nursing practice. Since Socialization can be defined simply as the process by
the 1970s, nursing research has focused on practice- which people (a) learn to become members of groups and
related issues. Nursing research as a dimension of the society and (b) learn the social rules defining relationships
nurse’s role is discussed further in Chapter 3. into which they will enter. Socialization involves learning
to behave, feel, and see the world in a manner similar to
SPECIALIZED EDUCATION Specialized education is an other persons occupying the same role (Hardy & Conway,
important aspect of professional status. In modern times, 1988). The goal of professional socialization is to instill in
the trend in education for professions has shifted toward individuals the norms, values, attitudes, and behaviours
programs in colleges and universities. Many nursing edu- deemed essential for the survival of the profession.
cators believe that the undergraduate nursing curriculum Various models of the socialization process have
should include liberal arts education, in addition to the been developed. Benner’s model (1984) describes five
biological and social sciences and the nursing discipline. levels of proficiency in nursing based on the Dreyfus
The CNA recommends the baccalaureate degree general model of skill acquisition (Dreyfus & Dreyfus,
as the level of education required for entry to practice 1980). The five stages, which have implications for teach-
as a registered nurse, and the provincial and territorial ing and learning, are novice, advanced beginner, com-
regulatory bodies require the degree for licensure, with petent practitioner, proficient practitioner, and expert
the exception of Quebec. (See Chapter 2 for more infor- practitioner. Benner writes that experience is essential for
mation on nursing education at all levels.) the development of professional expertise. See Box 1.4.
SERVICE ORIENTATION A service orientation differenti-
ates nursing from an occupation pursued primarily for
BOX 1.4 BENNER’S STAGES OF NURSING
profit. Many consider altruism (selfless concern for others)
the hallmark of a profession. Nursing has a tradition of EXPERTISE
service to others. This service, however, must be guided STAGE I, NOVICE
by certain rules, policies, or codes of ethics. Nursing is an
No experience (e.g., nursing student). Performance is
important component of the health care delivery system.
limited, inflexible, and governed by context-free rules and
PROFESSIONAL ORGANIZATION Operation under the regulations, rather than experience.
umbrella of a professional organization differentiates a STAGE II, ADVANCED BEGINNER
profession from an occupation. For registered nurses, the
CNA, in addition to the provincial and territorial nursing Demonstrates marginally acceptable performance. Recognizes
organizations, performs the self-regulatory functions. the meaningful “aspects” of a real situation. Has experienced
enough real situations to make judgments about them.
AUTONOMY AND SELF-REGULATION A profession is
autonomous if it regulates itself and sets standards for STAGE III, COMPETENT PRACTITIONER
its members. Providing autonomy is one of the purposes Has 2 or 3 years of experience. Demonstrates organiza-
of a professional association. If nursing is to have profes- tional and planning abilities. Differentiates important factors
sional status, it must function autonomously in the forma- from less important aspects of care. Coordinates multiple,
tion of policy and in the control of its activities. To be complex care demands.
autonomous, a professional group must be granted legal
STAGE IV, PROFICIENT PRACTITIONER
authority to define the scope of its practice, describe its
particular functions and roles, and determine its goals and Has 3 to 5 years of experience. Perceives a situation as a
accountabilities in delivery of its services. See Chapter 6 whole, rather than in terms of parts, as in Stage II. Uses
for additional information on scopes of practice and legis- maxims as guides for what to consider in a situation. Has
lated authority. holistic understanding of the client, which improves deci-
sion making. Focuses on long-term goals.
CODE OF ETHICS Nurses have traditionally placed a high
STAGE V, EXPERT PRACTITIONER
value on the worth and dignity of others. The nursing pro-
fession requires integrity of its members; that is, a member Performance is fluid, flexible, and highly proficient; no longer
is expected to do what is considered right. Ethical codes requires rules, guidelines, or maxims to connect an under-
change as the needs and values of society change. Nursing standing of the situation to appropriate action. Demonstrates
has developed its own codes of ethics. It is within the nursing highly skilled, intuitive, and analytical ability in new situations.
educational program that the nurse develops, clarifies, and Is inclined to take a certain action because “it feels right.”
internalizes professional values. Specific professional nurs- Source: Benner, Patricia, From novice to expert: excellence and power in clinical
ing values are stated in nursing codes of ethics (see Chapter nursing practice, Commemorative Edition, 1st Ed., (c) 2001. Reprinted and electroni-
cally reproduced by permission of Pearson Education, Inc., Upper Saddle River,
5), in standards of nursing practice (discussed earlier in this New Jersey.
chapter), and in the legal system itself (see Chapter 6).
M01_KOZI2703_04_SE_C01.indd 15 27/02/17 10:37 AM

One of the most powerful mechanisms of profes- more knowledge about health and illness than in the
sional socialization is interaction with fellow students past. Consumers also have become more aware of oth-
(Hardy & Conway, 1988). Within this student culture, ers’ needs for care. The ethical and moral issues raised
students collectively set the level and direction of their by poverty and neglect have made people more vocal
scholastic efforts. They develop perspectives about the about the needs of minority groups and the poor.
situation in which they are involved, the goals they Most Canadians strongly believe that health is a right
are trying to achieve, and the kinds of activities that are of all Canadians. The media increasingly emphasize the
expedient and proper, and they establish a set of prac- message that individuals must assume responsibility for
tices congruent with all of these. Students become bound their own health by obtaining a physical examination
together by feelings of mutual cooperation, support, and regularly, checking for signs of cancer and cardiovascu-
solidarity. The Canadian Nursing Students’ Association lar disease, and maintaining their mental well-being by
(CNSA) helps link nursing students with nursing leader- balancing work and recreation. As more of the popula-
ship groups. This organization exposes student nurses to tion struggles with chronic diseases, expectations of sup-
issues impacting the nursing profession while promoting port for self and others continue to rise. Many people
collegiality and leadership qualities. now want more than freedom from disease—they want
energy, vitality, and a feeling of wellness.
Increasingly, the consumer has become an active
Factors Influencing participant in making decisions about health and nurs-

ing care. Planning committees concerned with providing
Contemporary Nursing nursing services to a community usually have an active

consumer membership. Recognizing the legitimacy of
Practice public input, many federal, provincial, and territorial
nursing associations and regulatory agencies have con-
sumer representatives on their governing boards.
To understand nursing as it is practised today and as it will
be practised tomorrow requires an understanding of some
of the social forces influencing this profession. These forces
usually affect the entire health care system, and as a major
Family Structure
component of that system, nursing cannot avoid the effects. Family structures influence the need for and provision
of nursing services. Society’s definitions of “family”
has changed significantly over the past few decades.
Economics Moreover, tasks such as child or elder care, which were
Greater financial support provided through public and pri- traditionally carried out by extended family members,
vate health insurance programs has increased the demand may not be as readily available today. For additional
for nursing care. While basic health care in Canada is information about the family, see Chapter 13.
available to all, each provincial and territorial system iden-
tifies the services which are covered and which are not.
Currently, the health care industry is shifting its Science and Technology
emphasis from inpatient care to outpatient care with Advances in science and technology affect nursing prac-
pre-admission testing, increased outpatient same-day tice. Some of these advances are in new or repurposed
surgery, post-hospitalization rehabilitation, home health pharmacological treatments for old and new diseases.
care, health maintenance, physical fitness programs, Others include the use of technology for nursing practice,
and community health education programs. As a result, for example, the electronic health record. Still others, such
more nurses are being employed in community-based as electronic applications for hand-held devices, assist
health care settings, such as home health agencies, hos- nurses in keeping current with the latest scientific findings.
pices, and community clinics. As well, advanced practice In some settings, technological advances have required
nurses, such as nurse practitioners or foot care specialists, that nurses become highly specialized. Nurses frequently
are practising collaboratively or independently in non- have to use sophisticated computerized equipment to pro-
traditional settings. These changes in employment for vide care for clients. In addition, information technology
nurses have implications for nursing education, nursing advances have given the nurse and the client access to much
research, and nursing practice. more information. Nurses and clients must view this infor-
mation with a critical eye. As technologies change, nursing
education changes, and nurses require more advanced
Consumer Demands education to provide effective, safe nursing practice.
Consumers of nursing services (the public) have become The need for long-distance monitoring of astronauts
an increasingly effective force in changing nursing prac- and spacecraft, lighter materials, and miniaturization of
tice. On the whole, people are better educated and have equipment in the U.S. space program has given rise to
M01_KOZI2703_04_SE_C01.indd 16 02/03/17 9:36 AM

advanced technologies. Health care has benefited as these Psychiatric and practical nurses are also part of nursing
new technologies have been adapted to health care aids, organizations, as described shortly. Increasingly, nurs-
such as the insulin infusion pump, the voice-controlled ing specialty organizations are being formed, for exam-
wheelchair, magnetic resonance imaging (MRI), laser sur- ple, the Canadian Association of Nurses in Oncology
gery, filters for intravenous fluid control devices, and moni- (CANO). In addition, many nurses are part of unions.
toring systems for intensive care (see Chapter 25). Participation in the activities of nursing associations
enhances the growth of involved individuals and helps
nurses collectively influence policies that affect nursing
Demography practice. Nurses advocate and influence policy at provin-
cial, territorial, and federal levels through professional
Demography is the study of populations, including sta-
organizations, such as CNA and provincial/territorial
tistics about distribution by age and place of residence,
professional associations.
mortality (death), and morbidity (incidence of disease).
From demographic data, the needs of the population for
nursing services can be assessed:
Canadian Nurses Association
• The total population in Canada is increasing. The pro-
The CNA is a federation of 11 provincial and territorial
portion of older adults has also increased, creating a
nursing associations, representing more than 293 205
growing need for nursing services for this group. This
registered nurses. The CNA’s mission states that it is
change in demographics has also highlighted differences
“the national professional voice of registered nurses. . .
in generations. For instance, as the “baby boomer” gen-
[and it] advances the practice and profession of nursing
eration (those born between 1945 and 1964) ages, a
to improve health outcomes and strengthen Canada’s
variety of social processes, including health care, have
publicly funded not-for-profit health system” (CNA,
been influenced.
2015). Toward this end, it promotes high standards of
• The population is shifting from rural to urban settings. practice, education, research, and administration. In
This shift signals increased needs for nursing related to some provinces and territories, the regulatory body and
problems caused by pollution and other effects on the the professional association are within the same organiza-
environment by concentrations of people. Yet, the rural tion. In other provinces, these are separate organizations.
population still needs access to care. The CNA is the national RN nursing association of
• Mortality and morbidity studies reveal the presence of Canada. Nurses do not join the CNA independently but
risk factors. Many of these risk factors (e.g., smoking) are obtain membership by paying a fee to the provincial or
major causes of death and disease that can be prevented territorial organizations. In November 1985, the Ordre des
through changes in lifestyle. The nurse’s role in assess- infirmières et infirmiers du Québec (the Quebec Nurses
ing risk factors and helping clients make healthy lifestyle Association, or OIIQ) withdrew from the CNA. In recent
changes is discussed in Chapter 8. years, several provincial regulatory associations have also
withdrawn from the CNA and have been replaced by pro-
vincial nursing associations with advocacy roles. The CNA
The Women’s Movement has developed national standards and a code of ethics, and
it offers support to all provincial and territorial organiza-
The women’s movement brought public attention to both
tions. Certification in specific clinical specialties can also be
women’s and human rights. People are seeking equality
obtained through the CNA (see Chapter 2). Through the
in all areas, particularly educational, political, economic,
Canadian Nurses Foundation, research grants, fellowships,
and social equality. Because the majority of nurses are
and scholarships are offered to Canadian nurses. The
women, this movement has altered nursing’s perspectives
official journal of the CNA, Canadian Nurse, is published
on economic and educational needs. As a result, nurses
monthly and sent to each nurse member.
are increasingly asserting themselves as professional people
who have a right to equality with men in health care pro-
fessions and are demanding more autonomy in client care.
International Council of Nurses
The ICN was established in 1899. Nurses from Great
Britain, the United States, and Canada were among
Nursing Organizations the founding members. The council is a federation of
national registered nurses’ associations, such as the CNA
As nursing has developed, an increasing number of and the American Nurses Association.
nursing organizations have been formed at the local, pro- Through the ICN, member national associations
vincial and territorial, national, and international levels. can work together for the mission of representing nurs-
The organizations that involve most Canadian registered ing worldwide, advancing the profession, and influencing
nurses and nursing students are the CNA and the ICN. health care policy. The five core values of the ICN are
M01_KOZI2703_04_SE_C01.indd 17 27/02/17 10:37 AM

visionary leadership, inclusiveness, flexibility, partner- (e.g., Community Health Nurses Canada [CHNC]), oth-
ship, and achievement (ICN, 2015). The official journal ers are by type of job (e.g., the Provincial Nurse Educator
of the ICN is International Nursing Review. Interest Group [PNEIG], the Canadian Association for
Nursing Research [CANR], the Academy of Canadian
Executive Nurses [ACEN], and the Canadian Association
Canadian Council of Registered Nurse of Practical Nurse Educators [CAPNE]). These orga-
nizations further the profession by contributing posi-
Regulators tion statements and group-specific standards of practice,
As noted earlier in the chapter, as part of self-regulation of influencing public policy, and participating in knowledge
registered nurses, there are regulatory bodies within each translation and dissemination.
province or territory, often aligned with the provincial or
territorial nursing association but sometimes existing as dis-
tinct entities. The Canadian Council of Registered Nurse Licensed (Registered) Practical Nurses
Regulators (CCRNR) is a relatively new national group. Practical nurses are licensed in all provinces and territories
As part of its activities, it manages the examination for RN except Ontario, where they are registered. Although all
licensure in Canada. The purpose of the council is as follows: provinces have a professional organization, the national
• Promote excellence in professional nursing regulation organization is inactive at this time. Of the territories, only
• Serve as a national forum and voice regarding interpro- Yukon has a professional association for LPNs, and it is in
vincial/territorial, national, and global regulatory mat- the beginning stages. In addition, the practical nurse regu-
ters for nursing regulation (CCRNR, n.d.) latory bodies have a national organization: the Canadian
Council for Practical Nurse Regulators (CCPNR). It notes
national commonalities, but the organizations are differ-
ent in all jurisdictions. The CCPNR has contributed to
Sigma Theta Tau International Honor development of national policies for practical nursing.
Society of Nursing The Canadian Association of Practical Nurse Educators
The Sigma Theta Tau International Honor Society (CAPNE) counts as its members “practical nursing educa-
of Nursing (STTI) was founded in 1922 and is head- tors and regulatory bodies from every province/territory
quartered in Indianapolis, Indiana. The Greek letters with the exception of Quebec” (CAPNE, 2015).
stand for the Greek words storga, tharos, and tima, mean-
ing “love,” “courage,” and “honour.” The society is a
member of the Association of College Honor Societies.
Registered Psychiatric Nurses
The society’s purpose is professional, rather than social. In the four Western provinces of Canada, another cate-
Membership is attained through academic achievement. gory of nurses is the registered psychiatric nurse (RPNs).
Nursing students in baccalaureate programs and those in The Canadian Institute for Health Information’s defini-
masters, doctoral, and postdoctoral programs are eligible tion of a registered psychiatric nurse is found in Box 1.2
to be selected for membership. In addition, community (see page 10). The Registered Psychiatric Nurses of
nurses “who are legally recognized to practice nursing in Canada (RPNC) comprises the regulatory bodies or
their country, have a minimum of a baccalaureate degree associations from all four provinces. In some settings,
or equivalent in any field, and demonstrate achievement RNs and RPNs will be working side-by-side in the same
in nursing” can apply to become members (Sigma Theta positions. It also liaises with other psychiatric nursing
Tau International, 2015). STTI became an interna- organizations globally.
tional organization with the creation of a chapter at the
University of Western Ontario. Now chapters span the
globe, and there are eight STTI chapters in Canada. Unions
The official journal of STTI, Journal of Nursing
The majority of today’s nurses are union members by
Scholarship, is published quarterly. The journal publishes
virtue of their employment. The Canadian Federation
scholarly articles of interest to nurses. STTI also orga-
of Nurses Unions (CFNU) represents nine provincial
nizes at least one international research conference each
unions and one students’ association and speaks for close
year, held in a different city each time.
to 200 000 members. Created in 1981 as the National
Federation of Nurses Unions, it seeks to “advance solu-
tions to improve patient care, working conditions and our
Specialty Organizations public health care system” (CFNU, 2012). Depending on
Within Canadian nursing are a large number of specialty the worksite and collective agreements, each union may
organizations. These may be linked to the provincial, include registered nurses, licensed (registered) practi-
territorial, or national (CNA) professional associations. cal nurses, and registered psychiatric nurses within the
Although some are groups of nurses in specialized practice membership.
M01_KOZI2703_04_SE_C01.indd 18 27/02/17 10:37 AM

Case Study 1
The supply of nurses in Canada has historically been partially stated today that he has not changed his mind: ‘male nurses
shaped by constraints over who could train as a nurse and who will not get commissions in the medical services (nursing). . . .’
could practise in certain areas, such as pediatrics, obstetrics, His main objection is that ‘the men would stay in nursing
psychiatric hospitals, and the military. The following cases illus- and would possibly become Matron in the
trate some criteria that have been used in the past to include or Armed Services. This would not be good in a
exclude people as nurses. male-oriented service’” (Library and Archives
Edith Anderson Monture was a member of the Upper Canada, 1966).
Mohawk band of the Six Nations of the Grand River Reserve
near Brantford, Ontario. She was denied entrance to nursing
schools in Canada, but she graduated first in her class from the
New Rochelle Hospital School of Nursing in New York in 1914. CRITICAL THINKING QUESTIONS
Following volunteer service with the American Expeditionary
Force in World War I, she returned to the hospital on the Six
1. The preferred candidates for nursing students until the
Nations Reserve, where she worked as a nurse and midwife until
mid-twentieth century were young, white, Canadian-
her retirement in 1955 (Moses, 2005).
born women. What are the different factors in these
Estelle Tritt applied for training at the Montreal General
examples that have historically determined who could
Hospital School of Nursing and was told that the school did
be a nurse?
not take Jewish nurses because “they get married too soon”
(Toman, 2007, p. 47). She subsequently applied successfully 2. In what ways are these criteria still influencing the
to the Women’s General Hospital at Westmount, Quebec, and composition of the nursing workforce? What has
graduated from training in 1941. After working at the Jewish changed regarding the manifestations of such criteria?
General Hospital in Montreal to gain the required years of gradu- What additional characteristics are shaping the nurs-
ate experience, Tritt was accepted as a military nurse (nursing ing profession? To what extent is the profession more
sister) with the Royal Canadian Army Medical Corps and served inclusive now, and how might some people still face
overseas during World War II. barriers?
This memo was sent to Helen Mussallem, CEO of Canadian
Nurses Association, January 18, 1966: “The Surgeon General Visit MyNursingLab for answers and explanations.
KEY TERM S
client p. 8 demography p. 17 profession p. 14 standards for nursing
consumer p. 8 patient p. 8 socialization p. 15 practice p. 12
C HAPTER HIGHL IG HTS

• Knowledge of how larger and changing sociocultural and and serve to clarify the nurse’s activities. These roles
political contexts have influenced the development of nurses include caregiver, communicator, teacher, client advocate,
and their practice in the past is key to understanding the counsellor, change agent, leader, and research consumer.
relevance of history to present-day concerns in nursing. • A desired goal of nursing is professionalism, which
• The term nursing has many definitions and descriptions, but requires specialized education; a unique body of knowl-
the essence of nursing is caring for and caring about people. edge, including specific skills and abilities; ongoing
• The scope of nursing practice is outlined by the profes- research; a code of ethics; autonomy; a service orienta-
sional associations (or organizations) of each province and tion; and a professional organization.
territory. It describes what it is that nurses in a particular • Socialization is a lifelong process by which people become
province or territory have the legislated authority to do. functioning participants of a society or a group. Although
• Although traditionally the majority of nurses were several models of the socialization process have been devel-
employed in hospital settings, today the numbers of oped, Benner’s five stages—novice, advanced beginner,
nurses working in home health care, ambulatory care, competent practitioner, proficient practitioner, and expert
and community health settings are increasing. practitioner—can serve as guidelines to establish the phase
and extent of an individual’s socialization in nursing.
• Standards of clinical nursing practice reflect the values of
the profession and clarify what professional organizations • Participation in the activities of nursing associations and
expect of their members. other professional and nonprofessional groups enhances
the growth of involved individuals and helps nurses col-
• Every nurse can function in a variety of roles that are not lectively influence policies affecting nursing practice.
exclusive; in reality, the functions often occur together
M01_KOZI2703_04_SE_C01.indd 19 02/03/17 9:38 AM

N CL EX- ST YLE PRACTI CE QUI Z

Odd numbered questions are also available through Learning Catalytics™ for additional student practice or in-class assessment.
1. What is the primary purpose of historical research on 6. What describes the principle of comprehensiveness in
the nursing profession? the Canada Health Act?
a. Showcase achievements of nurses in the past a. All levels of health care are available to the residents
b. Provide alternative perspectives for understanding of a particular jurisdiction.
nursing issues b. Individuals who move within Canada are covered at
c. Prove that nursing has been a true profession for a all times.
long time c. There are no user fees for basic services within the
jurisdiction.
d. Justify nurses’ demands for greater respect and
improved salaries d. The administration of the plan is devolved to the
local authorities.
2. Which social force is most likely to significantly impact
7. What represents the best application of nursing practice
the future demand for nurses?
standards?
a. The women’s movement
a. A statute is enacted to protect the public through the
b. The growth of nursing organizations, such as the provision of safe, competent nursing practice
Canadian Nurses Association (CNA) b. A group of student nurses identify that a particular
c. Advances in technology procedure is outside the permitted boundaries of
d. The changing demographics in Canada their practice.
c. A nurse attends a professional development work-
3. Which of the following groups had a historically signifi- shop on wound care.
cant influence on the beginnings of formal educational d. A nurse recognizes the importance of safeguarding a
preparation for practising nurses in Canada? (Select all client’s confidential information.
that apply.)
a. Federal government 8. Which statement most accurately reflects Benner’s
Competent Practitioner stage of nursing expertise?
b. French Canadian religious communities
a. A nurse with approximately 4 years of experience
c. The British system associated with Florence has a holistic understanding of the client and focuses
Nightingale on long-term goals.
d. Victorian Order of Nurses b. The nurse is highly skilful and intuitive in analyzing
e. Canadian Nurses Association new situations.
c. A new graduate nurse is guided by rules but has
4. Which of the following statements best illustrates enough experience to make judgments about real
the difference between primary health care and situations.
primary care? d. The nurse with 2 years of experience can recognize
a. Primary health care is a theoretical approach to patterns, identify salient information, and coordinate
health care, whereas primary care is a system of complex care demands.
delivering services.
b. Primary health care is illness focused, whereas 9. What requirements are necessary for nursing to be
primary care is health promotion focused. defined as a profession rather than an occupation?
(Select all that apply.)
c. Primary health care is a set of government
a. Levels of expertise
standards for Canadian health care, whereas
primary care provides a set of principles for b. Well-defined body of knowledge
delivering care. c. Maintains a code of ethics
d. Primary health care is a philosophical approach d. Government control
to providing health care, whereas primary care e. Autonomy and self-regulation
provides an entry point to the health care system.
f. Service orientation
5. Which activity would be considered in the category of 10. Many nursing theorists have developed their own defini-
restoring health? tions of nursing. What are the common themes shared
a. Running a newborn clinic at the local public health by these different definitions of nursing?
facility a. Delivery of holistic, adaptive, and client-centred care
b. Administering medications to a clients in a hospital b. Delivery of care to a passive recipient
orthopedic unit
c. Assistant to the physician while delivering care
c. Facilitating a parenting class at the hospital
d. A profession of entrepreneurs delivering indepen-
d. Starting a seniors’ walking program at the local mall dent care
M01_KOZI2703_04_SE_C01.indd 20 27/02/17 10:37 AM

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https://www.cna-aiic.ca/en/about-cna/who-we-are#vision-mission. Nursing reconsidered. Ithaca, NY: Cornell University Press.
Cassel, J. (1994). Public health in Canada. In P. Dorothy (Ed.). The Nightingale, F. (1938). Notes on nursing: What it is, and what it is not.
history of public health and the modern state (pp. 276–312). London, New York, NY: Appleton-Century Company.
UK: Wellcome Institute Series in the History of Medicine. Nursing Education in Nova Scotia. (n.d.). 1899 Graduating class photo.
Cayne, B. S. (Ed.). (1988). New Lexicon Webster’s dictionary of the English Retrieved from http://www.msvu.ca/library/archives/nhdp/
language (Rev. ed.). New York, NY: Lexicon Publications. schools/VGH.htm.
Charles, A. (2003). Women’s work in eclipse: Nuns in Quebec hos- Paul, P. (2005). Religious nursing orders of Canada: A presence
pitals, 1940–1980. In G. Feldberg, M. Ladd-Taylor, A. Li, & K. on all western frontiers. In C. Bates, D. Dodd, & N. Rousseau
McPherson (Eds.), Women, health and nation: Canada and the United (Eds.), On all frontiers: Four centuries of Canadian nursing (pp. 125–138).
States since 1945 (pp. 264–291). Montreal, PQ: McGill-Queen’s Ottawa, ON: University of Ottawa Press & Canadian Museum of
University Press. Civilization.
Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental Penney, S. M. (1996). A century of caring: 1897–1997, the history of the
activities involved in directed skill acquisition. Unpublished report sup- Victorian Order of Nurses for Canada. Ottawa, ON: VON Canada.
ported by the Air Force Office of Scientific Research (AFSC), USAF Richardson, S. (1998). Frontier health care: Alberta’s district and
(Contract F49620–79-C-0063), University of California at Berkeley. municipal nursing services, 1919 to 1976. Alberta History, 46, 2–9.
Elliott, J. (2004). Blurring the boundaries of space: Shaping nursing Ross-Kerr, J. C. (2003). Professionalization in Canadian nursing. In
lives at the Red Cross outposts in Ontario, 1922–1945. Canadian J. C. Ross-Kerr & M. Wood (Eds.), Canadian nursing: Issues and per-
Bulletin of Medical History, 21(2), 303–325. spectives (4th ed.) (pp. 29–38). Toronto, ON: Mosby.
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Rousseau, N., & Daigle, J. (2000). Medical service to settlers: The Villeneuve, M., & MacDonald, J. (2006). Towards 2020: Visions for
gestation and establishment of a nursing service in Quebec, nursing. Ottawa, ON: Canadian Nurses Association.
1932–1943. Nursing History Review, 8, 95–116. Violette, B. (2005). Healing the body and saving the soul: Nursing
Sandelowski, M. (2000). Devices and desires: Gender, technology and American sisters and the first Catholic hospitals in Quebec (1639–1880).
nursing. Chapel Hill, NC: University of North Carolina Press. In C. Bates, D. Dodd, & N. Rousseau (Eds.), On all frontiers: Four
Saskatchewan Registered Nurses’ Association. (2007). Standards and centuries of Canadian nursing (pp. 57–71). Ottawa, ON: University of
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Second World War. Vancouver, BC: UBC Press.
M01_KOZI2703_04_SE_C01.indd 22 27/02/17 10:37 AM

Chapter 2
Nursing Education
in Canada
Updated by
Linda Ferguson, RN PhD
Professor, College of Nursing, University of Saskatchewan
Cynthia Baker RN PhD

Executive Director, CASN
I
LEARNING OUTCOMES
After studying this chapter, you will be able to n the early twentieth
1. Describe the different types of nursing education programs century in Canada, nurs-
in Canada. ing was viewed as an
2. Describe aspects of baccalaureate level entry to professional extension of the maternal role, and
nursing practice. expectations of nurses were limited.
3. Explain the importance of continuing nursing education. Schools of nursing focused primar-
ily on teaching students what they
4. Describe the role of national nursing associations in shaping
nursing education in Canada. needed to know to work in hospital
settings. Strangely, after graduation,
5. Analyze issues influencing nursing education in Canada.
most nurses worked in the community
or in private duty nursing in patients’
homes. In fact, the need for student
nurses to staff a particular hospital
was the major reason for the exis-
tence of most nursing schools during
this period (Pringle, Green, & Johnson,
2004). Nursing education has evolved
a great deal over the past century and
today prepares students to practise
in a broad range of areas, to think
critically, and to use the best scien-
tific evidence available when providing
care. Provincial and territorial nursing
organizations and national accrediting
bodies provide internal professional
control of nursing education. c
M02_KOZI2703_04_SE_C02.indd 23 17/03/17 10:52 AM

c In 1874, the General and Marine Hospital in St. Catharines, Ontario, offered the first training
program for nurses in Canada. It soon became the norm for hospitals across the country to operate
their own schools of nursing. The hospital training programs of the 1920s, 1930s, and 1940s were
characterized by limited coordination of classroom and clinical teaching, and for students, long hours,
night duty without supervision, and numerous housekeeping chores (Baumgart & Larsen, 1992). The
medical staff and nursing supervisors provided the instruction and were the only clinical teachers. The
American National League for Nursing Education (now the National League for Nursing [NLN]) pub-
lished a curriculum guide for registered nursing programs in 1917 and revised it in 1937 (NLN, 1937).
This curriculum guide was also adopted in Canada. The beginning of the Canadian Nurses Association
(CNA) in 1908 was associated with membership limited to alumnae of registered nurse training pro-
grams, thus constituting the first time that trained nurses were registered on the association roster.
Nonetheless, until educational institutions were responsible for nursing education, hospitals used
nursing students for service rather than focusing on their education.
In 1939, the Canadian Nurses Association recommended that each province develop educational
programs for nursing assistants as a solution to a shortage of nurses that had increased as a result
of World War II (Mussalem, 1960). In 1941, the Registered Nurses Association of Ontario (RNAO)
implemented a demonstration program for Nursing Assistants. The St. Boniface School for Practical
Nurses opened its doors in September 1943 with the approval of the Manitoba Association of
Registered Nurses. Practical nurses evolved from these early nursing assistant programs. Programs
continued to be established for practical nurses as health care services expanded (Pringle, Green, &
Johnson, 2004).
Today, as nursing responds to new scientific knowledge and technological innovation and to
cultural, political, and socioeconomic changes in Canada, nursing education curricula are continually
being updated to prepare students for very complex clinical situations and a rapidly evolving health
care system. Programs of study for registered nurses and registered psychiatric nurses are based on
a broad knowledge of biological, social, and physical sciences, as well as the liberal arts and humani-
ties. There is a strong focus on critical thinking and on health prevention and promotion, as well as on
health maintenance and health restoration. Educational programs for practical nurses have increased
in length, depth, and breadth in response to an expansion of their scope of practice and increased
autonomy of practice over time (Pringle et al., 2004).
Nursing Education new NPs. Only the four Western provinces recognize
the registered psychiatric nurse (RPN ). Quebec distinguishes
RNs by type of education: diploma (only in Quebec) or
Today, provincial and territorial laws and union regula- baccalaureate. Responsibilities differ for the five groups.
tions in Canada recognize four distinct groups within Definitions and roles for the RN, LPN or RPN, and RPN
the profession of nursing. Not every province or terri- can be found in Box 1.2 in Chapter 1.
tory, however, recognizes all four of the groups. Each Currently, two major educational routes lead to RN licen-
province and territory recognizes the registered nurse (RN ) sure: diploma and baccalaureate programs. In most Canadian
and the licensed practical nurse (LPN, called a registered practi- jurisdictions, however, the baccalaureate degree is required
cal nurse [RPN] in Ontario only). All jurisdictions recog- for entry to practice. Baccalaureate nursing degrees
nize the nurse practitioner but Yukon does not license are offered by universities, university colleges, and
M02_KOZI2703_04_SE_C02.indd 24 02/03/17 9:39 AM

Chapter 2 Nursing Education in Canada 25
polytechnic institutes, often in partnerships with commu- programs as required by competency assessment prior to
nity colleges. In generic programs, students are admitted eligibility to take the licensure examination. These bridg-
directly into the nursing program and graduate with a ing programs include both classroom experience and
degree (BN or BSN). Programs also exist for students clinical experience and are tailored to meet their educa-
with a previous non-nursing degree or substantial credits tional needs. Bridging programs also provide opportuni-
toward a degree. In these programs, the nursing content ties to learn about Canadian cultural expectations and
has been reconfigured so that students can graduate with health care delivery in this country.
a nursing degree in approximately 24 months. These Minimum standards for basic nursing education
are variously called second entry, compressed, or accelerated are established in each province and territory and are
programs. A listing of the programs offered by members monitored by the respective nursing regulatory body.
of the Canadian Association of Schools of Nursing Schools that meet these minimum standards are granted
(CASN) can be found in the Weblinks section online. In provincial or territorial approval for a specified length
addition, colleges in Quebec provide diploma education of time. Approvals may include conditions. In addi-
for nurses. tion to approval in Canada for baccalaureate nursing
Basic educational programs for practical nurses are education, the CASN grants accreditation to qualifying
generally offered in colleges. No national list exists for approved programs. Accreditation is focused on stan-
practical nursing programs; however, provincial or ter- dards of excellence for nursing education.
ritorial lists can often be found on the provincial or
territorial regulatory websites. Psychiatric nurses can com-
plete their basic education at the diploma or degree
level, depending on the province. A listing of national
psychiatric nursing education programs can be found in
Types of Educational
the Weblinks section online.
Graduates of all programs take a licensing exam-
Programs
ination for their group (e.g., RN, LPN or RPN, RPN)
provided by the appropriate regulatory authority and, if
Hospital Diploma Programs
successful, are licensed within their professional group. Florence Nightingale developed a nursing program
Only graduates of approved nursing programs can based on religious, military, and public health concerns
take the licensing examination. The National Council and insisted on the moral superiority of her recruits
Licensure Examination for RNs (NCLEX-RN) exami- (Cohen, 2000). After she established the first school of
nation is a computer-adaptive multiple-choice test that nursing—the Nightingale Training School for Nurses—
measures the applicant’s ability to integrate the compe- at St. Thomas’ Hospital in England in 1860, the concept
tencies expected of a new graduate nurse. This exami- travelled quickly to North America. Nursing education
nation, developed by the National Council of State in the early years largely took the form of apprentice-
Boards of Nursing (NCSBN) and administered under the ships. Along with minimal formal classroom instruction,
authority of the Canadian nurse regulators, allows for students learned by doing, that is, by providing care
licensure in Canada and the United States. NCLEX-RN to patients in hospitals. Curricula were not standard-
results are reported to candidates as pass or fail. National ized, and no approval or accreditation was available at
examinations for all groups of nurses are administered that time. Programs were designed to meet the service
or authorized by the provincial or territorial regulatory needs of the hospital, not the educational needs of the
authorities. The successful candidate becomes licensed students.
in that province or territory, even though the examina- Over the years, curricula in nursing education pro-
tions are the same for all national candidates regardless grams have changed progressively with the development
of jurisdiction. To practise nursing in another province of the health care system, medical care, and nursing
or territory, the nurse must receive licensure by applying knowledge base. New knowledge, new procedures, and
to that province’s or territory’s regulatory body. Both new systems of delivery have influenced practice, and in
licensure and registration must be renewed each year to turn, changes in practice have resulted in the develop-
remain valid. ment of new knowledge and the creation of new types
Students in all nursing groups are increasingly more of nursing groups. The overall goal is the health of
diverse, as many first- and second-generation young Canadians.
Canadian immigrants enrol in nursing education pro- In Chapter 1, we discussed the number of regulated
grams. The nursing student body is, therefore, becoming nurses in Canada and their distribution by category.
more representative of the cultural diversity in Canadian In this chapter, we examine the educational background
communities (Anderson et al., 2003). In addition, the of those nurses. The highest level of education in nurs-
trend has been to provide nurses who have been edu- ing reported by all regulated nurses in 2014 is given in
cated in other countries, known as internationally Table 2.1. These statistics exclude education in disci-
educated nurses (IENs) with educational bridging plines other than nursing.
M02_KOZI2703_04_SE_C02.indd 25 25/01/17 9:21 AM

TABLE 2.1 Educational Preparation of the Regulated and then moved to a hospital-based model for practical
Nursing Workforce (in percentages) experience. A fifth year at the university completed what
was labelled a “sandwich” program. It was not until
Licensed
(Registered) Registered
the 1960s that the number of students enrolled in these
Registered Practical Psychiatric baccalaureate programs increased markedly. Currently,
Education Nurse Nurses Nurses baccalaureate programs are offered by universities or
Diploma 54.6 97.6 85.8 colleges, alone or in collaboration with other postsecond-
ary institutions, depending on the province or territory.
Baccalaureate 41.3 — 13.8
The curricula include courses in the liberal arts, sciences,
Master’s/ 4.2 — 0.4
humanities, and nursing. The degree awarded is usually
doctorate
a bachelor of science in nursing (BScN, BSN) or a bach-
Source: From Canadian Institute for Health Information. (2015). Regulated Nurses 2014.
Ottawa, ON: Author. Reprinted with permission.
elor of nursing (BN).
Many baccalaureate programs also admit registered
nurses who have diplomas. Some programs have spe-
cifically designed curricula to meet the needs of these
Evolution of Registered Nursing students. Some universities offer nursing students the
opportunity to pursue a self-paced or independent study
Education program. Many programs offer some distance education
COLLEGE DIPLOMA PROGRAMS Mussalem (1960) iden- and online courses that can be accessed by nursing stu-
tified some problems in hospital-based, 3-year nursing dents. Many accept transfer credits from other accred-
diploma programs resulting from the hospital’s control ited universities and offer students the opportunity for
over education. Community college nursing education prior learning assessment and recognition (PLAR) when
programs began to appear in the 1960s, also offering the students believe they have acquired the required
2-year diploma preparation; by the 1970s, most diploma competencies. These programs are referred to as BScN
nursing programs had moved into community colleges completion, BN transition, or post-diploma programs. In recent
(Baumgart & Larsen, 1992). Today, the majority of nurs- years, however, a downward trend has been seen in the
ing programs for registered nurses in community colleges enrollment of diploma-holding nurses in degree pro-
are offered in a collaborative partnership with university grams because of the increase in the number of nurses
schools, which provide a common curriculum leading to a entering practice with a baccalaureate degree, a require-
baccalaureate degree in nursing. Some colleges have been ment in most jurisdictions in Canada.
granted degree-granting privileges by their provincial leg- The newest type of program, second entry, second degree,
islation and independently offer a baccalaureate education accelerated, or compressed program, is one in which the stu-
in nursing. In Quebec, in 2004, the DEC-BACC (diplôme dents come with all or part of a university degree in
d’études collégiales – baccalauréat) program (3 years in a collège another discipline. Usually 2 to 3 years long, this program
d’enseignement général et professionnel CEGEP, plus 2 years in a builds on the courses already completed and may com-
university) was introduced. Currently, the only diploma press the structure of the nursing curriculum typically by
programs in Canada are in Quebec. including spring and summer sessions into the program.
Today, universities and colleges have control over all
BACCALAUREATE DEGREE PROGRAMS In 1919, the
components of education, and nursing students receive
first baccalaureate degree program in nursing in English
a liberal education combined with a professional one.
was established at the University of British Columbia
Entry to registered nurse practice programs is offered
in Vancouver, followed in 1920 by the McGill School
by 114 schools, and 88 of these programs are bacca-
of Graduate Nurses in Montreal (Street, 1973). The
laureate programs; the diploma-level schools are only
first baccalaureate program in French was developed by
in Quebec. In 2012, students entered registered nursing
Institut Marguerite d’Youville in 1938. With the estab-
programs and 11 987 graduated that year (CASN, 2015).
lishment of these programs, nursing moved into the
The majority of nursing programs are 4 academic years
university sector.
long, an academic year being approximately 8 calendar
In 1932, the CNA and the Canadian Medical
months. Many educational institutions offer students the
Association (CMA) commissioned Dr. George Weir to
opportunity for accelerated completion of the program.
conduct a study of nursing education in Canada. He
Requirements for university admission include a Grade
found that education was secondary to hospital service as
12 or a high-school diploma with specific prerequisites,
a priority in the schools. In his Survey of Nursing Education
such as chemistry and biology.
in Canada, Weir (1932) recommended that nurses be
given a liberal education in addition to a technical one GRADUATE NURSING EDUCATION Graduate programs
and that university training programs award degrees. are conducted by departments within the graduate school
The 1950s saw the greatest expansion of university or faculty of a university, and the applicant must first
schools of nursing. Students enrolled in the university meet the requirements established by the graduate school.
for 1 or 2 years for nursing and non-nursing courses Although graduate schools differ, for Canadian students,
M02_KOZI2703_04_SE_C02.indd 26 02/03/17 9:41 AM

common requirements for admission to graduate programs 16 doctoral nursing programs in Canada, with 84 students
in nursing include the following: entering these programs (CASN, 2015). A major benefit
of doctoral education is the preparation of nurses who
• The applicant must be a registered nurse and licensed
are able to develop the nursing knowledge base through
or eligible for licensure within the program’s province
research and discover the evidence needed to provide high-
or territory.
quality patient care. As of 2009, approximately 0.2% of
• The applicant generally must hold a baccalaureate registered nurses reported being educated at the doctoral
degree in nursing from a recognized university. level in nursing (CNA, 2013) and even fewer at the post-
• The applicant must give evidence of scholastic ability. doctoral level. Until recently, nursing programs leading
• Letters of recommendation from supervisors, nursing to a doctoral degree in Canada were limited, and many
faculty, or nursing colleagues indicating the applicant’s completed a doctor of philosophy (PhD) degree in other
ability to do graduate study are required. disciplines, such as sociology, psychology, or education.
Doctoral programs in nursing awarding PhDs began in the
Master’s Programs Growth of university nursing
1960s in the United States. The first formal Canadian pro-
programs encouraged the development of graduate study gram began at the University of Alberta in 1991. Doctor
in nursing. In Canada, the first master’s program in nurs- of Nursing Science (DNS) and Doctor of Nursing Practice
ing was established at the University of Western Ontario (DNP) programs are offered in the United States only.
in London, Ontario, in 1959. This was followed by a
program at McGill University in Montreal in 1961 and Practical Nursing Programs Practical nurses are
a French program at Université de Montréal in 1962. In educated and licensed or registered in all provinces and
2012, 33 schools offered master’s programs and 839 stu- territories. Programs for practical nurses were intro-
dents were admitted to these programs. duced in provinces across the country between 1939 and
Master’s programs may be course based or 1960. The first formal nursing assistant/practical nurse
a combination of course work and thesis research. training program was offered in 1945 in Manitoba. The
Programs generally take 1 to 2 years to complete. Degrees last two decades have seen an expansion of the scope of
most frequently granted are master of nursing (MN), practice of practical nurses and a corresponding increase
master of science in nursing (MScN), master of science in the length of educational programs. Although LPNs
(MS or MSc), and master of psychiatric nursing (MPN). or RPNs have programs of varying lengths, the trend is
Master’s degree programs provide specialized knowledge moving toward a 2-year program leading to a diploma
and skills that enable nurses to assume advanced roles in in practical nursing. In 2010, 97.6% of practical nurses
practice, education, administration, and research. earned a certificate or diploma as entry to practice
(CIHI, 2015). Entrance requirements vary across the
Nurse Practitioner Programs “A nurse practi-
provinces and territories but usually include a high-
tioner (NP) is a registered nurse (RN) with additional
school diploma. Bridging programs for practical nurses
education and experience in health assessment, diag-
who want to obtain their baccalaureate in nursing are
nosis and management of illnesses and injuries, includ-
becoming more formalized across Canada.
ing ordering tests and prescribing drugs” (Canadian
Nurses Association & Canadian Institute for Health Registered Psychiatric Nursing Programs RPNs
Information [CNA & CIHI], 2005, p. 7). In 2014, 28 are educated and licensed in the four Western provinces.
Canadian schools of nursing offered NP programs, with Educational programs specific to psychiatric nursing began
449 NP graduates in 2014 (CASN, 2015). Originally in Canada in the 1920s. Application requirements gener-
aimed at preparing nurses to work in northern nursing ally include a high-school diploma. RPNs are educated
stations, NP programs were available as early as 1967 at at the diploma or baccalaureate level. A significant num-
Dalhousie University. Currently, all provinces and terri- ber of RPNs go on to complete graduate-level educa-
tories have in place legislation and regulations regarding tion. In January 2011, the first students were admitted to
NP status. The vast majority of NP programs are offered the Master of Psychiatric Nursing program at Brandon
at the master’s or post-master’s level. Conversely, clinical University, Manitoba, the first graduate program exclu-
nurse specialists (CNSs) are master’s-prepared nurses sively for psychiatric nurses in Canada.
who have expertise in a clinical specialty, such as human
immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS), geriatric, or newborn nursing;
no specific licensure is needed for this specialty role, and Nursing Associations and
these nurses have advanced practice but do not have an
expanded scope of practice as NPs do.
Their Influence on Education
Doctoral Programs Nurses with doctoral and post- Several national nursing associations have influenced
doctoral education are needed in both academic and nursing education in Canada through their funding of
practice settings for advanced clinical practice, adminis- research, pilot education projects, and policy develop-
tration, education, and research. As of 2012, there were ment. These include the CNA, the Registered Psychiatric
M02_KOZI2703_04_SE_C02.indd 27 25/01/17 9:21 AM

Nurses of Canada, and the CASN. Although the orga- nephrology, neuroscience, occupational health, oncology,
nizations for practical and psychiatric nurses tend to orthopedics, perinatal, perioperative, psychiatric or men-
more strongly influence the education of their own con- tal health, and rehabilitation. In Quebec, the first two
stituents, the CNA and CASN have influenced regulated specialty certifications will be available in mental health
nursing education at all levels. and the prevention and control of infections.
Canadian Nurses Association Canadian Association of Schools

As early as 1895, a desire was expressed to create a of Nursing
group that would represent the nurses of Canada. In In 1942, the Provisional Council of University Schools
1908, the Canadian National Association of Trained and Departments was formed. The name of the organi-
Nurses (Cohen, 2000) became that organization. From zation was changed in 1971 to the Canadian Association
this beginning, the CNA has become a federation of 11 of University Schools of Nursing, with a mandate in
provincial and territorial registered nurses’ associations, 1973 to provide accreditation to university nursing pro-
representing more than 150 000 Canadian RNs (see grams in Canada. In 2002, the colleges providing all or
Chapter 1). Quebec nurses do not belong to the CNA. part of a baccalaureate degree programs in collaborative
The CNA has influenced nursing education in partnerships with a university joined the CASN. Today,
Canada in several key areas. Its co-sponsorship of the the 91 member schools deliver all or part of a bacca-
Weir Report (1932) is one example. In addition, in 1948, laureate degree, a graduate degree, or both in nursing.
the CNA, with financing from the Red Cross, established The purpose of the CASN is to lead nursing education and
the Metropolitan School of Nursing in Windsor, Ontario nursing scholarship in the interest of healthier Canadians. To
(Jensen, 2007). This demonstration school was Canada’s that end, the CASN (a) speaks for Canadian nursing
first independent school of nursing, separated financially education and scholarship, (b) establishes and promotes
and physically from hospitals. This pioneer project led national standards of excellence for nursing education,
to the establishment of the first nursing program in an (c) promotes the advancement of nursing knowledge,
educational setting in Canada at the Ryerson Institute (d) facilitates the integration of theory, research, and
of Technology in 1963. Similar independent schools of practice, (e) contributes to public policy, and (f) provides
nursing in Canada were established once community a national forum for issues in registered nursing educa-
colleges were developed in the 1970s and 1980s. tion and research (CASN, 2014a).
As education is under provincial and territorial juris- The CASN has recently published The National
diction, it is through the provincial and territorial regis- Nursing Education Framework (CASN, 2014d) to guide
tered nurses associations that approval of basic nursing nursing education in Canada, including baccalaureate,
education programs occurs. Approval by the provincial master’s, and doctoral education. In this framework,
or territorial body ensures that programs meet standards general competencies for each level of nursing educa-
and prepares graduates from a specific program, on tion have been enunciated through national consultation
graduation, to write the licensure examinations, now the with Canadian nurse educators. The framework includes
NCLEX-RN. This approval must be renewed on a regu- six domains: (1) knowledge, (2) research methodolo-
lar basis. In 2004, the CNA, in conjunction with the pro- gies, critical inquiry, and evidence, (3) nursing practice,
vincial and territorial bodies, developed the entry-level (4) communication and collaboration, (5) professional-
competencies, which were endorsed by each jurisdiction ism, and (6) leadership. Each level of nursing education
as competencies for new RN graduates. Schools of nurs- addresses all six domains at the appropriate degree of
ing use these competencies as a basis for their curricula. competency and provides a framework for curriculum
Another influence of the CNA on nursing educa- development.
tion is certification, which is a voluntary and periodic The CASN baccalaureate accreditation program
(recertification) process by which an organized specialty provides national standards of excellence for programs
group verifies that a registered nurse has demonstrated of baccalaureate nursing education. Although accredita-
competence in a nursing specialty by having met identi- tion is voluntary in most jurisdictions, some have man-
fied standards of that specialty (CNA, 2015). In 1982, the dated that the CASN accreditation function as approval
CNA board of directors adopted a recommendation that in that province or territory. The CASN has also pub-
the CNA promote the development of certification in lished several position papers on nursing education top-
nursing specialties (CNA, 1982). The first certification ics, which nursing schools use to plan their curricula and
was offered in occupational health nursing. Currently, shape new programs. The CASN is a founding mem-
certification is offered in 19 specialty areas: cardiovascu- ber of the Global Alliance for Leadership in Nursing
lar, community health, critical care, critical care pediat- Education and Science (GANES), an organization that
rics, emergency, enterostomal therapy, gastroenterology, provides a global forum to discuss issues of concern for
gerontology, hospice palliative care, medical-surgical, nursing education programs worldwide.
M02_KOZI2703_04_SE_C02.indd 28 25/01/17 9:21 AM

Canadian Nursing Students’ Association by the year 2000 the minimum educational requirement
for entry into the practice of nursing should be the suc-
The Canadian Nursing Students’ Association (CNSA) cessful completion of a baccalaureate degree in nursing”.
is a national organization affiliated with both CNA and The CNA’s position was based on an examination of the
CASN. The CNSA maintains a close working relation- future health needs of the country and the type of nurs-
ship with the CASN and has a membership of over ing services that would be required to meet them. Nurses’
20 000 students across Canada (CNSA, 2014). The CNSA associations in every province and territory supported
maintains an influence on nursing education through its this policy. In 2004, the CASN and the CNA issued a
partnership with other national and international orga- joint statement supporting the baccalaureate degree as
nizations and through its research and advocacy. It also the entry-to-practice credential in Canada. This goal
provides a network of students across Canada, a national has been realized in every province and territory, with the
conference, and a forum for nursing students. exception of Quebec.
In 1991, New Brunswick became the first govern-
ment to support the baccalaureate degree as the entry
Issues Facing Nursing point into nursing by the year 2000. The following year
(1992), Prince Edward Island became the first prov-
Education ince to achieve the goal of a baccalaureate degree as
the minimal level of entry into nursing. Baccalaureate
education as a requirement for entry to practice came
Nursing education is facing a number of complex issues,
into effect in Saskatchewan for the year 2000; however,
partly because societal changes in Canada have implica-
the Saskatchewan government attempted to reinstate a
tions for professional nursing practice. Nurses must have
diploma exit at the end of year three of the program. A
an understanding of these changes and the issues facing
compromise reached among the Saskatchewan govern-
education. They use critical thinking skills to actively
ment, the Saskatchewan Registered Nurses’ Association
engage in addressing these issues and shaping the nurs-
(SRNA), and the Nursing Education Program of
ing profession.
Saskatchewan (NEPS) protected the nursing degree but
offered options with regard to accelerated completion
of the nursing baccalaureate program. In Manitoba,
Changes in Health Care Needs diploma programs admitted their final students in 2010
Shifts are occurring within health care in Canada today. and moved to baccalaureate education only. In October
Whether or not a person agrees with the futuristic pictures 2011, in a historic move, the Ordre des infirmières et
painted in such documents as Toward 2020 (Villeneuve & infirmiers du Québec voted to work with government to
MacDonald, 2006), it is clear that nursing in the future ensure that new RNs needed to be baccalaureate edu-
will be different from what it is today. One anticipated cated. Unfortunately, the newly elected provincial gov-
change is the shift away from acute care services toward ernment rescinded this agreement in 2012, so diploma
primary health care. The second is the shift toward com- programs are still in existence in this province.
munity-based care, including home care services for With the move to the baccalaureate degree as the
clients. Clients are being discharged from hospital with entry-to-practice requirement for registered nurses,
higher acuity levels and more complex care needs. Nurses practical nurses have also adjusted their educational
need to work collaboratively and interprofessionally. A requirements in response to the changing skill mix. In
third shift is the aging of the Canadian population and Ontario, for example, a fourth semester was added to the
increases in chronic illnesses in this population. Partly diploma program to better prepare the students for the
because of these shifts, nurses are involved in new roles, changing skill mix (Baumann et al., 2009).
such as case manager, program manager, or community Educational programs must develop the knowledge,
developer. Besides new roles, many nurses are performing attitudes, and skills a new graduate will need to provide
additional administrative functions, such as participating safe and effective care. A National Nursing Competency
on boards, chairing committees, and preparing budgets. project involved 26 provincial and territorial bodies that
These shifts influence what is taught in nursing education regulate nursing in a collaboration to develop the specific
programs as students require skills to carry out these roles competencies that registered nurses, practical nurses,
and administrative functions. and psychiatric nurses require on entering the nursing
workforce (Black et al., 2008). These competencies are
based on a profile of the practice expectations for new
graduates and a set of underpinning assumptions. They
Entry to Practice are used to guide the curricula in various nursing edu-
In 1982, the CNA approved the following policy state- cation programs. One assumption for entry-to-practice
ment regarding the future educational requirements for RN competencies is that the new graduate is a begin-
RNs: “The Canadian Nurses Association believes that ning practitioner whose level of practice autonomy and
M02_KOZI2703_04_SE_C02.indd 29 02/03/17 9:42 AM

proficiency will grow best through collaboration, mentor- (NAPN), now renamed the University of Saskatchewan
ing, and support from RN colleagues, managers, other Community of Aboriginal Nurses (UCAN), began in
health care team members, and employers. A similar 1986. Saskatchewan has the highest population percent-
assumption has been identified for practical nurses. age of Aboriginal persons, and the NAPN has supported
many Aboriginal baccalaureate nursing students, with
54 graduates in 2014.
Ensuring the Appropriate Number As Canadian nurse educators move toward retire-
ment age, active efforts to recruit more nurse educators
of Regulated Nurses are underway. Current initiatives include additional PhD
It has proved difficult to accurately project the number programs in nursing and provincial financial support for
of new nurses needed and to align admissions into nurs- doctoral students, along with creative means of including
ing programs with future demands because of changes clinical practice and simulation opportunities. This ques-
in the scope of practice and care delivery models. As a tion of sufficient nurse educators remains an important
result, there have been periods of nursing shortages in one to address.
Canada, when the number of graduates has been insuf-
ficient to meet the need, as well as periods of limited
employment opportunities for new nurses ready to enter Technological Advancements
the workforce.
After several decades of declining numbers of stu- The growth of technology is influencing nursing edu-
dents enrolled in nursing programs following a peak cation. Advances in web-based technology and com-
in the early 1970s, admissions to registered nursing puter-based instruction offer the potential for flexible,
programs began to increase steadily from 8947 in 1999 self-directed, interactive learning activities for students in
to 14 010 in 2008–2009 in response to a shortage. As a on-site and off-site nursing programs. Computer-based
result, the number of new RN graduates rose from 4816 distance education also makes it possible for nursing pro-
in 2003 to 11 974 graduates in 2013. (CIHI, 2015). The grams to offer courses through the Internet over a large
numbers enrolled in practical and psychiatric nursing geographical area. By 2004, 41 programs were offered
programs have also increased in recent years, resulting in in full or part through distance technology. Twenty of
7895 LPN/RPN graduates and 277 psychiatric nursing these were baccalaureate, sixteen were master’s pro-
graduates in 2013 (CIHI, 2015). grams, and five were PhD programs. Some programs
may also include videoconferencing and other means of
distance learning. For nurses who already hold a degree,
Changing Demographics computer-mediated instruction supports continuing edu-
cation opportunities.
in Nursing Programs Another technological advance that has been impor-
Student populations in nursing programs are changing. tant in nursing education is high-fidelity simulation.
Aboriginal students, mature students, male students, Considered an adjunct learning opportunity for students,
international students, and students with disabilities these high-technical mannequins allow nursing students
are enrolling in increasing numbers. While studying, and graduates to practise specific skills including clini-
more students work part time to obtain the funds for cal reasoning and clinical decision-making, in a safe
their tuitions and living expenses. These changes mean environment. The use of simulation technology offers
that nurse educators must take into account a variety opportunities to engage learners in realistic situations
of needs among learners, and nursing programs have where critical thinking and problem-solving skills can be
changed to accommodate these trends. More options practised. Recent research has demonstrated that up to
are being explored that permit part-time study. Many 50% of clinical experience in a nursing program could
programs are now offering distributed learning courses be obtained through simulation experiences; however,
as an alternative to traditional modes of learning, allow- most nursing programs are still using simulation as an
ing students to complete part or all of their courses while adjunct to learning rather than a replacement for clinical
living in their preferred locations. experience (Hayden et al., 2014).
Until recently, few Aboriginal people from Northern With the introduction of the electronic record, sig-
Canada entered the nursing profession. To provide for nificant changes in the delivery of health care are under-
Inuit nurses, Nunavut Arctic College in Iqaluit and the way. These changes are having an impact on health
School of Nursing at Dalhousie University collabo- care education. Nursing students will need to learn
rated on a 4-year baccalaureate program. The program new approaches to information management to provide
admitted its first class of Inuit students in October 1999. care in technology-enabled environments. National-level
Another solution has been to work within established informatics competencies have been identified for all
programs, offering support to Aboriginal students. One graduates of RN entry-to-practice programs and form
such program, the Native Access Program to Nursing the basis for curriculum development (CASN, 2014c).
M02_KOZI2703_04_SE_C02.indd 30 25/01/17 9:21 AM

Interprofessional Education Continuing Education

Nurses have long recognized that they need to work with to Maintain Competency
other health care professionals to deliver quality care to To provide competent nursing care (see Box 2.1), all
their patients, but more recently, educators have recognized nurses, RNs, LPNs/RPNs, and RPNs, must continu-
that students in health professional programs should be ally enhance the knowledge, skills, and critical think-
educated together to facilitate such collaboration. Such ing required to meet client needs in a changing health
interprofessional education (IPE) requires educa- care system. Each jurisdiction and each group of nurses
tors to work together to provide educational experiences have continuing competency requirements for licence or
that enable students to develop interprofessional competen- registration renewal. Continuing education or lifelong
cies, as enunciated in the national interprofessional com- learning is a strategy to achieve this goal. The CNA
petencies statement (Canadian Interprofessional Health interprets continuing nursing education as consist-
Collaborative, 2010). Interprofessional education is sup- ing of planned learning experiences undertaken follow-
ported by the Accreditation of Interprofessional Health ing a basic nursing education. Acknowledging the need
Education (AIPHE) initiative. Eight organizations that to ensure safe practice, the CNA published A National
accredit prelicensure education for six Canadian health Framework for Continuing Competency Programs for Registered
care professions have collaborated in promoting the inte- Nurses in September 2000. The framework represents a
gration of IPE in their respective accreditation standards. consensus of nursing regulatory bodies in all provinces
They have developed a framework to assist health care pro- and territories, including Quebec.
fessions to integrate IPE competencies in accreditation stan- Continuing education is the responsibility of each
dards, and work by each of the accrediting bodies to do this practising nurse and the employer. The CNA advocates
is underway (AIPHE, 2011). With the increase in the scope for the voluntary participation of nurses in continu-
of practice of practical nurses, intraprofessional education ing education in which they select learning activities
is important in nursing as is interprofessional education. It based on their own experiences, learning styles, and
is important for nursing students to collaborate with each practice requirements. A variety of educational and
other for the changing skill mix in the clinical environment health care institutions conduct continuing education
(See the Evidence-Informed Practice box). programs. They are usually designed to meet one or
more of the following needs: (a) to keep nurses abreast
of new techniques and competence, (b) to help nurses
EVIDENCE-INFORMED PRACTICE attain expertise in a specialized area of practice, such
as intensive care nursing or community nursing, and (c)
Educating Registered Nurses to provide nurses with information essential to nursing
practice, for example, knowledge about the legal aspects
and Practical Nurses of nursing.
for Intraprofessional Mandatory versus voluntary continuing educa-
Collaborative Practice tion has been a topic of interest to practising nurses,
educators, administrators, professional and regulatory
This qualitative study of 250 students (165 BScN and associations, unions, and governments. Most registered,
85 PN) conducted in an Ontario college explored how
psychiatric, and licensed practical nursing jurisdictions
educational strategies facilitated intraprofessional relations
between registered nurse and practical nurse students in in Canada view continuing education itself as voluntary
the college. Students in these two programs were inter- with a strong link in a mandatory continuing compe-
viewed or submitted written text for analysis. The study tency or professional development program.
illustrated that students were aware of the differences
in boundaries and scope of practice of the two levels of
nurses but were striving to understand the differences
and student-perceived inequities between them. Students BOX 2.1 EDUCATIONAL SUPPORT
attempted to reconcile the tensions between the two FOR COMPETENT NURSING PRACTICE
groups following educational programming intended to
foster understanding. The competence of registered nurses (RNs) is an essen-
tial element of safe and high-quality nursing practice.
NURSING IMPLICATIONS: Use of similar educational Competence is defined as a way to act with the necessary
strategies to enhance understanding could be insti- knowledge and skills in a certain context (Le Boterf, 2006).
tuted at the educational levels or within the workplace Competence is one of the main aspects to consider
to facilitate positive intraprofessional relationships and
when evaluating quality of care. To practise safely and com-
reduce power inequities in the workplace.
petently, RNs comply with professional standards, base their
Source: Based on J. Limoges & K. Jagos, (2015). The influences of nursing educa- practice on relevant knowledge, and, in adherence with the
tion on the socialization and professional working relationships of canadian practical Code of Ethics for Registered Nurses, acquire new skills and
and degree nursing students: A critical analysis. Nurse Education Today, 35,
1023–1027. doi: 10.1016/j.nedt.2015.07.018. knowledge in their area of practice on a continuing basis.
M02_KOZI2703_04_SE_C02.indd 31 20/02/17 1:23 PM

In-Service Education piece of equipment, about specific isolation practices,

or about methods of implementing a nurse theorist’s
An in-service education program is administered by conceptual framework for nursing. Some in-service pro-
an employer and is designed to upgrade the knowledge grams are mandatory, such as cardiopulmonary resusci-
or skills of employees. For example, an employer might tation (CPR) and fire safety programs.
offer an in-service program to inform nurses about a new
Case Study 2
A friend, who knows that you are a nursing student, tells you that
he is considering nursing school and wants
2. What did you consider when choosing your nursing
educational program?
your advice on the best level of nursing edu-
cation he can undertake. He also asks which
nursing program you would recommend. Visit MyNursingLab for answers and explanations.
CRITICAL THINKING QUESTIONS
1. What questions would you ask before responding?
KE Y TERM S
baccalaureate nursing diploma programs p. 26 internationally educated licensing
degrees p. 24 entry-to-practice 29 nurses p. 25 examination p. 25
continuing nursing in-service interprofessional master’s
education p. 31 education p. 32 education (IPE) p. 31 programs p. 27

• Nursing education has changed dramatically since the Master’s and doctoral programs in nursing grew signifi-
mid-nineteenth century. Early apprenticeship programs cantly in the latter part of the twentieth century.
established in the nineteenth century were designed to • Nursing education curricula are continually being
meet the service needs of hospitals, not the educational revised in response to new scientific knowledge and
needs of students. Today, nursing education is provided technological, cultural, political, and socioeconomic
primarily in college and university settings. changes in society.
• Although baccalaureate programs began in the early • Continuing education is the responsibility of each practis-
twentieth century, baccalaureate education began to take ing nurse to keep abreast of scientific and technological
hold only after the release of the Weir Report in 1932. changes, as well as changes within the nursing profession.

1. Who is responsible for monitoring minimum standards 2. What was one of the greatest influences on the evolution
for basic nursing education in Canada? of Canadian registered nursing education programs?
a. Provincial or territorial nursing regulatory bodies a. Requirements of the national regulatory bodies
b. The individual school of nursing b. Introduction of the nursing unions
c. Canadian Association of Schools of Nursing (CASN) c. Recommendations of the Weir Report
d. Provincial or territorial governments d. Creation of the Mack Training School
M02_KOZI2703_04_SE_C02.indd 32 20/02/17 1:23 PM

3. What would be the best example of continuing nursing 7. What is currently recognized as an important issue that
education? has implications for nursing education in Canada?
a. A course on leadership offered at a college or university a. The need to establish national competencies
b. A course given by the employer on the new b. Changing societal health care needs
electronic charting c. The increasing cost of nursing education
c. Cardiopulmonary resuscitation (CPR) recertification d. An oversupply of nurse educators
offered by a community agency
d. A course in fitness offered through community 8. What differentiates the practice of a nurse practitioner
services (NP) from a clinical nurse specialist (CNS)? (Select all
that apply.)
4. What trend has resulted in practical nurse (LPN or a. Is a nurse with master’s level preparation
RPN) programs to increase program length to a 2-year
diploma? b. Has an expanded scope of practice
a. A shortage of qualified nurses in health care c. Must write and pass a licensure examination
b. An expansion in the scope of practice of practical d. Provide administrative leadership in a practice
nurses setting
c. The increasing cost of baccalaureate education 9. Which of the following has responsibility for continuing
d. A decrease in entrance requirements for practical education?
nurse programs a. The college or university
5. What does the term entry to practice mean? b. The employing agency
a. The amount of time spent in preparing for profes- c. The practising nurse
sional practice d. The provincial or territorial regulating body
b. Courses required by the educational institution
10. What was the major impetus for moving nursing
c. The level of education required to achieve licensure education programs away from the hospital setting?
d. Curriculum required by the accreditation process a. To demonstrate the value of apprenticeship models
of education
6. What is the purpose of nursing certification programs?
b. To force physicians to come to the university to
a. To achieve advanced standing in a graduate nursing teach
program
c. To enable the profession to gain control over the
b. A requirement for a nursing leadership position educational process
c. To acquire new technical skills in nursing practice d. To remove the influence of religious groups over
d. To gain competence and recognition in a specialized nursing
area of nursing
REFERENCES
Accreditation of Interprofessional Health Education. (2011). Canadian Production: Potential New Supply. Retrieved from http://
Interprofessional health education accreditation standards guide. Retrieved www.casn.ca/2015/11/9974/
from http://wwwaiphe.ca. Canadian Association of Schools of Nursing. (2014c). Nursing
Anderson, J. P, Blue, J. C., Browne, A., Henderson, A., Khan, Informatics Entry-to-Practice competencies for Registered Nurses.
Koushambhi B., … Smythe, V. (2003). “Rewriting” cultural safety Ottawa, ON: Author. Retrieved from http://www.casn.
within the postcolonial and postnational feminist project: Toward ca/2014/12/casn-entry-practice-nursing-informatics-
new epistemologies of healing. Advances in Nursing Science, 26(3), competencies/.
196–214. Canadian Association of Schools of Nursing. (2014d). National
Baumann, A., Blythe, J., Baxter, P., Alvarado, K., Martin, D. (2009). Nursing Education Framework. Retrieved from http://www.casn.ca/
Registered practical nurses: An overview of education and practice. NHSRU: education/national-nursing-education-framework/.
Health Human Resources Series 12. Retrieved from http://www. Canadian Institute for Health Information (CIHI). (2015).
NHSRU.com. Regulated Nurses 2014. Ottawa, ON: Author. Retrieved from
Baumgart, A. J., & Larsen, J. (Eds.). (1992). Canadian nursing faces the https://secure.cihi.ca/free_products/RegulatedNurses2014_
future (2nd ed.). Toronto, ON: C. V. Mosby. Report_EN.pdf.
Black, J., Redern, L., Muzio, L., Rushowick, B., Balishi, B., Canadian Interprofessional Health Collaborative. (2010). A
Martens, P., … Round, B. (2008). Competencies in the context national interprofessional competency framework. Retrieved
of entry-level registered nurse practice: A collaborative project in from www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf.
Canada. International Nursing Review, 55(2), 171–178. Canadian Nurses Association & The Canadian Institute of Health
Canadian Association of Schools of Nursing. (2014a). CASN/ACESI Information. (2005). The Regulation and Supply of Nurse Practitioners in
mission. Retrieved from http://www.casn.ca/about-casn/casnacesi- Canada. Ottawa, ON: Authors.
mission/. Canadian Nurses Association. (2013). 2011 workforce profile of registered
Canadian Association of Schools of Nursing. (2015). Registered Nurses nurses in Canada. Ottawa, ON: Author.
education in Canada statistics, 2013–2014 – Registered Nurse workforce,
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Canadian Nurses Association. (2015). The CNA certification program. Le Boterf, G. (2006). Contruire les compétences individuelles et collectives
Ottawa, ON: Author. Retrieved from http://nurseone.ca/en/ (4e éd.). Paris, France: Éditions d’Organisation.
certification. Mussalem, H. (1960). Spotlight on nursing education. Ottawa, ON:
Canadian Nursing Students’ Association. (2014). The Canadian Canadian Nurses Association.
Nursing Students’ Association Governing Bylaws. Retrieved from http:// National League for Nursing Education. (1937). A curriculum guide for
www.cnsa.ca/english/publications/bylaws. schools of nursing. New York: Author.
Cohen, Y. (2000). Profession infirmière: Une histoire des soins dans les Pringle, D., Green, L., & Johnson, L. (2004). Nursing education in
hôpitaux du Québec. Montréal, PQ: Les presses de l’Université de Canada. Historical review and current capacity. The Nursing Sector
Montréal. Study Corporation, 99 Fifth Avenue, Suite 10, Ottawa K1S 5K4.
Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., Retrieved from http://www.cna-nurses.ca/CNA/documents/pdf/
& Jeffries, P.R. (2014). The NCSBN national simulation study: publications/nursing_education_Canada_e.pdf.
A longitudinal, randomized, controlled study replacing clinical Street, M. M. (1973). Watch-fires on the mountains: The life and writings
hours with simulation in prelicensure nursing education. Journal of of Ethel Johns. Toronto, ON: University of Toronto Press.
Nursing Regulation, 5(2), July supp., S3–S66. Villeneuve, M., & MacDonald, J. (2006). Toward 2020: Visions for
Jensen, P. M. (2007). Nursing. Canadian Encyclopedia Historica. nursing. Ottawa, ON: Canadian Nurses Association.
Retrieved from http://www.thecanadianencyclopedia.com/index. Weir, G. M. (1932). Survey of nursing education in Canada. Toronto,
cfm?PgNm=TCE&Params=A1SEC825469. ON: University of Toronto Press.
M02_KOZI2703_04_SE_C02.indd 34 25/01/17 9:21 AM

Chapter 3
Nursing Research
in Canada
Updated by
Joanne Profetto-McGrath, RN, PhD
Faculty of Nursing, University of Alberta
N
LEARNING OUTCOMES
After studying this chapter, you will be able to urses actively gener-
1. Summarize the concepts and language of research. ate, publish, and apply
research in practice to
2. Identify common research methods used in clinical inquiries.
improve client care and enhance
3. Describe the ways that theory, research, and practice interrelate.
nursing’s scientific knowledge base.
4. State the significance of research to the practice of nursing. The use of research has three main
5. List seven ways the nurse can participate in research activities in benefits for clients. It helps nurses (a)
practice. understand the client’s situation more
6. Differentiate the quantitative approach and the qualitative approach thoroughly, (b) assess the client more
in nursing research. accurately, and (c) intervene more
7. Analyze the nurse’s role in protecting the rights of human subjects effectively. Nursing research findings
in research. not only improve client care but also
8. Outline the 11 steps of the research process. affect the health care system itself.
For example, research studies have
demonstrated the cost-effectiveness
of registered nurses (RNs) as health
care providers.
M03_KOZI2703_04_SE_C03.indd 35 17/03/17 10:53 AM

Nursing Research supplies. As a result, soldiers died from starvation and dis-
eases such as dysentery, cholera, and typhus (Woodham-
Smith, 1950). By systematically collecting, organizing,
The Canadian Nurses Association (CNA) is committed and reporting data, Nightingale was able to institute
to promoting research as the foundation for clinical prac- sanitary reforms and significantly reduce the rate of mor-
tice. Reading research, evaluating the results of research tality from contagious diseases. Despite the early work
studies, and, where appropriate, integrating new findings of Nightingale and her influence on the early Canadian
into practice are necessary competencies of professional nursing schools, the development of nursing research in
nursing practice. Research-based nursing prac- Canada was a gradual process.
tice simply means nursing practice that is informed by Nursing research in Canada was ignited by the estab-
valid and reliable research findings obtained from sci- lishment of the first nursing journal in 1969, called Nursing
entific investigations. The term evidence-based practice, or Papers (later Canadian Journal of Nursing Research) (Gottlieb,
evidence-based decision making, is gaining popularity in 1999). Dr. Moyra Allen viewed the journal as a vehicle
nursing and, in some cases, is preferred to research-based for scholarly debate and knowledge sharing (Gottlieb,
practice. Evidence-based practice or evidence- 1999). This was followed by the first National Nursing
informed practice is “broadly defined as the use of Research Conference in 1971 in Ottawa, organized by the
the best clinical evidence in making patient care deci- University of British Columbia School of Nursing with
sions” (Loiselle, Profetto-McGrath, Polit, & Beck, 2011, financial assistance from the National Health Research and
p. 3). In recent years, more emphasis has been placed on Development Program (NHRDP) (Lander, 2011). Dr. Faye
integrating appropriate evidence into practice to inform Abdellah, the only nurse invited to speak, offered a histori-
decisions and policymaking, advance the quality of care, cal perspective of nursing research in the United States. In
and achieve the best possible outcomes for patients, the same year, the first Centre for Nursing Research was
regardless of setting. Although evidence generated by established in Canada at McGill University, with assistance
findings from research studies is of primary importance, from the federal Department of Health and Welfare, to
it is not the only source of knowledge used by nurses. support the development of nursing research. However,
Carper (1978) identified four patterns of nursing knowl- it was not until the second National Nursing Research
edge that are essential to nurses: empirical, aesthetic, Conference in 1973 in Montreal that discussions centred
personal, and moral. on how nursing theory research could be used to guide
Nursing research is the systematic, objective practice (Gottlieb, 1999). Since then, research conferences
investigation of phenomena (experiences, events, or cir- and centres have continued to support nursing’s emphasis
cumstances) of importance to nursing, with the goal of on research development.
improving practice. Research can be classified, accord- Initially, there was little opportunity for nurses to
ing to the purpose of the study, as basic or applied. Basic develop expertise in conducting research without travel
research is concerned with generating knowledge and is to the United States for graduate-level education. This
sometimes called pure research. Applied research is con- changed in 1959 with the establishment of a 1-year
cerned with using knowledge to solve immediate problems. diploma program in nursing service administration, the
Research is different from problem solving. Problem first publicly funded graduate program, at the University
solving is specific to a given situation in which alterna- of Western Ontario (Overduin, 1973), now known as
tives are explored and chosen and immediate action is Western University. The momentum continued when
taken. Knowledge gained from research is transferable to other graduate-level programs started across the coun-
other situations. The body of knowledge called nursing sci- try, eventually leading to the establishment of the first
ence and the growth and development of professional nurs- funded Canadian PhD program at the University of
ing depend on research undertaken by nurses. Alberta in 1991. Simply stated, “nursing researchers are
Although the focus for all nurses is the use of research educated in universities” (Lauri, 1990, p. 171), with doc-
findings in practice, the level of participation in research toral preparation as the foundation to the development
depends on the nurse’s educational level, position, experi- of nursing science (Glass, 1977). Today, nursing research
ence, and practical environment. Refer to the “Developing is developing at a more rapid pace, and most of it is ini-
Research-Based Practice” section for specific examples of tiated in university settings because of faculty members’
ways in which nurses participate in research. preparation as researchers. In college settings, faculty
members are conducting applied research, particularly
in the area of nursing education.
A Brief History
As early as 1854, Florence Nightingale demonstrated
the importance of research in the delivery of nursing
Linking Theory, Practice, and Research
care. When Nightingale arrived in Crimea, she found An interrelationship exists among nursing research, the-
the military hospital barracks overcrowded, filthy, rodent- ory, and practice. Research can be used to demonstrate
infested, and lacking in food, drugs, and essential medical that one nursing practice intervention is more effective
M03_KOZI2703_04_SE_C03.indd 36 20/02/17 1:30 PM

Chapter 3 Nursing Research in Canada 37
than another. Examples of changes in nursing practice interest to their ministries, for example, distribution of
motivated by research include the following: the nursing workforce in the rural areas of Canada.
Several non-nursing provincial, territorial, and fed-
• Initial development and psychometric testing of an
eral agencies accept proposals that meet their funding
instrument to measure the quality of children’s end-
guidelines when submitted by qualified nurse research-
of-life care (Widger, Tourangeau, Steele, & Streiner,
ers. These include the Social Sciences and Humanities
2015).
Research Council (SSHRC), Canadian Health Services
• Emotional and informational needs of women undergo- Research Foundation (CHSRF), and the Canadian
ing outpatient surgery for breast cancer (Dawe, Bennett, Institutes of Health Research (CIHR). The SSHRC is
Kearney, & Westera, 2014). a federal agency that promotes and supports university-
• Influences shaping nurses’ use of distraction for manag- based research in social sciences and humanities. The
ing children’s pain during procedures (Olmstead, Scott, CHSRF is an independent organization dedicated to
Mayan, Koop, & Reid, 2014). accelerating the improvement and transformation of
health care for Canadians. It collaborates with govern-
Research ideas, while often born in practice, also
ments, policymakers, and health system leaders to con-
come from nursing literature and theory. Published arti-
vert evidence and innovative practices into actionable
cles about nursing research may stimulate questions,
policies, programs, tools, and leadership development.
which lead to interest in further studies. Nursing theorists
Its vision is “timely, appropriate and high-quality services
generate research questions to piece together ideas that
that improve the health of all Canadians” (http://www.
explain why something happens. Their explanations are
chsrf.ca).
then tested, through research, to determine if they are
The CIHR was established by an Act of Parliament
credible for use in clinical practice.
in 2000 and is Canada’s foremost federal agency for
Health care agencies have begun to formally define
health research. Its predecessor was the Medical
the link between nursing research and practice. Strategies
Research Council. The CIHR provides funding oppor-
include the cross-appointment of faculty among hospi-
tunities for biomedical, clinical, health systems services,
tals, health care agencies, and universities; the imple-
social, cultural, environmental, and population health
mentation of programs to develop staff nurses as users
research. The CIHR integrates research through a
of research in their practice; the establishment of ethics
unique interdisciplinary structure made up of 13 “vir-
committees to review research proposals; the appoint-
tual” institutes (e.g., Aboriginal People’s Health, Aging,
ment of unit research coordinators; the establishment
Population and Public Health) that encourage partner-
of nursing research committees; the development of
ship and collaboration across sectors, disciplines, and
strategic plans for nursing research; and the use of
regions. Each institute embraces a range of research
evidence-based decision-making models in practice set-
from fundamental biomedical and clinical research, to
tings. These strategies create an environment to support
research on health systems, health services, the health of
evidence-informed practice.
populations, societal and cultural dimensions of health,
and environmental influences on health. Other recent
funding endeavours include the Canadian Foundation
Support for Nursing Research for Innovation (CFI), a nonprofit corporation funded
Nursing research costs money. Computer and library ser- by the federal government, beginning in 1997, to
vices, data collection, statistical consultation, employment enable Canada’s research community to conduct
of research assistants, and release time for researchers research and develop technology. In 2014, the CIHR
from their regular work responsibilities can be expen- unveiled a 10-year plan entitled “Strategy for Patient-
sive. Although funding sources have developed, financial Oriented Research” (CIHR, 2016). One of the major
support is still difficult to obtain. Collaborative, inter- components of this plan is to support best practices
disciplinary studies have a greater chance of receiving in health care.
financial support compared with research conducted only Foundations and voluntary associations, such as the
by RNs. Insufficient funding is an obstacle for nursing Alzheimer Society of Canada, Canadian Cancer Society,
research. and the Kidney Foundation of Canada, are other sources
Nursing research funding comes from a variety of of funding for nurse researchers.
sources. At the provincial or territorial level, research
funding varies, as few provincial nursing associations
have developed the capacity for funding nursing research.
Approaches to Nursing Research
Nationally, the Canadian Nurses Foundation funds The two predominant research approaches are quanti-
research, and specialty groups, such as the Canadian tative and qualitative approaches. Quantitative research is
Gerontological Nursing Association, also provide finan- generally considered objective and uses data-gathering
cial assistance to their members to conduct research. techniques that can be verified by others. The research
Governments sponsor research related to areas of problems contain dependent and independent variables, except
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for descriptive research, which has no dependent vari-

ables. The dependent variable is the behaviour, EVIDENCE-INFORMED
characteristic, or outcome that the researcher wants to PRACTICE
explain or predict. The independent variable is the
presumed cause of, or influence on, the dependent vari- Can Adverse Patient Events Be
able. Qualitative research is more subjective, which means
that qualitative researchers study important aspects in
Attributed to Nursing Care?
their natural settings, attempting to make sense of phe- According to D’Amour, Dubois, Tchouaket, Clarke, and Blais
nomena in terms of the meanings people bring to them. (2014), previous research into patient safety indicates that
Qualitative studies do not contain variables. adverse events that are correlated with nursing care remain
These approaches originate from different philo- high. These events include pressure sores, falls, medication
administration errors, pneumonias, urinary tract infections,
sophical perspectives and use different methods for the
and inappropriate use of restraints.
collection and analysis of data. Through a cross-sectional review of 2699 charts of
QUANTITATIVE RESEARCH Quantitative research 22 medical units in 11 hospitals in Quebec, Canada, the
authors provide comprehensive information on hospital
is a systematic, logical approach to studying phenom-
safety in Canada, the inconsistent methods of measuring
ena that are measureable and quantifiable, using rig- outcomes related to nursing care, and the lack of knowl-
orous and controlled designs, and statistical analysis edge related to how nursing care could be adapted to pre-
(Loiselle, Profetto-McGrath, Polit, & Beck, 2011). The vent the top six adverse events. Their research indicates
quantitative approach is most frequently associated that (1) 1 out of 7 patients (15.3%) developed at least one
with logical positivism, a philosophical doctrine that of the aforementioned adverse events while in hospital,
asserts that scientific knowledge is the only kind of fac- (2) 1 out of 15 patients (6.8%) developed other health con-
sequences (prolonged stay, other inventions, temporary or
tual knowledge. Quantitative research is often viewed
permanent health status change) as a result of the adverse
as “hard” science and tends to emphasize deductive event, and (3) nursing care was attributed to the develop-
reasoning and the measurable attributes of human expe- ment of adverse events 76.8% of the time, with medica-
rience. Data are usually collected by using structured tion administration errors and inappropriate use of restraints
methods and procedures and are analyzed by using most strongly correlated to nursing care.
a number of statistical procedures (see Evidence- NURSING IMPLICATIONS: Patient safety and quality of
Informed Practice box). nursing care are interdependent. There is a need to
The following are examples of research questions understand the role of nursing in the development of
that lend themselves to a quantitative approach: these six adverse events to prevent their occurrence
in the future.
• What is the effect of nurse home visits on the parenting
ability of teen mothers? Source: Based on D. D’Amour, C. Dubois, É. Tchouaket, S. Clarke, & R. Blais
(2014). The occurrence of adverse events potentially attributable to nursing care
• Does rocking in older adults elicit the physiological in medical units: Cross sectional record review. International Journal of Nursing
Studies, 51(6), 882–891. doi:10.1016/j.ijnurstu.2013.10.017.
changes of the relaxation response?
• What is the effect of social support intervention on coping
in nurses working in intensive care units?
would be appropriate for the following types of research
QUALITATIVE RESEARCH Qualitative research is
questions:
“associated with naturalistic inquiry, which explores
the subjective and complex experiences of human • What is the nature of the bereavement process in spouses
beings” (Berman, Snyder, & Frandsen, 2008, p. 32). of clients with terminal cancer?
The collection of rich narrative material and analysis • What is the nature of adjustment after a mastectomy?
take place simultaneously with the use of an induc-
• What is the impact of eating disorders on family life?
tive approach to analysis. In the qualitative approach,
no formal instruments are used; instead, loosely struc-
tured narrative data are collected. Using the inductive
method, data are analyzed by identifying themes and
The Research Process
patterns that emerge. This approach is most often asso- Loiselle et al. (2011) defined research as a “systematic
ciated with the naturalistic paradigm, which began inquiry that uses disciplined methods to answer ques-
as a countermovement to positivism. This perspective tions or solve problems” (p. 2). Whether a quantitative
assumes that multiple perspectives of reality exist, each or qualitative approach is used, all research must be
within a context. meticulously planned, systematically implemented, and
The qualitative approach explores complex human carefully analyzed. To achieve this goal, researchers
experiences and focuses on the holistic aspects of these adhere to a formal course of action known as the research
experiences from the perspectives of those who are liv- process. This process has 11 steps, beginning with the
ing them (Loiselle et al., 2011). The qualitative approach formulation of the research problem and ending with
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the communication of the research. However, sometimes provides the foundation on which new knowledge can be
variation exists in the terms given to these steps, depend- built. Through a literature review, a researcher may also
ing on the nature of the study. acquire information about available techniques, instru-
ments, and methods of data analysis that have been used
1. STATE A RESEARCH PROBLEM The investigator’s in prior research, as well as potential flaws or problems
initial task is to narrow a broad area of interest to a cir- and how to avoid them. The literature review helps to
cumscribed research problem that specifies exactly determine the best approach for studying the problem
the situation that needs to be described, explained, or (Gillis & Jackson, 2002).
predicted. The ideas for research may arise from recur-
rent problems encountered in practice, questions that 4. FORMULATE THE RESEARCH QUESTION OR
are difficult to resolve because of contradictions in the HYPOTHESIS Once nurse researchers have identified a
literature, or areas in which minimal or no research has research problem and are knowledgeable of the litera-
been done. ture, they formulate a research question. The ques-
In formulating a research problem, Loiselle et al. tion may be stated in one of three ways: (a) a statement,
(2011) suggested five important considerations: (a) sig- (b) a question, or (c) a hypothesis. If researchers are
nificance, (b) usefulness, (c) researchability, (d) feasibil- going to describe something, they may make a statement,
ity, and (e) ethical soundness. A research problem has such as “The purpose of this study is to identify gender
significance if it has the potential to contribute to nursing differences in the nursing care of patients admitted to
science by enhancing client care, testing or generating a rehabilitation units.” They could also ask a question,
theory, or resolving a day-to-day clinical problem. The such as “What are the communication styles of nurses
question “So what?” must be answered adequately to that produce client satisfaction with nursing care?”
determine whether a research problem is significant. If conducting an experiment, researchers must have
The usefulness of a study relates to the potential a hypothesis about what the outcome will be so that
usefulness in nursing practice of the findings. Not only hypothesis-testing statistics can be applied. For example,
should the problem be significant, but it must also be “Family members of palliative care patients attending
relevant and applicable to nursing practice. support groups will demonstrate more positive coping
Researchability means that the problem can be sub- strategies compared with those who do not attend” is
jected to scientific investigation by using appropriate and a testable hypothesis. Whichever way a research ques-
sound methodology. Many significant problems that pro- tion is stated, it must be clearly expressed. Wood and
duce ambiguity and uncertainty in clinical situations are Ross-Kerr (2010) identify three levels of questions: (a)
not amenable to research. For instance, “Should nurses Level one questions relate to topics with little or no
support voluntary euthanasia?” is a relevant, timely, and prior knowledge, and this leads to an exploration; (b)
difficult question, but it cannot be answered through level two questions are useful when a topic has already
research. been well described and any variables arising from the
Feasibility pertains to practical issues, such as availabil- descriptions prompt the researcher to consider relation-
ity of time and the material and human resources needed ships between these variables; and (c) level three ques-
to investigate a research problem or question. Conducting tions build on previous research and look for causal
a study involves the use of space, money, equipment, relationships.
supplies, computers, subjects, research assistants, and
consultants. 5. SELECT A RESEARCH DESIGN A research design
A study is ethically sound if ethical issues are addressed is the “overall plan for addressing a research question”
by adhering to rigorous procedures and appropriate (Loiselle et al., 2011, p. 422). The choice of design
ethical reviews, where needed. See the “Protecting the depends on the nature of the problem. Level one ques-
Rights of Human Subjects” section later in this chap- tions lend themselves to various qualitative designs,
ter for details concerning the ethical principles guiding whereas levels two and three are more appropriate
research in Canada. for quantitative designs. Sometimes, a combination of
approaches is used and is described as mixed meth-
2. DEFINE THE STUDY’S PURPOSE OR RATIONALE The ods. The research design includes the study setting, the
statement of the study’s purpose indicates what the sample, and the type of data to be collected, as well as
researcher intends to do with the research problem iden- strategies to reduce bias.
tified. The study purpose includes what the researcher The quantitative research design has three categories:
will do, who the subjects will be, and where the data will
be collected. 1. Experimental design. The investigator manipulates
the independent variable by administering an experi-
3. REVIEW THE LITERATURE Before proceeding with mental treatment to some subjects while withholding
the development of the research design, the investigator it from others. The conditions are tightly controlled
determines what is known and what is not known about to objectively test the hypothesis to predict cause-and-
the problem. A thorough review of the literature effect relationships (Polit & Tatano Beck, 2014).
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2. Quasi-experimental design. The investigator ma- study begins. The research procedure is conducted on
nipulates the independent variable but without either a few subjects to determine the feasibility of the data
the randomization or the control that characterizes collection plan, identify flaws, and refine the proposed
true experiments. This design is common in health care plan to strengthen the research methodology (Berman
studies because random assignment to treatment and et al., 2008).
control groups is not always feasible in a clinical setting
(Polit & Beck, 2014). 8. COLLECT THE DATA When designing a study,
researchers must consider how data will be collected.
3. Nonexperimental design. The investigator does not
The most commonly used methods of collecting data
manipulate the independent variable. Researchers use
in nursing are questionnaires, rating scales, interviews,
nonexperimental designs to measure characteristics and
observation, and biophysical measures.
determine relationships or correlations among these
In quantitative designs, the validity and reliability
variables (Loiselle et al., 2011).
of measurement tools need to be established before the
As noted earlier, qualitative designs seek to derive start of data collection. Validity is the degree to which
meaning and understanding from human experience. an instrument measures what it is supposed to measure.
In such disciplines as nursing, where it is necessary to If a nurse measures anxiety, how can the nurse be sure
know what the participant is experiencing, a qualitative that what is being measured is not fear or stress, which
design may be the preferred method of identifying data. are related concepts? Reliability is the degree of con-
A qualitative design differs from a quantitative design in sistency with which an instrument measures a concept or
the phenomenon studied, the data collection and analysis variable. If an instrument is reliable, repeated measure-
procedures, and the interpretation of the data. Often, ments of the same variable should yield similar or nearly
data collection and analysis are done simultaneously. similar results.
Qualitative designs do not have identifiable measurable
9. ANALYZE THE DATA In this step, the collected data
variables and data are not processed through statistical
are organized, coded, and analyzed for the purpose of
analysis.
answering the research question or testing the hypothesis.
Ethnography, grounded theory, and phenomenol-
Even before data collection is initiated, there must be a
ogy are some of the commonly used qualitative meth-
systematic plan for analyzing the results. Measurement
ods. Ethnographic research is used to describe social
is a critical part of the research process. Measurement is
behaviours within a particular group or setting. The goal is
not a feature of qualitative designs; the discussion here is
to understand the culture and norms from the participant’s
relevant to quantitative designs. Variables are important
viewpoint (Polit & Tatano Beck, 2014). Studies related to
components of measurement. The identified research
the nursing care or health practices of a particular culture
question helps the researcher identify the variables and
would be examples of ethnographic nursing research.
possible relationships among them. The variables must be
Grounded theory research is used to develop nursing
clearly defined, observable, and measurable to permit the
theory from collected data. Theory may be generated
results of a study to be interpretable. Regardless of the
for relatively new areas, where very little is known, or for
method of measurement used, it must have evidence of
more familiar areas where a fresh viewpoint is sought.
objectivity. This means that the system of measurement
Phenomenology is a philosophical research method that
must be so clear that anyone following the prescribed
regards each human as having a unique experience. The
rules will assign the same or similar score to what was
researcher uses in-depth conversations to attempt to derive
observed.
meaning from individuals’ descriptions of their experi-
Data analysis can involve descriptive or inferential
ences (Polit & Tatano Beck, 2014).
statistics. Descriptive statistics, procedures that sum-
In selecting the approach, the researcher should
marize large volumes of data, are used to describe and
try to identify factors that may affect the study’s results.
synthesize data, showing patterns and trends. Descriptive
Sometimes, these factors are called limitations. The
statistics include measures of central tendency and mea-
researcher should acknowledge the limitations of the
sures of variability.
study, as much as possible, before the data are collected.
Measures of central tendency describe the cen-
6. SELECT THE POPULATION, SAMPLE, AND tre of a distribution of data, denoting where most of the
SETTING At this stage, the researcher chooses the study subjects lie. These include the mean, median, and mode.
population, selects a sample, and decides on the set- Measures of variability indicate the degree of disper-
ting where the sample can be found. The population sion, or spread, of the data. These include the range, vari-
includes all members of the group who meet the criteria ance, and standard deviation. See Box 3.1 for definitions
for the study. The sample is the segment of the popula- of these measures. Typically, in a research report, the mean
tion from whom the data will actually be collected. and the standard deviation are reported together to give
the reader an idea of the nature of the data distribution.
7. CONDUCT A PILOT STUDY In quantitative studies, a The following is an example: systolic blood pressure
pilot study is a small-scale trial done before the actual = 130 ± 30 mm Hg. The two statistics reported are the
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BOX 3.1 DEFINITIONS OF MEASURES Conclusions are then drawn: What do these findings
mean? At this point, researchers can be subjective and
OF CENTRAL TENDENCY AND VARIABILITY
insert some of their own thinking into the research
CENTRAL TENDENCY report. The results of the current research are com-
pared with previous studies that investigated the same or
Mean: The sum of all scores divided by the number of
similar phenomena. The researcher should discuss any
subjects; commonly symbolized as X or M
problems encountered in the course of the study or any
Median: The middle score or value in a distribution of scores;
limitations that may have influenced the findings.
the value above and below which 50% of the scores lie
After the findings are interpreted, the researcher
Mode: The score or value that occurs most frequently in a should indicate the implications for nursing. Implications
distribution of scores
are suggestions for ways of thinking about the phenom-
VARIABILITY enon in the future. Nursing research may unearth indica-
tions for changes to nursing practice, administration, or
Range: The difference between the highest and the lowest education. For example, in a review of research literature
values in a distribution of scores
on the impact of international placements on nursing
Variance: The square of the standard deviation students, the findings suggested that students become
Standard deviation: The average to which scores deviate more sensitive to cultural issues and cross-cultural care
from the mean; commonly symbolized as SD or S; the most as a result of these experiences (Button, Green, Tengnah,
frequently used measure of variability Johansson, & Baker, 2005). An implication is that nurse
educators need to provide culturally diverse opportunities
for students. In a study examining what percentage of
clients had postoperative pain at home and what impact
mean and the standard deviation. The number 130 indi- the pain had on their activity, the findings identified that
cates the mean systolic blood pressure, whereas 30 rep- clients had received no information on how to cope with
resents 1 standard deviation (SD) from the mean. Hence, pain and were not knowledgeable about analgesic use
1 SD from the mean would include blood pressures from (Collins & MacDonald, 2000). These findings indicate
100 mm Hg to 160 mm Hg (1 SD less than the mean to a need for providing clients with educational resources
1 SD more than the mean). on the management of postoperative pain following dis-
After the data have been analyzed, nurse researchers charge from hospital.
attempt to determine whether the results are statistically
significant. Underlying this statement is the notion of prob- 11. COMMUNICATE THE RESEARCH Implicit in con-
ability. By convention, a p (probability) value less than 0.05 ducting research is the requirement to share with others
is considered the acceptable level of significance; a p value the knowledge generated, primarily through publica-
greater than 0.05 is considered statistically insignificant. tion in professional journals or by reporting the results
In research, the desire is to generalize beyond the sample; orally or in poster format at professional conferences.
a need exists to determine the probability that the results Interpreting the results, communicating the findings,
were due to chance or a fluke, rather than a true occur- and suggesting directions for further study conclude the
rence in the population. Hence, a p value of 0.05 means research process.
that the probability of the findings being caused by chance In Canada, nursing research findings can be com-
alone is 5 in 100 (Berman et al., 2008). municated in numerous ways. At the local, provincial
In qualitative studies, data analysis is often done or territorial, and national levels, nursing associations
simultaneously with data collection, which enables the and special interest groups use their newsletters, pub-
researcher to focus and shape the study as it proceeds. lications, annual meetings, and conferences to promote
The researcher consistently thinks about the data, nursing research and disseminate findings. The best
works to organize them, and tries to discover meaning method of reaching a large number of nurses is through
in them. publication in nursing journals (see Box 3.2 for exam-
ples). Canadian Nurse (L’infirmière Canadienne) publishes
news items on research activities, abstracts of Canadian
10. INTERPRET THE FINDINGS In either quantitative
research articles, and articles that report research
or qualitative research, when interpreting the results
findings.
of data analysis, the researcher first reports the find-
ings that are directly related to the research question.
Sometimes, the researcher uncovers unexpected find-
ings, and these are also reported. Hirst (2000) articu-
Developing Research-Based Practice
lated a definition of resident abuse as perceived by those The nurse needs to be research minded, that is, aware
living and working within long-term care institutions of and open to nursing research. Nurses should criti-
and unexpectedly found that older adults were devalued cally read, interpret, and evaluate research evidence for
in these same facilities. applicability to their nursing practice. When reviewing
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BOX 3.2 EXAMPLES OF RESEARCH the libraries of academic institutions and large hospitals,
and many are now published online.
JOURNALS IN NURSING
The most efficient way to access research articles is to
These are just a few of the nursing journals that are currently conduct a search on an index of journal articles (Polit &
available: Tatano Beck, 2014). Examples of these indexes include the
Canadian Oncology Nursing Journal Cumulative Index to Nursing and Allied Health Literature
Canadian Journal of Cardiovascular Nursing (CINAHL), International Nursing Index, MEDLINE, and
PubMed. Computerized search assistance is available in
Canadian Journal of Nursing Leadership
health care libraries; the trick to finding relevant articles
Canadian Journal of Public Health is to identify the key words to be used for the search. It
Canadian Operating Room Nursing Journal may take several searches using different key terms and
Canadian Journal of Nursing Research databases to locate the articles. The Canadian Research
Canadian Journal of Nursing Informatics Information Database (CRID) is a resource for researchers
Clinical Nursing Research and others interested in accessing the results of research in
Canada on the Internet. During online searches, one must
Nursing Research
be aware of the credibility of the source and when the site
International Journal of Nursing Studies was last updated.
Nursing Science Quarterly The Cochrane Library is a collection of databases
Qualitative Health Research with high-quality evidence obtained through systematic
Biological Research for Nursing reviews. Results from several similar randomized tri-
als are brought together and combined to produce an
overall statistic by using exact methodology. This process
facilitates evidence-informed decision making for clinical
research articles or reports, consider the philosophi- treatment.
cal view taken in the study; for example, where does The Virginia Henderson International Nursing Library
knowledge exist? Does it exist in individuals’ experiences is sponsored by Sigma Theta Tau International and pro-
(qualitative) or in the logical reasoning of the researcher vides online access to reliable nursing information. It also
(quantitative)? Nursing has possibilities for both. includes the Registry of Nursing Research Database, with
Research-based practice enables nurses to provide up-to-date study and conference abstracts.
high-quality, cost-effective care. Through clinical prac- The CNA, Health Canada, and the First Nations
tice, nurses can identify nursing problems that need to and Inuit Health Branch of Health Canada have cre-
be investigated. Nurses can participate in the implemen- ated NurseONE, a secure web-based resource to provide
tation of research studies by helping principal research- nurses that are current CNA members “with access to
ers collect data in clinical settings. They can also help current and reliable information to support their nurs-
disseminate research-based knowledge by sharing useful ing practice, manage their careers, and connect with
findings with colleagues. Nurses with graduate educa- colleagues and health care experts” (CNA, n.d., p. 1).
tion also assume the role of clinical experts on clinical It supports an evidence-based approach to care by pro-
practice teams, integrate research findings into practice, viding easily accessible digital libraries, online journals,
design studies, and collaborate with other researchers electronic material, and databases that are all approved
(Polit & Tatano Beck, 2014). by the CNA.
Research utilization involves a number of activities
by nurses to link research findings to practice. To do so,
nurses need to access current research findings and cri-
tique this literature to determine its appropriateness for
Critiquing Research
a particular clinical setting. Critiquing involves intensive scrutiny of a study, includ-
ing its strengths and weaknesses, its statistical and clini-
cal significance, and the generalizability of the results.
Loiselle et al. (2011) suggested different approaches
Locating Nursing Research Findings to critiquing quantitative and qualitative research.
In 1952, the first nursing journal in North America, For quantitative research, using the IMRAD format
Nursing Research, was established in the United States and (i.e., introduction, method, results, and discussion) will
served as a vehicle to communicate nurses’ research and address the study components found in most research
scholarly productivity (Donahue, 1985). The publication reports. See Table 3.1 for relevant questions about each
of many other nursing research journals followed, some of these components.
devoted to research and others combining clinical, the- Qualitative research reports are generally less struc-
ory, and research publications. Journals are available in tured and organized according to the themes. However,
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TABLE 3.1 Critique of a Quantitative Research Report
Aspect of the Report Questions to Consider
Title Does the title inform you of the research problem and study population?
Abstract Does the abstract summarize the main features of the article?
Introduction
Problem Statement Is the problem clear and easy to identify?
Does the problem statement identify key concepts and the population?
Is the problem significant for nursing?
Is a quantitative approach suitable?
Does the research problem fit the methods?
Literature Review Is the literature review current and complete?
Is it based mostly on primary sources?
Does the literature review summarize what is known about the dependent
and independent variables and how they are related?
Does it provide a solid framework for the new study?
Conceptual Framework Are key concepts fully defined from a theoretical perspective?
Is a theoretical framework described? Is it appropriate?
If no theoretical framework is present, does the report justify the absence?
Hypothesis or Research Questions Are the research questions or hypotheses clear and explicit?
If not, is there a rationale for their absence?
Is there consistency among the questions and hypotheses, the literature
review, and the conceptual framework?
Method
Research Design Was a rigorous design used given the study purpose?
Were appropriate comparisons made for ease of interpreting the findings?
Was there evidence of efforts to minimize threats to internal and external
validity?
Population and Sample Were the population and sample identified and described?
Was the sampling design devised to promote a representative sample?
Was sample size sufficient? Was a sample size estimate done by using power
analysis?
Data Collection and Measurement Was there congruence between the operational and conceptual definitions?
Were key variables defined in an operational manner?
Were the instruments well described?
Did the report provide evidence of high reliability and validity of data?
Procedures Was the intervention (if used) described and correctly implemented?
Were data collected in such a way as to minimize bias?
Was the staff collecting the data trained in data collection?
Were procedures used to safeguard the rights of study participants?
Was there an ethics review?
Results
Data Analysis Did the analysis address each research question or hypothesis?
Were statistical methods matched to measurement level of the variables
and number of groups being compared?
Findings Were the findings summarized by using tables and figures?
Do findings demonstrate sound evidence about the research questions?
(continued)
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TABLE 3.1 Critique of a Quantitative Research Report (continued )

Discussion
Interpretation of Findings Are major findings interpreted, discussed, and related to prior research
and the conceptual framework used?
Was there consistency among the interpretations and results or limitations
of the study?
Implications Does the article provide details about the generalizability of the findings?
Overall
Presentation Was the report well organized, and did it provide adequate detail for critical
analysis?
Was the study understandable?
Was the study written in such way as to make the findings accessible
to practising nurses?
Summary Assessment Despite the identified limitations, do the findings appear valid?
Does the study contribute to evidence that can be meaningfully used in
nursing practice or the discipline of nursing?
Source: Republished with permission of Lippincott Williams & Wilkins, from Canadian Essentials of Nursing Research, Carmen G. Loiselle, 3rd ed., 2011, permission conveyed through
Copyright Clearance Center, Inc.
a similar approach can be used to critique qualitative contingent on an REB review. REBs have the authority
research (see Table 3.2). to require modifications to the proposed research and
In general, the critique should include consideration can terminate research that is not conducted according
of the following: to specific requirements. Also offering guidance to nurse
researchers in Canada are the CNA’s Code of Ethics for
• Amount of detail about the method, ethical consider-
Registered Nurses (2008) and the Canadian Institutes of
ations, and interpretation of findings
Health Research, Natural Sciences, and Engineering
• Clarity of language Research Council of Canada, and the Social Science
• Objectivity and lack of bias in presentation and Humanities Research Council of Canada’s Tri-
• Organization and logical presentation of ideas Council Policy Statement on Ethical Conduct for Research Involving
Humans (1998 with 2000, 2002, and 2005 amendments;
• Correct use of grammar and rules of good writing
second edition, 2010).
• Sensitivity to gender, race, and ethnicity All nurses who practise in settings where research is
• Appropriateness of title to capture key concepts and being conducted with human subjects or who participate
target population in such research as data collectors or collaborators play
• Adequacy of summary of research problem, study an important role in safeguarding the rights of human
methods, and key findings (Loiselle et al., 2011) subjects. The Tri-Council Policy is based on the following
guiding ethical principles:
Protecting the Rights of Human Subjects RESPECT FOR HUMAN DIGNITY Respect for human
dignity means protecting the interests of the person in
When research is conducted with human participants, all spheres: physical, psychological, and social/cultural.
the researcher and the nurse have a responsibility to This cardinal principle forms the basis of ethical obliga-
protect the participant from harm that may result from tions in modern research.
participation in the study. The nurse, as client advocate,
must ensure that participants’ rights are protected. RESPECT FOR FREE AND INFORMED CONSENT It is
All institutions in which research is conducted should presumed that individuals have the capacity and right to
have, or have access to, a research ethics board (REB), a com- make free and informed decisions. Obtaining informed
mittee of qualified individuals to approve the research consent is the responsibility of the principal inves-
activity and to ensure that the rights of participants are tigator. It is a contract between the investigator and
protected. The principle of protecting rights is enforced, the participant. All clients must be informed about the
to some extent, by major granting agencies, such as consequences of consenting to serve as research par-
the CIHR and the SSHRC, which make their funding ticipants. The client needs to be able to judge whether a
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TABLE 3.2 Critique of a Qualitative Research Report
Title Does the title reflect the main phenomenon and the group or community
under study?
Abstract Does the abstract summarize the main features of the article?
Introduction
Statement of the Problem Is there a clear identification of the phenomenon of interest?
Is the problem clearly stated and easy to identify?
Is the problem significant for nursing?
Does the research problem fit the methods?
Is the qualitative approach suitable?
Literature Review Does the literature review summarize knowledge related to the problem?
Is the literature review current and complete?
Does the literature review set down a basis for the new study?
Conceptual Underpinnings Are key concepts fully defined from a theoretical perspective?
Does the report identify the philosophical or ideological basis, conceptual
framework, and research tradition?
Is the approach congruent with the research questions?
Research Questions Are the research questions clear and explicit?
If not, is there a rationale for their absence?
Method
Research Design and Tradition Does the research tradition fit with the data collection and analysis methods?
Was sufficient time spent in the field or with study participants?
Did the researcher build on prior understanding by adapting an existing
design in the field?
Was there evidence of reflective thought by the researcher?
Was the number of contacts with participants sufficient?
Sample and Setting Were the population, sample, and setting identified and described?
Was an appropriate approach used to access the participants?
Was an optimal sampling method used?
Was the sample sufficient?
Was there saturation of data?
Data Collection Procedures Were the data gathered in an appropriate manner?
Were two or more methods of data gathering used to achieve triangulation?
Were the right questions or observations used?
Were these recorded appropriately?
Were sufficient data collected for depth and richness?
Was there a clear description of the data collection and recording
procedures?
Were steps taken to minimize bias or altered behaviour?
Were procedures used to safeguard the rights of study participants?
Was there an ethics review?
Enhancement of Rigour Was there a description of the methods used to promote trustworthiness
of the analysis?
Were sufficient methods used to enhance credibility?
Were the research procedures and decision processes documented to be
auditable and confirmable?
(continued)
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TABLE 3.2 Critique of a Qualitative Research Report (continued )
Results
Data Analysis Were the methods of data management and analysis clearly described?
Did the analysis approach fit with the research tradition, nature, and type
of data gathered?
Did the analysis produce a tangible output (theory, taxonomy, thematic
pattern, etc.)?
Findings Were the findings summarized with the use of quotes?
Do the themes capture the meaning of the data?
Did the researcher conceptualize the themes or patterns in the data?
Did the analysis identify a thought-provoking and meaningful picture of the
phenomenon?
Theoretical Integration Are there logical connections among the themes or patterns, and do these
connect to form a meaningful whole?
Were figures, maps, or models effectively used to summarize the
conceptualization?
Are the themes or patterns logically linked to a conceptual framework
or ideology (if one was used to guide the study)?
Discussion
Interpretation of Findings Is the interpretation of the findings situated in an appropriate context
(e.g., group, cultural, or social)?
Are the major findings interpreted, discussed, and related to prior research?
Is there consistency between the study’s interpretations and limitations?
Does the report discuss transferability of the findings?
Implications Are the implications of the study for clinical practice or future study
discussed?
Are the implications reasonable?
Overall
Presentation Was the report well organized, and did it provide adequate detail for critical
analysis?
Were the methods, findings, and interpretations richly described?
Summary Assessment Do the findings seem trustworthy?
Does the study contribute to meaningful evidence that can be used in
nursing practice or the discipline of nursing?
Source: Republished with permission of Lippincott Williams & Wilkins, from Canadian essentials of Nursing research, Carmen G. Loiselle, 3rd ed., 2011, permission conveyed through
Copyright Clearance Center, Inc.
reasonable balance exists between the risks of participat- informed consent by obtaining a participant’s consent in
ing in the study and the potential benefits. writing is important. Participants who can give only oral
Informed consent may appear to be straightfor- permission must have their consent witnessed by a third
ward and easy to implement, but this is not always true. person. If the participant is a minor or is not capable
Sometimes, researchers avoid obtaining informed consent, of consenting because of mental or physical disability,
believing that the client’s knowledge of being observed a legally authorized representative, such as a parent or
could alter behaviour and distort the findings. It is the guardian, may sign the consent. Consent must be vol-
nurse’s responsibility to safeguard participants’ human untary and informed, and the participant should not be
rights and ensure that informed consent is obtained subjected to any risk, discomfort, or invasion of privacy
before the participants are involved in any research study. other than that stated in the consent document. The par-
Informed consent includes written and oral explana- ticipant must also be guaranteed that refusal to take part
tions. It should be in the participant’s preferred language in or withdrawal from the study will not jeopardize the
and at an appropriate educational level. Documenting quality of nursing care.
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RESPECT FOR VULNERABLE PERSONS Greater ethi- situations. The risk can be physical, emotional, legal,
cal obligations toward vulnerable people and those who financial, or social. For instance, withholding standard
have diminished competence or decision-making capac- care from a client in labour for the purpose of studying
ity must be met. Children, people in institutions, and the course of natural childbirth clearly poses a potential
others are entitled to special protection against abuse physical danger. Risks can be less overt and involve psy-
and exploitation. In research, this often means that chological factors, such as exposure to stress or anxiety, or
special procedures are needed to protect the interests of social factors, such as loss of confidentiality or loss of pri-
vulnerable people. vacy. This means that research should involve the smallest
number of human subjects and smallest number of tests
RESPECT FOR PRIVACY AND CONFIDENTIALITY The on subjects that will ensure scientifically valid data.
principle of respect for privacy and confidentiality is Maximizing benefit, or beneficence, is the duty
considered fundamental to human dignity in many cul- to benefit others and maximize the net benefits. This is
tures. Standards of privacy and confidentiality protect particularly relevant in social science disciplines, such as
personal information and enable a client to participate social work and nursing, in which the advancement of
without worrying about later embarrassment. The ano- knowledge can produce benefits for society.
nymity of a study participant is ensured if the investi-
gator cannot link a specific subject to the information RIGHT TO FULL DISCLOSURE Even though it may be
reported. Confidentiality means that any information possible to collect data about a client as part of everyday
a subject provides will not be made public or available to care without the client’s particular knowledge or consent,
others without the subject’s consent. Investigators must to do so is considered unethical. Full disclosure is a
inform research subjects about the measures that provide basic right. It means that deception, either by withhold-
for these rights. Such measures may include the use of ing information about a client’s participation in a study
pseudonyms or code numbers or the reporting of only or by giving the client false or misleading information
aggregate or group data in published research. about what participating in the study will involve, will
not occur.
RESPECT FOR JUSTICE AND INCLUSIVENESS The
ethics review process is required to have fair methods RIGHT OF SELF-DETERMINATION Many clients in
and standards for reviewing research protocols so that no dependent positions, such as people in nursing homes, feel
segment of the population is unfairly burdened with the pressured to participate in studies. They feel that they must
harms of research and those who are vulnerable are not please the doctors and nurses who are responsible for their
exploited for the advancement of knowledge. Conversely, treatment and care. The right of self-determination
justice also implies a duty to ensure that some individuals means that subjects should feel free from constraints, coer-
and groups are not neglected or discriminated against cion, or any undue influence to participate in a study.
with respect to inclusion in research studies. Masked inducements, for instance, suggesting to poten-
tial participants that they might become famous by tak-
BALANCING HARMS AND BENEFITS Minimizing harm, ing part in the study, make an important contribution
or nonmaleficence, is the duty to avoid, prevent, or to science, or receive special attention, must be strictly
minimize harm to others. A research subject should not avoided. Nurses must be assertive in advocating for this
be exposed to the possibility of injury beyond everyday essential right.
Case Study 3
A research study is being implemented on the unit as Jamie,
a third-year baccalaureate nursing student in a large university
2. What questions might Jamie ask of the researchers as
he explores his possible interest in the study?
in Western Canada, starts his adult health course rotation. He
participates in the orientation session held 3. How might Jamie ensure that he protects the rights of
by the researchers to inform the staff about his patients, if they decide to participate in the study?
their study. The purpose of the study is to
understand the presurgical experiences of Visit MyNursingLab for answers and explanations.
patients. Jamie is interested in working with
the researchers.
1. Identify the responsibilities of beginning nurses in relation

to nursing research.
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KE Y TERM S
applied research p. 36 full disclosure p. 47 nonexperimental reliability p. 40
basic research p. 36 grounded theory p. 40 design p. 40 research p. 38
beneficence p. 47 hypothesis p. 39 nonmaleficence p. 47 research design p. 39
confidentiality p. 47 implications p. 41 nursing research p. 36 research problem p. 39
critiquing p. 42 independent phenomenology p. 40 research question p. 39
dependent variable p. 38 variable p. 38 pilot study p. 40 research-based nursing
descriptive informed consent p. 44 population p. 40 practice p. 36
statistics p. 40 logical positivism p. 38 problem solving p. 36 review of the
dignity p. 44 mean p. 41 qualitative literature p. 39
ethnographic measures of central designs p. 40 right of self-
research p. 40 tendency p. 40 qualitative determination p. 47
evidence-based measures of research p. 38 sample p. 40
practice p. 36 variability p. 40 quantitative standard
evidence-informed median p. 41 research p. 38 deviation p. 41
practice p. 36 mode p. 41 quasi-experimental study purpose p. 39
experimental naturalistic design p. 40 validity p. 40
design p. 39 paradigm p. 38 range p. 41 variance p. 41

• Nurses are now generating new knowledge and applying • There is an ongoing effort to conduct nursing research on
research in practice to guide and improve client care. a wide range of nursing questions.
• Nurses at all levels are participating in nursing research • Qualitative and quantitative methods or mixed methods
activities. All nurses practising in settings in which research are employed in nursing research.
is conducted have a role in safeguarding the clients’ rights. • Seven ways that nurses can participate in research are
• The use of research will help nurses understand the by (a) identifying nursing problems that need to be
client’s situation more thoroughly, assess more accurately, investigated, (b) helping principal researchers collect
and intervene more effectively. data in clinical settings, (c) disseminating research-based
• The Canadian Nurses Association is a leader in the knowledge by sharing useful findings with colleagues,
promotion of evidence-based nursing practice. (d) assuming the role of clinical expert on clinical
practice teams, (e) integrating research findings into
• Most nursing research is initiated in university set- practice, (f) designing studies, and (g) collaborating with
tings because of the preparation of faculty members other researchers.
as researchers; however, many questions are raised by
nurses in the practice settings. • Research utilization involves a number of activities by
nurses to link research findings to practice. To do so,
• In Canada today, nursing research faces both capabilities nurses need to access current research findings and
and constraints for its ongoing development. critique this literature to determine its appropriateness
• The nurse has a duty to protect the rights of the research for a particular clinical setting.
participants.

1. Which is an example of a strategy employed to link c. Promoting studies that focus on nursing as a distinct
theory, practice, and research in nursing? discipline rather than interdisciplinary studies
a. Ensuring that nursing research is exclusively con- d. Establishing concise health information systems
ducted by qualified, university-based scientists containing only essential medical data for ease
b. Implementing cross-appointments of faculty among of use
hospitals, health care agencies, and universities
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2. Which of the following research roles is expected of a c. Identify data collection methods
baccalaureate nurse working as a staff nurse in an acute d. Conduct a pilot study
care hospital?
a. Designing studies and collaborating with other 7. What variable will influence the choice of a research?
researchers
a. Preferences of the researcher conducting the research
b. Assuming the role of clinical expert on clinical prac-
tice teams b. Availability of tested measurement instruments for
the variables of interest
c. Identifying nursing problems that need to be inves-
tigated c. Availability of potential subjects to participate in the
study
d. Submitting research proposals to the hospital ethics
board for approval d. The nature of the problem being investigated
3. What should a student or staff nurse seeking guidance 8. A nurse manager is planning for a staff inservice to
from published research do? address the increased gastrointestinal system–related
infection rates on the unit. What source of information
a. Accept the findings without question, since the study is most likely to have the greatest impact on the nurses’
has been published evidence-informed practice?
b. Compare the study subjects with clients to determine a. Share a systematic research review on antibiotic-
if the findings are applicable resistant organisms (AROs)
c. Look for another study since at least two sources b. Provide the unit’s results from the most recent hand
are needed to ensure that the findings are hygiene audit
consistent
c. Present the best practice guidelines (BPGs) for reduc-
d. Write to the researchers for the raw data so the ing transmission of AROs
data can be analyzed by the nurses themselves
d. Request that the clinical educator reinforce agency
policies concerning droplet transmission-based pre-
4. Which study would best lend itself to a quantitative cautions
research approach?
a. Measuring the effects of preoperative teaching on 9. The nurse on a special assessment unit with children
postoperative wound healing who have developmental disorders has been asked to
b. Examining perceptions of adolescents with type 1 help identify potential participants for an institutionally
diabetes mellitus approved research study on independent community liv-
c. Exploring factors influencing social isolation among ing options for adolescents with Down syndrome. One
seniors living alone in the community of the clients is an 18-year-old, who has told the nurse
previously that he wants to move out of his parents’
d. Describing the experience of adjustment following home and live independently, but his parents are against
sudden infant death such a move. How would the nurse protect the rights of
the client in this case?
5. Which study would best lend itself to a qualitative a. Discuss the dilemma with the client and his family
research approach? together
a. Measuring nutrition and weight changes in clients b. Refer the client’s name to the researcher and leave
with cancer the decision up to her
b. Examining the relationships between urinary infec- c. Talk to the nursing manager and seek her advice in
tions and indwelling catheters this matter
c. Examining the relationships among infant, mother, d. Talk to the client alone and ask him what he would
and contextual factors and mother–low-birth-weight like to do about participation in the study
infant interaction
d. Exploring the caregiving role adult daughters 10. The nurse is developing a workshop on teenage pregnancy
play when a parent is hospitalized for a cardiac for school children from 12 to 14 years of age. What is the
condition best way to gather information for the presentation?
a. Ask parents what they think teenagers should know
6. The nurse is conducting a research project on differ- about pregnancy
ences in long-term psychological functioning in young
women choosing different pregnancy resolution deci- b. Do an Internet search of websites for pregnant
sions (abortion, adoption, keeping the baby). What is teenagers
the next step in the research process after identifying the c. Conduct a literature review of research on teenage
problem? pregnancy
a. Select the population and sample d. Consult other nurses who work with pregnant teenagers
b. Review the literature
M03_KOZI2703_04_SE_C03.indd 49 20/02/17 1:30 PM

RE F ERENCES
Berman, A., Snyder, S. J., & Frandsen, G. (2015). Kozier and Erb’s Gottlieb, L. (1999). From nursing papers to research journal: A
fundamentals of nursing (10th ed.). Upper Saddle River, NJ: Pearson/ 30-year odyssey. Canadian Journal of Nursing Research, 30(4), 9–14.
Prentice Hall. Hirst, S. (2000). Resident abuse: An insider’s perspective. Geriatric
Button, L., Green, B., Tengnah, C., Johansson, I., & Baker, C. Nursing, 21, 38–42.
(2005). The impact of international placements on nurses’ per- Lander, J. (2011). Nursing research in Canada. In J. C. Ross-Kerr &
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Nursing, 50(3), 315–324. (pp. 118–138). Toronto, ON: Elsevier Canada.
Canadian Institute for Health Research (CIHR). (2016). Strategy Lauri, S. (1990). The history of nursing research in Finland.
for patient-oriented research (SPOR). Available from http://www. International Journal of Nursing Studies, 27(2), 169–173.
cihr-irsc.gc.ca/e/41204.html Loiselle, C. G., Profetto-McGrath, J., Polit, D. F., & Beck, C. T.
Canadian Institutes of Health Research, Natural Sciences and (2011). Canadian essentials of nursing research (3rd ed.). Philadelphia,
Engineering Research Council of Canada, & The Social Science PA: Lippincott Williams & Wilkins.
and Humanities Research Council of Canada. (1998 with 2000, Olmstead, D. L., Scott, S. D., Mayan, M., Koop, P. M., & Reid,
2002, and 2005 amendments; 2nd ed., 2010). Tri-council policy state- K. (2014). Influences shaping nurses’ use of distraction for chil-
ment: Ethical conduct for research involving humans. Ottawa, ON: Author. dren’s procedural pain. Journal for Specialists in Pediatric Nursing,
Canadian Nurses Association. (n.d.). NurseONE: The Canadian nurse’s 19(2), 162–171. doi:10/1111/jspn.12067.
portal. Ottawa, ON: Author. Retrieved from http://www.cna-aiic. Overduin, H. (1973). People and ideas: Nursing at Western, 1920–1970.
ca/CNA/documents/pdf/publications/Portal_Overview_2_e.pdf. London, ON: Faculty of Nursing, University of Western
Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ontario.
Ottawa, ON: Author. Polit, D. F., & Tatano Beck, C. (2014). Essentials of nursing research:
Carper, B. (1978). Fundamental patterns of knowing in nursing. Appraising evidence for nursing practice (8th ed.). Philadelphia, PA:
Advances in Nursing Science, 1(1), 13–23. Lippincott Williams & Wilkins.
Collins, M., & MacDonald, V. (2000). Managing postoperative pain Wood, M. J., & Ross-Kerr, J. C. (2010). Basic steps in planning nursing
at home. Canadian Nurse, 96(7), 26–29. research: From question to proposal (7th ed.). Sudbury, MA: Jones and
Dawe, D. E., Bennett, L. R., Kearney, A., & Westera, D. (2014). Bartlett.
Emotional and informational needs of women experiencing Woodham-Smith, C. (1950). Florence Nightingale. London, UK:
outpatient surgery for breast cancer. Canadian Oncology Nursing Constable & Co.
Journal, 24(1), 20–24. doi:10.5737/1181912x2412024 Widger, K., Tourangeau, A. E., Steele, R., & Streiner, D. L. (2015).
Donahue, M. P. (1985). Nursing: The finest art. St. Louis, MO: Mosby. Initial development and psychometric testing of an instrument to
Gillis, A., & Jackson, W. (2002). Research for nurses: Methods and interpre- measure the quality of children’s end-of-life care. BMC Palliative
tation. Philadelphia, PA: Davis. Care, 14(1). doi:10.1186/1472-684x-14-1
Glass, H. P. (1977). Research: An international perspective. Nursing
Research, 26, 230–236.
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Chapter 4
Nursing Philosophies,
Theories, Concepts,
Frameworks, and Models
Updated by
Marjorie McIntyre, RN, PhD
Professor Emeritus, School of Nursing, University of Victoria
Carol McDonald, RN, PhD

Associate Professor, School of Nursing, University of Victoria
P
LEARNING OUTCOMES
After studying this chapter, you will be able to
hilosophical thinking is
1. Identify the purposes and essential elements of theories in nursing. an indispensable feature
2. Examine the purposes and benefits of philosophies in nursing. of our everyday lives. When people
3. Describe three main areas of philosophical inquiry and the two reflect on the meaning of their experi-
research traditions. ences, consider how they might eval-
4. Compare selected philosophical approaches in relation to the uate the truth of an observation, or
questions they pose for nursing. try to determine the best course of
5. Identify selected theoretical works in terms of how nursing action in a particular situation, they
is conceptualized and the assumptions underpinning these are engaging in philosophical thought.
conceptualizations. The word philosophy, translated from
6. Define the terms philosophy, paradigm, assumption, concept, its original Greek, means simply “love
conceptual framework, conceptual model, and theory. of wisdom.” Philosophical thinking is
also what people draw on to make
their way, as wisely as they can,
through their lives. To be wise means,
in part, to use knowledge well.
Therefore, nurses should be com-
mitted to using philosophical think-
ing to improve their understanding
of the particular values, beliefs, and
assumptions that inform their thinking
and influence what they say and do.
Philosophical thinking provides
the foundation for the development c
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c and analysis of the concepts (including conceptual models and conceptual frameworks) and theories
used to articulate knowledge of the discipline. Concept is another word for idea. Nurses make use
of concepts to highlight the ideas that are important to the discipline. A conceptual framework,
viewed simply, is a cluster of related concepts around a particular topic. A conceptual model is a
diagram or illustration showing graphically how concepts within a particular cluster are positioned in
relation to each other. A theory goes beyond conceptual models and frameworks to show the nature
and significance of relationships among concepts. Theories offer ways of looking at (conceptualizing)
a discipline—such as nursing—in clear, explicit terms that can be communicated to others. Along with
the idea of theory and the application of particular theories in nursing practice and research, a practice
discipline such as nursing draws strongly on the notion of theorizing. “The ability to theorize provides
nurses with a way to think about their practice: a way to make sense of, to articulate and to critique
nursing practice . . . Without the ability to theorize for themselves, nurses are limited to the sometimes
unthinking of applications derived by others” (McIntyre & McDonald, 2013).
Philosophical and theoretical thinking support the discipline’s professionalism and collegial status
with other health care professionals. Nurses must communicate clearly what makes their place in the
interdisciplinary team important. To achieve this clarity, concepts and theories are used to organize
and analyze nursing knowledge. To use this knowledge wisely, the philosophical beliefs and assump-
tions that are the foundation for its creation and use must be made clear.
Knowledge of nursing theory is critical to the development of the thoughtful, evidence-informed
nurse. Three domains of baccalaureate education, as enunciated by the Canadian Association of Schools
of Nursing (CASN, 2014) are addressed by knowledge of nursing theory. The knowledge domain indi-
cates that graduates demonstrate foundational knowledge of nursing theory, and the research domain
supports graduates in demonstrating an appreciation of the salience of inquiry for nursing as a profes-
sion and a discipline. The communication domain indicates that graduates demonstrate the ability to
self-monitor their own beliefs, values, and assumptions and recognize the impact of these beliefs on
interpersonal relationships with clients and team members. In addition, graduates demonstrate the ability
to articulate a nursing perspective in the context of the health care team. Being clear about the theoreti-
cal perspective of nursing facilitates nursing and interprofessional team-based practice.
What Is Philosophy? • Assessing arguments made to defend or critique particu-

lar ways of thinking
Although the word philosophy has an ordinary, everyday
meaning—in the sense that people say they each have
their own philosophy, or set of beliefs and assumptions,
about the world and their place in it—philosophy is also
Philosophy’s Three Primary
a scientific discipline. Science here means the systematic
formulation of a body of knowledge. In a formal sense,
Areas of Inquiry
philosophy is a scientific discipline that raises, explores, Philosophy’s three primary areas of inquiry are ontol-
and attempts to answer questions bearing on “our ideas ogy, epistemology, and ethics. These terms refer to areas of
about our experience, the universe, and human affairs” inquiry somewhat familiar to most people. Ontology
(Fry, 1992, p. 87). In philosophy, people use critical investigates the nature of being. It asks such questions as,
analysis in pursuit of goals. What is the nature of reality? What is the meaning and
Philosophical thinking can assist with the following: purpose of our existence? What does it mean to be a per-
• Identifying and questioning assumptions son or a nurse? Epistemology investigates the nature
• Clarifying how concepts are used and how they have of knowledge: How do we know something? What are
meaning the limits of knowledge? On what grounds can we say
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Chapter 4 Nursing Philosophies, Theories, Concepts, Frameworks, and Models 53
something is true? What is the difference between what is, scientists can and should prevent subjective biases and
is believed to constitute knowledge and what is described beliefs from influencing their perceptions. According to
as opinion? Ethics explores the nature of moral con- this paradigm, it is possible to produce objective knowl-
duct and judgment: What is good? How should people edge of the world.
behave or react in particular circumstances? How should By contrast, according to the interpretive para-
people judge the actions of others? The ways in which digm, there is no single fixed reality against which
we answer these kinds of ontological, epistemological, knowledge can be measured. Knowledge of the world
and ethical questions reflect our basic assumptions and independent of theorizing about it is not possible.
beliefs about the world. Knowledge of the world is always mediated through
assumptions. In fact, some scholars in the interpretive
tradition argue that the nature of human understanding
World Views is itself interpretive and that it is our nature as human
beings to create meaning from our experiences.
and Paradigms Each of these two philosophical paradigms includes
many variations. People who work in one of these para-
A world view is a particular way of thinking based on a digms often express their beliefs and assumptions some-
specific set of beliefs, values, and assumptions, similar to a what differently. Therefore, simply labelling a work as
personal philosophy. Each person’s world view influences empiricist or interpretive is of limited use. It is much
how she or he perceives, comprehends, and interprets more fruitful to consider the specific beliefs and assump-
the world. It shapes people’s understanding of events tions that underlie a particular work.
and the means used to seek knowledge. Nevertheless, Both the empiricist and interpretive paradigms have
people may be unaware of their underlying beliefs, val- strong adherents, but the point here is not to suggest the
ues, and assumptions. In particular, assumptions often rightness or wrongness of either. Rather, it is to recog-
operate unconsciously and are beliefs that are taken for nize that paradigms provide a general orientation to the
granted, without evidence that has been systematically world, a way to organize perceptions and experience.
generated. In knowledge-generating activities, paradigmatic views
Many social arrangements rest solely on assump- influence directions for research and study, problem
tions. For example, the idea that nursing is “women’s identification, and guidelines for inquiry and action.
work” relies on an assumption that particular kinds of Because writers often do not make their world views
work are best suited for women and other kinds of work or paradigmatic location explicit, readers of nursing
are more appropriate for men. This assumption is often research and theory should carefully consider exactly
based on other unexamined beliefs about what is somewhat assumptions are in play.
times described as women’s natural capacity for car-
ing and nurturing. To critique this assumption requires
examining particular beliefs and values, such notions as
caring, men’s and women’s “proper” positions in society, Philosophy in Nursing
the difference between men and women, and the social
value attributed to various kinds of work. This kind of Philosophy is an essential feature of all scientific dis-
inquiry might suggest that women’s historical associa- ciplines, and nursing is no exception. The study of
tion with activities of care is a reflection not so much philosophy in nursing enables nurses to further their
of women’s essential nature but, rather, of the ways in understanding of the values, beliefs, assumptions, and
which social roles and responsibilities have been allo- knowledge that constitute the discipline. Generally
cated throughout history. Philosophical inquiry helps speaking, the study of philosophy in nursing can be
make explicit what underlies the assumption that nursing understood as the “philosophical inquiry about nurs-
is women’s work. ing’s social and humanitarian roles, its form of thought,
In contrast to world views, a paradigm is a way nature, scope, purpose, methods, language, moral pre-
of organizing knowledge according to philosophical suppositions, and knowledge claims” (Fry, 1999, p. 6).
assumptions. Although many paradigms exist, two ways Philosophy in nursing involves consideration of the same
of understanding the world have been particularly influ- sorts of ontological, epistemological, and ethical ques-
ential in nursing: the empiricist and the interpretive tions mentioned earlier in the chapter. Here, we formu-
paradigms. According to the empiricist paradigm, late how these questions are studied in relation to the art,
a single reality exists independently of our knowledge science, and practice of nursing. Thus, an ontological
of it. The world exists separate from human know- inquiry will consider the nature of nursing; an episte-
ers. Knowledge can be obtained by observation and mological inquiry will consider nursing knowledge; and
experiment—in other words, by means of the scien- an ethical inquiry will consider the moral questions that
tific method. Truth can be determined by comparing arise in nursing. Nurses use philosophy to think, to exam-
knowledge claims against this independently existing ine assumptions, to analyze concepts, and to carefully
reality. In making discoveries about this world as it really consider arguments. In this sense, philosophical inquiry
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in nursing is an invaluable practical activity in which all also propose how these phenomena can be known. It
nurses should participate. may also address ethical concerns by specifying how to
Developing a particular philosophy of nursing understand moral phenomena encountered in nursing
involves careful clarification and reflection on what practice. The building blocks of theories are concepts.
nurses are trying to do, why they do it, and what knowl- Concepts are abstract ideas or mental images of
edge they use. A useful philosophy of nursing will help phenomena. They are words that bring forth mental
accomplish these goals. First, it will identify the central pictures of the properties and meanings of objects,
phenomena of the discipline, sometimes referred to as a events, or things. Concepts can be (a) readily observ-
metaparadigm. The second task in developing a philosophy able, or concrete, ideas, such as thermometer, rash, and
of nursing is to relate nursing to a particular paradigm. lesion; (b) indirectly observable, or inferential, ideas,
Third, the philosophy will offer some criteria concern- such as pain and temperature; or (c) non-observable, or
ing knowledge development in the discipline (Salsberry, abstract, ideas, such as equilibrium, adaptation, stress,
1994). Formulating a philosophy of nursing is about and powerlessness. Many concepts apply to nurs-
making nurses’ frame of reference for being in the world ing: concepts about human beings, health, helping
explicit (Smith, 1994). relationships, and communication. Nursing theories
Scientific inquiry is still the predominant mode of address and specify relationships among four major
inquiry in nursing. However, science cannot answer abstract concepts referred to as the metaparadigm
some nursing questions (Kikuchi, 1992). Scientific of nursing—the most global philosophical or concep-
inquiry is directed toward the material world, to what tual framework of a profession. A metaparadigm is a
can be measured or is observable through the senses. higher level of abstraction than a paradigm. It identi-
Thus, techniques of science cannot answer some ques- fies the concepts central to the discipline without relat-
tions concerning the nature of nursing, the moral ing them to the assumptions of a particular paradigm.
ground of nursing practice, or the particular meanings Although consensus exists that the following four con-
of nurse–client relationships. Interpretive approaches cepts make up nursing’s metaparadigm (Fawcett, 1984,
as well as empiricist approaches are important in nurs- 2005), others have proposed alternative metaparadigms
ing philosophy. (Newman, Sime, & Corcoran-Perry, 1991; Parse, 1987;
Philosophical thinking in nursing has developed on Newman, Smith, Dexheimer Pharris, & Jones, 2008).
many fronts, and nurses have used philosophy in many The metaparadigm concepts as originally identified by
different ways. Since the 1980s, nurses have published Fawcett are as follows:
many articles and books about nursing philosophy, and
they have organized many conferences around philo- 1. Person or client: the recipient of nursing care (includes
sophical themes. In 1988, the Institute for Philosophical individuals, families, groups, and communities)
Nursing Research was founded at the University of 2. Environment: the internal and external surroundings that
Alberta. The Institute’s aim is to provide leadership in affect the client, which includes people in the physical envi-
the pursuit of philosophical nursing knowledge that ronment, such as families, friends, and significant others
underlies the advancement of the nursing practice. If the 3. Health: the degree of wellness or well-being that the cli-
philosophy of nursing is understood as simply an activity ent experiences
that uses philosophical methods and raises certain kinds
4. Nursing: the attributes, characteristics, and actions of
of questions about the discipline of nursing, it is possible
the nurse providing care on behalf of, or in conjunction
to appreciate the necessity to support within nursing a
with, the client
number of different approaches to philosophy.
Nurse theorists’ definitions of nursing’s major con-
cepts vary in accordance with their world view, their
philosophy, and their experience in nursing. Nursing
Concepts and Theories theories serve several purposes (see Box 4.1).
The terms theory and conceptual framework are often
Philosophical thinking provides the foundation for the used interchangeably in the nursing literature. Strictly
development and critical analysis of nursing knowledge. speaking, they differ in their levels of abstraction; a
Nursing knowledge is organized and communicated by conceptual framework is more abstract than a theory. As
using concepts, models, frameworks, and theories. A noted earlier, a conceptual framework is a group of related
theory of nursing will address the subject matter of the concepts. It provides an overall view or orientation to
discipline of nursing in accordance with a particular focus thoughts. A conceptual framework can be visual-
philosophical world view. For example, a theory of nurs- ized as an umbrella under which many concepts can
ing will include some conceptualization of the nature exist. A theory is a supposition or system of ideas that is
of nursing, its scope, and purpose. It will identify and proposed to explain a given phenomenon. For example,
describe the central nursing concepts, such as person, Newton proposed his theory of gravity to explain why
health, nursing, and environment (see Table 4.1), and objects always fall to the ground. A theory goes one step
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BOX 4.1 PURPOSES OF NURSING THEORIES them are conceptualized. We speak of this process of
theorizing as making explicit the relationships between
AND CONCEPTUAL FRAMEWORKS
and among those concepts. The product of the theoriz-
Nursing theories and conceptual frameworks provide direc- ing—that is, the theory—provides direction for nursing
tion and guidance for (a) structuring professional nursing practice. The nature of the direction provided for nurs-
practice, education, and research, and (b) differentiating the ing practice can be traced back to the philosophical
focus of nursing from other professions.
views underpinning each of the concepts. An example
IN PRACTICE can be useful here. Select any one of the theorists dis-
cussed in this chapter. Ask yourself which of his or her
• Help nurses to describe, explain, and predict everyday
concepts are highlighted as important and what the
experiences
nature of the relationship between these concepts is.
• Guide assessment, intervention, and evaluation of
nursing care The final question for you will be whether you can see
the direction this relationship provides for professional
• Provide a rationale for collecting reliable and valid data
about the health status of clients, which are essential for nursing practice.
effective decision making and implementation Because the purpose of nursing theory is to generate
• Help establish criteria to measure the quality of nursing knowledge to direct nursing practice, nursing theory and
care nursing research are closely related (see the Evidence-
• Help build a common nursing terminology to use in Informed Practice box). Nursing knowledge is generated
communicating with other health care professionals: within empiricist and interpretive research traditions.
ideas are developed and words defined
Empiricist approaches can be theory generating or the-
• Enhance the autonomy (independence and self- ory testing, whereas interpretive approaches expose the
governance) of nursing by defining its own independent
functions understandings of experiences.
IN EDUCATION
• Provide a general focus for curriculum design
• Guide curricular decision making EVIDENCE-INFORMED PRACTICE
IN RESEARCH
How Important Is Patient Involvement
• Offer a framework for generating knowledge and new
ideas in Planning Complex Medication
• Assist in discovering knowledge gaps in the specific field Regimes?
of study
• Offer a systematic approach to identify questions for Using a case study approach, researchers Leslie Paldry
study, select variables, interpret findings, and validate and Alice March examined how experienced registered
nursing interventions nurses can engage the circle-of-caring model to improve
a patient’s adherence to complicated medication regimens
following cardiac transplantation. The model incorporates
nursing and medical information alongside an assessment
of the patient’s readiness to learn, learning style, and per-
beyond a conceptual framework by relating concepts ceptions of the meaning of his or her illness and the need
through definitions that state significant relationships for medication.
between concepts. The use of the theoretical circle-of-caring model resulted
in increased ownership of health outcomes by patients and
an understanding of the importance of following the agreed-
upon plan for medication administration. The advantage of
Frameworks, Concepts, and Theories: the circle-of-caring model is that it takes into account the
Direction for Nursing Practice patient’s needs and desires, ensuring participation in the plan
and thus improving the long-term quality of life and survival
The major purpose of a conceptual framework is to give for people receiving cardiac transplants.
clear and explicit direction to the three areas of nursing:
NURSING IMPLICATIONS: Theoretical models such as
(a) practice, (b) education, and (c) research. A conceptual the circle-of-caring model, in which the planning and
framework makes explicit the concepts important to implementation of medication administration takes
the discipline and the professional practice of nursing. into account not only nursing and medical information
Theories are constructed by making explicit the rela- but also the life of the individual patient, can lead to
tionships between and among these identified concepts. increased patient commitment to long-term medication
Most, if not all, nursing theories include, either implic- regimes.
itly or explicitly, the concepts of health, persons, environ- Source: Based on Palardy, l., & March, A. (2011). Circle of caring model: Medication
ment, and nursing. What distinguishes one theory from adherence in cardiac transplant patients. Nursing Science Quarterly, 24(2), 120–125.
doi: 10.1177/0894318411399463.
another is the way in which the relationships among
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Empirical knowledge is derived from testing hypoth- knowledge obligates the nurse to act in particular ways
eses (assumptions). In the research process, comparisons in professional practice.
are made between the observed outcomes of research and Building on Carper’s four ways of knowing, Chinn
the relationship predicted by the hypotheses. Research and Kramer introduced the additional pattern of eman-
findings may be developed into theories to provide direc- cipatory knowing. Emancipatory knowing supports nurses
tion for nursing practice, education, or future research. to engage with issues of justice and equity in nursing
practice and to promote change. This knowing “culti-
vates awareness of how problematic conditions converge,
reproduce, and remain in place to sustain a status quo
The Influence of Ways of Knowing that is unfair for some groups within society” (Chinn &
on Theory Development and Direction Kramer, 2011, p. 64).
for Practice
In addition to conceptual frameworks already discussed,
writers have also proposed ways of knowing as influ- Overview of Selected
encing the generation of nursing theory. One such
framework, originally developed by Barbara Carper Nursing Theories
(1978) is commonly referred to as Carper’s ways of knowing
and includes personal, empirical, aesthetic, and ethical Theory development gained momentum in the 1960s
ways of knowing. Personal knowing is about the nurse’s and has progressed markedly since then. Because opin-
knowledge of himself or herself, and the way in which ions on the nature and structure of nursing vary, theories
that knowledge is used to authentically engage in rela- continue to be developed. Each theory bears the name
tionships with others. Empirical knowing addresses the of the person or group that developed it and reflects the
knowledge of nursing science needed for professional beliefs of the developer.
practice. Empirical knowing includes knowledge gen- The following nursing theories vary considerably in
erated through research and theory from within and their (a) level of abstraction, (b) conceptualization of the
beyond the discipline of nursing. Aesthetic knowing, some- client, health or illness, and nursing, and (c) ability to
times described as the art of nursing, is the unique describe, explain, or predict. Some theories are broad in
interpretation and particularizing of nursing science in scope; others are limited. Only brief summaries of the the-
the momentary encounter experienced by the nurse in orists’ central theme and basic assumptions are included
his or her relationship with others. Ethical knowing, which here. See Table 4.1 for a summary. For more detailed infor-
is essential in decision making, is central to nursing mation on how specific theories are used in current nursing
practice. This form of knowledge underpins daily deci- practice, refer to Alligood and Tomey (2010) and Alligood
sions about what the nurse ought to know and how this (2010) listed in the references of this chapter.
Table 4.1 Selected Nurse Theorists’ Conceptualization of Nursing, Health, Environment, and Human Beings
Nightingale • Nursing is the act of using the environment of the patient to assist in recovery.
• Health is linked to five environmental factors: fresh air, pure water, efficient drainage, cleanliness, and
light. A deficiency in any of these factors is linked to illness.
• Human beings are described as recipients of compassionate care.
Peplau • Nursing is a therapeutic relationship between the nurse and the client.
• Health includes interpersonal and intrapersonal experiences.
• Environment includes the client’s internal experiences and the relational environment in which he or
she lives.
• Human beings are conceptualized as subjects of their own experience rather than as objects of pro-
fessional care.
Henderson • Nursing is assisting sick or well individuals to gain independence in meeting their fundamental needs,
or caring for the client to a peaceful death.
• Health is linked to the 14 fundamental needs identified by Henderson.
• Environment is understood as the physicality of the client and his or her immediate physical surround-
ings. Nurses manage the environment as a way of moving the client toward performing activities
unaided.
• Human beings are physical beings who experience a variety of needs and are in relation with others
for the purpose of meeting those needs.
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Roy • Nursing is the promotion of client adaptation in experiences of health, quality of life, and death with
dignity.
• Health is the way in which human beings interact with and adapt to environmental stimuli.
• Environment is understood as the variable and constantly changing stimuli to which a person must
adapt.
• Human beings are seen as interacting with their physical and social environments and in relationship
with the world and with God: “Persons are seen as adapting to those stimuli present as a result of his
or her position on the health–illness continuum” (Roy & Andrews, in Fawcett, 2005, p. 367).
Watson • Nursing is an intentional consciousness of caring enacted between a nurse and another, transcend-
ing the boundaries of time, space, and physicality.
• Health “refers to unity and harmony within the mind, body and soul. Health is also associated with
the degree of congruence between the self as perceived and the self as experienced” (Watson, 1988,
p. 48).
• Environment, both internal and external, is interdependent and strongly influences health and illness.
Healing environments comprise physical and nonphysical energies and consciousness whereby
wholeness, comfort, beauty, dignity, and peace are potentiated.
• Human beings physically are confined in space and time, whereas the mind and soul are not.
Parse • Nursing is co-creating a situation in which clients choose and bear responsibility for patterns of
health.
• Health is a continuously changing process, the quality of life co-created by human beings in relation
with the universe.
• Environment is understood as the world in which lived experiences unfold.
• Human beings are open, indivisible, freely choosing beings who co-create patterns of relating.
Leininger • Nursing is “a learned humanistic and scientific profession and discipline which is focused on human
care phenomenon and activities to help people maintain or regain their well-being or health in cultur-
ally meaningful ways” (Leininger & McFarland, 2006, p. 7).
• Health is a culturally defined, valued, and practised state of well-being that reflects people’s abilities
to perform their daily activities.
• Environment is the physical, ecological, sociopolitical, and cultural context of events or experiences.
• Human beings, families, clans, and collective groups are constituted within cultural contexts, including
values, beliefs, and life ways.
Newman • Nursing is the study of caring in the human health experience.

• Health is conceptualized as expanding consciousness that occurs when a person gains insight from
a disturbance in the flow of daily living. The process of evolution of consciousness is also the process
of health.
• Environment is unbroken wholeness in which health and illness are viewed as a single process.
• Human beings are continuous with the undivided wholeness of the universe and can be identified by
their patterns of consciousness: “The person does not possess consciousness, the person is con-
sciousness” (Newman, in Fawcett, 2005, p. 452).
Campbell (UBC • Nursing is the activities that help patients learn and maximize their coping abilities to manage critical
[University of situations within their life cycle.
British Columbia] • Health is stability—preferably at the most optimum level possible within the situation.
Model) • Environment is anything that is outside the individual’s system.
• Person refers to individuals, each of whom shares nine basic needs. The individual meets those
needs through coping mechanisms.
Allen (McGill Model) • Nursing is the response of the profession to individuals’ search for healthy living.
• Health is a social process. Health can be described, measured, and modified.
• Environment is the social context in which learning takes place.
Gottlieb (Strengths- • Person in this model refers to the family or other social group.
Based Care) • Nursing is a relational phenomenon; everything a nurse sees, does, and experiences arises from the
relationship with person, family, or community.
• Health is about creating wholeness whereby the person develops capacities to live life and deal with
life’s challenges.
• Person is at the centre of clinical decision making. Personhood is the right of people to have their
values and beliefs respected.
• Person and environment are integral to one another, as the person is an essential part of her or his
environment.
• Environment includes the internal, external, and sociocultural milieus in which a person lives.
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Nightingale’s Environmental Theory significantly to the use of therapeutic relationships and

the nurse as a therapeutic tool in many areas of nursing
Florence Nightingale, often considered the first nurse practice.
theorist, defined nursing more than 150 years ago as
“the act of utilizing the environment of the patient to
assist him in his recovery” (Nightingale, 1860/1957). She
linked health with five environmental factors: (a) pure or Henderson’s Definition of Nursing
fresh air, (b) pure water, (c) efficient drainage, (d) cleanli- In 1966, Virginia Henderson formulated a definition
ness, and (e) light, especially direct sunlight. Deficiencies of the unique function of nursing. This definition was
in these five factors caused lack of health, or illness. a major stepping stone in the emergence of nursing as
These environmental factors attain significance a discipline separate from medicine. Like Nightingale,
when we consider that sanitation conditions in the hos- Henderson described nursing in relation to the client and
pitals of the mid-nineteenth century were extremely the client’s environment. Unlike Nightingale, Henderson
poor and that women working in the hospitals were often saw the nurse as being concerned with both well and
unreliable, uneducated, and incompetent. ill individuals, acknowledged that nurses interact with
In addition to those factors, Nightingale also stressed clients even when recovery may not be feasible, and
the importance of keeping the client warm, maintaining described the teaching and advocacy roles of the nurse.
a noise-free environment, and attending to the client’s Henderson conceptualized the nurse’s role as helping
diet in terms of assessing intake, timeliness of the meal, sick or well individuals to gain independence in meeting
and its effect on the person. 14 fundamental needs ranging from basic physiological
Nightingale set the stage for further work in the function to activities of daily living and psychosocial
development of nursing theories. Her general concepts needs (Henderson, 1966; 1991, pp. 22–23), similar to
about ventilation, cleanliness, quiet, warmth, and diet the hierarchy of needs identified by Maslow. Henderson
remain integral parts of nursing and health care today. published many works and continues to be cited in cur-
Dunphy (2010) noted that in addition to manifesting rent nursing literature. Her emphasis on the importance
these core ideals of health, Nightingale, as an original of nursing’s independence from, and interdependence
nurse-activist, demonstrated the ways in which the values with, other health care disciplines is well recognized. In
of caring can be transformed into an activism capable Henderson’s later work (1991), she questioned whether
of transforming “our current health care system into a nurses continue to value engagement with clients in the
more humanistic and just one” (Dunphy, 2010, p. 51). palliative (relieving suffering and providing comfort) expe-
In this way, Nightingale was a role model for showing rience or if the profession has shifted toward a medical
through practice that actions driven by caring and com- approach in which the focus is prolonging life, even when
passion bring about justice. death is inevitable.
Peplau’s Interpersonal Relations Model Roy’s Adaptation Model

Hildegard Peplau, a psychiatric nurse, introduced her Sister Callista Roy’s adaptation model was first published
interpersonal concepts in 1952. Central to Peplau’s the- in book form in 1976. She defined adaptation as “the
ory is the use of a therapeutic relationship between the process and outcome whereby the thinking and feeling
nurse and the client. Although now a taken-for-granted person uses conscious awareness and choice to cre-
practice in nursing, in the early 1950s, the idea of engag- ate human and environmental integration” (Roy, 1997,
ing with clients as subjects, rather than treating them p. 44).
as objects, was a revolutionary one. Despite the early Roy later restated her scientific and philosophical
resistance to her approach, Peplau’s work is responsible assumptions for the twenty-first century. These assump-
for the integration of the therapeutic relationship, the tions focused on the increasing complexity of person
nurse–client relationship, into nursing theory. Traces of and environment, self-organization, and the relationship
Peplau’s emphasis on the nurse–client relationship can among human beings, the universe, and God, or what
be found in all the major theoretical works today. can be considered a supreme being. Her philosophical
Nurses enter into a personal relationship with an assumptions were refined by using major characteristics
individual when the need is present. The nurse–client of “creation spirituality”—a view that “persons and the
relationship evolves in four phases: orientation, work- earth are one and that they are in God and of God” (Roy,
ing phase as identification, working phase as exploita- 1997, p. 46). “Roy also uses the idea of cosmic unity that
tion, and termination. To help clients fulfill their needs, stresses her vision for the future and emphasizes the
nurses assume many roles: stranger, teacher, resource principle that people and Earth have common patterns
person, surrogate, leader, and counsellor. Peplau’s model and integral relationships” (Roy & Zhan, 2010, p. 171).
continues to be used by clinicians and has contributed In this way, Roy moved past her earlier supposition that
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the system acts to maintain itself, shifting the emphasis Box 4.2 Watson’s Assumptions
to the “purposefulness of human existence in a creative
of Caring
universe” (p. 171).
Roy focused on the individual as a biopsychosocial • Human caring in nursing is not just an emotion, concern,
adaptive system that employs a feedback cycle of input attitude, or benevolent desire. Caring connotes a per-
(stimuli), throughput (control processes), and output sonal response.
(behaviours or adaptive responses). Both the individual • Caring is an intersubjective (between human subjects)
human process and is the moral ideal of nursing.
and the environment are sources of stimuli that require
modification to promote adaptation, an ongoing purpo- • Caring can be effectively demonstrated only
interpersonally.
sive response. Central to Roy’s theoretical model is the
• Effective caring promotes health and individual or family
belief that “health is defined as (a) a process, (b) a state of
growth.
being, and (c) becoming whole and integrated in a way
• Caring promotes health more than does curing.
that reflects individual and environment mutuality” (Roy
• Caring responses accept people not only as they are
& Zahn, 2010, p. 174). Although Roy originally con-
now but also for what they may become.
ceptualized her model with regard to the health of the
• A caring environment offers the development of potential
individual, more recently, the modes of the model have while allowing the person to choose the best action at a
been expanded to speak to groups as well as individuals. given time.
Each person’s or group’s adaptation level is unique and • Caring occasions involve action and choice by nurse and
constantly changing. client. If the caring occasion is transpersonal, the limits of
Individuals and groups respond to needs (stimuli) openness expand, as do human capacities.
in one of four modes: physiological mode, self-concept • The most abstract characteristic of a caring person is
mode, role function mode, and interdependence mode. that the person is somehow responsive to another per-
The goal of Sister Callista Roy’s model is to enhance son as a unique individual, perceives the other’s feelings,
and sets one person apart from another.
life processes through adaptation in these four adaptive
• Human caring involves values, a will and a commitment
modes.
to care, knowledge, caring actions, and consequences.
• The ideal and value of caring is a starting point, a stance,
and an attitude that has to become a will, an intention, a
commitment, and a conscious judgment that manifests
Watson’s Human Caring Theory itself in concrete acts.
Jean Watson (1979) believed the practice of caring is cen-
tral to nursing; it is the unifying focus for practice. Her
major assumptions about caring are shown in Box 4.2.
Watson originally referred to the nursing interventions
of an intentional (conscious) transpersonal caring occa-
related to human care as carative factors, a guide Watson
sion transcends time, space, and physicality: The effect
refers to as the “core of nursing.” Watson later expanded
of a caring interaction can go beyond the time and space
each of the carative factors to become clinical caritas pro-
boundaries of a given caring moment. Watson’s theory
cesses. Watson explains: “What differs in the clinical caritas
of human caring has received worldwide recognition
framework is that a decidedly spiritual dimension and an
and is a major force in redefining nursing as a caring–
overt evocation of love and caring are merged for a new
healing health model.
paradigm for this millennium” (Watson & Woodward,
2010, p. 355). The term caritas originates from a Greek
word meaning “to cherish or appreciate.”
In addition to the carative factors or caritas pro- Parse’s Theory of Humanbecoming
cesses, three major ideas underpin all of Watson’s work:
(a) the transpersonal caring relationship, (b) the caring Parse first published her theory in 1981 in Man-Living-
moment, or caring occasion, and (c) the caring (healing) Health: A Theory for Nursing and later retitled her work as A
consciousness. Theory of Humanbecoming, substituting the term human for
Although numerous theorists include the idea of man. Parse proposed three assumptions about “human-
caring in their work, Watson’s work spoke particularly becoming” (1995):
of transpersonal caring, in which the nurse seeks to “con-
1. Humanbecoming is freely choosing personal meaning in
nect with and embrace the spirit or soul of the other”
situations in the intersubjective process of relating value
through genuine and authentic engagement (Watson &
priorities.
Woodward, 2010, p. 356). The caring moment is under-
stood to be “the moment of coming together” of the 2. Humanbecoming is co-creating rhythmic patterns or relat-
nurse and the client in which each person brings all of ing in a mutual process with the universe.
her or his experiential history with an intention of care 3. Humanbecoming is co-transcending multidimensionally
and a possibility of connection. For Watson, the process with the emerging possibilities.
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These three assumptions focus on the concepts of Given the increasing globalization of health and
meaning, rhythmicity, and co-transcendence: health care, the role of culturally appropriate care across
diverse culture will continue to expand. Leininger’s the-
• Meaning arises from a person’s interrelationship with
ory makes an important contribution to nursing practice
the world and refers to happenings to which the person
(Leininger & McFarland, 2010). Leininger’s theory is
attaches varying degrees of significance.
presented in MyNursingLab.
• Rhythmicity is the movement toward greater diversity.
• Co-transcendence is the process of reaching out beyond
the self.
Margaret Newman and Expansion
Parse’s theory of humanbecoming emphasizes how
individuals choose and bear responsibility for patterns of
of Consciousness
personal health. Parse contends that the client, not the Margaret Newman’s theory was influenced by her early
nurse, is the authority figure and decision maker. The life experiences in caring for her mother, when she
nurse’s role involves helping individuals and families in began to think of health as other than the absence
choosing the possibilities for changing the health proof disease. Following her undergraduate and gradu-
cess. Specifically, the nurse’s role consists of illuminating ate nursing education, informed by Martha Rogers,
meaning (uncovering what was and what will be), syn- Newman proposed that illness reflects the life pattern
chronizing rhythms (leading through discussion to recog- of the person and that illness and health are part of a
nize harmony), and mobilizing transcendence (dreaming unitary life process, one no more important than the
of possibilities and planning to reach them). other. The essential characteristic of the unitary whole,
The Parse nurse uses “true presence” in the nurse– or the unitary–transformative paradigm does not situate
client process. “In true presence, the nurse’s whole being “mind, body, spirit, and emotion as separate entities,
is immersed with the client as the other illuminates the but rather sees them as manifestations of an undivided
meanings of his or her situation and moves beyond the whole” (Dexheimer Pharris, 2010). As she continued to
moment” (Parse, 1994, p. 18). The theory of humanbe- develop her theory in the 1970s, Newman articulated the
coming continues to evolve into the twenty-first century central thesis of her work that health is the expansion of
as Parse scholars and Parse herself engage with the consciousness (Newman, 1986).
theory and the parallel humanbecoming hermeneutic When challenged about the scientific basis for her
approach to research (Parse, 2010). theory, Newman interestingly sidestepped the controversy
of the scientification of nursing theory and instead claimed
that her work “is not necessarily about science but rather
Leininger’s Cultural Care Diversity about meaning: the meaning of life and health . . . found
and Universality Theory in the evolving process of expanding consciousness”
(Newman, 1986, p. 4). Newman suggested that the use of
Madeleine Leininger, a well-known nurse anthropologist, the theory of health as expanded consciousness requires
first published her cultural care diversity and universality education in a curriculum that disrupts a view of health
theory in 1985 in the journal Nursing and Health Care and and illness as dichotomous or even as disparate ends of
explained it further in 1988 and then in 1991 in her book a continuum and instead has a “view of disease as a
Culture Care Diversity and Universality: A Theory of Nursing. meaningful aspect of health. Furthermore, the nurse has
Leininger stated that care is the essence of nursing to let go of wanting to control the situation. The client’s
and the dominant, distinctive, and unifying feature of choices have to be respected and supported, even when
nursing. She emphasized that human caring, although those choices conflict with the nurse’s personal values”
a universal phenomenon, varies among cultures in its (Fawcett, 2005, p. 462).
expressions, processes, and patterns; it is largely cultur-
ally derived. Leininger’s work draws on the premise that
people of different cultures are capable of informing
caregivers of the kind of care they need. McFarland Campbell’s UBC (University of British
points out that Leininger’s theory was the first nursing Columbia) Model of Nursing
theory “explicitly focused on care and culture in nursing
environments” (Leininger & McFarland, 2010, p. 320). Margaret Campbell (1987) developed the UBC model of
Leininger defined culture, culture care, culture care nursing. Campbell guided nurse practitioners, research-
diversity, culture care universality, generic care, and pro- ers, and educators to look to the following elements of a
fessional care. For nurses to assist people of diverse cul- model to guide their practice: “the view of the client,”
tures, Leininger also presented three intervention modes: or “the recipient of care,” and “the role and function
of nursing in relation to the recipient of care and as
• Culture care preservation and maintenance a distinct and separate member of the team of health
• Culture care accommodation, negotiation, or both care professionals” (Campbell, 1987, p. 5). In the UBC
• Culture care restructuring and repatterning model, the major theme is a behavioural system with
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interacting and interdependent subsystems, each repre- Within the McGill model, health is conceptualized as
senting a basic human need. Campbell viewed human a distinct entity that exists alone or co-exists with ill-
beings as having nine basic human needs, constantly ness (Gottlieb, 1998). The optimal state exists when the
striving to satisfy these needs by using a range of cop- individual is free of disease and displays positive and
ing behaviours, both innate and acquired. According to constructive health behaviour; the least satisfactory state is
this model, environment is that which lies outside the when an individual has a disease and, at the same time,
boundary of the system. The nurse is seen as nurtur- his health behaviours fail to permit him to cope with it
ing “individuals experiencing critical periods so that and to learn further (Allen, 1981).
they may develop and use a range of coping behav- The McGill Model of Nursing directs the nurse to
iours that will permit them to satisfy their basic human focus on the family as the unit of concern; when work-
needs, to achieve stability and to reach optimum health” ing with individuals, the nurse understands the person
(Campbell, 1987, p. 10). through a “family filter” (Gottlieb & Rowat, 1987). “The
Campbell developed this model on the basis of sev- family influences healthy development and coping and is
eral assumptions about Canadian society. She assumed where people learn healthy ways of living. The nature of
that society views optimal health as a desirable goal for the nurse–person relationship is a collaborative partner-
all of its members and that members of society would ship. The person is active and shares responsibility for his
assume responsibility for utilizing behaviours that pro- care. The person has knowledge and capabilities that he
mote and maintain positive health. She further assumed can use to understand and manage his illness or problems
that society expects its members will behave in ways that or work toward his goals in ways that are meaningful to
will not be harmful to themselves or others in the satis- him; the nurse is a facilitator who encourages people
faction of their needs. She assumed that society expects to share their perceptions and expertise, to participate
health care professionals to function competently and in joint decision making, and to develop the person’s
ethically. Lastly, Campbell assumed that society expects autonomy and self-efficacy. The nurse helps people more
the UBC model for nursing, or any model for nursing, to fully use their strengths and resources and has knowledge
be congruent with the values of that society. of their illnesses and themselves. . . . The nature of the
nurse–person relationship is reciprocal and mutual; each
partner gives and receives, and, thus, the relationship is
Allen’s McGill Model of Nursing balanced. It involves the continual negotiation of goals,
roles, and responsibilities. Both partners give up some
Another example of a nursing model is the McGill autonomy as they value and trust the other’s expertise.
model developed by Moyra Allen (1986). The McGill Both partners gain and grow” (Gottlieb & Feeley, 2006,
Model of Nursing espouses a collaborative, family- p. 6). “Collaboration is not coercion, cooperation, or
centred approach to care. Health is the central element co-opting.” (Buck, 2011).
of the model and the goal of nursing is to engage the
individual, family, and community in the process of
learning about and acquiring healthier ways of living.
Health is a complex phenomenon and has multiple
Gottlieb’s Strengths-Based Care
determinants that include income and social status, Strengths-based care (SBC) is a theory of nursing care
social support networks, education and literacy, employ- that focuses on the strengths of people, families, and com-
ment or working conditions, social environments, physi- munities. SBC “looks for solutions instead of dwelling on
cal environments, personal health practices and coping problems” (Gottlieb & Feeley, 2006, p. 29) and considers
skills, healthy child development, biology and genetic what is working positively while living with adversity and
endowment, health services, gender, and culture (Public challenges including illness and disability (p. 29). The
Health Agency of Canada, 2010). Health is a process SBC approach is constituted through the interrelation-
rather than an end point, and it develops throughout ships among four approaches: (1) person-centred care,
the lifespan. It involves setting and achieving goals (2) empowerment movement, (3) health promotion and
and developing competencies to manage normative and prevention, and (4) collaborative partnership.
non-normative life events. Competencies include such Person-centred care, when used in the SBC approach,
skills as regulating and expressing emotion, problem brings to the forefront the person receiving care and her
solving, developing supportive relationships, and carry- or his identified family. In a deep way, all aspects of
ing out roles and responsibilities (Gottlieb, 1998). Coping, the person’s life are taken into consideration, including
a component of health, refers to efforts made to deal strengths, resources, and challenges. Importantly, this
with some problematic situation—it is aimed at mastery approach views all aspects of the person’s past and cur-
or problem solving, rather than at simply reducing ten- rent life circumstances as relevant to care.
sion. Development, another dimension of health, relates Drawing on a history of twentieth century grass-
to the achievement of life goals. This broad concept of roots social justice movements, Gottlieb (2013) traces
health means that the nurse focuses on strengths and empowerment, past and current, to situations in which
potential rather than only on weaknesses or deficits. people come to recognize their inherent abilities and
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potential to “assume responsibility for their health and Box 4.3 Strengths-Based Care
to gain some mastery over their own lives” (p. 17). While
family members and communities are seen as central A strengths-based care approach is constituted
to the energy of empowerment, the role of health care through the interrelationships among four approaches:
(1) person-centred care, (2) empowerment movement,
providers is to “create the conditions that enable people
(3) health promotion and prevention, and (4) collaborative
to acquire the skills to foster their own empowerment”
partnerships.
(Gibson, 1991, in Gottlieb, 2013, p. 17).
SBC shifts the focus from illness treatment to health
promotion and illness prevention, with an emphasis on
the need for increased personal, community, and insti-
tutional responsibility for optimal health. In addition on “a complex process of clinical reasoning,” personal
to a renewed call for self-care and personal responsi- strengths, and family and community resources (p. 26).
bility for lifestyle choices, SBC brings attention to the The person and his or her family determine outcomes
need for policymakers and governments at all levels of care, those goals that support an improved quality of
to make healthy lifestyle choices accessible for people life. See Box 4.3.
(Gottlieb, 2013, p. 19). This emphasis on self-care is
interconnected with the four central approaches to SBC
(person-centred care, empowerment, health promotion
and prevention, and collaborative partnership), and thus
Sister Simone Roach’s Attributes
self-care is always viewed within the particular social, of Professional Caring
material, and political contexts of the person. In her book The Human Act of Caring, first published in
A collaborative partnership represents a nurse– 1992, Dr. Simone Roach put forth the notion that car-
patient relationship in which the patient (person) is an ing is a required component in human development
active partner in her or his own care. The nurse values and survival (Roach, 2002). Roach claimed that nurses’
the experience, the subjective knowledge, and the exper- professional caring has five important attributes: (a) com-
tise the person brings to the relationship. Decisions are passion, (b) competence, (c) confidence, (d) conscience, and (e)
made in the service of the person’s goals, wishes, and commitment. In the 2002 edition of the book, she added
desires, rather than in service of taken-for-granted pro- the sixth attribute, comportment (see Box 4.4 for a descrip-
tocols or plans of care (Gottlieb, 2013, p. 21). tion of each).
Gottlieb (2013) presents SBC as a compelling alterna-
tive to deficit or problem-based nursing care, commonly
practised in many health care venues across the country
(Gottlieb, 2013, p. 25). Beginning with the primary aim
Box 4.4 Roach’s Attributes
of care, SBC moves from a focus on problems to a focus
of Professional Caring
on strengths and capacities, even in the face of adversity.
Unlike problem-based nursing, SBC avoids the use of Roach claims that nurses’ professional caring has six
labels, categories, and diagnoses. Rather, SBC focuses on important attributes:
the particular person and the context in which the person 1. Compassion: sensitivity to the pain and brokenness of the
is constituted. The importance of the situated context of other; a quality of presence that allows one to share with
the person stands in stark contrast to deficit-based care and make room for the other
that is frequently viewed as context free. SBC engages 2. Competence: having the knowledge, judgment, skills,
with the hopeful language of “challenges, opportunities, energy, experience, and motivation required to respond
adequately to the demands of the professional responsi-
and possibilities” (p. 25).
bilities
As discussed, the nurse–person relationship is col-
3. Confidence: the self-belief that fosters trusting relation-
laborative rather than hierarchical. The person and
ships
the family are “primary sources of information” with
4. Conscience: a state of moral awareness that grows with
particular value “placed on the person’s story, narratives, experience
reflections” (p. 25). SBC continues to value objective
5. Commitment: a complex, affective response characterized
information from multiple sources, including laboratory by convergence between desires and obligations and by
tests, radiographs, and so on, but in contrast to deficit- the deliberate choice to act in accordance with them
based care, this objective information is held in the 6. Comportment: use of dress, language, and personal bear-
context of the subjectivity of the person and the family ing to communicate caring and respect for the dignity of
(p. 25). Unlike approaches in which “nurses diagnose the both the patient and the nurse
problem and use a standardized care plan to fix or cor-
Source: Adapted from Roach, M. S. (2002). The human act of caring: A blueprint for
rect the problem” (p. 26), SBC builds a unique individual the health professions (2nd revised ed.). Ottawa, ON: CHA Press.
plan of care in collaboration with the person, drawing
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Case Study 4
Kaili is a 32-year-old man with human immunodeficiency virus advanced cancer. The nurse wanted to take
(HIV) infection. His first acquired immunodeficiency syndrome measures to stop the diarrhea and supplement
(AIDS)–defining illness caused his weight to drop from 80 kg to nutrition in the meantime. Kaili’s friends and
54 kg because of intractable diarrhea. The physician thought family were pleased with the nurse’s approach,
caloric intake was of primary importance and urged Kaili to but Kaili was not as easily convinced.
eat whatever he desired. Antidiarrheal medications were also
prescribed, but Kaili was not happy because of the adverse
effects of these medications. Since Kaili was getting worse, the CRITICAL THINKING QUESTIONS
nurse argued that he needed intravenous feedings and that his
oral intake should be restricted to bland foods until the diarrhea 1. What concepts are present in this case?
stopped. The nurse suggested further that more foods could be 2. How are the nurse and the physician defining the para-
added one at a time, based on Kaili’s tolerance of them. Kaili’s digm? What are their main perspectives?
family and friends offered to manage his intake.
3. How might Florence Nightingale analyze this situation?
The physician’s stance was that AIDS was similar to advanced
cancer in terms of quality of life, so he would not order intrave- 4. Which of the nursing models in this chapter best sup-
nous feedings, just as he would not for someone with advanced ports the nurse’s plan of care?
cancer. The nurse argued that this was Kaili’s first AIDS infection
and that his prognosis was better than that for an individual with Visit MyNursingLab for answers and explanations.
KEY TERM S
assumptions p. 53 conceptual model p. 52 interpretive paradigm paradigm p. 53
concept p. 52 empiricist paradigm p. 53 p. 53 scientific method p. 53
conceptual framework epistemology p. 52 metaparadigm p. 54 theory p. 52
p. 52 ethics p. 53 ontology p. 52 world view p. 53

• Nursing is now deeply involved in identifying its own testing hypotheses generated by theories for nursing.
unique knowledge base—that is, the body of knowledge Research determines the utility of those hypotheses, and
essential to nursing practice, or a nursing science. research findings may be developed into theories for
• Nurses must communicate their unique and important nursing.
contributions to client care in the interdisciplinary team. • The major distinction between a theory and a conceptual
• Theories offer ways of conceptualizing a discipline in framework or model is the level of abstraction, with the
clear, explicit terms that can be communicated to others. conceptual framework being more abstract than theory.
A conceptual model is a system of related concepts or
• Because opinions about the nature and structure of nurs- a conceptual diagram. Its major purpose is to give clear
ing vary, theories continue to be developed. Each nursing and explicit direction to the three areas of nursing:
theory bears the name of the person or group that devel- practice, education, and research. A theory generates
oped it and reflects the beliefs of the developer. knowledge in a field.
• The theories vary considerably in (a) their level of abstraction,
(b) their conceptualization of the client, health and illness, and • Nursing theories address and specify relationships among
nursing, and (c) their ability to describe, explain, or predict. four major concepts, the building blocks of theory: nursing,
Some theories are broad in scope; others are limited. health and illness, environment, and the person or client.
• Nursing theories serve several essential purposes, some of • Each nurse theorist’s definitions of these four major
which are to differentiate the focus of nursing from those concepts vary in accordance with personal philosophy,
of other professions; to structure professional nursing scientific orientation, experience in nursing, and how that
practice, education, and research; to help build a common experience has affected the theorist’s view of nursing.
nursing terminology to use in communicating with other • Conceptual models for nursing relate to the nursing process
health care professionals; and to enhance the autonomy in that they are operationalized or made real by the use of
of nursing by defining its own independent functions. the nursing process. How nurses view human beings influ-
• Because the one purpose of nursing theory is to generate ences how they assess and intervene.
scientific knowledge, nursing theory and nursing research • Today, models for nursing are being refined in accor-
are closely related. Scientific knowledge is derived from dance with societal needs and with their tested usefulness.
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N CLE X- st yl e practic e qui z

1. What is true about philosophical thinking in experience pain less than adults do. What does her
nursing? belief exemplify?
a. It provides a graphic illustration of how a. A philosophical inquiry
concepts within the profession are related to one b. An ethical opinion
another.
c. An assumption
b. Nursing philosophy offers a way of conceptualizing
the discipline in clear, explicit terms that can be d. A physiological fact
communicated to others.
c. There is only one philosophical perspective that is 6. In 1978, the nursing scholar Carper identified four
appropriate for nursing practice. patterns of nursing knowledge, including empirics, aes-
thetics, personal knowledge, and ethics. What area of
d. It provides a foundation for the development and philosophical inquiry does this represent?
analysis of concepts and theories used to articulate
nursing knowledge. a. Ontology
b. Epistemology
2. Nursing theory is important to the development of the c. Paradigm
nursing discipline for what reason? d. Scientific method
a. It specifies the direction of research efforts in the
profession.
7. What are the central themes in Gottlieb’s nursing the-
b. It tells us exactly how to act in various situations. ory? (Select all that apply.)
c. It articulates the role of nurses and differentiates a. Health is linked to 14 fundamental needs.
nursing from other professions.
b. This theory uses a health promotion focus.
d. It helps us question our assumptions.
c. This theory promotes person-centred care.
3. Which example best illustrates an inferential concept? d. Health is culturally defined and valued.
a. Pulse rate e. Health is linked to five environmental factors.
b. Caring f. Human beings are recipients of compassionate
care.
c. Empowerment
d. Pain 8. Which abstract concept is generally included in the
metaparadigm of nursing, the global framework of the
4. While Jake and Marcy are studying for a nursing profession?
examination, Marcy asks what the difference between a
a. Caring
theory and a conceptual framework is. Which statement
made by Jake would reflect an accurate understanding b. Research
of the two terms? c. Client
a. “A theory explicitly states the relationship between d. Practice
concepts, whereas a conceptual framework is a group
of related concepts.” 9. Many of the nursing theorists use the concept of caring
b. “A theory is more abstract compared with a concep- as a strong element within their theory. Which of the fol-
tual framework.” lowing theorists is BEST known for her theory on caring?
c. “There is absolutely no difference between the terms a. Florence Nightingale
theory and conceptual framework; the terms are used b. Jean Watson
interchangeably.”
c. Virginia Henderson
d. “A theory is limited in scope, and its purpose is to
give direction to nursing research, practice, and edu- d. Madeleine Leininger
cation, whereas a conceptual framework is broad in
scope, and its purpose is to relate concepts through 10. The UBC (University of British Columbia) model of
definitions.” nursing could be considered which type of theory?
a. Systems
5. A nurse is taking care of a pediatric client who
b. Interpersonal
has undergone surgery for a ruptured appendix.
Postoperatively, the nurse is reluctant to administer any c. Caring
analgesics to her client because she believes children d. Developmental
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R efere nc es
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of nursing: A practice-derived mode. Advances in Nursing adaptation. Nursing Science Quarterly, 10(1), 42–48.
Scholarship, 9(4), 51–61. Roy, C., & Zahn, L. (2010). Sister Callista Roy’s adaptation model.
Henderson, V. (1966). The nature of nursing: A definition and its implica- In M. E. Parker & M. Smith (Eds.), Nursing theories and nursing
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(pp. 26–37). Newbury Park, CA: Sage. Constructing? Evolving? In J. Kikuchi & H. Simmons (Eds.),
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Leininger, M. M. (1988). Leininger’s theory of nursing: Cultural Watson, J. (1979). Nursing: The philosophy and science of caring. Boston,
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Bartlett.
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Chapter 5
Values, Ethics,
and Advocacy
Updated by
Linda Ferguson, RN, BSN, PGD (Cont. Ed), MN, PhD
Professor, College of Nursing, University of Saskatchewan
I
LEARNING OUTCOMES
After studying this chapter, you will be able to n their daily work,
1. Explain how values, moral frameworks, and codes of ethics affect nurses deal with inti-
decisions. mate and fundamental
2. Explain how nurses can use their knowledge of values and values human events, such as birth, death,
clarification to facilitate ethical decision making by clients. and suffering. They must evaluate the
3. Identify the moral issues and principles involved when presented morality of their own actions when
with an ethical situation. they face the many ethical issues
4. Explain the uses and limitations of professional codes of ethics. that surround such sensitive areas.
Because of the special nature of the
5. Describe reflective practice in nursing.
nurse–client relationship, nurses are
6. Describe common ethical problems facing health care
frequently the ones who support
professionals, including moral distress, moral residue, and
integrity. and advocate for clients and fami-
lies who are facing difficult choices.
7. Describe ways in which nurses can enhance their ethical decision
making and practice. The nurse is frequently confronted
with decisions about the rightness
8. Discuss the advocacy role of the nurse.
or wrongness of particular actions
within a given context. It is essential,
therefore, that nurses have a strong
grounding in ethics and a sound
approach to ethical decision making.
Ethical issues in nursing evolve
to reflect the challenges facing soci-
ety. Although numerous ethical chal-
lenges affect patients and families
in health care settings, a panel of
Canadian clinical bioethicists identi-
fied 10 issues that they felt were the c
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Chapter 5 Values, Ethics, and Advocacy 67
c most pressing (Breslin, MacRae, Bell, & Singer, 2005). Box 5.1 lists these by rank. Nurses face many
of these challenges on a daily basis.
According to the Canadian Nurses Association (CNA, 2010a), nurses have increasingly expressed
concern about their ability to deliver safe care in today’s health care system. The potential for compro-
mised safety creates new moral problems and intensifies old ones, making it critical for nurses to make
sound moral decisions. Therefore, nurses need to (a) develop sensitivity to the ethical dimensions of
nursing practice, (b) examine their own and their clients’ values, (c) understand how values influence
their decisions, and (d) think ahead to the kinds of moral problems they are likely to face. This chapter
explores the influences of values and moral frameworks on the ethical dimensions of nursing practice
and on the nurse’s role as a client advocate.
Values individuals. For example, some clients may feel strongly

about their need for privacy, whereas others may dismiss
it as unimportant.
Values are enduring beliefs or attitudes about the worth
of a person, an object, an idea, or an action. Values are
important because they influence decisions and actions,
including nurses’ ethical decision making. Even though
Values Transmission
they may be unspoken and perhaps even unconsciously Values are learned through observation and experience.
held, values underlie all moral decisions and dilem- As a result, they are heavily influenced by a person’s
mas. People hold values about work, family, religion, sociocultural environment—that is, by societal tradi-
politics, money, and relationships, as well as moral val- tions; by cultural, ethnic, and religious groups; and by
ues including truth, integrity, honour, commitment, and family and peer groups. For example, if a parent consis-
duty. Values are often taken for granted. People usually tently demonstrates honesty in dealing with others, his
do not think about their values; they simply accept them or her child will probably begin to value honesty. Nurses
as part of themselves, and act on them. should keep in mind the influence of values on health.
A value set is the small group of values held by an For example, some cultures value treatment by a folk
individual or group. People organize their sets of values healer over that by a health care provider. For additional
internally along a continuum from most important to information about cultural values related to health and
least important, forming a value system. Value sys- illness, see Chapter 11.
tems are basic to a way of life, give direction to life, and
PERSONAL VALUES Although people derive values
form the basis of behaviour—especially behaviour that
from society and their individual subgroups, they inter-
is based on decisions or choices.
nalize some or all of these values and perceive them as
Values consist of beliefs and attitudes, which are
personal values. People need societal values to feel
related, but not identical, to values. People have many
accepted, and they need personal values to have a sense
different beliefs and attitudes but only a small number of
of individuality.
values. Beliefs (or opinions) are interpretations or con-
clusions that people accept as true. They are based more PROFESSIONAL VALUES Nurses’ professional val-
on faith than on fact and may or may not be true. Beliefs ues are acquired during socialization into nursing from
do not necessarily involve values. For example, the state- codes of ethics, nursing experiences, teachers, and peers.
ment “If I study hard I will get a good grade” expresses The College of Nurses of Ontario (CNO, 2012) iden-
a belief that does not involve a value. By contrast, the tifies the following values as being most important to
statement “Good grades are really important to me, and nursing care: client well-being, client choice, privacy
I must study hard to obtain good grades” involves both and confidentiality, respect for life, the maintaining of
a value and a belief. commitments, truthfulness, and fairness. The Registered
Attitudes are mental positions or feelings toward a Nurses’ Association of Ontario (RNAO, 2015) has
person, an object, or an idea (e.g., acceptance, compas- framed its Person and Family-Centred Care program around
sion, openness). Typically, an attitude lasts over time, a widely accepted set of professional values (see Box 5.2).
whereas a belief may be short-lived. Attitudes are often In client-centred care, the client is viewed as a whole
judged as bad or good, positive or negative, whereas person and the approach involves advocacy, empower-
beliefs are judged as true or false. Attitudes have thinking ment, and respect for the client’s autonomy, voice, self-
and behavioural aspects. Attitudes vary greatly among determination, and participation in decision making.
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BOX 5.1 TOP 10 HEALTH CARE ETHICS CHALLENGES FACING THE CANADIAN PUBLIC
RANK SCENARIO IMPLICATIONS FOR NURSING PRACTICE
1 Disagreement between patients/ Ongoing dialogue about treatment between patients or families and provid-
families and health care professionals ers is a key component of nursing care.
about treatment decisions
2 Waiting lists Demand for nurses specializing in perioperative, rehabilitation, and surgical
nursing will continue to increase.
3 Access to needed health care Nurses with the skills and abilities to provide care to these vulnerable
resources for the aged, chronically ill, populations across diverse settings are essential.
and mentally ill
4 Shortage of family physicians or Expanded nursing practice and roles, such as the nurse practitioner, will
primary care teams in both rural and form a cornerstone of our health care system.
urban settings
5 Medical error Accountability for individual nursing practice and the recognition of systemic
causes of error will gain importance.
6 Withholding/withdrawing life-sustaining Improved communication between health care providers and patients or
treatment in the context of terminal or families can prevent the use of unwanted and inappropriate therapies.
serious illness
7 Achieving informed consent Nurses are in a position to assess whether the patient and family have fully
understood the procedure for which they gave consent. Nurses can advo-
cate for additional discussion.
8 Ethical issues related to subject Nursing researchers abide by guidelines for ethical conduct of research.
participation in research
9 Use of substitute decision makers When patients are compromised and unable to consent to medical
interventions, nurses work with substitute decision makers, such as
family members, to promote sound ethical decisions.
10 Surgical innovation and new Nurses should consider the implications of new technologies from an
technologies ethical perspective.
Source: Based on Breslen, J. M., MacRae, S. K., Bell, J., & Singer, P. A. (2005). Top 10 health care ethics challenges facing the public: Views of Toronto bioethicists (table 1).
BMC Medical Ethics, 6, 5.
BOX 5.2 PATIENT AND FAMILY-CENTRED Table 5.1 lists the values and professional behaviours
BEST PRACTICE RECOMMENDATION associated with these values.
Nurses embrace as foundational to patient-centred care the

following values and beliefs: Values Clarification
• Fostering relationships and trust
Values clarification is a process by which people
• Respect for the person and personalizing care
identify, examine, and develop their own individual val-
• Empowerment, autonomy, and the right of ues. A principle of values clarification is that no one set
self-determination
of values is right for everyone. When people identify
• Evidence-based practice their values, they can reflect on them, and possibly
• Physical and emotional comfort change them, and thus act on the basis of freely chosen,
• Access to care and services rather than unconscious, values. Values clarification pro-
• Partnering with the patient and family motes personal growth by fostering awareness, empathy,
• Communicating effectively and insight. Therefore, it is an important step that nurses
must take in dealing with ethical problems.
• Care based on the social determinants of health
Often, a values clarification exercise can be useful in
• Ensuring continuity of care
helping individuals or groups to become more aware of
These values and beliefs must be incorporated into, and their values and how they may influence their actions. For
demonstrated throughout, every aspect of client care and example, asking a client to agree or disagree with a list
service. of statements or to rank in order of importance a list of
Source: Based on Person and family-centred care, Registered Nurses’ Association
beliefs can assist the nurse and client to make the client’s
of Ontario, 2015. values more open so they can be considered in planning
the client’s care. See Table 5.2 for an example of a general
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TABLE 5.1 Essential Nursing Values and Behaviours
Values Professional Behaviours

Altruism is a concern for the welfare and well-being of others. 1. Demonstrate the professional standards of moral, ethical,
In professional practice, altruism is reflected by the nurse’s con- and legal conduct.
cern for the welfare of patients, other nurses, and other health
care providers.
Autonomy is the right to self-determination. Professional prac- 2. A
ssume accountability for personal and professional
tice reflects autonomy when the nurse respects patients’ rights behaviours.
to make decisions about their health care.
Human dignity is respect for the inherent worth and uniqueness 3. P
romote the image of nursing by modelling the values
of individuals and populations. In professional practice, human and articulating the knowledge, skills, and attitudes of the
dignity is reflected when the nurse values and respects all nursing profession.
patients and colleagues.
Integrity is acting in accordance with an appropriate code of 4. D
emonstrate professionalism, including attention to appear-
ethics and accepted standards of practice. Integrity is reflected ance, demeanour, respect for self and others, and attention
in professional practice when the nurse is honest and provides to professional boundaries with patients and families, as
care based on an ethical framework that is accepted within the well as among caregivers.
profession.
Social justice is upholding moral, legal, and humanistic prin- 5. Demonstrate an appreciation of the history of and contem-
ciples. This value is reflected in professional practice when the porary issues in nursing and their impact on current nursing
nurse works to ensure equal treatment under the law and equal practice.
access to quality health care.
6. Reflect on one’s own beliefs and values as they relate to
professional practice.
7. Identify personal, professional, and environmental risks that
impact personal and professional choices and behaviours.
8. Communicate to the health care team one’s personal bias
on difficult health care decisions that impact one’s ability to
provide care.
9. Recognize the impact of attitudes, values, and expectations
on the care of the very young, frail older adults, and other
vulnerable populations.
10. Protect patient privacy and confidentiality of patient records
and other privileged communications.
11. Access interprofessional and intraprofessional resources to
resolve ethical and other practice dilemmas.
12. Act to prevent unsafe, illegal, or unethical care practices.
13. Articulate the value of pursuing practice excellence, lifelong
learning, and professional engagement to foster profes-
sional growth and development.
14. Recognize the relationship between personal health, self-
renewal, and the ability to deliver sustained quality care
Source: From American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice (pp. 8–9). Washington, DC: Author.
Reprinted with permission.
TABLE 5.2 Questionnaire for Personal Values Clarification
Rating on a
Scale of 1 to 3* Personal Value Example of Activity That Demonstrates That Value
Help Society Do something which contributes to improving the world we live in
Help Others Be directly included in helping other people, either individually or in small groups
Work Ethics Feel satisfied from a job well done
Enjoyment of Life Enjoy life, having fun in life
(continued)
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TABLE 5.2 (continued )
Rating on a
Scale of 1 to 3* Personal Value Example of Activity That Demonstrates That Value
Honesty Be able to tell people what I really think and believe; having them be honest with me
Approval Have other people like me
Competition Engage in activities that pit my abilities against those of others
Make Decisions Have the power to decide on courses of action
Respect Have other people think highly of me and hold me in good esteem
Leadership Be in a position to influence the attitudes or opinions of other people
Knowledge Gain understanding through study and/or experience
Work Mastery Become an expert in whatever work I do
Peace Live in a peaceful, harmonious society and environment
Creativity Have the opportunity to create new things, ideas, products, and works of art
Freedom Be able to do or say what I want
Good Character Know inside that I do the right, moral, just thing
Loyalty Stick with people who are close to me and/or believe in what I do
Justice Be fair and just and having others treat me fairly and justly
Stability Have a routine and duties that are largely predictable
Safety Be assured of being safe and free from harm
Recognition Be publicly recognized
Children Have happy, healthy children
Excitement Experience a high degree of (or frequent) excitement
Adventure Have duties that require frequent risk taking
Power Have authority over others
Economic Security Have enough money to buy whatever I want
Leisure Have time for hobbies, sports, other activities
Inner Harmony Be at peace with myself
Wealth Make profit, gain, a lot of money
Trustworthiness Have people trust me and being able to trust them
Challenge Do activities that use my physical and/or mental capabilities
Independence Be able to determine the nature of my day without significant direction from others
Change and Variety Have varied, frequently changing responsibilities and settings
Moral Fulfillment Feel that whatever I do contributes to a set of moral standards that I feel are very
important
Community Be a part of a close and supportive community
Caring Experience love and affection daily
Health Be free from disease or sickness, feeling good physically
Religion/Spirituality Do what is right according to my religious and/or spiritual beliefs
Family Make sure my family members are healthy and safe
Friendship Have good, reliable friends I can count on
*1 = Things I value very much; 2 = Things I value; 3 = Things I do not value very much.
Now, list your top five essential values (from those rated 1 above).
MY FIVE MOST ESSENTIAL VALUES
1. 4.
2. 5.
3.
Source: From Johns Hopkins Center for Communication Programs. (2002). Questionnaire for values clarification. Copyright 2002. Retrieved from http://www.jhuccp.org/research/download/
Valuesinstrument.pdf.
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values clarification exercise. Depending on the patient’s 2. Examine possible consequences of choices. Make sure the
health status, a discussion with the patient and/or family client has thought about the possible outcomes of
may be sufficient to identify their important values. each action. Ask, “What do you think you will gain
from doing that?”
CLARIFYING THE NURSE’S VALUES Nurses and nurs-
ing students need to examine the values they hold about 3. Choose a preferred action. To determine whether the client
life, death, health, and illness (CNO, 2012). One strategy chose freely, ask, “Why did you choose that action?”
for gaining awareness of personal values is to consider “Do you have a choice?”
your own attitudes about specific issues, such as abortion 4. Feel good about the choice. To determine how the client feels,
or euthanasia, or by asking the following questions: Can ask, “How do you feel about that decision (or action)?”
I accept this or live with this? Why does this bother me? 5. Affirm the choice. Ask, “How will you discuss this choice
What would I do or want done in this situation? Nurses with others (family, friends)?”
use critical thinking (see Chapter 21) to reflect on vari-
6. Act on the choice. To determine whether the client is pre-
ous viewpoints and previous experiences that may have
pared to act on the decision, ask, for example, “When
influenced their own values.
will you initiate this action?”
CLARIFYING CLIENT VALUES To plan effective care, 7. Act consistently. To determine whether the client consis-
nurses need to identify patients’ values as they relate to tently behaves in a certain way, ask, “How many times
a particular health problem. For example, a patient with have you done that before?” or “Would you act that way
failing eyesight will probably place a high value on the again?”
ability to see, and a client with chronic pain will value
comfort. The nurse needs to ask such questions as these: When implementing these seven steps to clarify
“What really matters to you in this situation?” “What do values, the nurse helps the client think through each
you want to have happen here?” “What do you want from question but does not impose personal values. The nurse
me as a nurse?” The reflective nurse will soon recognize rarely, if ever, offers an opinion when the client asks for
that without an understanding of a client’s values, it is it. Because each situation is different, what the nurse
impossible to answer the questions. Therefore, this under- would choose in his or her own life may not be relevant
standing is foundational for ethical practice. For informa- to the client’s circumstances. Thus, if the client asks the
tion about health beliefs and values, see Chapter 7. nurse, “What would you have done in my situation?” it
When clients hold unclear or conflicting values that is best to redirect the question back to the client rather
are detrimental to their health, the nurse should use val- than answering from a personal point of view.
ues clarification as an intervention. Examples of behav-
iours that may indicate the need for clarification of CLARIFYING VALUES AND OBLIGATIONS IN CARE
health values are listed in Table 5.3. SITUATIONS Nurses need to understand their own val-
The following process may help clients clarify their ues in the broader sense, but they also need to identify
values related to a specific health issue: values that are relevant in individual care situations.
1. List alternative actions. Make sure that the client is aware They need to ask themselves the following: What factors
of all alternative actions. Ask, “Are you considering in this situation might affect how I think about “right”
other courses of action?” “Tell me about them.” action? Are there particular contextual features that
might change my views? For example, the nurse might
value autonomy as a general rule but might question
TABLE 5.3 Client Behaviours That May Indicate Unclear/ this value if it means supporting a client’s decision to use
Conflicting Values illicit drugs.
Because of their unique position in the health care
Behaviour Example hierarchy, nurses often experience conflicts among their
Ignoring a health care A client with heart disease ignores loyalties and obligations to patients, families, other health
professional’s advice advice to exercise regularly. care providers, employing institutions, and licensing bod-
Inconsistent communi- A pregnant woman says she ies. Patient needs may conflict with institutional policies,
cation or behaviour wants a healthy baby but health care provider preferences, needs of the client’s fam-
continues to drink alcohol and ily, or even laws. According to the CNA’s code of ethics,
smoke tobacco. the nurse’s first loyalty is to the patient. However, it is not
Numerous admissions A middle-aged, obese woman always easy to determine which action best serves the cli-
to a health care agency repeatedly seeks help for back ent’s needs. For instance, a nurse may think that a patient
for the same problem pain but does not lose weight. needs the most current evidence-based information, but
Confusion or uncer- A woman wants to obtain a job to that information may conflict with the physician’s advice;
tainty about which meet financial obligations but also if the patient goes against that advice, it may damage the
course of action to take wants to stay at home to care for physician–patient relationship. The nurse will then have to
her ailing husband.
decide what the greater good is in the situation.
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Ethical Obligations When faced with difficult decisions, it is important

that the nurse be able to distinguish between ethics and
Making a commitment to treat others with respect law. Laws do reflect the moral values of a society, and
and to uphold the values of well-being, choice, and they offer strict guidance in determining what is moral
dignity are fundamental to nursing. Nurses have an according to society. There are penalties for not follow-
obligation to maintain commitments that they assume ing laws. However, an action can be legal but not moral.
as regulated health care professionals, such as keeping For example, an order for full resuscitation of a dying
promises, being honest, and meeting obligations toward client is legal, but the nurse could question whether the
their clients, one another, the nursing profession, other act is moral. Conversely, an action can be moral but
members of the health care team, and quality practice illegal. If a child at home stops breathing, it is moral
settings (CNO, 2012). However, despite such clear moral but not legal to exceed the speed limit when driving to
commitments, nurses may still face situations in which the hospital. The legal aspects of nursing practice are
the right action is not easily identified (Davis, Fowler, covered in Chapter 6.
& Aroskar, 2009). A good decision is one that is in the
client’s best interests and at the same time preserves the
integrity of all involved. Nurses have ethical obliga-
tions, or responsibilities that are imposed as a result of Moral Theories
ethical imperatives, to their clients, to the agency that Moral theories, which are a set of abstract principles,
employs them, and to other health care professionals. provide different lenses through which nurses can view
Unfortunately, there will be times when some of these and clarify client care situations that can be disturbing.
obligations appear to be in conflict, as when the nurse Nurses can use moral theories in developing explanations
feels a strong duty to follow institutional policy but at for their ethical decisions and actions and in discussing
the same time feels that the policy does not serve the problem situations with others. Three types of moral
best interests of the client. theories are widely used, and they can be differentiated
by their emphasis on (a) consequences, (b) principles and
duties, or (c) relationships.
Consequence-based (teleological) theories
Ethics look to an action’s outcomes (consequences) in judging
whether that action is right or wrong. Utilitarianism,
The term ethics is defined as a system of values and one form of consequentialist theory, views a good act
beliefs for determining right or wrong and for making as one that brings the most good and the least harm for
judgments about what should be done to or for other the greatest number of people. This is called the prin-
human beings (RNAO, 2007). This term has several ciple of utility. This approach is often used in making
meanings in common use. It refers to (a) a method of decisions about the funding and delivery of health care.
inquiry that helps people understand the morality or Teleological theories focus on issues of fairness.
goodness of human behaviour, (b) the practices or beliefs Principles-based (deontological) theories
of a certain group (e.g., medical ethics, nursing ethics), involve logical and formal processes and emphasize indi-
and (c) formal statements about expected standards of vidual rights, duties, and obligations. The morality of
moral behaviour of a particular group. Thus, it is gener- an action is determined not by its consequences but by
ally used to refer to a broader understanding of moral whether it is done according to an impartial, objective
life through the application of theories and sets of prin- principle. For example, while following the rule “Do not
ciples that give structure to morality (Monteverde, 2014). lie,” a nurse might believe he or she should tell the truth
Nurses are often faced with moral quandaries in about his death to a dying client, even though the physi-
practice, that is, with decisions about what ought or should cian has given instruction not to do so. There are many
be done, often in challenging circumstances. For example, deontological theories.
the nurse might have to decide about whether or not Relationship-based (caring) theories stress
to use physical restraints on clients who are confused courage, generosity, commitment, and the need to nur-
and in danger of hurting themselves. The question is ture and maintain relationships (Figure 5.1). Unlike the
whether taking away a person’s physical freedom is truly two preceding theories, which frame problems in terms
in that person’s best interests and, therefore, whether the of justice (fairness) and formal reasoning, caring theories
nurse ought or ought not to do it. The nurse’s action will be (see Chapter 4) judge actions according to a perspective
guided by his or her individual belief system (morality) of caring and responsibility. Principles-based theories
and by the broadly accepted standards of the society and stress individual rights, whereas caring theories promote
the profession (as articulated in ethics theory and codes the common good or the welfare of the group.
of ethics). A code of ethics is a formalized statement of A moral theory guides moral decisions and actions,
a group’s beliefs, as in the Canadian Nurses Association but it does not determine the outcome. Imagine a situa-
Code of Ethics (CNA, 2008). tion in which a frail older patient has made it clear that
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that applied as the basis for a solution that was accept-

able to all. For example, most people would agree with
the principle that nurses are obligated to respect their
clients, even if they disagree as to whether the nurse
should deceive a particular client about the prognosis.
The original principles of bioethics were autonomy, benefi-
cence, nonmaleficence, and justice. Later, principles of fidelity
and veracity were added, and autonomy was expanded
to respect for persons. These principles are very useful in
discussions about ethical dimensions of particular care
situations in nursing.
The principle of autonomy (respect for per-
sons) states that individuals have the right to make
choices about their own lives. It also means showing
respect for others and accepting them as unique individ-
uals with personal histories that influence their decision
making. In health care, this means that health care pro-
viders must honour the person’s right to choose methods
or approaches to diagnosis and treatment. Choices must
be free and informed, that is, made without coercion
and with the benefit of all necessary information (see
University of Calgary
Chapter 6). Some clients are unable to make their own

decisions (e.g., older persons with cognitive impairment,
young children, or comatose patients), and their family
members become their decision makers. In rare situa-
FIGURE 5.1 Relational caring is a professional relationship.
tions, health care professionals are obligated to make
decisions that, to the best of their knowledge, the persons
would make for themselves.
he does not want further surgery, but the family and Nonmaleficence is the duty to do no harm.
surgeon insist. Three nurses have each decided that they Although this would seem to be a simple principle to fol-
will not help with preparations for surgery and that they low, in reality, it is complex. Harm can mean intentional
will work through proper channels to try to prevent it. harm, risk of harm, and unintentional harm. In nursing,
Using consequence-based reasoning, Nurse A reasons, intentional harm is never acceptable. However, nurses
“Surgery will cause him more suffering; he probably sometimes unintentionally inflict harm during a nursing
will not survive it anyway, and the family may even feel intervention that is intended to be helpful. Causing such
guilty later.” Using principles-based reasoning, Nurse B harm would not be unethical as such. For example, a
reasons, “This violates the principle of autonomy. This nurse may be required to carry out treatments that cause
man has a right to decide what happens to his body.” pain or discomfort, such as administering chemotherapy
Using caring-based reasoning, Nurse C reasons, “My that has unpleasant side effects, such as severe nausea
relationship with this patient commits me to protecting and vomiting. If the principle of nonmaleficence were
him and meeting his needs. I must try to help the family taken at face value, it would appear to dictate that the
understand that he needs their support.” Although each nurse should not carry out such actions. On reflection,
perspective is based on the nurse’s moral framework, the however, the nurse would realize that failure to admin-
action of protecting the patient is the result. ister the drugs would cause the patient greater harm by
allowing the cancer to progress unchecked. The nurse
must consider the risk of harm from various sources
Principles-Based Ethics and consider which action would be the most beneficial
Principles-based ethics is the most widely known to the patient. Thus, the nurse must examine potential
approach to health care ethics. This approach was first harms and benefits in considering whether the acts of
described in Beauchamp and Childress’s Principles of harm were unethical.
Biomedical Ethics (2009). Their idea was that when health Beneficence is the obligation to “do good.”
care providers encountered an ethical problem, they Nurses have a duty to implement actions that benefit
would examine the situation, decide which ethical prin- their clients; that is, to act in the client’s best interests.
ciples applied, and use them to make a decision. Their However, what is considered “good” in any situation is
belief was that principles would be useful because even not always clear. Is it better, for instance, to mobilize a
if people disagreed about which action was right in a patient following surgery or allow him to remain in bed
situation, they might be able to agree on the principles to avoid the pain he will experience when ambulating?
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Which would be of greater benefit? An important ques- Nursing Ethics and Relational Ethics
tion that arises in discussions of benefit is: Who defines
“good”? Should it be the health care professional or the Some authors believe that nursing’s ethical foundation
patient and the family? The nurse must then consider must be based on caring and, therefore, nursing is better
whose beliefs should prevail in this instance. When served by an approach that takes into account the rela-
health care providers make decisions for clients without tionship between nurse and patient (Gastmans, 2006).
seeking their input, it is called paternalism. Today, Some also suggest that caring is a virtue, that is, a
clients are respected as having the ability to make deci- highly valued personality characteristic that predisposes
sions for themselves, and paternalism is not considered a person to act in a certain way. Armstrong (2006) sug-
ethical. Nurses who want to make decisions for patients gested that nurses must possess the virtue of caring if
“in their best interests” must question whether they are they are to make ethical decisions in practice.
being paternalistic. Ethical theories coming from these perspectives are
Justice is often referred to as fairness. In health called relational ethics theories or ethics of care.
care, justice issues arise most often in deciding how scarce These theories suggest that we all have a moral obligation
resources should be used. Such questions as who should to others simply because we are human and that we ought
get a heart for transplantation, whether a patient should to act in others’ best interests. Actions are judged accord-
be discharged to make room for another patient who ing to whether they demonstrate caring and responsibility.
seems more ill, or whether funding should be directed An example is Roach’s 6 Cs of Caring (see Chapter 4).
to heart-health programs or home care for the seniors Bioethics theory tends to consider situations more in the
require justice-based decisions. Nurses make justice deci- abstract, whereas relational theories take into account
sions all the time in prioritizing care. For example, a the individual’s personal story or narrative. Thus, they are
nurse making home visits finds one client tearful and more concrete and rooted in the patient’s own reality.
depressed and knows that staying for 30 minutes more Relational ethics theory seems to fit well with the
to talk would help. However, that would take time from caring concepts that are central to nursing, as it demands
another client. Many factors must be considered in the that clients be affirmed as persons, not objects (Marck,
decision, and require careful thought. 2000). However, it is important to remember that caring
Fidelity means to be faithful to agreements and is not unique to nursing and that some have criticized
promises. Nurses often make promises to patients, such the caring perspective for (a) reinforcing the stereotype
as “I’ll be right back with a medication for your pain,” of women as caregivers and (b) overlooking other impor-
or “I’ll find out for you.” Clients take such promises tant moral principles, such as fairness and autonomy
seriously. As professional caregivers, nurses have respon- (Bowden, 1995). Nonetheless, nursing scholars seem to
sibilities to multiple patients as well as their employers. be in agreement that the commitment to others that is
Sometimes, these responsibilities are in conflict, as when reflected in an attitude of caring is the basis, if not the
several patients need attention at the same time, and the whole, of nursing ethics (Marck, 2000).
nurse must decide on priorities in this situation.
Veracity refers to telling the truth. Although this
seems straightforward, in practice, choices are not always Nursing Codes of Ethics
clear. Should a nurse tell the truth when it is known that
it will distress the patient? Does a nurse tell a lie if the No single theory of ethical decision making is univer-
lie will relieve anxiety and fear? These kinds of decisions sally applicable to nursing. However, within the profes-
form the basis for many moral dilemmas in nursing. sion, norms of practice can be used to help the nurse
Although bioethics principles are meant to help the make moral decisions. These norms are reflected in
health care provider make decisions, it is never quite as a professional code of ethics, which is a set of ethical
simple as deciding which principle applies in any one principles that (a) is shared by members of the group, (b)
case. Often, several principles apply, and the principles reflects their moral judgments over time, and (c) serves
may conflict with each other. If a nurse working in as a standard for their professional actions. Codes of
community health observes a young mother exhibiting ethics usually have higher requirements than do legal
inappropriate parenting practices, does the nurse respect standards. Nursing codes of ethics have the following
the mother’s autonomy and right to care for her child purposes:
as she sees fit (respecting autonomy), or does the nurse • To inform the public about the standards of the profes-
intervene and insist that changes be made (beneficence)? sion and professional nursing conduct
Does a nurse mark the menu of a patient newly diag-
• To signify the profession’s commitment to the public it
nosed with diabetes to ensure that he receives the right
serves
foods (nonmaleficence) or let him mark his menu himself,
risking poor food choices (respecting autonomy)? Such • To outline the major ethical considerations of the pro-
questions are very difficult and require active reflection fession
based on ethical principles to guide practice. • To provide general guidelines for professional behaviour
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• To guide the profession in self-regulation

• To provide guidance in nurses’ decision making
Ethical Decision Making
Codes of ethics for nursing have been developed at In this chapter, we have discussed several types of ethics
the international level by the International Council of theory (teleological, deontological, and relational ethics). In
Nurses (ICN), and at the national level by different coun- addition, we have discussed codes of ethics and the impact
tries. The ICN (2006) Code of Ethics for Nurses notes that of personal and professional values on decision making.
nurses have four fundamental responsibilities: to promote How can these various parts be brought together to help a
health, to prevent illness, to restore health, and to allevi- nurse develop a plan to enhance ethical practice? Providing
ate suffering. The CNA Code of Ethics for Registered Nurses ethical care requires considerable thought and reflection,
(2008) articulates the value system held by the nursing and ethical decision making can be enhanced if nurses have
profession in Canada and, as such, serves as a blueprint an understanding of the values that drive their practice.
for ethical practice by Canadian nurses (registered nurses,
licensed practical nurses or registered practical nurses,
registered psychiatric nurses). However, the code cannot Making Ethical Decisions
provide answers to particular care decisions. Instead, the Responsible ethical reasoning is rational and systematic.
code reflects the mandate of professional nursing and It should be based on ethical principles and codes rather
the elements that must be considered in making ethi- than solely on emotions, intuition, fixed policies, or prec-
cal practice decisions. Nurses are responsible for being edent (i.e., an earlier similar occurrence). One decision-
familiar with the code that governs their practice. Box 5.3 making model is shown in Box 5.4.
describes the nursing values that are the foundation for A good decision is one that is in the patient’s best
the CNA’s Code of Ethics. See the Weblinks placed online interests while preserving the integrity of all involved.
for this chapter for a link to the complete Code of Ethics. Nurses have ethical obligations to their patients, to the
agency that employs them, and to health care provid-
BOX 5.3 CANADIAN NURSES ASSOCIATION’S ers. Therefore, nurses must weigh competing factors
CODE OF ETHICS FOR REGISTERED NURSES when making ethical decisions. See Box 5.5 for examples.
The CNA’s Code of Ethics for Registered Nurses (2008)
outlines the values that should guide Canadian nursing
BOX 5.4 AN ETHICAL DECISION-MAKING MODEL
practice. Each value is accompanied by an itemized list of
ethical responsibilities: The following is an example of an ethical decision-making
1. Providing safe, compassionate, competent, and ethical model (Toren & Wagner, 2010) that can be used in clinical
care: Nurses provide safe, compassionate, competent, practice to facilitate ethical choices:
and ethical care. • Define the ethical dilemma.
2. Promoting health and well-being: Nurses work with • Clarify the personal and professional values, ethical prin-
people to enable them to attain their highest possible ciples, and laws involved.
level of health and well-being.
• Identify the possible alternatives for actions.
3. Promoting and respecting informed decision making:
• Choose an action.
Nurses recognize, respect, and promote a person’s right
to be informed and make decisions. • Generalize the solution to other similar cases.
4. Preserving dignity: Nurses recognize and respect the
intrinsic worth of each person. Source: Based on Toren, O., & Wagner, N. (2010). Applying an ethical decision-
making tool for a nurse management dilemma. Nursing Ethics, 17, 393–402.
5. Maintaining privacy and confidentiality: Nurses recog-
nize the importance of privacy and confidentiality and
safeguard personal, family, and community information
obtained in the context of a professional relationship.
6. Promoting justice: Nurses uphold principles of justice by BOX 5.5 EXAMPLES OF NURSES’ OBLIGATIONS
safeguarding human rights, equity, and fairness and by IN ETHICAL DECISIONS
promoting the public good.
Nurses must meet a variety of obligations in making ethical
7. Being accountable: Nurses are accountable for their ac-
decisions:
tions and answerable for their practice.
• Maximize the client’s well-being.
Source: From Code of ethics for registered nurses. © Canadian Nurses Association.
Reprinted with permission. Further reproduction prohibited.
• Balance the client’s need for autonomy with family mem-
bers’ responsibilities for the client’s well-being.
• Support each family member, and enhance the family
support system.
CLINICAL ALERT • Carry out agency policies.

• Protect other clients’ well-being.
Ethical behaviour is contextual; what is an ethical action or
decision in one situation may not be so in a different situation. • Protect the nurse’s own standards of care.
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Although ethical reasoning is principle based and has

Experiencing the
the patient’s well-being at its centre, being involved in situation or encounter
ethical problems and dilemmas is stressful for nurses and Now
What?
other health care professionals. An example is the moral what?
dilemma for an individual nurse’s decision regarding hon-
ouring picket lines during employee strikes. The nurse
may experience conflict, feeling the need to support co- Applying, Processing,
workers in their efforts to improve working conditions, changing, or keeping reflecting after the
for the future situation or encounter
feeling the need to ensure patients receive care and are not
abandoned, and feeling loyalty to the hospital employer.
Reflective Practice So
what?
Reflection is a method of accessing, making sense of, and
learning through experience. As a key competency of self- What? The “what” consists of observations and/or information that
directed learners, evidence of reflective practice is a man- can be the result of one’s personal reflections about a specific situa-
tion or the results of a broader self-assessment.
dated element of the continuing competency requirements
So What? The “so what” is the meaning one makes of the informa-
for most nursing jurisdictions. Several years ago, Schon
tion after thinking about it or reflecting on it.
(1983) described reflective practice as having two compo-
Now What? The “now what” is what one will do with the informa-
nents: reflection in action and reflection on action. Reflection tion to reinforce changes in knowledge and skills for the future
in action outlines the thinking processes in the midst of prac- where necessary. “What, so what, and now what” thinking is a criti-
tice and what contributes to action. Reflection on action is the cal part of self-reflection.
process of reflecting after the fact and thinking about how
FIGURE 5.2 “What? So What, and Now What?” Model.
one might improve on one’s performance when faced with
a similar situation in the future. It is this component that has
often been termed reflective practice in nursing circles are moral agents. Nurses realize that many problems at
today. There are several structures that can assist nursing the institutional level are really ethical issues. For exam-
students and nurses to engage in reflective practice; one ple, workload becomes an ethical issue for nurses when
that has been quite popular is the “What—So What—Now a unit is insufficiently staffed to enable them to uphold
What” model. The “What” refers to observations and/or the values of well-being and respect. When nurses are
information that can be the result of one’s personal reflec- too busy to listen to patients or to employ comfort strate-
tions about a specific situation. The “So What” refers to gies, then professional values are being violated. Rodney
the meaning one makes of the information after reflection.
The “Now What” is what one will do with the information
to reinforce changes in knowledge or skills that will be made
BOX 5.6 EXAMPLES OF REFLECTIVE
in the future. Figure 5.2 illustrates the process, and Box 5.6
QUESTIONS
outlines questions that can be asked as part of the process.
WHAT?
Decision Making in Practice How did the situation begin?
What did you observe or hear?
A decision-making framework can help the nurse in
making ethical decisions. Frameworks must take into How did the situation end?
account the facts, beliefs, and values inherent in the SO WHAT?
situation. Knowing the kinds of questions to ask in a
situation is essential if the nurse is to get the necessary Did you learn something new?
information needed to support the decision. How might someone else in the situation view the same
situation?
Did anything about the situation surprise you?
Selected Ethical Issues

Are you pleased with the outcome?
Are others in the situation pleased with the outcome?
in Nursing How do you know?
NOW WHAT?
Moral agents have the capacity for making moral What learning did you take from this experience?
judgments and for taking actions that are consistent with Would you engage in the same actions another time?
morality. With changes in the profession, nurses’ aware- Different actions?
ness of ethical issues in practice is growing, and nurses
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and Varcoe (2001) argued that such problems must be requesting it, a situation of moral distress for some health
examined from an ethics perspective and that nurses care professionals. Often, the problem is that the family or
must begin to understand that striving for better working the physician wants aggressive care to continue, whereas
conditions is part of nursing’s moral imperative. If the nurses believe that the client’s dignity is being eroded by
quality of work life is unsatisfactory, and the standard of continued treatment. Sometimes, the opposite applies;
care is compromised, nurses’ moral base is eroded. nurses believe that treatment should continue, and others
Developing and maintaining a trusting, caring, and want it to be terminated. Either way, the situation can
supportive relationship with a patient is the foundation cause the nurse moral distress, particularly if he or she
of nursing ethics (Gastmans, 2006). The CNA’s Code of feels powerless to influence the decision making.
Ethics for Registered Nurses (2008) indicates the values held Redman and Fry (2000) analyzed numerous pub-
by the profession. However, the code acknowledges that lished reports of studies of ethical conflict in nursing and
“given the complexity of ethical situations, the code can determined that the most common disagreements centre
only outline nurses’ ethical responsibilities and guide on decisions about the medical treatment of patients.
nurses in their reflection and decision-making. It can- When such disagreement exists, communication and
not ensure ethical practice” (p. 4). Thus, it points again problem-solving skills are particularly important. The
to the need for nurses to have a clear understanding of nurse can use a framework to analyze the problem on the
their own values. basis of understanding the patient’s and family’s wishes
Nurses must consider how their values might affect
the care they give to patients. Certainly, every caregiving
situation has moral components and will be affected by
the values, beliefs, and attitudes of all those involved.
However, some kinds of care situations cause nurses EVIDENCE-INFORMED
to pay particular attention to their own values. Moral PRACTICE
integrity refers to the quality of one’s character and
has integrated virtues including honesty and truthfulness Interventions to Address Moral
(Butts & Rich, 2005). Moral dilemmas are situations Distress in Nurses
involving conflicting ethical claims and often create such
questions as these: “What ought I to do?” “What harm In this philosophical inquiry study, two nurse researchers
and benefit will result from this decision or action?” from British Columbia, Canada, and their Australian col-
(Davis, Fowler, & Aroskar, 2009). Moral distress occurs league explored the concept of moral distress in an effort
to identify interventions to resolve it. They did so from the
when the individual knows the ethically correct action to
perspective of relational ethics, positing that nurses are influ-
take but is unable to take the action because of internal enced by the sociopolitical structures of the institutions in
or external barriers (Jameton, 1992). Moral residue is which they practise. From this theoretical perspective, moral
the emotional response that nurses may carry forward distress is seen to be present not only in the broader health
from ethical situations in which they have felt compro- care structures but also within the individual nurse. They
mised, and that provides the basis for reflection on ethi- were then able to identify interventions to assist nurses to
cal decision making for the future (CNA, 2010a). As seen resolve their distress.
Interventions included (1) morally supportive work en-
in the Evidence-Informed Practice box, situations caus-
vironments, (2) discussions of ethical issues, (3) regular pre-
ing moral distress can occur during the practice of nurs- structured debriefing sessions, (4) built-in rounds to learn
ing. To address moral distress, the American Association from, with, and about health care professionals in terms of
of Critical Care Nurses (McCue, 2010) advises that their moral agency, and (5) advocacy work through individu-
nurses consider “four A’s: Ask, Affirm, Assess, and Act.” als and their professional associations.
This framework is depicted in Figure 5.3. NURSING IMPLICATIONS: This research study rein-
The unprecedented advances in medical technol- forced the importance of recognizing moral distress as
ogy over the past 4 decades have engendered significant a form of trauma experienced by professional caregiv-
changes in professional, social, and legal expectations ers, and the importance of discussion with others in
about care outcomes (Shield, Wetle, Teno, Miller, & similar situations. Certain high-stress situations, such
Welch, 2010). Ethical issues related to medical futility, as those encountered in palliative care and intensive
care units, are likely to precipitate such feelings, and
defined as life-sustaining care that is unlikely to result in
thus, interventions should be in place to provide sup-
meaningful survival, continue to present challenges in port and opportunities for discussion. The same situ-
nursing practice. Euthanasia and the withholding or with- ations also occur on general nursing units. Where
drawal of life-sustaining treatment are frequently cited structures are not in place, individual nurses should
by Canadian nurses as ethical issues (Oberle & Hughes, seek opportunities to find the support they need, to
2001). A 2015 decision of the Supreme Court of Canada discuss their distress, and thus to resolve it.
has determined that Canadians have a constitutional Source: Musto, L. C., Rodney, P. A., & Vanderheide, R. (2015). Toward interventions
right to doctor-assisted suicide in situations of irremedi- to address moral distress: Navigating structure and agency. Nursing Ethics, 22(1),
91–102. doi 10.1177/09697330145344879.
able illness and suffering in the case of competent adults
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ASK
You may be unaware of the exact nature of
the problem but are feeling distressed.
Ask: “Am I feeling distressed or showing

signs of suffering? Is the source of my
distress work related? Am I observing
symptoms of distress within my team?”
Goal: You become aware that moral dis-

tress is present.
ACT AFFIRM
Prepare to Act Affirm your distress and
Prepare personally and profes- your commitment to take
sionally to take action. Creation care of yourself.
of a healthy
Take Action Validate feelings and percep-
environment
Implement strategies to initiate where critical tions with others.
the changes you desire. care nurses make
their optimal Affirm professional obligation
Maintain Desired Change to act.
contributions
Anticipate and manage setbacks. to patients
Continue to implement the 4 A’s and Goal: You make a commitment
to resolve moral distress. families to address moral distress.
Goal: You preserve your

integrity and authenticity.
ASSESS
Identify the sources of your distress.
• Personal
• Environment
Determine the severity of your distress.
Contemplate your readiness to act.
• You recognize there is an issue but may
be ambivalent about taking action to change it.
• You analyze risks and benefits.
Goal: You are ready to make an action plan.
FIGURE 5.3 The four A’s to rise above moral distress.

Source: American Association of Critical Care Nurses (AACN) from AACN Ethics Work Group. (2004). The 4 A’s to rise above moral distress. Aliso Viejo, CA: AACN.
and can use values cited in the CNA Code of Ethics (2008) may be unable to resolve the dilemma and may continue
to develop an argument for approaching the problem to experience moral distress. Thus, the importance of
from a nursing ethics perspective. Nurses need to be pre- values clarification again becomes evident. Discussion
pared to explore, with the physician, patient, and family, with patients and other health care providers about dif-
why they each believe that a particular pathway should ferences in values can help ease the tension that such
be followed and come to a common understanding that situations produce (CNA, 2008).
is acceptable to all. Sometimes, agreement is not pos- The increasing cultural diversity evident both in
sible. See Box 5.7 for additional discussion. The question patients and their families and in the nursing popula-
that must be asked in every instance is this: Whose needs tion in Canada can create ethically charged situations.
are being met? If the nurses place priority on their own Differences in values, lifestyle, and background demand
values above those of the patients (which may be con- ongoing dialogue to achieve common understandings
trary to the CNA Code of Ethics for Registered Nurses), they about issues with ethical implications.
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BOX 5.7 VARIATIONS IN APPLYING MORAL PRINCIPLES

Although a moral principle may exist and be valued in different cultures, the degree to which it is valued and the manner in which
it is used in health care may be quite variable. Nurses must become familiar with how moral principles are viewed within the cul-
tural groups in which they practise. Without stereotyping any individuals, nurses need to be aware of possible cultural variations,
and to explore them with their patients (Good & Hannah, 2015).
Principle Examples of Ethnic and Cultural Variations

Autonomy Family members, rather than the patient, receive information on the patient’s condition and take
primary responsibility for decision making. The family and community are viewed as affected by
the patient’s condition and decisions as much as the individual is affected: Chinese, Koreans,
Mexican Americans.
Veracity The preference is that the patient not be told directly of a life-threatening condition: Hispanics,
Asians, Pakistanis, Italian Americans, Canadian Aboriginals.
Nonmaleficence Discussion of advance directives and such issues as cardiopulmonary resuscitation may be
viewed as physically and emotionally harmful to the patient: Filipino, Canadian Aboriginals,
Chinese.
Beneficence Health care providers should promote patient well-being and hope: Asian cultures, Canadian
Aboriginals, Russians.
Sources: From Ellerby, J. H., McKenzie, J., McKay, S., Gariepy, G. J., & Kaufert, J. M. (2000). Bioethics for clinicians: 18. Aboriginal cultures., Canadian Medical Association Journal,
163, 845–850; Searight, H. R., & Gafford, J. (2005). Cultural diversity at the end of life: Issues and guidelines for family physicians. American Family Physician, 71, 515–522.
Most of the issues just considered are centred on Nurses are expected to “advocate for persons in
acute care settings. It is important to recognize that their care if they believe that the health of those persons
nurses in other areas of practice also experience ethical is being compromised by factors beyond their control,
issues, although the problems may not be as obviously including the decision making of others” (CNA, 2008,
dramatic as the life-and-death concerns of acute care p. 11). Hubinette, Dobson, and Regehr (2015) argued
nurses (Oberle & Tenove, 2000). For example, nurses that advocacy has two components: (1) agency, in acting
in the community may experience difficulties in work- within the system to obtain services that a patient may
ing with individuals who have chosen to adopt at-risk not be able to access without support, and (2) activism,
lifestyles, such as illicit drug use or prostitution. A moral involving working for changes to the system to improve
dilemma may exist in terms of providing support to the the services available to meet patient needs, including the
person without appearing to condone or support the principles of accessibility, universality, and comprehen-
lifestyle. Honouring client autonomy and at the same siveness of services (CNA, 2008). Curtin (1979) defined
time trying to change the individuals’ behaviours may be advocacy as the moral art in nursing that evolves from
in conflict. Because nurse–client relationships are essen- shared vulnerability, past experiences, and humanity in
tial to practice in all settings, nurses who fail to attend to the nurse–client relationship. The overall goal of a client
the ethical dimensions of relationships will be unable to advocate is to protect clients’ rights.
provide effective care. An advocate is one who expresses and defends the
cause of another. Three primary elements constitute
advocacy by the nurse, according to Tschudin and Hunt
(1994). The first is that the nurse’s position is proactive,
Nursing and Advocacy rather than passive and subordinate. Second, the nurse
speaks up and acts on behalf of the patient. Finally,
Within the powerful institutional structure of the health some kind of difficulty or conflict exists that necessitates
care system, the patient or client may be relatively pow- the need for advocacy.
erless in his or her own care. The notion of advocacy Nurses are frequently placed in an advocacy role
in nursing is closely tied to empowering patients and when clients and families are unable, or unwilling, to
clients through the provision of information, support, speak up for themselves. Nurses must ensure that clients
and intervention (MacDonald, 2007). One definition of and families have the necessary information to enable
advocacy is “acting to the limit of professional ability to them to consider options and must support them when
provide for the client’s interests and needs as the patient they make decisions. Sometimes, the nurse must defend
defines them” (Dubler, 1992). Advocacy and patient the client’s or family’s views when others are trying to
autonomy are concepts that may be in conflict, but when convince them to make a different decision. This role
the patient cannot exercise autonomy, then advocacy is difficult as it may position health care team members
by the health care provider is needed (Cole, Wellard, & against one another. However, the nurse must be guided
Mummery, 2014). by the professional code, which places patient choice,
M05_KOZI2703_04_SE_C05.indd 79 02/03/17 9:47 AM

dignity, and well-being as the highest values. To be an

effective advocate involves the following: Enhancing Ethical Practice
• Recognizing that the rights and values of clients and It should be noted that decisions about a patient’s care
families must take precedence when they conflict with are not made by nurses alone. Although the nurse’s
those of health care providers input is important, in reality, several people are usually
• Being aware that conflicts may arise over issues that re- involved in making an ethical decision. Therefore, col-
quire consultation, confrontation, or negotiation laboration, communication, and compromise are impor-
• Using excellent communication techniques and assert- tant skills for health care professionals. When nurses do
ively presenting one’s position not have the autonomy to act on their moral or ethical
choices, compromise with the patient and other care
Advocacy may be required at the broader, systems team members becomes essential. Integrity-preserving
level as well. For example, the CNA Code of Ethics (2008) compromises are most likely to be produced by collab-
articulates a value of quality practice environments, orative decision making. The mnemonic device LEARN
that is, environments conducive to safe, competent, can remind nurses to work toward collaboration in ethi-
and ethical care (CNA, 2010a). Nurses may have to be cal decisions (Berlin & Fowkes, 1983):
involved in political action when underfunding threatens
the integrity of the health care system. It is a nurse’s moral Listen to others.
obligation to work to ensure that the best possible condi- Explain your perceptions.
tions exist for the clients’ health care needs to be met. This Acknowledge and discuss differences.
advocacy also extends to environmental sustainability in Recommend alternatives.
communities, as well as nationally and internationally
(Dunphy, 2014). Nurses are also obligated to advocate for Negotiate agreement.
social justice in health care services, recognizing that As should be evident from the preceding discussion,
disparities exist in levels of economic, social, health, and excellent ethical decision-making skills require consider-
well-being (Paquin, 2011). These disparities exist both able reflection and practice. Davis et al. (2009), Rodney
within Canada and between Canada and other countries, and Starzomski (1993), and Monteverde (2014) described
most commonly developing countries (CNA, 2010b). a number of strategies to help nurses overcome possible
Advocacy is an important role for nurses. organizational and social constraints that may hinder the
Nonetheless, nurses must be careful not to suggest (or ethical practice of nursing:
believe) that they are the only advocates for the client.
The term advocacy is potentially divisive; that is, it could • Become aware of your own values and the ethical
cause conflict in itself because it suggests that the client aspects of nursing.
needs to be protected. Not all clients feel the need for • Be familiar with the code of ethics that is to guide your
protection, and the nurse must honour their right to practice.
self-determination. Physicians, too, consider themselves • Learn about and respect the values, opinions, and respon-
to be patient advocates, as do many other professionals, sibilities of other health care professionals.
such as social workers and physiotherapists. The nurse • Discuss ethically challenging situations with colleagues.
has a moral obligation to the patient but also an obliga-
tion to keep the health care team functioning cohesively. • Participate in or establish ethics rounds. Ethics rounds,
Therefore, the nurse must be sensitive to the implications using hypothetical or real cases, incorporate the tradi-
of such terms as advocacy and use them carefully. The tional teaching approach for clinical rounds but focus on
basic values in client advocacy are shown in Box 5.8. the ethical dimensions of client care, rather than clinical
diagnosis and treatment.
• Serve on institutional ethics committees.
BOX 5.8 BASIC VALUES IN PATIENT ADVOCACY In addition, the researchers stressed the impor-
The basic values in patient advocacy are the following: tance of striving for collaborative practice in which
• The patient is a holistic, autonomous being who has the nurses function effectively in cooperation with patients
right to make choices and decisions. and health care professionals. Ethical practice does not
• Patients have the right to expect a nurse–patient relation- just happen—it takes a great deal of work. Every nurse
ship that is based on shared respect, trust, collaboration has an obligation to understand the ethical foundations
in solving health-related problems, and consideration of of practice and to make a conscious effort to examine
their thoughts and feelings.
and reflect on the ethical dimensions of each caregiv-
• It is the nurse’s responsibility to ensure the client has
ing encounter. It is only with an understanding of the
access to health care services that meet health needs.
ethical components of a situation that nurses can meet
• All health care professionals have an ethical obligation to
advocate for their patients.
their obligation to act in the best interests of their
clients.
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Case Study 5
At a Canadian acute care hospital, nurses expressed concern distress, they put pressure on the physician to have the DNR
with the plan of care for a 98-year-old Asian woman. She had order instituted and discontinue therapy. The
been in a nursing home for several years and had been bedrid- physician was reluctant. A consultation with
den because of severe arthritis. As a result, she had numerous the clinical ethics committee was called by
contractures, which made it difficult to position her, and her skin the unit manager.
had broken down in several areas. She was responding only to
painful stimuli, and the nurses observed indications of consid-
erable pain whenever she was moved. She had a pulmonary
infection and was receiving triple-antibiotic therapy. The antibiot- CRITICAL THINKING QUESTIONS
ics gave her severe diarrhea, which necessitated more frequent
moving and bathing. The antibiotics had not been effective, and 1. How can this situation be explored by applying ethical
the order was due for renewal. The nurses expressed the view principles?
that the antibiotics ought to be discontinued and that further 2. What are the goals of care? Are these goals shared by
aggressive care should be terminated. In their view, continuing the patient? the nurses? other health care professionals?
treatment was robbing the patient of the possibility of a dignified
3. How does a focus on relationships improve your ethical
death. Nurses wanted a DNR (do not resuscitate) order insti-
understanding of the situation?
tuted. The patient’s daughter adamantly disagreed, saying that
it was her obligation to see that her mother got every possible 4. How would everyone (client, family, caregivers, institu-
treatment. In their culture, she argued, it was a demonstration of tions, organization, society) be affected by the decision?
respect to try to preserve life at all costs. 5. What external conditions must be considered?
What could the nurses do? They wanted to respect the 6. What (and whose) values must be considered?
daughter’s wishes, but they believed that treatment was caus-
ing harm to the patient and that it was wrong to continue to 7. Discuss the features of this case that make the experience
use scarce resources trying to preserve life in this futile situ- of moral distress likely for the providers involved. What
ation. They felt constrained by the desire to respect cultural could be done to mitigate moral distress in this case?
differences but also felt strongly that the patient was being
harmed, even tortured, by nursing actions. Because of their Visit MyNursingLab for answers and explanations.
KEY TERM S
advocacy p. 79 fidelity p. 74 paternalism p. 74 relational ethics
attitudes p. 67 justice p. 74 personal values theories p. 74
autonomy (respect medical futility p. 67 relationship-based
for persons) p. 73 p. 77 principle of utility (caring) theories
beliefs p. 67 moral agents p. 76 p. 72 p. 72
beneficence p. 73 moral dilemmas principles-based social justice p. 80
code of ethics p. 72 p. 77 (deontological) theo- utilitarianism p. 72
consequence-based moral distress p. 77 ries p. 72 value set p. 67
(teleological) moral integrity professional value system p. 67
theories p. 72 p. 77 values p. 67 values p. 67
ethical obligations moral residue p. 77 quality practice environ- values clarification
p. 72 moral theories p. 72 ments p. 80 p. 68
ethics p. 72 nonmaleficence reflective practice veracity p. 74
ethics of care p. 74 p. 73 p. 76 virtue p. 74

• Values are enduring beliefs that give direction and mean- • The term ethics refers to the moral problems that arise in
ing to life and guide a person’s behaviour. nursing practice and to ethical decisions that nurses make.
• Values clarification is a process in which people identify, • Morality refers to what is right and wrong in conduct,
examine, and develop their own values. character, or attitude.
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• Moral issues are those that arouse conscience, are con- best interests of the client; reaching the agreement may
cerned with important values and norms, and evoke such require compromise.
words as good, bad, right, wrong, should, and ought. • Reflective practice refers to the ability to take informa-
• Three common moral frameworks (approaches) are tion about experience, knowledge, or skills levels based on
consequence-based (teleological), principles-based (deon- assessments (by the nurse herself or by others), analyze
tological), and relationship-based (caring) theories. this information, and determine how to act on this infor-
• Moral principles (e.g., autonomy, beneficence, nonma- mation in the future.
leficence, justice, fidelity, and veracity) are broad, general • Nurses are responsible for determining their own
philosophical concepts that can be used to make and actions and for supporting clients who are making
explain moral choices. moral decisions or for whom decisions are being made
• A professional code of ethics is a formal statement of a by others.
group’s ideals and values that serves as a standard and • Nurses can enhance their ethical practice and client
guideline for the group’s professional actions and informs advocacy by clarifying their own values, understanding
the public of its commitment. the values of other health care professionals, becoming
• Moral distress occurs when the individual knows the ethi- familiar with nursing codes of ethics, and participating in
cally correct action to take but is unable to take the action ethics committees and rounds.
because of internal or external barriers. • Client advocacy involves concern for and actions on
• Nurses’ ethical decisions are influenced by their moral behalf of another person or organization to bring about
theories and principles, personal and professional values, change.
and nursing codes of ethics. • The functions of the advocacy role are to inform, sup-
• The goal of ethical reasoning, in the context of nursing, port, and mediate.
is to reach a mutual, peaceful agreement that is in the

1. When an ethical issue arises, what is one of the most decision. Which moral principle provides the basis for
important nursing responsibilities in managing client- the nurse’s actions?
care situations? a. Respect for autonomy
a. Being able to defend the morality of one’s own b. Nonmaleficence
actions
c. Beneficence
b. Remaining neutral and detached when making
ethical decisions d. Justice
c. Ensuring that a team is responsible for deciding 4. Which statement by the nurse would be most helpful in
ethical questions assisting clients in clarifying their values?
d. Following the client’s and family’s wishes exactly a. “That was not a good decision. Why did you think it
would work?”
2. Which situation is most clearly a violation of the under-
lying principles associated with professional nursing b. “The most important thing is to follow the plan of
ethics? care. Did you follow all your doctor’s orders?”
a. The hospital policy permits use of internal fetal c. “Some people might have made a different decision.
monitoring during labour. However, literature both What led you to make your decision?”
supports and refutes the value of this practice. d. “If you had asked me, I would have given you my
b. When asked about the purpose of a medication, a opinion about what to do. Now, how do you feel
nurse colleague responds, “Oh, I never look them about your choice?”
up. I just give what is prescribed.”
5. After recovering from her hip replacement, an older cli-
c. The nurses on the unit agree to sponsor a fundraising ent wants to go home. The family wants the client to go
event to support a labour strike proposed by fellow to a nursing home. If the nurse were acting as a client
nurses at another facility. advocate, what should the nurse do?
d. A client reports that he did not quite tell the doctor a. Inform the family that the client has a right to decide
the truth when asked if he was following his thera- on her own
peutic diet at home.
b. Ask the primary care provider to discharge the client
3. Following a motor vehicle collision, the parents refuse to to her home
permit withdrawal of life support from their child, who c. Suggest the client hire a lawyer to protect her rights
has no apparent brain function. Although the nurse d. Help the client and the family communicate their
believes the child should be allowed to die and organ views to each other
donation considered, the nurse supports the parents’
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6. Mr. Goldman, 78 years old, was admitted with con- to tell her mother that the nurse does not know why she is
gestive heart failure. His wife tells the nurse that she in the hospital if her mother asks. In this situation, what
is afraid her husband’s condition is deteriorating, and ethical principle is the nurse being asked to disobey?
despite several requests, the physician has not been in to a. Beneficence
see him. Which of the following is the most appropriate
nursing action? b. Nonmaleficence
a. Assess Mr. Goldman and inform the couple that the c. Veracity
physician will be contacted to convey their concerns d. Fidelity
b. Explain to Mrs. Goldman that she may speak with
the physician later during rounds 9. A nurse is experiencing moral distress over the inad-
equate pain relief provided to a client. What statement
c. Reassure Mrs. Goldman that her husband is receiv-
by the nurse best illustrates the third stage in the 4 A’s
ing appropriate care
moral distress framework?
d. Inform Mrs. Goldman that the nurse-in charge will
a. “On a scale of 0 to 5, my level of distress is a 4.”
be notified of her concerns
b. “Am I showing signs of suffering?”
7. Which is an example of a nurse engaging in reflective c. “I will make an appointment with the unit
practice? manager.”
a. Contributing to decision making about a client d. “I have a professional responsibility to act.”
within an interprofessional team
b. Asking for feedback and engaging in discussion with 10. Which activity reflects the nurse’s role as advocate?
a colleague about the nurse’s own performance. a. Conducting a research study into the benefits of
c. Giving advice to a student nurse regarding his per- exercise
formance b. Notifying the supervisor about a client’s adverse drug
d. Documenting care the nurse gave to a client in the reaction
client’s record c. Teaching clients how to care for themselves after
surgery
8. A daughter does not want her mother to learn of the
d. Assessing changes in blood pressure
mother’s diagnosis of advanced cancer. She asks the nurse
REFERENCES
Armstrong, A. E. (2006). Towards a strong virtue ethics for nursing Curtin, L. L. (1979). The nurse as advocate: A philosophical foun-
practice. Nursing Philosophy 7, 110–124. dation for nursing. Advances in Nursing Science, 1(3), 1–10.
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical eth- Davis, A., Fowler, M., & Aroskar, M. (2009). Ethical dilemmas and nurs-
ics (6th ed.). New York, NY: Oxford University Press. ing practice (5th ed.). Toronto, ON: Pearson Education.
Berlin, E. O., & Fowkes, W. C. (1983). A teaching framework for Dubler, N. (1992). Individual advocacy as a governing principle.
cross-cultural health care: Application in family practice. The Journal of Case Management, 1(3), 82–86.
Western Journal of Medicine, 139(6), 934–938. Dunphy, J. L. (2014). Healthcare professionals’ perspectives on envi-
Bowden, P. L. (1995). The ethics of nursing care and “the ethic of ronmental sustainability. Nursing Ethics, 21(4), 414–425.
care.” Nursing Inquiry, 2(1), 10–21. Gastmans, C. (2006). The care perspective in healthcare ethics. In
Breslin, J. M., MacRae, S. K., Bell, J., & Singer, P. A. (2005). Top A. J. Davis, V. Tschudin, & L. Raeve (Eds.), Essentials of teaching and
10 health care ethics challenges facing the public: Views of learning in nursing ethics: Perspectives and methods (pp. 76–89). Toronto,
Toronto bioethicists. BMC Medical Ethics, 6, 5. ON: Churchill Livingstone.
Butts, J. B., & Rich, K. (2005) Nursing ethics: Across the curriculum and Good, M-J. D., & Hannah, S. D. (2015). “Shattering culture”:
into practice. Sudbury, MA: Jones & Bartlett Learning. Perspectives on cultural competence and evidence-based
Canadian Nurses Association. (2008). Code of ethics for registered nurses. practice in mental health services. Transcultural Psychiatry, 52(2),
Ottawa, ON: Author. Retrieved from http://www.cna-aiic.ca/en/ 198–221.
on-the-issues/best-nursing/nursing-ethics. Hubinette, M., Dobson, S., & Regehr, G. (2015). Not just “for”
Canadian Nurses Association. (2010a). Ethics, relationships and but “with”: Health advocacy as a partnership process. Medical
quality practice environments. Retrieved from http://cna-aiic.ca/ Education, 49, 796–804.
en/on-the-issues/best-nursing/nursing-ethics/ethics-in-practice. International Council of Nurses. (2006). Code of ethics for nurses.
Canadian Nurses Association. (2010b). Social justice … a means to an Geneva, Switzerland: Imprimerie Fornara.
end, an end in itself (2nd ed.). Ottawa, ON: Author. Retrieved from Jameton, A. (1992). Nursing ethics and the moral situation of the
http://www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing- nurse. In E. Friedman (Ed.), Choices and conflict (pp. 101–109).
ethics/ethics-reading-resources. Chicago, IL: American Hospital Association.
Cole, C., Wellard, S., & Mummery, J. (2014). Problematising auton- MacDonald, H. (2007). Relational ethics and advocacy in nursing:
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College of Nurses of Ontario. (2012). Ethics. Retrieved from Marck, P. (2000). Nursing in a technological world: Searching for
http://www.cno.org/learn-about-standards-guidelines/educa- healing communities. Advances in Nursing Science, 23, 63–81.
tional-tools/learning-modules/ethics/.
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McCue, C. (2010). Using the American Association of Critical Care Rodney, P., & Starzomski, R. (1993). Constraints on the moral
Nurses framework to alleviate moral distress. OJIN: The Online agency of nurses. Canadian Nurse, 89(10), 23–26.
Journal of Issues in Nursing, 16(1), 9. Rodney, P., & Varcoe, C. (2001). Towards ethical inquiry in the eco-
Monteverde, S. (2014). Caring for tomorrow’s workforce: nomic evaluation of nursing practice. Canadian Journal of Nursing
Moral resilience and healthcare ethics education. Nursing Ethics, Research, 33(1), 35–57.
21(4), 1–11. Shield, R. R., Wetle, T., Teno, J., Miller, S. C., & Welch, L. C.
Oberle, K., & Hughes, D. (2001). Doctors’ and nurses’ perceptions (2010). Vigilant at the end of life: Family advocacy in the nursing
of ethical problems in end-of-life decisions. Journal of Advanced home. Journal of Palliative Medicine, 13(5), 573–579.
Nursing, 33, 707–715. Schon, D. A. (1983). The reflective practitioner. New York, NY: Basic
Oberle, K., & Tenove, S. (2000). Ethical issues in public health nurs- Books.
ing. Nursing Ethics, 7, 425–438. Toren, O., & Wagner, N. (2010). Applying an ethical decision-
Paquin, S. O. (2011). Social justice advocacy in nursing: What is it? making tool for a nurse management dilemma. Nursing Ethics, 17,
How do we get there? Creative Nursing, 17(2), 63–67. 393–402.
Redman, B. K., & Fry, S. (2000). Nurses’ ethical conflicts: What is Tschudin, V., & Hunt, G. (1994). Dissatisfaction: With professional
really known about them? Nursing Ethics, 7, 360–366. relationships, with the status quo and with health care in general.
Registered Nurses’ Association of Ontario (RNAO). (2007). Nursing Ethics: An International Journal for Health Care Professionals, 1(2),
Professionalism in patient care. Toronto, ON: Author. 69–70.
Registered Nurses’ Association of Ontario (RNAO). (2015). Person
and family-centred care. Toronto, ON: Author.
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Chapter 6
Accountability and Legal
Aspects of Nursing
Updated by
Karen Eisler, RN, BScN, MScN, PhD (SRNA)
Executive Director, Saskatchewan Registered Nurses Association
N
LEARNING OUTCOMES
After studying this chapter, you will be able to ursing practice is gov-
1. Describe the history and sources of Canadian law. erned by many legal
concepts. It is important
2. Identify regulatory considerations in nursing and their impact on
the practice of nursing in Canada. for nurses to know the basics of the
Canadian legal system and its rela-
3. Identify selected aspects of professional regulation and their role in
governing the practice of nursing, including expanding the scope tionship to the profession of nursing.
of nursing practice. Accountability is an essential con-
4. Discuss measures of accountability and discipline in nursing cept of professional nursing practice
practice. and the law. Knowledge of laws that
5. Identify the two interdependent legal roles of provider of service regulate and affect nursing practice
and employer or contractor for service in nursing. is needed for the following reasons:
6. Discuss areas of potential tort liability in nursing. • To ensure that the nurse’s deci-
7. Discuss informed consent, confidentiality, problematic substance sions and actions are consistent
use, and chemical dependency. with current legal principles
8. Discuss legal issues and safe practices in documentation, •

To protect the nurse from liability
telephone advice, incident reports, and reports of unsafe practices.
•
To protect the public
9. Identify ways nurses and nursing students can minimize their
chances of liability.
10. Discuss legal protection of nurses in practice.
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Relationship between THE CIVIL LAW TRADITION The tradition of civil law,
with its Roman roots, is quite different. A key distin-
Nurses and the Law guishing feature is that instead of emerging through the
courts, laws are written down in what is referred to as
a code. This code provides all citizens with an accessible
Law can be defined as “the sum total of rules and
and written collection of the laws that apply to them
regulations by which a society is governed. As such, law
and that judges must follow. Quebec’s Civil Code, first
is created by people and exists to regulate all persons”
enacted in 1866 just before Confederation, underwent a
(Guido, 2014, p. 2).
major revision in 1994 and is amended periodically. Like
other civil codes, it contains a comprehensive statement
of rules and general principles. Unlike common law
Functions of the Law in Nursing courts, courts in a civil law system first look to the code
The law serves a number of functions in nursing: and then refer to previous decisions for consistency.
• It provides a framework for establishing the legality of STATUTORY LAW The distinction between the com-
nursing actions in the care of clients. mon and civil law traditions reveals two different sources
• It outlines the responsibilities that govern nursing of legal authority: (a) case law or judge-made law and
practice and nurses’ relationships with physicians, (b) the Civil Code. Parliament and the provincial or ter-
other health care practitioners, and the health care ritorial legislatures are another key source of Canadian
system. law. Parliament has the power to pass laws for all of
• It helps establish the boundaries of independent nursing Canada, whereas the legislatures of each province and
action. territory pass laws of a more local nature. Laws enacted
by either of these legislative bodies are called statutes,
• It assists nurses in ensuring that they are consistent, com-
legislation, or acts. When Parliament or one of the legis-
petent, and safe in providing quality care that serves soci-
latures enacts legislation, that legislation then supersedes
ety while preserving individual rights and human dignity.
any case law dealing with the same subject. In Quebec,
much legislation exists to cover areas not dealt with in
the Civil Code.
History and Source of Canada’s Laws Responsibility for the Canadian health care system is
Historically, Canadian law is derived from two distinct shared between the federal government and the provincial
European systems, namely, English common law and or territorial governments, according to the division of pow-
French civil law. Quebec follows the civil law system, ers set out in the Constitution Act, 1867. However, despite
whereas the other Canadian provinces and territories the federal government having some jurisdiction in this area,
follow the common law legal tradition. health care delivery is interpreted as being largely within
provincial and territorial authority. For example, regulation
THE COMMON LAW TRADITION In the English com-
of health care professionals is a responsibility of the prov-
mon law tradition, legal principles and rules evolve
inces and territories and is one, as will be discussed here, that
through the courts. Judges interpret and apply principles
has been delegated, in many instances, by the provincial and
from similar decisions in previous cases (precedents) to
territorial governments to provincial and territorial profes-
the particular case before them to reach a decision. For
sional organizations.
this reason, common law is sometimes called case law or
The Canada Health Act was passed in 1984. “The
judge-made law. In reality, no two cases are identical, and
Canada Health Act is federal legislation that puts in place
common law develops through judges making distinc-
conditions by which individual provinces and territories
tions between cases and determining whether an earlier
in Canada may receive funding for health care services.
case is applicable to the case being considered. In this
There are five main principles in the Canada Health Act
way, common law at once provides some consistency and
(Canadian Health Care, 2016):
predictability.
The hierarchy within the courts has important • Public Administration: All administration of pro-
implications for the development of common law. Each vincial health insurance must be carried out by a
province and territory has a lower-level trial court and a public authority on a nonprofit basis. They also must
higher-level appeal court. The decisions of higher courts be accountable to the province or territory, and their
are binding on the lower courts in the same jurisdiction. records and accounts are subject to audits.
Decisions in one jurisdiction, province, or territory are
• Comprehensiveness: All necessary health services,
not binding in another jurisdiction, province, or terri-
including hospitals, physicians, and surgical dentists,
tory, but such decisions are often treated as a persuasive
must be insured.
source of law. In contrast, a decision from the Supreme
Court of Canada is binding on all other courts in the • Universality: All insured residents are entitled to the
country (Keatings & Smith, 2010). same level of health care.
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Chapter 6 Accountability and Legal Aspects of Nursing 87
• Portability: A resident who moves to a different an exclusivity of practice (a right of self-government or

province or territory is still entitled to coverage from self-regulation) and an obligation to monitor and discipline
his or her home province during a minimum waiting their own membership. The provincial and territorial nurs-
period. This also applies to residents who leave the ing regulatory bodies, such as the College of Registered
country. Nurses of British Columbia (CRNBC), the College and
• Accessibility: All insured persons have reasonable Association of Registered Nurses of Alberta (CARNA),
access to health care facilities. In addition, all physicians, the Saskatchewan Registered Nurses’ Association (SRNA),
hospitals, and others must be given reasonable compen- or the College of Nurses of Ontario (CNO), are given
sation for the services they provide. their authority by the provincial and territorial govern-
ments through legislation. Through such legislation and
Tort law refers to that body of the law through the associated regulations, these bodies are charged with
which a person who suffers injury caused by another regulating entry into the profession, approving entry-level
person is able to claim compensation for that injury. Tort nursing education programs, setting standards of compe-
law is divided into two main categories: (a) intentional tent practice, establishing continuing competence or edu-
torts and (b) negligence. When a person proves that he or cation and quality assurance improvement programs, and
she has suffered harm caused by another, either through drafting bylaws for the general and day-to-day governance
intentional action or through negligence, that person will of the profession.
have a claim for damages (compensation) against the person All entry-level nursing education programs must
who caused the harm (called the tortfeasor). The goal of receive approval from their regulatory body for their
compensation in tort law is to put the person who suf- graduates to be able to write the registration examina-
fered the harm back in the position he or she would have tion and apply for registration. Approval is based on the
been in had the tortfeasor not acted. This is a guiding nursing education programs meeting the standards and
principle and is clearly more feasible in some cases than competencies set by the regulatory bodies and is granted
in others. Negligence and those intentional torts most by the regulatory body. Approval of educational pro-
applicable to the nursing context are discussed in greater grams is mandatory.
detail later in this chapter. See Table 6.1 for examples of Accreditation, a standard for excellence for bac-
laws that affect nurses and nursing practice and page 90 calaureate programs, is assessed and awarded by the
for further discussion of tort law. Canadian Association of Schools of Nursing (CASN).
Accreditation is a voluntary and nonmandatory require-
ment. See Chapter 2 for additional information.
Regulatory Considerations in Nursing The laws regulating nursing in the provinces and
territories (other than Ontario and Quebec) are fairly
PROVINCIAL AND TERRITORIAL REGULATORY BODIES
uniform. Several provinces have umbrella legislation
In Canada, the regulation of nursing is a function of containing general provisions regarding all recognized
provincial and territorial law. Nurses have been granted health care professionals within the province, as well as
companion legislation relating specifically to nursing (see
examples of the legislation for each province and terri-
TABLE 6.1 Selected Categories of Laws Affecting Nurses tory listed in Table 6.2). For instance, in Ontario, the
Regulated Health Professions Act and the Nursing Act
Category Examples govern the nursing profession (Keatings & Smith, 2009).
Licensure and registration together are a way to
Constitutional Due process, equality protection
protect the public from unsafe practitioners and to assure
Statutory Nursing legislation; Good Samaritan/Emer-
employers that the nurse has met minimum require-
(legislative) gency Medical Aid acts; child protection
legislation; vulnerable persons legislation,
ments for entry to practice. The term registration
such as Protection for Persons in Care acts; means that an individual’s name is listed on an official
laws regarding advance directives or power roster. In Canada, practising nurses in all provinces and
of attorney for personal care; laws regarding territories are required by law to be registered or to hold
privacy and protection of health information; a valid permit or licence with their provincial or ter-
human rights acts ritorial nursing association. Registration usually occurs
Criminal Murder, manslaughter, theft, assault, active every year. Only those who are registered are entitled
(public) euthanasia, illegal possession of controlled to call themselves registered nurses, licensed (registered)
drug or substance practical nurses, or registered psychiatric nurses, or to
Contracts Nurse and client, nurse and employer, nurse use the initials RN, LPN/RPN, or RPN. To be regis-
(private or and insurance, client and agency, employer tered, the regulated nurse must have completed a basic
civil) and union (collective agreement)
course of nursing studies in an approved program of the
Torts (private Negligence, defamation, invasion of privacy, registering body and have passed the national qualifying
or civil) assault and battery, false imprisonment
examinations.
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TABLE 6.2 Nursing Legislation in Canadian Provinces and Territories
Province or Territory Health Care and Nursing Legislation for Registered Nurses (RNs)
British Columbia Health Professions Act and Nurses and Nurse Practitioners Regulations
Alberta Health Professions Act and Registered Nurses Profession Regulation
Northwest Territories and Nunavut Nursing Profession Act and Nunavut Nursing Professions Act
Saskatchewan The Registered Nurses Act
Manitoba Regulated Health Professions Act – pending
New Brunswick Nurses Act
Nova Scotia Registered Nurses Act
Prince Edward Island Registered Nurses Act
Newfoundland and Labrador Registered Nurses Act
Ontario Regulated Health Professions Act, Nursing Act, and Health Professions Procedural Code
Quebec Professional Code of Quebec
Yukon Registered Nurses Profession Act
Province or Territory Health Care and Nursing Legislation for Licensed Practical Nurses (LPNs)
British Columbia Health Professions Act and Nurses (Registered) and Nurse Practitioners Regulation
Alberta Health Professions Act and Licensed Practical Nurses Act
Northwest Territories and Nunavut Licensed Practical Nurses Act
Saskatchewan Licensed Practical Nurses Act
New Brunswick Licensed Practical Nurses Act
Nova Scotia Licensed Practical Nurses Act
Prince Edward Island Licensed Practical Nurses Act
Newfoundland and Labrador Licensed Practical Nurses Act
Ontario (Registered Practical Nurse) Regulated Health Professions Act, Nursing Act, and Health Professions Procedural Code
Quebec Professional Code of Quebec
Province or Territory Health Care and Nursing Legislation for Registered Psychiatric Nurses
British Columbia Health Professions Act and Nurses Regulation
Albert Health Professions Act
Saskatchewan Registered Psychiatric Nurses Act
Source: Updated and adapted from Keatings, M., & Smith, O. (2010). Ethical and legal issues in Canadian nursing (3rd ed.). Toronto, ON: Mosby Elsevier.
The Agreement on Internal Trade (AIT) came into continued competence encouraged by provincial and
effect in 2009. It reads as follows: territorial quality assurance programs. The Canadian
Nurses Association (CNA) offers certification in many
AIT promotes harmonization of standards across provinces areas.
such that a qualified practitioner in one province would
ultimately be able to move to another province and practice EXPANDING THE ROLE OF REGISTERED NURSES The
without going through an entirely new application/ various acts and regulations that govern the practice of
examination/supervision process. (King, 2011, p. 4) nursing in Canada are responsible for setting the scope
and nature of nursing. Recently, the development of
Certification is a voluntary practice that proves policy and legislation to expand the scope of RNs’ prac-
that a nurse has met the minimum standards of nursing tice has become a prominent issue across the country.
competence in specialty areas, such as perinatal nurs- Diverse models have been used to provide authority to
ing, pediatrics, mental health, gerontology, or critical RNs performing extended or expanded roles. Diagnostic
care nursing. Certification enhances a nurse’s confidence and treatment functions have been delegated by govern-
and proficiency in a specialty area. Certification is a ment to the medical profession through legislation (CNA,
commitment to the leading edge in national health care 2007a). In 2008, the CNA published Advanced Nursing
standards. It gives national scope to the principle of Practice: A National Framework, which includes information
M06_KOZI2703_04_SE_C06.indd 88 02/03/17 1:13 PM

about various aspects of advanced nursing practice determine the process to follow. The disciplinary role is
(ANP), such as competencies, educational preparation, central to the regulatory body’s duty to protect the pub-
and regulation (CNA, 2008a). lic, is taken very seriously, and can have significant con-
sequences for the registrant. When a case involves either
STANDARDS The establishment of nursing professional
civil or criminal wrongs, further legal consequences may
and practice standards is essential for a self-regulating
follow, separate and apart from the provincial and ter-
profession. In assessing the quality of care provided by
ritorial regulatory body discipline process.
nurses, it is crucial to have objective criteria by which
one can judge whether the care given is good, adequate,
or unsafe. Nursing professional standards are generally
broad in nature to capture the varied roles and practice
settings in which nurses practise. Each regulatory body
Contractual Arrangements
will have a document regarding standards of practice
for their members. Standards are also used as a template
in Nursing
for nurses to assess their own nursing practice annually
to determine their professional development goals and Legal Roles of Nurses
meet continuing competence requirements set out by the
provincial or territorial body. It is the responsibility of Nurses have two separate but interdependent legal roles,
all regulated members to understand their practice stan- each with rights and associated responsibilities: (a) pro-
dards and apply them to their nursing practices, specific vider of service and (b) employee or contractor for
to their areas of practice and roles. service.
Best-practice guidelines may also provide a good PROVIDER OF SERVICE The nurse is expected to pro-
indication of what a court may recognize as nursing vide safe and competent care so that no harm (physi-
practice standards. For example, the Registered Nurses’ cal, psychological, or material) comes to the recipient
Association of Ontario (RNAO) has produced a variety of the service. A nurse, for example, has an obligation
of documents that explain nursing practices that are to practise and direct the practice of others under the
research based, such as Therapeutic Nurse–Client Relationship, nurse’s supervision so that harm or injury to the client is
Culturally Sensitive Care, and Documentation (http://rnao.ca). prevented and standards of care are maintained. When
delegating care or assigning duties to others, the
nurse is responsible for ensuring that this delegation or
Accountability and Discipline in Nursing assignment is appropriate and that those delegated to
(e.g., family, other health care members, students) have
In addition to the elements just outlined, the nursing reg- the skills to fulfill the functions (CNA & CFNU, 2015).
ulatory bodies are also responsible for ensuring that stan- Nurses are obligated to follow physicians’ orders, unless
dards are established and maintained. This task includes they believe that these orders have the potential to harm
investigating complaints regarding the level of practice or injure the patient. The nurse must then carefully
or other competency issues of individual registrants and, assess the situation and obtain clarification from the
where appropriate, addressing them through consensual physician, if necessary. If the physician confirms the
resolution processes, or if required, disciplinary action. order and the nurse still believes the order to be unsafe,
informing the supervisor is the next responsibility. The
COMPLAINT PROCESS Each provincial and territorial
nurse also needs to carefully document, in chronological
nursing regulatory body has a mechanism in place to
order, the steps taken. At this point, resolving the prob-
review the conduct of its members to ensure safe and
lem of the questionable order should be the supervisor’s
ethical nursing practice. They are required to investigate
responsibility. It is imperative that a nurse speak out and
complaints against members and discipline those who
investigate orders that are believed to be unsafe, as the
fail to meet the standards of the profession. The regula-
nurse who carries out the order could be held legally
tory body may receive complaints about regulated nurses
responsible for any harm suffered by the patient.
from a variety of sources, including the public, hospitals
The standards of care by which a nurse acts or
or other employers, and other nurses or health care
fails to act are legally defined by nurse practice acts and
providers. Occasionally, nurses may decide to self-report
by the rule of reasonable and prudent action—what a
if they are concerned that they are not able to practise
sensible and careful professional with similar preparation
safely. The complaint process comprises a number of
and experience would do in similar circumstances.
steps, including the complaint intake or receipt and
initial assessment, the investigation process, the review EMPLOYEE OR CONTRACTOR FOR SERVICE Nurses,
process, the consensual resolution and possibly a hear- whether in independent practice or as employees, have
ing and an appeal. Variations exist across jurisdictions, employment contracts. A contract is an agreement
and so do many similarities. Nurses are encouraged to between two or more persons and creates an obligation
check with their provincial or territorial association to to do or not do a particular thing (Black’s Law Dictionary,
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2004). For a contract to exist (Fraser & Parisi, 2006), the liability. This legal doctrine provides that an employer,
following conditions must be met: whether an individual or an institution, is held liable
for the negligence of its employees to an individual
• Each contract must have a lawful purpose.
harmed by this negligence. This is in recognition of the
• Each party entering the contract must be competent control an employer has in the workplace and to ensure
and understand the subject matter. a remedy for successful plaintiffs. An employment rela-
• Each party must understand the obligations of the tionship must have existed at the time of the incident,
contract. and the defendant employee must have been sued for
• Each party must have obligations and benefits derived work done within the scope of his or her employment.
from the contract. Consequently, it is very common for the employer’s
liability insurance to cover the legal defence costs (legal
• At minimum, all employment contracts must meet the
fees, related disbursements, and damages) of nurses who
standards set forth in provincial, territorial, and federal
are sued in connection with the work they are employed
labour standards and codes.
to do (CNPS, 2016). The doctrine of vicarious liability
Employment contracts can be oral, written, or does not imply that the nurse cannot be held liable as
implied. If a union is not involved, the nurse and the an individual. Employees should verify whether they are
employer can negotiate an individual employment con- covered by their employer or their employer’s insurance
tract that sets forth the rights and obligations of each in the event of claims arising out of their employment.
party. A nurse who is employed directly by a client (a An employer generally cannot be held liable under the
nurse in private practice) usually has a written contract doctrine of vicarious liability for conduct falling outside
with that client, and under this contract, the nurse agrees the scope of employment. Conduct that takes place at
to provide professional services for a certain fee, and as work but cannot be reasonably considered to be part of
such, has contractual obligations. In a unionized the scope of employment or enabled by the employer,
organization, the terms and conditions of employment such as theft of narcotics or assault, may not give rise to
are those of the union contract with the employer. Verbal vicarious liability on the part of the employer.
employment contracts can be problematic because they The doctrine of vicarious liability does not gener-
lack proof of the terms negotiated. ally apply to nurses who are independent contractors or
Contractual relationships vary among practice self-employed. Independent contractors must decide on
settings. The nurse employed by a hospital typically the type and amount of liability protection they require,
functions within an employer–employee relationship, in which will respond to the types of liability they may
which the hospital is responsible for the workplace, and incur. Seeking advice from a business adviser is recom-
the nurse provides nursing care on behalf of the hos- mended (CNPS 2006). See Box 6.1 for information on
pital. As an employee, a nurse must abide by the legal protection for nurses.
employer’s policies. A nurse in independent practice The nurse is expected to respect the rights and
is a contractor for service, whose contractual relation- responsibilities of other health care participants. For
ship with the client is an independent one. No matter example, although the nurse has a responsibility to
what the practice setting, the parties involved should explain nursing activities to a patient, the nurse does not
have a common understanding of the nurse’s status as have the right to comment on medical practice in a way
employee or independent contractor. It will have an that disturbs the client or denounces the physician. The
impact on their daily working relationship and will be same applies to other health care professionals. At the
relevant should the nurse be the subject of an allegation same time, the nurse has the right to expect reasonable
of negligence. and prudent conduct from other health care profession-
If a nurse is found negligent, a court may order als. See Table 6.3 for examples of the roles, responsibili-
that nurse to pay damages to the plaintiff. This form ties, and rights of nurses.
of liability is called direct liability. The Canadian Nurses
Protective Society (CNPS) professional liability protec-
tion is designed to assist nurses with this kind of damage
award. A health care facility may also be found negligent Areas of Potential Tort
and held directly liable for breaching duties it owed to
the patient. These could include, for example, the duty Liability in Nursing
to select professional staff using reasonable care, adopt
and enforce appropriate policies and procedures, provide
reasonable supervision of staff, and provide adequate
Tort Law
staffing, equipment, or resources. A tort is a civil wrong committed against a person or a
If a nurse working as an employee is found neg- person’s property. Battery and failure to obtain informed
ligent, the court is also very likely to find the nurse’s consent, discussed later in this chapter, are examples of
employer liable pursuant to the doctrine of vicarious torts. Torts are usually litigated in court by civil action
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BOX 6.1 LEGAL PROTECTION IN AN standard expected of an ordinary, reasonable, and pru-
EMPLOYEE–EMPLOYER RELATIONSHIP dent nurse (Canadian Nurses Protective Society, 2004a).
Such conduct places another person at risk for harm.
Nurses should be aware of the liability protection they have: Failing to obtain informed consent, failing to follow
• Nurses should confirm in advance with their employer(s) proper procedure in moving a patient, or administering
or professional associations that it (they) provide liability the wrong dosage of medication all constitute examples
protection for their employees, and if so, whether there are
any limits to the coverage provided in the event of litiga- of negligence in nursing. Four elements must be present
tion. If there are limits, obtain advice from a reliable source, in a negligence lawsuit against a nurse:
such as CNPS, regarding the implications of those limits.
• Nurses should ensure that the employer is notified imme- 1. Duty. The nurse must have a relationship with the cli-
diately if they are sued or if litigation is threatened in rela- ent that involves providing care. Such duty is evident
tion to an incident that happened at work. They should when the nurse has been assigned to care for a client in
also obtain written confirmation that the employer will the home, hospital, or community by virtue of employ-
provide legal representation and pay any damages relat-
ment. In contrast, a nurse in private practice may have
ing to the litigation.
the option of deciding whether to accept a patient for
• If the employer’s insurer defends the claim, nurses
should cooperate with the employer’s insurer and lawyer care; as such, the duty is established when the nurse
representing (defending) them. takes on an individual as a patient.
• Nurses who practise as independent practitioners, 2. Breach. A standard of care must be expected in the spe-
whether full-time, part-time, or as volunteers, should also cific situation, and it must be evident that the nurse did
have in place adequate professional liability protection. not enact that standard. This is the failure to act as a
This may already be available from the CNPS as a benefit
of licensure or registration with their regulator or associa- reasonable, prudent nurse under the circumstances.
tion. These nurses may also face other forms of liability The practice is measured against that of similar nurses,
risk and should inquire from a reliable source about their unless the nurse undertakes a practice outside the usual
needs for other forms liability protection (such as general nursing role. In such an instance, the nurse may be
commercial liability insurance, business insurance, etc.) held to a higher standard based on advanced training.
The standard can come from documents published by
Source: Based on Canadian Nurses Protective Society. (1998). Vicarious liability.
infoLAW, 7(1), as amended, February 2016.
national or professional organizations, provincial or ter-
ritorial nursing practice standards, institutional policies
and procedures, or textbooks or journals, or it may be
between individuals. In other words, the person claimed stated by expert witnesses.
to be responsible for the tort is sued for damages. Tort 3. Harm. The client must have sustained injury, damage, or
liability is based on fault; that is, something that was harm. The plaintiff will be asked to document physical
done incorrectly (an unreasonable act of commission) injury, medical costs, loss of wages, pain and suffering,
or something that should have been done but was not and any other damages.
(omission). Torts can be broadly categorized as either
4. Causation. It must be proved that the harm occurred as
negligence or intentional.
a direct result of the nurse’s failure to follow the standard,
NEGLIGENCE In the nursing context, negligence and the nurse could have (or should have) known that
involves conduct or behaviour that falls below the failure to follow the standard could result in such harm.
TABLE 6.3 Legal Roles, Responsibilities, and Rights
Role Responsibilities (Obligations) Rights

Provider of service To provide safe and competent care commensu- The right to reasonable and prudent conduct from
rate with the nurse’s preparation, experience, clients (e.g., provision of accurate information,
and circumstances as required)
To inform clients of the consequences of various
alternatives and outcomes of care
To provide adequate supervision and evaluation of
others for whom the nurse is responsible
Employee or contractor To fulfill the obligations of contracted service with The right to adequate working conditions (e.g.,
for service the employer safe equipment and facilities)
To respect the employer The right to compensation for services rendered
To respect the rights and responsibilities of other The right to reasonable and prudent conduct by
health care providers other health care providers
Citizen To protect the rights of the recipients of care The right to respect of the nurse’s own rights and
responsibilities by others
Right to physical safety
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BOX 6.2 BASIC NURSING CARE ERRORS THAT The hospital took immediate action to find the patient;
CAN RESULT IN A FINDING OF NEGLIGENCE unfortunately, he had experienced cardiac arrest and died
in another rural hospital. Possible legal investigations in
Three kinds of nursing errors can result in negligence. such a case may or may not lead to legal proceedings
Examples of each kind of error are listed below. and penalties. In 2004, the Institute for Safe Medication
ASSESSMENT ERRORS Practices Canada generated a detailed report with recom-
mendations for practitioners and institutions (Borg, 2008).
• Failing to gather and chart client information adequately
Patients can suffer accidental falls while under nurs-
• Failing to recognize the significance of certain information ing care, which may result in injury. Some falls can be
(e.g., laboratory values, vital signs)
prevented by elevating the side rails on the cribs, beds,
PLANNING ERRORS and stretchers for babies, small children, and, when
necessary, adults. If a nurse leaves the side rails down
• Failing to chart each identified problem
or leaves a baby unattended on a bed, that nurse may
• Failing to use language in the care plan that other care-
givers understand be found liable in negligence if the patient falls and is
injured as a direct result. Most hospitals and nursing
• Failing to ensure continuity of care by ignoring the care plan
homes have policies regarding the use of safety devices,
• Failing to give discharge instructions that the client
understands such as side rails and restraints. The nurse needs to be
familiar with these policies and to take precautions to
INTERVENTION AND EVALUATION ERRORS prevent accidents. Information about providing a safe
• Failing to interpret and carry out a doctor’s orders environment for patients can be found in Chapter 32.
• Failing to perform nursing tasks correctly In some instances, ignoring a patient’s complaints
can constitute negligence. The nurse who does not report
• Failing to pursue the physician if the physician does not
respond to calls or failing to notify the nurse manager if a client’s complaint of acute abdominal pain is negligent
the physician is unavailable and may be found liable if appendix rupture and death
• Failing to report unsafe working conditions ensue. By failing to take the vital signs and to check the
dressing of a patient who has just had abdominal sur-
gery, a nurse omits important assessments. If the patient
To avoid charges of negligence, nurses need to rec- suffers a hemorrhage and dies, the nurse may be found
ognize those nursing situations in which negligent actions liable for negligence.
are most likely to occur and to take measures to prevent Negligence in the nursing context is illustrated in the
them (see Box 6.2). A common situation is a medication following example, Sozonchuk v. Polych, 2013 ONCA 253
error. Nurses must ensure that the patient receives the (Sozonchuk). In this case, the patient suffered a subarach-
right drug, in the proper dose, at the right time, for the noid hemorrhage as a result of an aneurysm that burst
right reason, and in the proper manner. Appropriate in the anterior communicating artery in his brain, which,
administration of medications is discussed in Chapter 33. in turn, left him with significant functional limitations.
A nurse’s responsibility for adverse effects and criti- An agency nurse (Polych) was the primary care
cal incidents (National Steering Committee on Patient nurse for the patient in the neurology step-down unit of
Safety, 2002) will be weighed in accordance with the the hospital. When the agency nurse started her shift,
provincial or territorial professional nursing standard. the patient had a Glasgow Coma Scale (GCS) score of
Health care employers often have policies and proce- 10 (on a scale of 3–15) and was being monitored for
dures for medication administration and standards for vasospasm. During the shift in question, the patient’s
documentation that include the steps to follow once an blood pressure dropped significantly, there were con-
error has been discovered. Such standards also include cerns about his temperature, and the patient’s level of
the requirement to keep up to date with the latest pro- consciousness decreased. The agency nurse was found
fessional and technological developments, such as new by the court to have made a single request to the charge
intravenous tubing or intravenous pumps. nurse that a physician be paged to attend to this patient
Despite a nurse’s diligence, medication errors still but had not followed up on her request.
occur. Such was the case in which a 67-year-old man in At 13:45, the patient was seen by a nurse practi-
the emergency department was given 10 mg of hydromor- tioner (NP), who noticed weakness on the patient’s face
phone intramuscularly instead of 10 mg of morphine. He and paralysis on the patient’s right side, both of which
was given this drug just before discharge as the patient had not been noted by the nurse. The NP paged both
declined to stay for observation. Hydromorphone that the neurosurgical and neurovascular fellows on call and
was packaged in a similar way to morphine was mistak- ordered more blood work and a computed tomography
enly selected from the opioid cupboard. The dose given (CT) scan. The CT scan showed a significant new area
to the patient (who was opioid naive) was equivalent to of injury on the patient’s left frontal lobe that was caused
about 60 mg to 70 mg of morphine. Within 1 hour of the by severe constriction of the left internal carotid artery
patient’s discharge, the opioid count revealed the error. resulting from vasospasm.
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The Court found that the agency nurse had failed to activity and even if the client benefits from the nurse’s
identify or appreciate the significance of the changes in action. Case law also indicates that it is battery “where
the patient’s neurological condition through the morn- a nurse in good faith administers a vaccination believing
ing and early afternoon of the day in question and failed wrongly that there has been consent” (Toews v. Weisner
to make accurate and timely records of the patient’s [2001, BCSC], as cited by Linden & Feldthusen, 2011).
medical condition and treatment. (This failure was very Battery clearly exists when consent is not obtained
damaging to the agency nurse–much of her evidence for treatment. However, the courts will also consider as
at trial was rejected by the court, largely because it was battery treatments that either go beyond or are different
unsupported by the notes in the patient’s chart.) from that for which consent was obtained (e.g., when
The court also found that the charge nurse’s actions the wrong spinal disc is operated on) or when consent
were negligent, for failing to understand the seriousness is obtained through fraud or misrepresentation (Linden
of the patient’s condition and failing to assist the agency & Feldthusen, 2011). In contrast, when a patient has
nurse in caring for the patient. An agency nurse may consented to treatment but then complains that he or
require a higher level of attention from a charge nurse, she was not given adequate information, for example, as
and the charge nurse did not provide this assistance to to the risks associated with the procedure, the plaintiff
the agency nurse. The charge nurse also did not take would properly bring the claim of negligence. For con-
appropriate steps when the pages to physicians were not sent to be valid, the patient must be competent to give
being answered. consent. It can be very difficult to determine whether
Both the agency nurse and the charge nurse were clients who are very old, who have specific mental disor-
found negligent, and liability was apportioned equally. ders, or who take particular medications are competent
to agree to treatments. If the nurse is uncertain whether
INTENTIONAL TORTS Negligence is different from a client refusing a treatment is competent, the supervi-
intentional torts. The main difference is that neg- sor and physician should be consulted to ensure that the
ligent acts are unintentional, and intentional torts are treatment is ethically and legally permissible.
committed on purpose by the tortfeasor. Another differ- False imprisonment is the intentional confin-
ence is that harm is a required element in negligence, ing of a person within fixed boundaries, without that
whereas no harm need be suffered by the plaintiff for a person’s consent. As others have explained, the name
defendant to be found liable of an intentional tort. Also, is somewhat misleading. Linden and Feldthusen (2011)
because no standard of care is involved, no expert wit- explain it as follows:
nesses are needed. Assault, battery, false imprisonment,
and invasion of privacy are some of the intentional torts Firstly, there is no need for any prison to be involved.
most likely to be relevant in the nursing context. Although one can certainly imprison someone by
Assault can be described as an attempt or threat to incarceration behind prison walls, it can also be
touch another person unjustifiably. Assault precedes bat- a ccomplished in other ways [for example, one can
tery; it is the act that causes the person to believe a battery imprison someone in a psychiatric hospital, room, car,
is about to occur. For example, the person who threatens or boat]. Secondly, the confinement cannot be “false” in
someone by making a menacing gesture with a club or the sense of being unreal. The word “false” is intended
a closed fist is guilty of assault. A nurse who threatens a to impart the notion of unauthorized or wrongful
client with an injection after the client refuses to take the d etention. (p. 50)
medication orally would be committing assault.
Battery is intentional harmful or offensive contact The plaintiff does not need to prove damages to
with another person (or the person’s clothes or even successfully bring a false imprisonment action but must
something the person is carrying) without that person’s show that he or she was intentionally restrained with no
consent. It is not necessary that a battery actually result avenue of escape. The plaintiff does not have to be con-
in harm to the plaintiff; instead, “offensive contact is scious of the confinement at the time it occurred (Picard
enough, however trivial it may seem, for it may trig- & Robertson, 2007).
ger retaliatory measures by persons whose dignity and The 1994 case Lebel v. Roe in the Yukon provides
self-respect are threatened” by the contact (Linden & a clear example of false imprisonment in the nursing
Feldthusen, 2011, p. 44). “[B]attery is … a tort or legal context. In that case, a patient agreed to be admit-
wrong which protects people’s ‘dignitary interests,’ their ted to a psychiatric facility after being advised (incor-
rights to personal autonomy and to freedom from wan- rectly) by a mental health nurse that she would be
ton, humiliating or otherwise unwelcome interference” apprehended by the Royal Canadian Mounted Police
(Irvine, Osborne, & Shariff, 2013, p. 160). In the previ- (RCMP) if she refused to come voluntarily. The court
ous example, if the nurse followed through on the threat awarded the patient $5000, holding that the nurse ought
and gave the injection without the client’s consent, the to have known her statement was incorrect, that her
nurse would be committing battery. Liability applies, statement resulted in the patient believing that her free-
even though the physician ordered the medication or the dom was restricted, and that her admission to the facility
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constituted false imprisonment (as discussed by Picard & confidential patient information to others who are not
Robertson, 2007). Although nurses may suggest, under directly involved in the care of that patient or by intrud-
certain circumstances, that a patient remain in the hos- ing into the patient’s private domain. In this context, a
pital room or in bed, the patient must not be detained delicate balance must be maintained between the need
against his or her will. The patient has the right to leave, for a number of people to contribute to the diagnosis
even though it may be detrimental to his or her health. and treatment of a client and the client’s right to confi-
If the patient insists on leaving, most institutions dentiality. In most situations, necessary discussion about
require that he or she sign a release stating that the a client’s medical condition is considered appropriate,
agency will not be held responsible for any resulting but unnecessary discussions and gossip are considered a
harm. As with all situations, the nurse should try to breach of confidentiality. Necessary discussion involves
inform the patient of potential risks and alternative only those engaged in the client’s care. In some instances,
courses of action. The use of force to detain someone however, a statutorily imposed duty exists to report what
against his or her will can constitute battery, and even would normally constitute confidential information.
the threat of restraint made to detain the patient can be Most provinces and territories have a variety of statutes
considered assault. The nurse must be cautious with the that impose a duty to report some confidential patient
use of restraints (see Chapter 32). information. Four major categories are (a) vital statistics,
Invasion of privacy is a developing area of Cana- such as births and deaths, (b) infections and communi-
dian law: Although the right to privacy is well entrenched cable diseases, such as diphtheria, syphilis, and typhoid
in American tort law, the Canadian and English courts fever, (c) child or elder abuse, and (d) violent incidents,
have been reluctant to recognize a separate common law such as shootings and knife attacks.
right to privacy. The American model outlines four distinct
privacy torts: (a) intrusion on the plaintiff ’s seclusion or
private affairs, (b) public disclosure of embarrassing pri- Consent Issues
vate facts about the plaintiff, (c) publicity that places the Patients are entitled to make decisions about their health
plaintiff in a false light in the public eye, and (d) appropria- care and have the right to be given all available informa-
tion of the plaintiff ’s name or likeness for the defendant’s tion relevant to such decisions. Obtaining consent is not
advantage (Linden & Feldthusen, 2011, p. 59). a discrete event; rather, it is a process that should occur
Canadian courts have traditionally recognized inva- throughout the relationship between the patient and all
sions of privacy that fall under the fourth category only; health care providers.
however, an Ontario case, Jones v. Tsige (2012), decided Consent has three components: (a) disclosure, (b)
that in light of the technological advancements that allow capacity, and (c) voluntariness. Disclosure refers to the
for easy (proper and improper) collection, access, and dis- provision of information, including the risks of treat-
semination of personal information, it should recognize ment, alternative treatment and its associated facts and
a right to claim financial compensation if personal infor- risks, and the effects and risks of no treatment. Capac-
mation is accessed in circumstances where the access is ity refers to the patient’s ability to understand the rele-
intentional, the private affairs are invaded without legal vant information and appreciate the consequences of the
justification, and the invasion would be highly offensive to decision. Voluntariness refers to the patient’s right to
a reasonable person. This case was not in the medical con- come to a decision without force, coercion, or manipula-
text, but it has since been invoked in civil actions against tion by others (Etchells, Sharpe, Elliott, & Singer, 1999).
health care professionals seeking financial compensation When these three requirements are met—that is, when a
for inappropriate access to personal health information. patient has received all the information, has the capac-
The case involved an action for damages as a result of an ity to make the decision, and is free from coercion—the
unauthorized access of a bank employee’s financial infor- patient is then in a position to provide what is called
mation by another bank employee on several occasions. informed consent to the medical treatment.
The defendant sought to have the claim dismissed on the Consent is of two types: express and implied. Express
ground that Ontario law did not recognize such a cause of consent is a clear statement by the patient and can be
action. However, the judge found that “it is appropriate for either oral or written. Implied consent exists when the
this court to confirm the existence of a right of action for individual’s nonverbal behaviour indicates willingness.
intrusion upon seclusion” (Jones v. Tsige, 2012) and awarded Examples of implied consent include the following:
$20 000 in damages.
Another important exception to the courts’ hesita- • In emergency situations, when the individual cannot
tion in awarding liability for invasions of privacy is as provide express consent
follows: Breach of confidentiality will give rise to legal • During surgery, when additional procedures are needed
remedy against, for example, a nurse or other health that are consistent with the procedure already con-
care provider who divulges confidential patient informa- sented to
tion (Irvine et al., 2013). In nursing, liability can result • In therapy, when the person continues to participate
if the nurse breaches confidentiality by passing along without withdrawing previously provided consent
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In such situations, the CNPS (1994) suggests that may affect other members of the family, and, if so, they
provincial and territorial legislation, be followed. It is need to be consulted.
also important that nurses be aware of applicable hospi- In many areas of health care law and capacity, consent
tal policies and procedures. remains a confusing issue. The first is related to minors.
Canadian common law does not specify an age below
OBTAINING CONSENT AND DISCLOSING INFORMA- which a person is not presumed capable (Etchells et al.
TION Obtaining consent to medical or nursing care is a 1999). Some provinces have legislation that lowers the age
legal requirement. Under common law, treating a com- of consent below 18 years. A minor can give consent if
petent patient without obtaining any consent or treat- it is determined that the person has adequate knowledge
ing a patient who is refusing treatment constitutes battery, and judgment (is able to reasonably foresee consequences
whereas treating a patient without obtaining fully informed of a decision or lack of a decision) (Sharpe, 1993) and is
consent constitutes negligence (Fraser & Parisi, 2006). determined to be a “mature minor” (Royal College of
Obtaining informed consent for specific medical and Physicians and Surgeons of Canada, 2013). In terms of
surgical treatments is the responsibility of a physician. treatments for minor children, parents are usually involved
Although this responsibility is delegated to nurses in in providing consent, whereas older children are asked for
some agencies and no laws prohibit the nurse from being assent; that is, they are consulted and agree to the treat-
part of the information-giving process, this practice, ment. Some provinces have legislation that establishes the
nevertheless, is highly undesirable. The nurse does not age of consent to treatment; health care providers should
perform direct medical procedures and may not have the be aware of the legislative requirements of their own prov-
detailed medical knowledge of the physician performing ince or territory.
the procedure. Also, it is not the nurse’s responsibility to It is also important to remember that capacity can
“supply the gaps or deficiencies in the physician’s dia- change over time. A patient who is confused, disoriented,
logue with the patient”; however, it is the responsibility or sedated is not considered functionally competent;
of the nurse to ensure that when there are information however, this state may be temporary and requires care-
gaps, the physician is alerted (Irvine et al., 2013, p. 164). ful, skilled assessment. Individuals who are unconscious
Often, the nurse’s responsibility is to witness the giv- or injured in such a way that they are unable to give con-
ing of informed consent for medical procedures, which sent require substitute consent from another individual.
involves witnessing the exchange between the patient Statutes tend to provide a hierarchy of substitute
and the physician and establishing that the patient really decision makers. Priority is given to a court-appointed
did understand, that is, was truly informed. In most substitute decision maker or person with power of attor-
jurisdictions, nursing students cannot witness consents. ney for personal care or proxy. If such a person does not
Obtaining informed consent for nursing procedures is exist, authority falls to a spouse and then to various fam-
the responsibility of the nurse. This applies, in particular, ily members in accordance with the statutory list (CNPS,
to nurse midwives and nurse practitioners in performing 2009, p. 2). The substitute decision maker should be the
procedures in their advanced practices. However, it also person with the best knowledge of the patient’s specific
applies to other nurses performing direct care, such as wishes or of the patient’s values and beliefs. In every case,
inserting nasogastric tubes or starting an intravenous substitute decision makers must consider and respect the
infusion. It can be a challenge to determine the amount patient’s previously known wishes or advance directives
and type of information required for the client to make that were expressed when he or she was capable and
an informed decision. The client should have the follow- apply to the situation, and the patient’s best interests.
ing general information: In the case of a patient with a mental illness, capacity
to consent may or may not be valid, depending on whether
• The purposes of the treatment
the mental illness makes that patient unable to appreciate
• What he or she can expect to feel or experience the nature, quality, and consequences of the proposed treat-
• The intended benefits of the treatment ment. Provincial and territorial mental health acts or simi-
• The possible risks or negative outcomes of the treatment lar statutes generally provide direction and specify the rights
of people with mental illness under the law, as well as the
• The advantages and disadvantages of possible alterna-
rights of the professionals caring for such patients. Consent
tives to the treatment (including no treatment)
for treatment often presents ethical issues for health care
Informed consent regulations were originally written providers (see the Evidence-Informed Practice Box).
with acute care settings in mind. Nonetheless, ensuring
informed consent is equally important in providing nurs-
ing care in the home and community. Because the provi-
sion of home care often occurs over an extended period,
Patient Safety
the nurse has multiple opportunities to ensure that the Significant attention has been focused on issues related
client agrees to the plan of treatment. A challenge to to patient safety in Canada’s health care system because
informed consent in the home, however, is that the plan “the costs of unsafe health care—both personal and
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fiscal—to individuals, their families and their communi-

ties and to the state are massive” (Downie, Lahey, Ford, EVIDENCE-INFORMED PRACTICE
Gibson, Thomson, Ward, et al., 2006). In 2006, a report
entitled Patient Safety Law: From Silos to Systems, funded by What Are the Clinical Ethical
Health Canada, “explored the use of legal instruments
by governments to improve patient safety” (Downie et al.,
Conflicts That Hospital Nurses
2006, p. 1). The report provides an overview of the vari- and Physicians Experience in Their
ous legal tools in Canada that address issues of patient Practice Today?
safety. It also identifies strengths and weaknesses for each
area as well as for the system as a whole. The authors’ In a qualitative descriptive study, part of a larger investiga-
comments provide some helpful insights into some of the tion of four hospital clinical ethics committees in Atlantic
Canada, nurses and physicians were interviewed about their
problems and suggest some possible solutions:
ethical conflicts in clinical situations. The results were nine
themes of clinical ethical conflict common to both nurses and
Having taken a system governance perspective, we
physicians:
identified a body of law that can be described as patient
• Disagreement about care decisions or treatment options
safety law, in that it functions to protect the patient by
reducing unsafe acts within the health care system. The • Others not respecting a patient’s wishes
different areas of law that affect patient safety (e.g., tort • Patient not receiving quality end-of-life care
law, professional regulation, institutional regulation) are • Patient’s or family’s behaviour preventing safe or quality
not usually conceived of as an integrated system of law. care for self or others
However, conceiving of patient safety law as an integrated • Patient and/or family not having informed consent or full
entity has value, since it allows the discussion to move disclosure
away from thinking in terms of narrow siloed categories • Not knowing the “right thing to do”
of law to thinking of the larger systemic objectives the • System deficit or deficiency preventing quality care
legal framework should enable regarding the governance of • Nurse or physician values conflict with patient values or
patient safety. (Downie et al., 2006, p. 2) lifestyle choices
• Possible or perceived deficiencies in care owing to nurse
The report clearly highlights that a more holistic, or physician competency
system-wide approach to patient safety is in line with
Three additional themes were specific to physicians:
international trends and would address some of the gaps
• Disagreement with national clinical practice guidelines
identified in our current approach.
• Estimating the odds of survival and futility of treatment
• Balancing merit of survival with disability in an infant or child
Adverse Event Reporting NURSING IMPLICATIONS: All themes relate to the
nurse’s and physician’s desire to do the right thing for
One of the key areas addressed in the report on patient
a patient and/or family. The core theme “striving to do
safety was adverse event reporting. Although what is best for the patient” underpins all the clinical
“adverse events reporting systems are a structural facet ethical conflict themes described in this study.
of safety regulation in other sectors … they are a rel-
Source: Based on Gaudine, A., Lefort, S., Lamb, M., & Thorne, L. (2011). Clinical
atively recent innovation in the health care system” ethical conflicts of nurses and physicians. Nursing Ethics, 18(1), 9–19.
(Downie et al., 2006, p. 56). In some provinces (including
Saskatchewan, Manitoba, and Quebec), adverse event
reporting frameworks have been established through Saskatchewan, 2004) offers some additional insight into
legislative initiatives. The first example of this was Sas- what is required under the framework. The guideline
katchewan’s Regional Health Services Act, passed in defines a critical incident as “a serious adverse health
2002, which gave rise to mandatory reporting of adverse event including, but not limited to, the actual or potential
events to the provincial health department. In 2004, with loss of life, limb or function related to a health service
the addition of the Critical Incident Regulation under provided by, or a program operated by a regional health
the act, the requirements and details of the reporting authority (RHA) or health care organization (HCO)”
structure were made clearer and more complete. Under (p. 1). Some of the categories under which a reportable
this framework, for example, health care organizations incident can arise include “surgical events, product or
and the regional health authorities to which they report device events, patient protection events, care manage-
“are required to give notice of critical incidents arising ment events, environmental events and criminal events”
from their operations within 3 business days, or as soon (Downie et al., 2006, p. 56).
as possible thereafter” to the Saskatchewan Ministry of Although developments and initiatives are under-
Health (Downie et al., 2006, p. 56). Notification must be way, the concern expressed in the report of the National
followed up by a detailed written report. The Saskatch- Steering Committee on Patient Safety (2002) that C anada
ewan Critical Incident Reporting Guideline (Government of is behind several other countries in the development of
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such mechanisms has not yet been fully addressed. Some moral and legal obligations for nurses. Whenever pos-
of the recommendations made in the committee’s report sible, nurses uphold confidentiality, except where per-
include the following: mitted or required by law to disclose patient information
• The adoption of nonpunitive reporting policies within (i.e., suspected child abuse, infectious disease, informa-
a quality improvement framework across the system tion for workers’ compensation boards, or a court order).
that encourage and reward reporting, with limited The CNA Code of Ethics (2008b) states: “When nurses are
exceptions, and required to disclose information for a particular purpose,
they disclose only the amount of information necessary
• The review and revision of legislation across all C
anadian for that purpose and inform only those necessary. The
jurisdictions to protect patient safety data and reports attempt is to do so in ways that minimize any potential
from disclosure in legal proceedings. Facts relating to harm to the individual, family or community” (p. 15).
the event should be recorded on the patient’s health Legally, betrayal of a patient’s confidence is covered
record and should not be privileged. De-identified infor- under the area of professional misconduct and may
mation could be entered into a provincial or territorial result in discipline by the provincial or territorial conduct
or national database to facilitate the sharing of lessons committee of the professional nursing regulatory body.
learned across jurisdictions (Downie et al., 2006, p. 59). Confidential information is “intimate or private
The recommendations indicate a tension between knowledge” protected under a duty of confidentiality.
litigation and quality assurance or improvement systems. Confidentiality can be summarized as the duty of
The former does not encourage openness or transpar- someone (a professional) who has received confidential
ency in the wake of an adverse event, as this has the information in trust to protect that information and dis-
potential to expose those health care providers and insti- close it to others only with permission, or when rules or
tutions involved to liability. In contrast, to fully identify, laws authorize its disclosure. Confidential information
understand, learn from, and thereby reduce future likeli- can come directly from the patient, be received through
hood of adverse events, mechanisms that will encourage written documents or electronic data, or come from a
reporting and open discussion of such events are needed. third party. A common rule frequently noted in policy
Ultimately, such a system will help increase patient safety, is that all knowledge is considered confidential unless
as well as the accountability of both individuals and otherwise stated by the patient.
organizations within the health care system. See Box 6.3 Often, the notion of confidential information is dis-
on Canadian disclosure guidelines. cussed within the framework of the legal right to privacy.
In simple terms, privacy is about people, whereas con-
fidentiality is about duty to protect information. Privacy
is about a person’s right to control the intrusion of oth-
Selected Legal Aspects ers into his or her life. In other words, it concerns what
of Nursing Practice information a health care provider can have. A patient’s

right to privacy means that he or she has the right to
disclose details of his or her life, illness, feelings, finances,
Confidentiality and Privacy and family interactions or not to disclose them. Confiden-
tiality is about what a nurse does with the information.
As discussed earlier, fundamental to the nurse–patient
When patients give their personal information to nurses,
relationship is the professional obligation to respect
they trust that the nurses will disclose it only to appro-
patient confidentiality. Confidentiality brings with it both
priate members of the health care team. Maintaining
patient confidentiality is an important element of trust
BOX 6.3 CANADIAN DISCLOSURE GUIDELINES and as such is a moral obligation of nurses.
Many key documents have been written in the
The Canadian Disclosure Guidelines focus on disclosure of
adverse events and were developed by the Canadian Patient development and evolution of public policy concerning
Safety Institute (CPSI), a nonprofit organization that raises informational privacy. The Office of the Privacy Com-
awareness and facilitates the implementation of ideas and missioner of Canada (2004) offers information to help
best practices to achieve a transformation in patient safety. individuals learn about their rights under the Personal
“Healthcare providers have ethical and professional Information Protection and Electronic Documents Act (PIPEDA),
obligations to be open and honest when communicating Canada’s private sector privacy law (http://www.priv.
with patients” (p. 10). The guideline outlines for health care gc.ca). Also, many provinces have enacted health-specific
providers a process that promotes a clear and consistent privacy legislation, which can be found by checking indi-
approach to disclosure. vidual provincial or territorial websites.
Source: Based on information obtained from The Canadian Patient Safety Institute. The primary legal consideration with respect to any
(2011). Canadian disclosure guidelines: Being open with patients and families. information that the nurse obtains from a patient during
Retrieved from http://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/
Documents/CPSI Canadian Disclosure Guidelines.pdf. the course of the professional relationship is that such
information is confidential and cannot be disclosed to
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anyone who has no valid purpose for requesting it. It is their lives” (CNA, 2011, p. 24). Problematic substance
important for all nurses, health care professionals, and use and chemical dependency are serious problems,
employees to be aware of current developments in and endangering the safety of the public and the health
comply with the legislated requirements of Canadian of nurses. Many factors in the workplace are linked to
privacy law. nurses’ problematic substance use: shift work, stress, long
working hours, and access to a large variety of pharma-
cological substances all contribute to the risk (Adlersberg
Confidentiality and Social Media & Mackinnon, 2004). Prevention, early recognition, and
All health care professionals are held to a high stan- effective treatment programs are essential to promote the
dard of confidentiality with respect to all patient infor- health of nurses and ensure public safety.
mation. “Professional practice standards may also be Nurses have a professional responsibility to protect
applicable when nurses use social media in connection patients from harm. Education and prevention of prob-
with their professional activities and require nurses to lematic substance use must begin in schools of nursing
display professional conduct towards both patients and and nurses’ workplaces to heighten awareness and pro-
colleagues. Failure to abide by these standards can lead mote early detection. Denying that a problem exists is a
to serious legal consequences. For example, a nurse was common first sign of problematic substance use. Admit-
found guilty of unprofessional conduct by her profes- ting there is a problem may be the hardest step. It is not
sional licensing body because she posted a patient’s first uncommon for coworkers to explain or excuse unaccept-
name and the patient’s personal health information on a able behaviour rather than consider the possibility of
coworker’s Facebook page” (CNPS, 2010). problematic drug or alcohol use (CNA, 2009). Nurses
Risk management for nurses using social media need to be aware of signs of a potential problem (see
(CNPS, 2012) involves the following: Box 6.4). Consultation with licensing bodies is available to
help deal with suspected problems. Guidance for nurses
• Avoid posting/sharing confidential information: an is also provided by the CNA Code of Ethics (CNA, 2008b)
unnamed patient or person may be identifiable from and CNA Position Statement on Problematic Substance
posted information. Use by Nurses (CNA, 2009). Nurses must adhere to the
• Avoid using social media to vent or discuss work-related reporting requirements of the licensing bodies.
events or to comment on similar postings by others. Employers must have sound policies and procedures
• Avoid posting negative comments about your colleagues, for identifying and intervening in situations involving a
supervisors, and other health care professionals; disclos- possibly impaired nurse. The primary concern is for the
ing information obtained at work could be considered protection of clients, but it is also critically important
unprofessional and, if erroneous, could lead to a defa-
mation claim.
• Respect and enforce professional boundaries: Becoming BOX 6.4 BEHAVIOURAL INDICATORS
a patient’s electronic “friend” or communicating with OF CHEMICAL MISUSE
him or her through social media sites may extend the Nurses need to be aware of the signs of problematic drug
scope of professional responsibility. or alcohol use:
• Be aware that it is difficult to ascertain whether individ- • Increased isolation from colleagues, friends, and family
uals providing or seeking information through a social • Frequent reports of illness, minor accidents, and
media account are who they say they are. emergencies
• Avoid offering health-related advice in response to com- • Complaints about poor work performance
ments or questions posted on social media sites; if relied • Inability to meet schedules and deadlines
upon, such advice could trigger professional liability. • Tendency to avoid new and challenging assignments
• Make your personal profile private and accessible only • Mood swings, irritability, and depression
to people you know and trust. • Request for night shifts
• Create strong passwords, change them frequently, and • Social avoidance of staff
keep them private. • Illogical and sloppy charting
• Present yourself in a professional manner in photos, vid- • Excessive errors
eos, and postings. • Increasing carelessness about personal appearance
• Medication errors that require many changes in charting
• Arriving early or staying late for no reason
Problematic Substance Use • Volunteering to administer client medications, especially
and Chemical Dependency pain medications
“It is thought that between 10 and 20 percent of nurses Source: From Wolters Kluwer Health, Inc. (2004). Nurse’s legal handbook (5th ed.).
will have a substance abuse problem at some point in
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that the nurse’s problem be identified quickly so that extend to nurses employed as independent contractors.
appropriate treatment may be instituted. The signs pre- Whether a nurse is working as an independent contrac-
sented in Box 6.4 can be used to report the nurse sus- tor or an employee will be a question to be determined by
pected of chemical impairment. the court”(CNPS, 2006). Nurses in independent practice
A variety of programs have been developed to help also do not have this protection; they are held directly
nurses recover from problematic substance use. Nurses accountable for their practice and thus require their own
need the same caring attitude from peers as that shown professional liability protection (CNPS, 2004b).
to patients. The goal is to have nurses enter rehabilita- In Canada, legal support and liability protection
tive treatment. Employee and family assistance programs can be obtained through the CNPS, a nonprofit society
can provide support and direction for nurses who require established in 1988. CNPS protection is available to
assistance to deal with their substance involvement. registered nurses and nurse practitioners, provided they
Rehabilitation is a complex process. A work re-entry belong to their provincial/territorial professional nursing
plan can assist nurses to return to their job and provide associations/colleges, that their associations/colleges are
safe and competent care. members of CNPS, or that they are an individual ben-
eficiary of the CNPS.
CNPS Plus offers additional insurance to all regis-
Medical Assistance in Dying tered nurses at an annual premium. This added insur-
In February 2015, the Supreme Court of Canada made ance, originally designed for independent practitioners,
a unanimous decision in Carter et al. v. Attorney General nurse practitioners, and independent contractors, offers
of Canada that Canadians have a constitutional right business protection, commercial general liability protec-
to choose physician assistance in dying. In examining tion, directors’ and officers’ liability coverage, and mal-
the Criminal Code of Canada, the “Supreme Court practice insurance (CNPS, 2008).
declared that the general prohibition on assisted sui- Nurses often provide nursing services outside of
cide was unconstitutional, since it was overbroad. The employment-related activities, such as being available
Court stated that nothing in its decision compels physi- for first aid at children’s sport or social activities or pro-
cians to provide assistance in dying” (CNPS, 2015). The viding health screening and education at health fairs.
Court suspended the operation of its declaration until Neighbours or friends may seek advice about illnesses
June 6, 2016, to allow the federal government to consider or treatment for themselves or family members. In the
whether it should amend existing legislation or adopt new latter situation, the nurse may be tempted to give advice;
law on the matter. The federal government may study however, it is always advisable for the nurse to refer the
legislation that has already been drafted, such as Que- friend or neighbour to the family physician.
bec’s Respecting End-of- Life Care Act. Nurses may also act as Good Samaritans by pro-
The federal government was given a June 2016 dead- viding emergency assistance at an accident scene. This
line to amend the Criminal Code. It missed that deadline. type of professional activity is not covered by an employ-
Until the Criminal Code is amended, the law cannot be er’s insurance policy because the care given was not the
implemented on assisted suicide. responsibility of the employer. The Good Samaritan or
emergency medical aid acts are designed to protect those
acting reasonably, without gross negligence. Although the
Code of Ethics for Registered Nurses (CNA, 2008b) no longer
Legal Protections specifically mentions emergency care, it does note that
in Nursing Practice “during a natural or human-made disaster, including a

communicable disease outbreak, nurses have a duty to
provide care, using appropriate safety measures” (p. 9).
To encourage citizens to be Good Samaritans, most
Professional Liability Protection provinces and territories have now enacted legislation
All nurses are advised to have professional liability pro- releasing a Good Samaritan from legal liability for inju-
tection. Despite the high level of competence promoted ries caused in such circumstances, even if the injuries
and maintained, excellent communication with clients resulted from negligence of the person offering emer-
and the increasing awareness of the risks involved in gency aid. The Alberta Emergency Medical Act, estab-
giving care, a lawsuit can still be initiated by a client. lished in 1980, protects physicians and other registered
Nurses who are employees are generally covered by their health-discipline members, including nurses, unless gross
employer’s insurance through the operation of vicarious negligence is involved. The act covers people who give
liability. These insurance policies or programs gener- help in an emergency, at a level that would be provided
ally require that an employment relationship must have by a reasonably careful person under similar circum-
existed at the time of the incident and the defendant stances (Phillips, 2006). New Brunswick does not have
employee must have been sued for work done within the Good Samaritan legislation; however, it does protect
scope of his or her employment. “This coverage may not physicians who voluntary give first aid or emergency
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treatment outside of a hospital or doctor’s office from Providing Safe, Competent Nursing Care
liability, under the Medical Act of 1981 (Phillips, 2006).
It is vital for the Good Samaritan to consider that Competent practice is a major legal safeguard for nurses.
once he or she has begun to help the victim, he or she has Nurses need to provide care that is within the legal
entered into a nurse–client relationship with that person scope of their practice and within the boundaries of
and is bound by a duty of care to that person. “You now agency policies and procedures. Nurses, therefore, must
have a duty, in law, to the injured person to continue be familiar with their legislated scope of practice and
to treat that person until you are relieved by another the various job descriptions, which may be different
competent professional, the preference being one with across agencies. All nurses are responsible for ensuring
medical training, or until the person is out of immediate that their educational qualifications and experiences are
danger” (Phillips, 2006, p. 2). adequate to meet the responsibilities delineated in their
job description.
Application of the nursing process is another essen-
Carrying out a Physician’s Orders tial aspect of providing safe and effective client care. All
Nurses are expected to analyze the procedures and medi- assessments and care must be documented accurately.
cations ordered by physicians. It is the nurse’s respon- Effective communication can also protect the nurse from
sibility to seek clarification of ambiguous or seemingly negligence claims. Nurses need to approach every client
erroneous orders from the prescribing physician or cov- with sincere concern and include the client in conversa-
ering on-call physician. tions. In addition, nurses should always acknowledge
Nurses are not absolved of responsibility for their when they do not know the answer to a client’s questions,
actions simply because they are following a physician’s tell the client they will find out the answer, and then
order. The law states that nurses must understand the follow through. Ways to take legal precautions are sum-
cause and effect of the treatment. If nurses carry out treat- marized in Box 6.5.
ment they know is wrong, they are guilty of negligence.
To protect themselves legally, nurses must question
several categories of orders:
Quality Documentation
1. Question any order a client questions. For example, if a client The client’s medical record is a legal document and can
who has been receiving intramuscular injections tells be produced in court as evidence. Licensing bodies have
the nurse that the physician changed the order from an documentation standards in place to which nurses are
injectable medication to an oral medication, the nurse held accountable. Failure to meet these standards can
should recheck the order before giving the medication. result in disciplinary action against the nurse (CNPS,
2007). The courts look to the chart as a chronological
2. Question any order if the patient’s condition has changed. The record of all aspects of care from admission until dis-
nurse is considered responsible for notifying the physi- charge. Nursing documentation is often used as a means
cian of any significant changes in the patient’s condi- of reconstructing events surrounding the care given and
tion, whether the physician requests notification or not. dates and times, as a way of refreshing the memory of
For example, if a client who is receiving an intravenous a witness, because often several months or years elapse
infusion suddenly develops a rapid pulse, chest pain, before the lawsuit goes to trial. The effectiveness of a
and a cough, the nurse must notify the physician imme- witness’s testimony can depend on the accuracy of such
diately and question continuance of the ordered rate of records. Nurses, therefore, need to keep accurate and
infusion. If a patient who is receiving morphine for pain complete records of nursing care provided to clients.
develops severely depressed respirations, the nurse must Nurses have obligations to perform certain nursing
withhold the medication and notify the physician. acts, such as taking vital signs. In the eyes of the court,
3. Question and record verbal orders to avoid miscommunications. failure to document these acts may suggest that the act
In addition to recording the time, the date, the physi- was not performed. Omissions can constitute negli-
cian’s name, and the orders, the nurse documents the gence and be the basis for tort liability. Insufficient or
circumstances that occasioned the call to the physician, inaccurate assessments and documentation can hinder
reads the orders back to the physician, and documents proper diagnosis and treatment and result in injury to
that the physician confirmed the orders as the nurse the client.
read them back. To avoid miscommunication, verbal Privacy and confidentiality are also important con-
orders should be limited. siderations if e-mail is being considered as a method of
4. Question any order that is illegible, unclear, or incomplete. Mis- transferring patient health records or health informa-
interpretations in the name of a drug or in dose, for tion. Because the security and confidentiality of e-mail
example, can easily occur with handwritten orders. The systems are not guaranteed, it is not the recommended
nurse is responsible for ensuring that the order is inter- method for transmission of health information (CNPS,
preted the way it was intended and that it is a safe and 2012, 2014). See Chapter 24 for types of records and
appropriate order. facts about recording.
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BOX 6.5 LEGAL PRECAUTIONS FOR NURSES Reporting Crimes, Torts,

Nurses can do several things to protect themselves legally:
• Function within the legislated scope of nursing practice
and Unsafe Practices
(set by regulatory bodies), educational preparation, and
job description. Nurses may need to report nursing colleagues or other
• Follow the procedures and policies of the employing health care professionals for practices that endanger the
agency. health and safety of clients. For instance, problematic
• Build and maintain good rapport with clients. Keeping alcohol and drug use, theft from a client or agency, and
clients informed about diagnostic and treatment plans, unsafe nursing practice should be reported. Reporting
giving feedback on their progress, and showing concern a colleague is not easy. The person reporting may feel
for the outcome of their care can prevent a sense of disloyal, incur the disapproval of others, or feel that
powerlessness and a buildup of hostility in the client.
chances for promotion are endangered. When report-
• Always identify clients, particularly before initiating
ing an incident or series of incidents, the nurse must
major interventions (e.g., surgical or other invasive pro-
cedures, or when administering medications or blood be careful to describe observed behaviour only and not
transfusions). make inferences as to what might be happening. Box 6.6
• Observe and monitor the client accurately. Record and outlines guidelines for reporting a crime, tort, or unsafe
communicate to the physician any significant changes in practice. Reporting these events is referred to as whistle-
the client’s condition. blowing, and third party reporting mechanisms may be in
• Promptly and accurately document all assessments and place to protect those who report such practices.
care given. Records must show that the nurse provided “Whistle-blowers are people who expose negli-
and supervised the client’s care at regular intervals (the gence, abuses, [and] dangers, such as professional miscon-
frequency of required reporting varies with the agency).
duct or incompetence in the organization in which they
• Be alert when implementing nursing interventions, and work” (Hardingham, 1999, p. 1). The decision to be a
give each task your full attention and skill.
whistle-blower is never an easy one, unless there is a legal
• Perform procedures appropriately. Negligent incidents
obligation (e.g., in the cases of child abuse or the abuse
during procedures generally relate to equipment failure,
improper technique, and improper performance of the of vulnerable adults). Reporting it should be considered
procedure. For instance, the nurse must know how to the last resort when all else has failed. Nurses may be the
safeguard the client in the event that a respirator or other first to come upon unsafe practice or to identify actual or
equipment fails. potential hazards. It can be a difficult situation, where the
• Make sure the correct medications are given in the cor- nurse is caught between the values and standards of the
rect dose, by the right route, at the scheduled time, and profession and the values and norms of the employing
to the right client. See Chapter 33 for more detailed infor-
organization. The CNA’s Code of Ethics (CNA, 2008b) can
mation about the administration of medications.
be used as a guideline. Four values in the code are espe-
• When delegating nursing responsibilities, make sure that
the person who is delegated a task understands what
cially relevant to nurses deciding whether to report:
to do and that the person has the required knowledge 1. Promoting health and well-being
and skill. As the delegating nurse, you can be held liable
for harm caused by the person to whom the care was 2. Preserving dignity
delegated. 3. Maintaining privacy and confidentiality
• Protect clients from injury. Inform clients of the hazards,
and use appropriate safety devices and measures to pre-
4. Being accountable
vent falls, burns, or other injuries.
• Report all incidents involving clients. Prompt reports
enable those responsible to attend to the client’s well- BOX 6.6 GUIDELINES FOR REPORTING
being, to analyze why the incident occurred, and to pre- A CRIME, TORT, OR UNSAFE PRACTICE
vent recurrences.
• Always check any order that a client questions and Nurses should follow these guidelines when reporting a
ensure that verbal orders are accurate and documented crime, tort, or unsafe practice:
appropriately. Question and confirm standing orders if • Write a clear description of the situation you believe you
you are inexperienced in a particular area. should report.
• Know your own strengths and weaknesses. Ask for • Make sure that your statements are accurate.
assistance and supervision in situations for which you • Make sure you are credible. Obtain support from at least
feel inadequately prepared. one trustworthy person before filing the report.
• Maintain your clinical competence. For students, this • Report the matter by starting at the lowest possible level
demands study and practice before caring for clients. in the agency hierarchy.
For graduate nurses, it means continued study, includ-
ing maintaining and updating clinical knowledge and • Assume responsibility for reporting the individual by being
skills, and self-documentation of continuing competence open about it. Sign your name to the letter.
efforts. • See the problem through once you have reported it.
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Legal Responsibilities agency, and the instructor or preceptor accompanying

the student. Before the student enters clinical practice,
of Nursing Students the educator must be aware of the student’s capabilities
and whether the curriculum is current and relevant.
Students in clinical situations must be assigned activ-
Nursing students are responsible for their own actions
ity within their capabilities and be given reasonable guid-
and liable for their own acts of negligence committed
ance and supervision. Nursing instructors are responsible
during the course of clinical experiences. When they
for assigning students to the care of clients and for
perform duties that are within the scope of professional
providing reasonable supervision. Failure to provide rea-
nursing, such as administering an injection, they gener-
sonable supervision or the assignment of a client to a
ally share the responsibility with the instructor, health
student who is not prepared and competent can be a
care facility, and educational institution. Communication
basis for liability.
among all individuals must be clear and unambiguous in
To fulfill responsibilities to clients and to minimize
relation to goals and objectives to be achieved to meet the
chances for liability, nursing students need to:
students’ needs during the clinical experience. “Student
nurses are not held to a standard of perfection; rather, • Make sure they are prepared to carry out the necessary
they are held to the standard of their peers” (Phillips, care for assigned clients.
2007, p. 2), that is, their level within the program. • Ask for additional help or supervision in situations for
In the past, in cases arising from negligent acts by which they feel inadequately prepared.
nursing students, the student was traditionally treated as an • Comply with the policies of the agency in which they
employee of the hospital, which was held liable under the obtain their clinical experience.
doctrine of respondent superior. Today, nursing students are
not usually considered employees of the agencies in which • Comply with the policies and definitions of responsibil-
they receive clinical experience because nursing programs ity supplied by the school of nursing.
usually contract with agencies to provide clinical expe- Students who work as part-time or temporary nurs-
riences for students. Most educational institutions have ing assistants or aides must also remember that legally
protection related to negative outcomes related to student they can perform only those tasks that appear in the job
performance within their legitimate scope of practice. Stu- description of a nurse’s aide or assistant. Even though
dents carrying out actions outside of their educated scope a student may have received instruction and acquired
are not necessarily protected by such policies. competence in administering injections or suctioning a
Managing legal risks means first considering the tracheostomy tube, the student cannot legally perform
competence of the student. The responsibility for ensur- these tasks while employed as an aide or assistant. When
ing that the clinical experience is safe is shared by the acting as a paid worker, the student is covered for negli-
student, the educational institution, the health care gent acts by the employer, not by the school of nursing.
Case Study 6
Mrs. Jiminez is in the Royal Victoria Hospital in Montreal and will be here shortly, and he is expecting this
is not progressing well following extensive surgery for gastro- permit to be signed, so will you please sign
intestinal cancer. She has experienced severe weight loss and it now?”
has little desire to eat. Dr. Jones, the physician, has elected
to place a subclavian catheter to administer total parenteral
nutrition. Dr. Jones telephones the nursing unit and requests
that the nurse obtain the patient’s informed consent for this CRITICAL THINKING QUESTIONS
invasive procedure. The nurse completes the procedural con-
sent form according to the physician’s orders and goes to Mrs. 1. When the nurse takes the consent form into Mrs.
Jiminez’ room. Jiminez’ room for her to sign, is the patient actually
The nurse informs Mrs. Jiminez that the physician plans signing a valid consent?
to place a catheter into her subclavian vein so that addi- 2. What is the difference between informed consent and
tional nutrients can be administered to her. The nurse further signing a consent form?
explains that these nutrients will help Mrs. Jiminez heal and
regain her strength. In making decisions, Mrs. Jiminez often 3. Evaluate the nurse’s approach to Mrs. Jiminez regarding
relies on her eldest son because “he knows best.” Mrs. this invasive procedure.
Jiminez asks, “Will it hurt? I’m so tired of all this pain, I’m not 4. Who is responsible for obtaining the consent?
sure I want anything else done.” The nurse replies, “Oh, don’t
worry, we’ll make sure you don’t feel a thing. Your doctor Visit MyNursingLab for answers and explanations.
M06_KOZI2703_04_SE_C06.indd 102 20/02/17 2:00 PM

KEY TERM S
adverse event confidentiality p. 97 implied consent regulatory bodies
reporting p. 96 contract p. 89 p. 94 p. 87
assault p. 93 contractual informed consent standards of care
assigning duties obligations p. 90 p. 94 p. 89
p. 89 contractual intentional torts substitute decision
battery p. 93 relationships p. 90 p. 93 makers p. 95
capacity p. 94 critical incident p. 96 invasion of privacy tort p. 90
certification p. 88 delegating care p. 89 p. 94 tort law p. 87
civil law p. 86 disclosure p. 94 law p. 86 vicarious liability
common law p. 86 express consent p. 94 licensure p. 87 p. 90
competent care p. 89 false imprisonment negligence p. 91 voluntariness p. 94
confidential p. 93 privacy p. 97 whistle-blowers p. 101
information p. 97 Good Samaritan p. 99 registration p. 87

• Accountability is an essential concept of professional failed to carry out that duty according to standards,
nursing practice. (c) the client (plaintiff) was injured, and (d) the client’s
• Nurses need to understand laws that regulate and affect injury was caused by the nurse’s failure to follow the
nursing practice to ensure that their actions are consistent standard.
with current legal principles and to protect themselves • The nurse is responsible for ensuring that the informed
from liability. consent of a client is complete before nursing treatment
• In Canada, the regulation of nursing is a function of the regimens and procedures begin.
provinces and territories. • Informed consent implies that (a) the consent was
• Nursing has been granted an exclusivity of practice (a given voluntarily, (b) the client had the capacity and
right of self-government or self-regulation). competency to understand, and (c) the client was given
enough information with which to make an informed
• Professional regulation in nursing practice is determined decision.
and maintained by licensure and registration, continuing
competence programs, discipline and certification, in the • Good Samaritan and emergency medical aid acts pro-
public interest. tect health care professionals from claims of malpractice
when they offer assistance at the scene of an emergency,
• Scope of practice and standards of practice are devel- provided that no willful wrongdoing or gross departure
oped and published by provincial and territorial nursing from normal standards of care takes place.
regulatory bodies.
• Nurses can obtain professional liability protection through
• Agency policies, procedures, and job descriptions further the Canadian Nurses Protective Society.
delineate a nurse’s practice, but they cannot increase the
scope of practice. • Selected legal aspects of nursing practice include issues of
confidentiality and privacy, informed consent, the carry-
• The nurse has specific legal obligations and responsibili- ing out of physicians’ orders, quality documentation, and
ties to clients, employers, and the profession. As a citizen, problematic substance use.
the nurse has the rights and responsibilities shared by all
individuals in the society. • Problematic substance use and chemical dependency in
health care workers can occur because of the high levels
• Nursing regulatory bodies are also responsible for of stress involved in many health care settings and the
accountability and discipline in nursing. easy access to addictive drugs. Chemical impairment
• Legal roles in nursing vary according to nurses’ roles includes the problematic use of alcohol and addictive
as provider of service and employee or contractor for drugs. The nurse needs to know the proper methods
service. for reporting nursing colleagues who are chemically
• Nurses can be held liable for unintentional torts, such as impaired.
negligence, and for intentional torts, such as invasion of • Nursing students need to make certain that they are pre-
privacy, assault, and battery. pared to provide the necessary care to assigned clients
• Negligence of nurses can be established when (a) the and to ask for help or supervision in situations for which
nurse (defendant) owed a duty to the client, (b) the nurse they feel inadequately prepared.
M06_KOZI2703_04_SE_C06.indd 103 20/02/17 2:00 PM


1. Which of the following situations most accurately illus- 6. Which of the following is an accurate reflection of pro-
trates the concept of an unintentional tort? vincial or territorial documentation standards?
a. A community health nurse reports a client’s communi- a. Failure to meet these standards would not destroy
cable infectious disease to the public health department. the nurse’s defence in a lawsuit as he or she would be
b. A nurse provides emergency assistance to a person protected by the professional association.
who collapsed in a grocery store; this person dies. b. The courts look only at the documentation done by
c. A student nurse performed a procedure safely but the physician.
forgot to have the instructor supervise the procedure c. Failure to meet these standards could result in disci-
according to agency policy. plinary action against individual nurses.
d. A surgical nurse catheterizes a client without clean- d. Documentation is used strictly as a means of com-
ing the perineum, and this client gets a urinary tract munication between health care professionals and is
infection (UTI). not used by the courts in a lawsuit.
2. Which is an example of application of common law? 7. What is true regarding the clinical practice of student
nurses?
a. The provincial government passes tougher laws with
regard to drinking and driving. a. Student nurses are legally considered employees of
the clinical agency.
b. A court judge rules against a nurse named in a lawsuit
on the basis of similar decisions in previous cases. b. The nursing instructor and school of nursing are solely
accountable for client care administered by students.
c. The federal government establishes new tax legislation.
c. The school of nursing has sole responsibility for
d. Provincial/territorial nursing regulatory bodies estab-
ensuring students are competent to practise.
lish new practice standards.
d. Student nurses are responsible for their own actions
3. Which is true about licensure in Canadian nursing? and liable for their own acts of negligence commit-
ted during the course of clinical experiences.
a. It is a legal method to control the standards of the
nursing profession. 8. What is the most accurate definition of capacity in as it
b. Standards for licensure are established and regulated relates to informed consent?
by the Canadian Nurses Association (CNA). a. A clear statement of consent by the client that can
c. It applies only to those nurses returning to the probe either oral or written
fession who have completed a refresher course. b. The provision of information, including the risks of
d. Membership in each provincial or territorial nursing treatment, alternative treatment, and its associated
association does not require licensure. facts and risks
c. An understanding of the nature of the decision to be
4. Which is most accurate regarding nursing liability? made and the consequences of the decision, includ-
a. Nursing liability refers to not accepting responsibility ing the decision to decline the treatment
for one’s own actions. d. The client’s right to come to a decision without
b. A nurse can be held legally liable, even though the force, coercion, or manipulation from others
client did not sustain injury, damage, or harm.
c. Nurses can deny responsibility for a harmful act or 9. Which of the following would suggest a situation of
inaction on the grounds that someone else was also potential liability for a nurse?
involved. a. A child admitted to the unit is too weak to be
d. Nurses are legally responsible for harm caused to a weighed. The nurse obtains a verbal estimate from
client by an inappropriate nursing action or by a fail- the mother, documents the situation and the child’s
ure to perform a required nursing action. estimated weight, and ensures that the procedure is
done when safe to do so.
5. A client, alert and oriented, refuses to take an antipsy- b. A client, who is very obese, has come to the unit
chotic medication that the nurse brings to her. She states, after abdominal surgery. As the nurse cares for
“I don’t like the way it makes me feel.” What would be him the next day, he continues to refuse to get out
the most legally prudent nursing action to take? of bed and walk. The nurse documents the situ-
a. Tell the client that the medication is prescribed for ation, informs the charge nurse, and continues to
her and she should take it and then report the inci- encourage the client by exploring other related
dent to the charge nurse. range-of-motion exercises and teaching related to the
importance of walking after surgery.
b. Crush her medication and administer it in her food.
c. While admitting an older client to the unit, the daughter
c. Ask her son to convince her to take the medication. informs the nurse that her mother sometimes coughs
d. Withhold the medication, talk to the client about the and even chokes when she is eating. At dinner, the nurse
importance of taking the medication, document the informs the care aide that the client can feed herself and
incident, and notify the physician. can be left alone as long as she sits up to eat.
M06_KOZI2703_04_SE_C06.indd 104 20/02/17 2:00 PM

d. The nurse questions the physician about an order the registered nurse when providing feedback to the
for an antihypertensive medication dose that seems attendant?
rather high. After checking with the pharmacist, who a. Clients should be able to address by name those car-
feels the dose is high but safe, the nurse gives the ing for them.
medication, documents the client’s response to the
b. Young people do not understand the various levels
medication (low blood pressure), and ensures that the
of nursing staff.
risk for falls is noted on the client’s care plan.
c. All health care workers giving basic care to clients may
10. A personal care attendant introduces herself to a client, introduce themselves as a member of the care team.
18 years of age, by saying, “I am the nurse who will d. Clients should know the title and responsibilities of
give you a bath today.” Which principle should guide those providing their care.
REFERENCES
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substance misuse or abuse: RNABC’s role. Nursing BC, 36(2), number: HPRP 6795–15–5760009).
13–15. Etchells, E., Sharpe, G., Elliott, C., & Singer, P. (1999). Capacity. In
Black’s law dictionary (8th ed.). (2004). St. Paul, MN: Thomson West P. Singer (Ed.), Bioethics at the bedside: A clinician’s guide (pp. 17–24).
Publishing. Ottawa, ON: Canadian Medical Association.
Borg, E. (2008). Hydromorphone: Handle with care. Canadian Nurse, Fraser, R., & Parisi, L. (2006). The legal framework for health
104(1), 35. agencies and services. In J. Hibbard & D. Smith (Eds.), Nursing
Canadian Nurses Association. (2007a). Position statement on advanced management in Canada (3rd ed.). Toronto, ON: W. B. Saunders.
nursing practice. Ottawa, ON: Author. Gaudine, A., Lefort, S., Lamb, M., & Thorne, L. (2011). Clinical ethi-
Canadian Nurses Association. (2007b). Understanding self-regula- cal conflicts of nurses and physicians. Nursing Ethics, 18(1), 9–19.
tion. Nursing Now: Issues and Trends in Canadian Nursing, 21, 1–5. Government of Saskatchewan. (2004). Saskatchewan critical incident
Canadian Nurses Association. (2008a). Advanced nursing practice: A reporting guideline. Regina, SK: Author.
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Canadian Nurses Association. (2008b). Code of ethics for registered Saddle River, NJ: Prentice Hall.
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Canadian Nurses Association. (2009). Problematic substance use by The ethical dilemma of whistle-blowing. In Ethics in Practice
nurses. Ottawa, ON: Author (pp. 1–4). Ottawa, ON: Canadian Nurses Association.
Canadian Nurses Association. (2011). I think my colleague has a Institute for Safe Medication Practices Canada. (2004). Event analysis
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Canadian Nurses Association & Canadian Federation of Nurses Deer, AB: Author.
Unions [CFNU]. (2015). Practice environments: Maximizing Irvine, J. C., Osborne, P., & Shariff, M. (2013). Canadian medical
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The role of the nurse. InfoLAW, 3(2). Ottawa, ON: Author. nursing (3rd ed.). Toronto, ON: Mosby Elsevier.
Canadian Nurses Protective Society. (1998). Vicarious liability. King, M. C. (2011). An introduction to the Health Professions Act. Calgary,
InfoLAW, 7(1). Ottawa, ON: Author. AB: Calgary Regional Health Authority.
Canadian Nurses Protective Society. (2004a). Negligence. InfoLAW, Lebel v. Roe, [1994] Y.J. No. 62.
3(1). Ottawa, ON: Author. Linden, A. M., & Feldthusen, B. (2011). Canadian tort law (9th ed.).
Canadian Nurses Protective Society. (2004b). Independent practice: Toronto, ON: LexisNexis Canada.
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Canadian Nurses Protective Society. (2006). Collaborative practice: Are safer system: A national integrated strategy for improving patient safety in
nurses employees or self-employed? Ottawa, ON: Author. Canadian health care. Ottawa, ON: Author.
Canadian Nurses Protective Society. (2007). Quality documentation: Office of the Privacy Commissioner of Canada. (2004). Fact sheet:
Your best defence. InfoLAW, 1(1). Ottawa, ON: Author. Questions and answers regarding the application of PIPEDA, Alberta and
Canadian Nurses Protective Society. (2008). CNPS Plus: An British Columbia’s Personal Information Protection Act (PIPAs). Retrieved
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http://www.cnps.ca/cnps_plus/index_e.html. Phillips, E. (2006). Is there a risk in being a Good Samaritan? Retrieved
Canadian Nurses Protective Society. (2009). Consent for the inca- from http://www.cnps.ca/members/publications/articles/good_
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Canadian Nurses Protective Society. (2012). Social media. InfoLAW, Phillips, E. (2007). Managing legal risks in preceptorships. Retrieved from
19(3). Ottawa, ON: Author. http://www.cnps.ca/members/publications/articles/preceptor/
Canadian Nurses Protective Society. (2014). Legal risks of email preceptor_e.html.
(Part 1 and 2). InfoLAW, 22(2,3). Ottawa, ON: Author. Picard, E., & Robertson, G. (2007). Legal liability of doctors and
Canadian Nurses Protective Society. (2015). A “right to life” is not a hospitals in Canada (4th ed.). Toronto, ON: Carswell.
“duty to live.” Ottawa, ON: Author. Royal College of Physicians and Surgeons of Canada. (2013).
Canadian Patient Safety Institute. (2011). Canadian disclosure guidelines. Medical decision-making and mature minors. Available at http://
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toolsResources/disclosure/Documents/CPSI%20Canadian%20 decision-making-mature=minors-e
Disclosure%20Guidelines.pdf. Edmonton, AB: Author. Sharpe, G. (1993). Consent and minors. Health Law Canada, 13,
Downie, J., Lahey, W., Ford, D., Gibson, E., Thomson, M., Ward, 197–207.
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M06_KOZI2703_04_SE_C06.indd 105 20/02/17 2:00 PM

UNIT 2
7
Contemporary
Chapter Health Care in

Canada
Health, Wellness,
and Illness
Updated by
Lucia Yiu, BSc, BA, MScN
Associate Professor, Faculty of Nursing, University of Windsor
F
LEARNING OUTCOMES
After studying this chapter, you will be able to or many years, the
1. Explain the concepts of health, wellness, and well-being. focus for health was on
treatments and cures
2. Explain the common models of health and wellness.
for diseases. Today, the emphasis
3. Discuss primary prevention, secondary prevention, and tertiary
is on promoting health and wellness
prevention.
in individuals, families, and commu-
4. Differentiate illness from disease and acute illness from chronic
nities. Peoples’ health beliefs influ-
illness.
ence their health practices. Similarly,
5. Describe the effects of illness on the roles and functions of
nurses’ understanding of health and
individuals and families.
wellness will determine the scope
6. Discuss factors that determine health.
and nature of their nursing practice.
Throughout this chapter, the word
clients refers to patients in hospi-
tals as well as those in community
settings.
M07_KOZI2703_04_SE_C07.indd 106 17/03/17 10:56 AM

Chapter 7 Health, Wellness, and Illness 107
Concepts of Health, Box 7.1 Developing a Personal

Definition of Health
Wellness, and Well-Being Nurses can reflect on the following questions to explore
their personal definition of health. In what way:
Health, wellness, and well-being have many definitions and • Is a person more than a biophysiological system?
interpretations. Nurses must be familiar with their con- • Is health more than the absence of disease symptoms?
ceptual commonalities and consider how each term is
• Are health and wellness the same?
individualized with specific clients.
• Are disease and illness different?
• Is health static or changing?
Health • Are wellness, health, and illness separate entities or
points along a continuum?
Health is a state of being well and using every power • Is health the ability of an individual to adapt to the
that individuals possess to the fullest extent (Nightingale, environment?
1960/1969). The World Health Organization (WHO) • Is health a condition of a person’s actualization?
defines health as “a state of complete physical, mental, • Is health the effective functioning of self-care activities?
and social well-being, and not merely the absence of dis- • Is health socially determined?
ease or infirmity” (WHO, 1948). This definition reflects
• How do you rate your health, and why?
a concern for the functioning of individuals physically,
psychologically, and socially within their environments.
Peoples’ lives and health are affected by all interactions
self-responsibility; an ultimate goal; a dynamic, growing
with their environments. These environmental interac-
process; daily decision making in the areas of nutrition,
tions may include such elements as climate, food, shelter,
stress management, physical fitness, preventive health
clean air, and water, as well as interactions with family,
care, and emotional health; and, most importantly, the
friends, employers, coworkers, and community at large.
whole being of the individual.
Health has also been defined in terms of roles and per-
According to Employment and Social Development
formance. Talcott Parsons (1951) conceptualized health as
Canada (ESDC, 2015), well-being refers to quality of
the ability to maintain normal roles. Marc Lalonde, federal
life and individual and societal well-being. Ten indicators
Minister of Health (1974), in his report A New Perspective on
influence individual and societal well-being. Individual
the Health of Canadians, presented the health field concept,
well-being includes such factors as personal values,
which included human biology, environment, lifestyle, and
relationships with community, family and friends, work,
health care organizations. This landmark document shifted
health, and financial situation. Societal well-being
the focus of care from treatment to the importance of life-
includes the collective well-being of people and the qual-
style and environmental factors for health (see Figure 8.1 on
ity of interactions between and among people and their
page 121, Lalonde’s health field concept).
social institutions, for example, communities, the health
Personal Definition of Health Health is a highly care system, the education system, and the social security
individualized perception. People may say they feel healthy, system.
even though they have physical challenges that some would
consider illnesses. A person can view health as having fewer
symptoms of disease and pain, being active, or remaining Areas of Well-Being
in good spirits. It is a way of life through which the body, The following summarizes the 10 indicators of well-
mind, and emotions interrelate harmoniously. being (ESDC, 2015):
Many factors affect individual definitions of health,
including an individual’s previous experiences, expecta- 1. Work. Individuals may obtain their purpose in life
tions of self, age, and sociocultural influences. How people through their work accomplishments and monetarily
define health influences their behaviours. By understand- meet their basic and other needs through work. The
ing clients’ perceptions of health and illness, nurses can Canadian economy remains competitive when people
provide more meaningful assistance to help them regain are employed, which promotes societal well-being.
or attain a state of health. Nurses should be also aware 2. Housing. Individual and societal well-being may suf-
of their own personal definitions of health and appreciate fer when safe and affordable housing is inadequate or
that other people will have their unique definitions. See unavailable.
Box 7.1 on developing a personal definition of health. 3. Family life. Families influence individual and societal well-
being through their participation in the community and
the provision of social, physical, and emotional supports.
Wellness and Well-Being 4. Social participation. Trust and a sense of belonging pro-
Wellness is a state of well-being, which is also a com- mote the level of participation of individuals within
ponent of health. The basic concept of wellness includes their communities. Social networks are strengthened
M07_KOZI2703_04_SE_C07.indd 107 27/01/17 5:26 PM

108 UNIT TWO Contemporary Health Care in Canada
through volunteerism, recreational and sports partici-

pation, and political activism.
5. Leisure. Participating in enjoyable activities that reduce
North
stress and promote growth and well-being are benefi-
Winter
cial to health, aging, and development.
Spiritual
6. Health. Mental and physical well-being may be Water
Purity
enhanced in those individuals who are in good health, Renewal
thus enabling individuals to participate in the growth Childhood
Introspections
Adolescence
Experience
Elderhood
Emotional
of the community’s health and well-being.
Physical
Wisdom
Spring
Clarity
East
Fire
Air
Fall
West
7. Security. Actual or perceived threats to safety will influ-
ence individual and community well-being. Adulthood
Love
8. Environment. Balancing the use and protection of the Trust
surrounding physical environment is important for the Earth
Mental
well-being of all. Summer
9. Financial security. The ways in which income is equita- South
bly distributed across society will influence individual
and societal well-being.
10. Learning. Training and education may improve quality
of life through the enhancement of skills and knowl- Figure 7.1 Aboriginal medicine wheel.
edge, thus offering new opportunities for individuals
within their communities. family, community, and nation, and (d) the giving away
Aboriginal Views of Wellness Health Canada of wisdom. Traditional healing practices focus on restor-
(2012) acknowledges the diversity within First Nations, ing balance when a disruption of developmental tasks
Inuit, and Métis groups. In all groups, however, there exists occurs during one of these life cycles. When working
a belief of the interconnectedness of Aboriginal people with Aboriginal people, it is important to remember that
with all creation. This connection includes family, commu- health care providers also bring their own culture and
nity, nation, plants, animals, and the spirit people, as well attitudes to the relationship; therefore, it is important to
as those who have died and those not yet born. In addi- provide care that is respectful and culturally safe.
tion, Aboriginal people have a strong sense to use mutual
decision making to plan for future generations, to believe
that they have the duty to family and to all creation, to
be observant of their surroundings, and to believe that all
Models of Health
members have special gifts that can benefit the community.
Hales and Lauzon (2014) describe the holistic world
and Wellness
view of health and wellness of Aboriginal people by using Because health is such a complex concept, various mod-
the medicine wheel. The medicine wheel has many els described below can be helpful in assisting health care
variations, but they all emphasize “the way of good life” or professionals to examine the health and wellness needs
“everyday good living” in the context of human behaviour of individuals.
and interaction. The term medicine refers to spiritual energy
and healing or enlightened experience. Aboriginal people
see the interconnectedness between the physical and spiri- Clinical Model
tual worlds and among the mind, body, and spirit; healing
The clinical model has the narrowest interpretation
is created when balance and harmony are attained in one’s
of health. It views people as physiological systems with
decisions and actions. Aboriginal people view themselves
related functions, and health is identified by the absence
as an integral part of the land and nature. The medicine
of signs and symptoms of disease or injury. Medical
wheel has four colours representing north, south, east,
practitioners focus on the relief of signs and symptoms
and west (Figure 7.1). These coloured directions refer to
of disease and elimination of malfunction and pain.
seeking healthy minds (East), strong inner spirits (South),
When these signs and symptoms are no longer present,
inner peace (West), and strong, healthy bodies (North). A
the individual’s health is considered restored.
medicine wheel encourages reflection on one’s life.
The conceptualization of the medicine wheel helps
understanding human development as following four Role Performance Model
sequential life cycles associated with specific developmen-
tal tasks, including (a) learning of belonging, (b) learning Health is defined in terms of an individual’s ability to
new skills and behaviours, (c) service for the benefit of fulfill societal roles, that is, to perform his or her work.
M07_KOZI2703_04_SE_C07.indd 108 27/01/17 5:26 PM

People usually fulfill several roles (e.g., mother, daughter,

friend), and certain individuals may consider nonwork
roles the most important ones in their lives. According
to this role performance model, people who can
fulfill their roles are healthy even if they have clinical Environment
illness. For example, a man who works all day at his job
as expected is considered healthy, even though he is par-
tially deaf. In this model, it is assumed that sickness is the
inability to perform one’s work role.
Agent Host
Adaptive Model
In the adaptive model, health is a creative process;
disease is a failure in adaptation, or maladaptation. The
aim of treatment is to restore the ability of the person
to adapt, that is, to cope. According to this model, FIGURE 7.2 The agent–host–environment triangle.
extreme good health is flexible adaptation to the envi-
ronment and interaction with the environment to maxi-
mum advantage. The famous Roy adaptation model of When the variables are in balance, health is maintained;
nursing (Roy, 2009) views the person as an adaptive sys- when variables are not in balance, disease occurs. The
tem (see Chapter 4). The focus of this model is stability, model has three dynamic, interactive elements:
although there is also an element of growth and change. 1. Agent. Any environmental factor or stressor (biological,
chemical, mechanical, physical, or psychosocial) that by
its presence or absence (e.g., lack of essential nutrients)
Eudaimonistic Model can lead to illness or disease.
The eudaimonistic model incorporates a comprehen- 2. Host. A person or people who may or may not be at risk
sive view of health. Health is seen as a condition of actual- of acquiring a disease. Family history, age, and lifestyle
ization or realization of a person’s potential. Actualization habits influence the host’s reaction to an agent.
is the apex of the fully developed personality, described 3. Environment. Includes all factors external to the host that
by Abraham Maslow (see Chapter 12). In this model, the may or may not predispose the person to the development
highest aspiration of people is fulfillment and complete of the disease. The physical environment includes climate,
development, which is termed actualization. Illness, in this living conditions, sound (noise) levels, and economic level.
model, is a condition that prevents self-actualization. The social environment can include interactions with oth-
Pender, Murdaugh, and Parsons (2011) include sta- ers and life events, such as the death of a spouse.
bilizing and actualizing tendencies in their definition
of health: “the realization of human potential through
goal-directed behavior, competent self-care, and satisfy- Illness–Wellness Continua
ing relationships with others while adapting to maintain The illness–wellness continua developed by
structural integrity and harmony with the social and Anspaugh, Hamrick, and Rosato (2011) ranges from
physical environments” (p. 22). optimal health to premature death (Figure 7.3). The
Another model of this type is that of Margaret Newman model shows arrows pointing in opposite directions and
(2008) who stated that health is the expansion of conscious- joined at a neutral point. Movement to the right of the
ness. The basic assumptions of this model or theory are as neutral point indicates increasing levels of health and
follows: Health is an evolving unitary pattern of the whole, well-being for individuals. This improvement is achieved
including patterns of disease. Consciousness is the informa- through health knowledge, disease prevention, health
tional capacity of the whole and is revealed in the evolv- promotion, and positive attitudes. In contrast, movement
ing pattern. Pattern identifies the human–environmental to the left of the neutral point indicates decreasing levels
process and is characterized by meaning (p. 6). of health. Some people believe that a health continuum
is overly simplistic and linear when the real concepts are
more complex than the diagram suggests.
Agent–Host–Environment Model
The agent–host–environment model (Figure 7.2) is used
to identify risk factors that result from the interaction of
Levels of Prevention
agent, host, and environment. Health is an ever-changing Prevention refers to avoiding the development of
state, and the goal is to promote and maintain health. disease and occurs in three levels: primary, secondary,
M07_KOZI2703_04_SE_C07.indd 109 02/03/17 9:50 AM

Wellness Paradigm
Premature High-Level
Death Disability Symptoms Signs Awareness Education Growth Wellness
Treatment Paradigm
© 1972, 1988, 2004, John W. Travis, MD
Neutral Point
(No discernible illness or wellness)
A.
No
discernible Neutral
illness power
Premature Disability Design Optimal

signs Positive
death Health knowledge attitude health
Traditional medicine
Disease prevention
Health promotion
Illness Below- Average Above- Wellness

average health average
health health
B.
Figure 7.3 Illness–wellness continua.

Source: Anspaugh, D. J., Hamrick, M., & Rosato, F. D. (2011). Wellness: Concepts and applications (8th ed.). New York, NY: McGraw-Hill. Used by permission of McGraw-Hill Education.
and tertiary (Leavell & Clark, 1965). Table 7.1 sum- Box 7.2 Examples of Healthy
marizes the levels and their foci and provides examples Lifestyle Choices
of prevention activities. The levels can occur at various
points during the course of a disease and can overlap • Regular exercise
in practice. For example, a client may have experienced • Weight control
a heart attack, and a goal of secondary prevention is • Avoidance of saturated fats
to give cardiac medications immediately to limit dis- • Responsible use of alcohol and tobacco avoidance
ability. Teaching (e.g., lifestyle changes) provided to the • Seat belt use
client to prevent new complications will be similar to • Bike helmet use
the health-education activities in primary prevention. • Immunization updates
Tertiary prevention includes the goal for the client to • Regular dental checkups
return home with follow-up appointments, such as for • Regular health maintenance visits for screening
cardiac rehabilitation. examinations or tests
See Box 7.2 on examples of healthy lifestyle choices.
M07_KOZI2703_04_SE_C07.indd 110 27/01/17 5:26 PM

Table 7.1 Levels of Prevention, Foci, and Activities
Level Focus Examples of Activities

Primary Focuses on health promotion and protection against • Teaching accident and poisoning prevention, immu-
prevention specific health problems or disease. Precedes nizations, family planning, nutrition, exercise, stress
disease or dysfunction and is applied to generally management, home and occupational safety; lifestyle
healthy individuals or groups and nutrition to prevent cancer or heart disease
Secondary Focuses on early identification or detection of health • Screening for developmental delays and hyperten-
prevention problems and prompts intervention to alleviate sion; tuberculosis skin test; clinical breast examina-
health problems and limit future disability tion and testicular examination; annual physical and
dental examinations
Tertiary Focuses on restoration and rehabilitation to the opti- • Teaching foot care to clients with diabetes
prevention mal level of functioning. Begins after an illness, • Teaching range-of-motion exercises to patients
when a defect or disability is stabilized or deter- who have suffered a cerebrovascular accident
mined to be irreversible
Health-Promotion Models Health Locus of Control Model

Locus of control is a concept from social learning the-
Several theories and models of health beliefs and behav- ory, which nurses can use to determine whether clients
iours have been developed to help determine whether are likely to take action with regard to their health, that
an individual is likely to participate in health-promotion is, whether clients believe that their health status is under
or disease-prevention activities. They are useful tools in their own control or others’ control. People who believe
developing programs that help people adopt healthier that they have a major influence on their own health
lifestyles and develop positive attitudes toward preven- status are called internals. People who exercise internal
tive health measures. (See the sections “Pender’s Health- control are more likely than others to take the initiative
Promotion Model” and “The Transtheoretical Model: on their own health care, be more knowledgeable about
Stages of Health Behaviour Change” in Chapter 8.) The their health, make and keep appointments with primary
Lifespan Considerations box describes ways to foster health care providers, maintain diets, and give up smoking. In
promotion through activities with clients of all ages. contrast, people who believe that their health is largely
Lifespan Considerations
activities that use the major muscle groups, at least

Physical Activity and Health 2 days per week
Children (5–11 Years) • Previous levels of exercise, which predict continued and
future participation in physical activity
• At least 60 minutes of moderate- to vigorous-intensity • Family obligations and work stressors, which influence the
activity per day, including activities that strengthen muscle ability to remain fit
and bone at least 3 days per week
• Improvement of well-being and self-esteem, increased
• Engaging in physical activities after school, instead of energy, reduced stress and positive mental health
watching television or using the computer
• Reduction in the risk of premature death and chronic
• Positive influence of physically active older siblings on diseases, such as osteoporosis, coronary heart disease,
younger siblings breast and colon cancers, and type 2 diabetes
Adolescents Older Adults

• At least 60 minutes of moderate- to vigorous-intensity • At least 150 minutes of moderate- to vigorous-intensity
activity per day, including activities that strengthen muscle physical activity per week, in bouts of 10 minutes or more,
and bone at least 3 days per week including muscle and bone strengthening activities that use
• Competitive team sports as a form of socialization for the major muscle groups, at least 2 days per week
teens • Physical activities that can enhance balance, prevent falls,
and improve mental alertness
Adults • Participating in personally enjoyable activities (e.g., walk-
• At least 150 minutes of moderate- to vigorous-intensity ing, golfing, or swimming) that will improve overall health
aerobic physical activity per week in bouts of 10 minutes • Physical group activities, including social time with friends
or more, including muscle and bone strengthening and family, which reduce feelings of social isolation
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Individual perceptions Modifying factors Likelihood of action
Demographic variables Perceived benefits of

(age, gender, race, ethnicity, etc.) preventive action
Sociopsychological variables minus
(personality, social class, peer Perceived barriers to
and reference-group preventive action
pressure, etc.)
Structural variables
(knowledge about the
disease, prior contact with
the disease, etc.)
Perceived susceptibility to
Likelihood of taking
disease X
Perceived threat of disease X recommended preventive
Perceived seriousness
health action
(severity) of disease X
Cues to action
Mass media campaigns
Advice from others
Reminder postcard from
physician or dentist
Illness of family member or
friend
Newspaper or magazine
article
FIGURE 7.4 The health belief model.

Source: Republished with permission of Wolters Kluwer Health, from Becker, M. H., Haefner, D. P., Kasl, S. V., Kirscht, J. P., Maiman, L. A., & Rosenstock, I. M. (1977). Selected
psychosocial models and correlates of individual health-related behaviours. Medical Care, 15 (5 Suppl), pp. 27–46; permission conveyed through Copyright Clearance Center, Inc.
controlled by outside forces (e.g., chance or powerful oth- • Perceived threat. Perceived susceptibility and perceived
ers) are referred to as externals. seriousness combine to determine the total perceived
threat of an illness to a specific individual. For example,
a person who has high cholesterol, does not exercise,
Rosenstock and Becker’s Health and is the sole financial provider for the family may have
Belief Model an increased perceived threat of having a heart attack.
Rosenstock and Becker’s health belief model (HBM) MODIFYING FACTORS Factors that modify a person’s
(Rosenstock, Strecher, & Becker, 1988) is based on the perceptions include the following:
assumption that health-related action depends on the
• Demographic variables. Demographic variables include
simultaneous occurrence of three factors: (1) sufficient
age, gender, race, and ethnicity. An infant, for example,
motivation to make health issues viewed as important, (2)
does not perceive the importance of a healthy diet. An
belief that one is vulnerable to a serious health problem or
adolescent may perceive peer approval as more impor-
its consequences, and (3) belief that following a particular
tant than family approval and, subsequently, participate
health recommendation would be beneficial. The model
in risk-taking activities or adopt unhealthy eating and
includes individual perceptions, modifying factors, and
sleeping patterns.
variables likely to affect initiating action (Figure 7.4).
• Sociopsychological variables. Social pressure or influence
INDIVIDUAL PERCEPTIONS Individual perceptions from peers or other reference groups (e.g., self-help or
include the following: vocational groups) may encourage preventive health
• Perceived susceptibility. A family history of a certain dis- behaviours, even when individual motivation is low. The
order, such as diabetes or heart disease, may make the expectations of others may motivate people, for exam-
individual feel at high risk for having a heart attack. ple, not to drive after drinking alcohol.
• Perceived seriousness. The perception of the individual • Structural variables. Knowledge about the target disease
that the illness may cause death or have serious conse- and prior contact with it are structural variables that
quences, such as concern about having a heart attack are presumed to influence preventive behaviours. For
and the subsequent financial and lifestyle challenges. example, people who have had skin cancer may use
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sunscreen with a high sun protection factor (SPF) before BOX 7.3 FACTORS INFLUENCING ADHERENCE
going outside.
• Client motivation to become well
• Cues to action. Cues can be either internal or exter-
• Degree of lifestyle change necessary
nal. Internal cues include thoughts about an ill family
member. External cues include Internet and television • Perceived severity of the health problem
advertisements. • Value placed on reducing the threat of illness
• Ability to understand and perform specific behaviours
LIKELIHOOD OF ACTION The likelihood of a person • Degree of inconvenience of the illness itself or of the
taking recommended preventive health action depends regimens
on the perceived benefits of the action minus the per- • Beliefs that the prescribed therapy or regimen will or will
ceived barriers to the action. not help
• Perceived benefits of the action. Examples include refrain- • Complexity, side effects, and duration of the proposed
therapy
ing from smoking to prevent lung cancer, and eat-
• Cultural heritage, beliefs, or practices that support or
ing nutritious foods and avoiding snacks to maintain conflict with the regimen
weight control.
• Degree of satisfaction and quality and type of relationship
• Perceived barriers to action. Examples include cost, inconve- with health care providers
nience, unpleasantness, and lifestyle changes. • Overall cost of therapy
Pender, Murdaugh, and Parsons (2011) modified the
HBM to develop a health-promotion model. According
to Pender, the HBM explains health-protecting or preven- shortening of the normal lifespan. People once thought
tive behaviours but does not emphasize health-promoting disease was caused by “forces” or spirits. This belief was
behaviours (see the section “Pender’s Health-Promotion replaced by causation theory, according to which mul-
Model” in Chapter 8). tiple factors interact to cause disease and determine an
individual’s response to treatment.
The causation of a disease is called its etiology. For
Health Care Adherence example, a virus is the biological agent of severe acute respi-
ratory syndrome (SARS). However, other etiological factors,
such as age, nutritional status, and occupation, are involved
Adherence is the extent to which an individual’s behav-
in the development of SARS and the course of infection.
iour (e.g., taking medications as prescribed, following a diet
Illness can be acute or chronic. Acute illness is
plan, or making lifestyle changes) coincides with medical or
typically characterized by severe symptoms of relatively
health advice. Degree of adherence may range from disre-
short duration. The symptoms appear abruptly and
garding every aspect of the recommendations to following
subside quickly and, depending on the cause, may or
the total therapeutic plan. There are many reasons why
may not require intervention by health care provid-
some people adhere and others do not (see Box 7.3). The
ers. Some acute illnesses are serious (e.g., appendicitis
nurse must be aware that knowledge of health behaviours
may require immediate surgical intervention), but many
does not always translate into action. To encourage adher-
acute illnesses, such as colds, subside spontaneously with-
ence, nurses need to determine reasons for nonadherence
out medical intervention or after using over-the-counter
and ensure that the client is able to perform the activities,
(OTC) medications. Following an acute illness, most
understands the necessary instructions, is willing to take on
people return to their prior level of wellness.
the responsibility to establish goals of therapy, and values
Canadians living with chronic illnesses often require
the planned outcomes of behaviour changes.
the use of multiple resources to maintain self-management.
Chronic illness is a health priority because of increased
health care costs, and the incidence of older Canadians liv-
Illness and Disease ing with chronic illnesses is on the rise (Registered Nurses’
Association of Ontario, 2010). A chronic illness is one
Illness is a highly personal state in which the person’s that lasts for an extended period, usually 6 months or lon-
physical, emotional, intellectual, social, developmental, ger, and often for the person’s lifetime. Chronic illnesses
or spiritual functioning is thought to be diminished. It usually have a slow onset and often have periods of remis-
is not synonymous with disease and may or may not be sion, when the symptoms disappear, and exacerbation,
related to disease. An individual can have a disease, such when the symptoms reappear. Examples of chronic ill-
as diabetes, and not feel ill. Similarly, a person with a nesses are arthritis and diabetes mellitus. Nurses care for
headache can feel ill or uncomfortable and yet have no chronically ill individuals of all ages in all types of settings:
discernible disease. Illness is highly subjective; only the homes, nursing homes, hospitals, clinics, and other agen-
person experiencing it can say that he or she is ill. cies. Care should focus on promoting the highest level of
Disease can be described as an alteration in bodily independence and a sense of control in clients. Clients often
functions resulting in a reduction of capacities or a need to modify their activities of daily living (ADLs), social
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relationships, and perception of self and body image. Many

must learn how to live with increasing physical challenges EVIDENCE-INFORMED PRACTICE
and discomfort. Chronic illnesses may be best managed by
the client and a team of health care professionals who can How Do People with Dementia
help the client address various aspects of the illness.
Define their Quality of Life?
This collaborative qualitative study examined how persons
Effects of Illness living with dementia receiving home care perceived their
quality of life and what could be done to promote their well-
Illness changes the diagnosed individual and his or her being. The researchers interviewed a total of 136 partici-
family. The changes vary depending on the nature, sever- pants receiving home care in a community setting. These
ity, and duration of the illness; the attitudes associated participants defined “quality of life” as having increased
with the illness; financial demands; adjustments to usual access to nursing care, freedom and independence to
roles; and so on. make choices, their basic needs being met, good physi-
cal health, engaging in meaningful activities, and having
IMPACT ON THE CLIENT Clients with illnesses may expe- family support to meet their life’s goals. The researchers
rience behavioural and emotional changes, as well as changes concluded that self-determination and a caring environment
in lifestyle, self-concept, and body image. Behavioural and are needed to foster quality of life in people experiencing
emotional changes associated with short-term illness are dementia.
generally mild and short lived. The individual, for example, NURSING IMPLICATIONS: This study describes how
may become irritable and lack the energy or desire to inter- older adults with dementia define what health is and
act in the usual fashion with family members or friends. what good quality of life entails in relation to their life
Heightened responses are likely with severe, life-threatening, stage and health conditions. Nurses need to provide a
caring and supportive environment to enhance the qual-
chronic, or disabling illnesses. Anxiety, fear, anger, with-
ity of life of these individuals. An example that nurses
drawal, denial, a sense of hopelessness, and powerlessness can do is mobility assessments in older adults to pre-
are all common responses to severe or disabling illnesses. vent fall prevention. Nurses can educate older adults on
Certain illnesses can also change the client’s body the importance of active living or exercise therapy for
image or physical appearance, especially if it entails joint mobility or chronic pain management, as needed.
severe scarring or the loss of a limb. The client’s self-
Source: Based on Stewart-Archer, L. A., Afghani, A., Toye, C. M., & Gomez, F. A.
esteem and self-concept may also be affected (e.g., loss (2015). Subjective quality of Life of those 65 years and older experiencing dementia.
of bodily function, increased dependence on others, Dementia (London). doi: 10.1177/1471301215576227. Retrieved from http://dem.
sagepub.com/content/early/2015/03/17/1471301215576227.long
unemployment, and strained relationships with others).
(See Chapter 12.) Besides participating in treatments and
taking medications, the person with illness may need to the seriousness and length of the illness, and (c) the cultural
change his or her diet, activity, exercise, rest, and sleep and social customs the family follows.
patterns. See Evidence-Informed Practice box. The changes that can occur in the family include
Individuals with illness are vulnerable to loss of the following:
autonomy, which is the state of being independent and
self-directed without outside control. Nurses need to support • Role changes
clients’ right to self-determination and autonomy by provid- • Task reassignments and increased demands on time
ing them with sufficient information to participate in decision • Increased stress because of anxiety about the outcome
making and maintain feelings of control. Nurses can help of the illness for the client and conflict about new
their clients express their thoughts and provide care to help responsibilities
them effectively cope with change by doing the following:
• Financial problems
• Providing explanations about any necessary adjust- • Loneliness as a result of separation and pending loss
ments to the client and their significant others
• Change in social customs
• Making arrangements, wherever possible, to accommo-
date the client’s lifestyle
• Actively listening to clients as they share their feelings
about various changes
What Makes Canadians
• Reinforcing and incorporating desirable changes as a Healthy?
permanent part of the client’s lifestyle
Everything in the environment and society affects the
IMPACT ON THE FAMILY A person’s illness affects not health of individuals, families, and communities. Nurses
only the person who is ill but also the family or significant must maintain a spirit of inquiry and inquisitiveness about
others. The kind of effect and its extent depend chiefly on the world and the root causes of what determines health.
three factors: (a) the member of the family who is ill, (b) Box 7.4 describes the complex set of factors that determine
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the health conditions surrounding individuals, families, infected legs from this neighbourhood would you need to
communities, and nations. take care of if the roots of the problems continue?
This metaphor speaks about the importance of look-
ing beyond the immediate event when studying health.
Upstream and Downstream Views Nurses can make a difference every day in the lives of
patients or clients. As downstream thinkers, nurses act on
Imagine you are the nurse caring for Jason’s infected leg
the immediate problem at hand and provide only epi-
as described in Box 7.4. How many more children with
sodic care. Nurses who examine problems as upstream
thinkers promote and advocate for their clients’ health.
They invest not only in the biological factors but also in
BOX 7.4 WHAT MAKES CANADIANS HEALTHY?
the physical, psychological, cultural, spiritual, and socio-
This story speaks to the complex set of factors that determine economic factors associated with health.
health conditions.
Why is Jason in the hospital? Because he has a bad

infection in his leg. Social Determinants of Health
But why does he have an infection? Because he has a
“A health care system—even the best health care system in the
cut on his leg, and it got infected.
world—will be only one of the ingredients that determine
But why does he have a cut on his leg? Because he was whether your life will be long or short, healthy or sick, full
playing in the junk yard next to his apartment building, and
of fulfillment, or empty with despair.”
there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard? Because his —The Honourable Roy Romanow, 2004
neighbourhood is kind of run down. A lot of kids play (from Mikkonen & Raphael, 2010, p. 7)
there, and there is no one to supervise them.
It is not lifestyle choices or medical treatments that are
But why does he live in that neighbourhood? Because
the primary factors shaping Canadians’ health; instead,
his parents can’t afford a nicer place to live.
it is their experiences within their living environments.
But why can’t his parents afford a nicer place to live? These conditions are called the social determinants of health
Because his dad is unemployed and his mom is sick.
(Mikkonen & Raphael, 2010). The health of Canadians is
But why is his dad unemployed? Because he doesn’t largely shaped by access to quality housing and nutrition,
have much education and he can’t find a job. living conditions, how wealth is distributed, and so on; and
But why … ? these factors, among others, influence the range of health
inequities that exist.
Source: © All rights reserved. Toward a Healthy Future – Second Report on the The Public Health Agency of Canada (2003) uses
Health of Canadians. Public Health Agency of Canada, 2009. Adapted and repro-
duced with permission from the Minister of Health, 2016. a population health approach when examining the
health of Canadians. It is individuals’ interactions with
TABLE 7.2 Social Determinants of Health
Stress, Bodies, and Illness

Individuals living in adverse conditions experience excess psychological and physiological stress. When one experiences
prolonged stress, excess strain is placed on the body, which alters the metabolic, hormonal, and immune systems within the
body. Prolonged stress makes one more vulnerable to disease, illness, and coping choices that may be unhealthy.
Income and Income Distribution
The most important social determinant of health is income. Income influences the ability to purchase food, housing, and other
basic health prerequisites, and this affects psychological functioning. The health of a society can be predicted by examining
the income distribution within that society; equal distribution equates to a healthier society. Families with higher incomes were
more likely to save for their retirement and their children’s postsecondary education. Families with lower incomes placed greater
emphasis on saving for education (Statistics Canada, 2011).
Education
Literacy and education provide greater access to resources that bring about changes in society. Movement up the socioeconomic
ladder may also be attributed to education. As with the other determinants, this greater access is not gained in isolation and
influences other social determinants of health.
Unemployment and Job Security
Psychological stress, including depression and anxiety; social and material deprivation; and adapting unhealthy coping behaviours
may be the results of unemployment or lack of job security. Employment influences one’s daily life and provides a sense of
identity. Forcing one into part-time work and needing to seek employment with multiple jobs can lead to reduced health.
(continued)
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Employment and Working Conditions

Adverse working conditions, including long hours of work and not feeling valued, may lead to excess stress. This excess stress
may lead to the development of psychological and physical illnesses. Women, in particular, have reported that they are exposed
to too many daily demands and reduced time.
Early Childhood Development

The social and economic resources available to one’s family influence early childhood development. Latent and cumulative
effects of deprivation and loss may lead to lasting psychological, social, and physical influences on health well into adulthood.
Food Insecurity
Inadequate diet in terms of the quantity or quality of food may lead to dietary deficiencies. These deficiencies are associated with
the development of illnesses and difficulty with the management of those illnesses. Academic problems may develop in children
living in food-insecure households.
Housing
Homelessness, overcrowding, and inadequately maintained homes allow for the transmission of illnesses and may lead to
poor health and academic outcomes. Some Aboriginal people live in homes lacking even basic sanitation and clean water.
Social Exclusion
Chronic illness, crime, and a lack of educational attainment may be exacerbated due to social exclusion. Canadians who are
socially excluded, such as women, people with disabilities, new immigrants, and Aboriginal people, have reduced access to
cultural, economic, and social resources, and this leads to reduced health.
Social Safety Net

Services such as employment training, counselling, and community services lead to increased social cohesion. These supportive
social and financial services particularly help protect people’s health during unexpected life events.
Health Services
Many Canadians do not have private health insurance; therefore, the amount of out-of-pocket spending by individuals influences
other determinants of health. Although Canadian citizens enjoy the universality of health care, many treatments are not completed,
dental appointments are not kept, or prescriptions are not filled due to cost.
Aboriginal Status
Colonization, relocation of families, and residential schools have led to adverse health outcomes for many of Canada’s Aboriginal
peoples. Overcrowding in homes, food insecurity, and low income have caused increased rates of chronic illness and reduced
life expectancy.
Gender
Women most often do not have secure employment and earn lower wages compared with men. Men experience more
violence, homelessness, and reduced life expectancy during their lifetimes. Lesbian, gay, and transgendered Canadians
experience discrimination, which leads to adverse health outcomes.
Race
Racism negatively influences the health outcomes of individuals and society. Devaluing, government inaction, and segregation
influence health outcomes. Newcomers to Canada experience worsening health over time.
Disability
People with disabilities are more unemployed or are earning lower wages compared with those without any disability. Social
benefits provided to Canadians with disabilities are some of the lowest in the developing world, lessening their ability to participate
in society and meet the basic requirements of life.
Source: Copyright © 2010 Juha Mikkonen and Dennis Raphael.
their environments that have greater impacts on their improve the health of individuals and the overall health
health than do individual lifestyle choices and behav- of Canadian society.
iours. Originating from the Lalonde Report (1974), the
12 determinants of health have been modified to include
the 15 social determinants of health listed in Table 7.2.
Advocating for public policies that strengthen the Summary
health of Canadians, educating Canadians about the
influence of the determinants of health on health, Nurses play an important role in helping their clients attain
and lobbying political offices and agencies to allocate optimal health. Future health care will need to be client
resources that support a broader view of health will centred, respect people’s values, avoid fragmentation of
M07_KOZI2703_04_SE_C07.indd 116 02/03/17 1:16 PM

care, and ensure equitable access to services while maxi- health care and human resources. It will be the norm for
mizing financial, human, and structural resources (South health care providers and clients to share the responsibil-
West Local Health Integration Network, 2009). The ity for health and wellness. An understanding of various
future of health care includes enhancing the capacity for approaches to health will enhance health care providers’
community-based care, increasing access and sustainability ability to impart knowledge on health, identify the root
for hospital-based care, integrating information technology causes of problems, reduce barriers, and support positive
systems, and improving accountability and leadership for actions toward good health (see Case Study 7).
Case Study 7
Russel and Rayne have both suffered heart attacks; they live
near downtown Toronto and are members of the Anishnawbe
2. Both Russel and Rayne have heart disease. Russel
considers himself to be well, whereas Rayne considers
First Nation people. Russel, on advice from his traditional healer
himself to be ill. Explain this phenomenon on the basis of
and physician, requested a healing ceremony, started exercising,
the social determinants of health.
reduced his salt and fat intake, entered a stress-reduction pro-
gram, and with the support of his partner returned to work 6 weeks 3. What external factors may have influenced Russel’s
after his heart attack. He has a positive outlook, is doing well, and decision to implement positive health behaviours?
talks about “feeling well.” Rayne has also changed his dietary hab- 4. What factors may have prevented Rayne from developing
its and has started exercising; however, he has the same positive outlook and taking the same actions as
been unable to quit smoking, even though he Russel did to manage his illness?
wants to and has been advised to do so. Rayne
5. What nursing interventions would be most beneficial to
is frequently despondent, very fearful of having
Rayne with regard to his smoking problem?
another heart attack, has not yet returned to
work, and frequently talks about “feeling ill.”
Visit MyNursingLab for answers and explanations.
1. How does Russel’s psychological dimension of health

status differ from Rayne’s?
KEY TERM S
acute illness p. 113 exacerbation p. 113 locus of secondary
adaptive model p. 109 health p. 107 control p. 111 prevention p. 111
adherence p. 113 health belief model medicine societal
autonomy p. 114 (HBM) p. 112 wheel p. 108 well-being p. 107
chronic illness p. 113 health field concept p. 107 prevention p. 109 tertiary
clinical model p. 108 illness p. 113 primary prevention p. 111
disease p. 113 illness–wellness prevention p. 111 well-being p. 107
etiology p. 113 continua p. 109 remission p. 113 wellness p. 107
eudaimonistic individual role performance
model p. 109 well-being p. 107 model p. 109

• Nurses need to understand the concept of health because fillment of a person’s maximum potential for physical,
their personal definitions of health largely determine the psychosocial, and spiritual functioning.
scope and nature of their nursing practice. • Notions of health are highly individualized; the nurse
• Perspectives on health have changed; instead of being works with the client and the client’s perception of health
the absence of disease, health has come to mean the ful- to provide meaningful assistance.
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• Well-being is composed of 10 indicators and refers have been developed to help determine whether an indi-
to quality of life and individual and societal well-being. vidual is likely to participate in disease-prevention and
Individual well-being includes personal values, rela- health-promotion activities.
tionships with family and friends, and so on. Societal • Nurses can enhance health care adherence by identifying
well-being includes the quality of interactions between the reasons for nonadherence if it occurs, demonstrating
and among people and their social institutions, for exam- caring, and using positive reinforcement to encourage
ple, interactions with the health care system, and so on. healthy behaviours.
• Most people describe health as freedom from symptoms • Illness is usually associated with disease but may occur
of disease, the ability to be active, and a state of being in independently. Illness is a personal experience in which
good spirits. the person feels unhealthy or ill. Disease alters bodily
• Various models have been developed to explain health: functions and results in a reduction of capacities or a
clinical, role performance, adaptive, and eudaimonistic shortened lifespan.
models; Leavell and Clark’s agent–host–environment • An individual’s usual pattern of behaviour changes with
model; and the illness–wellness continua. illness, which may disrupt a person’s autonomy, lifestyle,
• The health status of a person is affected by many internal roles, and finances.
and external variables, over which the person has varying • The illness of one member of a family affects all other
degrees of control. members.
• Health belief and health behaviour models, such as • Various determinants significantly affect the health of
Rosenstock and Becker’s health belief model (HBM), individuals, families, and communities.
NCLE X- ST YLE PRACTI CE QUI Z

1. Mr. Smith is a 72-year-old man who lives alone in an apart- c. Middle-aged man receiving unemployment insurance
ment in an urban setting in Canada. He describes himself d. Newly arrived, young refugee who is pregnant
as healthy, self-sufficient, and financially secure. Mr. Smith
has no living relatives and states that he often feels sad and 5. A middle-aged homeless man has come into the clinic
lonely. He does his shopping at a grocery store across the with a generalized body rash. The client has strong
street and eats a well-balanced diet. Which health determi- body odour and appears very dirty. Which concept is
nant may have the most influence on Mr. Smith’s ability to most important for the nurse to understand?
maintain his health over the next few years?
a. The client needs education on proper bathing and
a. Income and income distribution hygiene practices.
b. Social exclusion b. Education regarding self-care hygiene practices is not
c. Housing going to be enough to change the client’s behaviours.
d. Gender c. Homeless people are always very dirty, and nothing
can be done to change that.
2. What altered health state is most often associated with d. Homeless people often do not care as much about
modified social relationships, change in body image, their hygiene as the rest of the population does.
and feelings of hopelessness?
a. Disability 6. A woman has an annual mammogram. She does not
b. Disease have a diagnosis of breast cancer or a family history of
this type of cancer. What is the most accurate descrip-
c. Chronic illness tion of this screening activity?
d. Acute illness a. Primary prevention
b. Secondary prevention
3. A woman is worried about her own health because her
mother and grandmother both had developed breast c. Tertiary prevention
cancer. What individual insights may subsequently influ- d. Health promotion
ence future prevention activities by this woman?
a. Perceived susceptibility 7. A new mother brings her newborn daughter to the
wellness clinic for a checkup. In the course of the assess-
b. Perceived seriousness ment, the nurse notices that the mother holds the baby
c. Sociopsychological variables only when necessary and does not communicate with or
d. Demographic variables look at her new baby. Believing this new family to be at
risk, the nurse offers support services of home care visits
4. Which individual is most at risk to have compromised and counselling. Which determinant of health is most at
health in the future? risk in this situation?
a. Transgendered high school student a. Social safety net
b. Older woman using the food bank b. Early child development
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c. Gender the following models is best illustrated in this client

d. Income and income distribution scenario?
a. Health belief model
8. A client has been exercising and calorie counting ever b. Clinical model
since being diagnosed with hypertension last fall. The
c. Role-performance model
client set a goal to have a reduction in blood pressure
over the next 6 months. What level of prevention is rep- d. Health and wellness model
resented in this scenario?
a. Primary prevention 10. A client sees a nurse at the vascular improvement
program (VIP). The client states, “I feel healthy, even
b. Secondary prevention
though I have vascular disease.” Which of the following
c. Tertiary prevention responses by the nurse is consistent with the generally
d. Disease prevention recognized definition of health?
a. “Health is influenced mainly by biology.”
9. A client was recently diagnosed with diabetes mel- b. “The definition of health is a personal belief.”
litus. The client is confident that he can control his
blood sugar with diet and exercise alone. He recently c. “Health is a state of complete physical, mental, and
checked out a video on the management of diabetes social well-being.”
at a community diabetes education centre. Which of d. “Health is defined as the absence of disease.”
R e f eren c es
Anspaugh, D. J., Hamrick, M., & Rosato, F. D. (2011). Wellness: Public Health Agency of Canada. (2003). What makes Canadians healthy
Concepts and applications (8th ed.). New York, NY: McGraw-Hill. or unhealthy—key determinant. Retrieved from http://www.phac-aspc.
Employment and Social Development Canada. (2015). Indicators of gc.ca/ph-sp/determinants/determinants-eng.php#income.
well-being in Canada. Retrieved from http://well-being.esdc.gc.ca/ Registered Nurses’ Association of Ontario. (2010). Strategies
misme-iowb/c.4nt.2nt@-eng.jsp?cid=14. to support self-management in chronic conditions: Collaboration with
Hales, D. R., & Lauzon, L. (2014). An invitation to health (4th Canadian clients. Toronto, ON: Registered Nurses’ Association of
ed.). Toronto, ON: Thomson Canada Ltd., Nelson Division. Ontario. Retrieved from http://rnao.ca/sites/rnao-ca/
Health Canada. (2012). The First Nations and Inuit Health Branch files/Strategies_to_Support_Self-Management_in_Chronic_
strategic plan: A shared path to improved health. Retrieved from Conditions_-_Collaboration_with_Clients.pdf.
http://www.hc-sc.gc.ca/fniah-spnia/pubs/strat-plan-2012/ Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social
index-eng.php. learning theory and the health belief model. Health Education
Lalonde, M. (1974). A new perspective on the health of Canadians. Quarterly, 12, 175–183.
Ottawa, ON: Government of Canada. Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle
Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in River, NJ: Prentice Hall.
his community (3rd ed.). New York, NY: McGraw-Hill. South West Local Health Integration Network. (2009). A healthier
Mikkonen, J., & Raphael, D. (2010). Social determinants of health: tomorrow: Integrated health service plan 2010–2013. Chatam, ON:
The Canadian facts. Toronto, ON: York University School of Author.
Health Policy and Management. Retrieved from http://www. Statistics Canada. (2011). Competing priorities—Education and retirement
thecanadianfacts.org/. saving behaviours of Canadian families. Retrieved from http://www.
Newman, M. A. (2008). Transforming presence: The difference that nursing statcan.gc.ca/pub/81-004-x/2011001/article/11432-eng.htm.
makes. Philadelphia, PA: F. A. Davis. World Health Organization. (1948). Preamble to the constitution of
Nightingale, F. (1960/1969). Notes on nursing: What it is, and what it is not. the World Health Organization as adopted by the International Health
New York, NY: Dover Books. (Original work published in 1860). Conference. New York, June 19–22, 1946; signed on July 22, 1946,
Parsons, T. (1951). The social system. Glencoe, IL: Free Press. by the representatives of 61 States (Official Records of the World
Pender, N. J., Murdaugh, C. L., & Parsons, M. J. (2011). Health promo- Health Organization, no. 2, p. 100) and entered into force on
tion in nursing practice (6th ed.). Upper Saddle River, NJ: Prentice Hall. April 7, 1948.
M07_KOZI2703_04_SE_C07.indd 119 27/01/17 5:26 PM

Chapter 8
Health Promotion
Updated by
H
LEARNING OUTCOMES
After studying this chapter, you will be able to ealth promotion is a
1. Describe the development of health-promotion initiatives in cornerstone of profes-

Canada. sional nursing prac-
2. Discuss the essential components of the following health-promotion tice (Community Health Nurses
models and documents: Lalonde Report, Ottawa Charter for Health of Canada, 2011). In the past
Promotion, Epp’s health-promotion framework, population health- 3 decades, the public has become
promotion model, the Jakarta Declaration, and Pender’s health-
increasingly aware of and interested
promotion model.
in the relationship between lifestyle
3. Describe the national health goals and the development process and illness. Many people are adopt-
specific to improving the health of Canadians.
ing health-promoting habits, such as
4. Differentiate health promotion from health protection and health being more physically active, balanc-
education.
ing stress and relaxation, maintain-
5. Identify various sites of health-promotion programs. ing good nutrition, achieving healthy
6. Explain the six stages of change in Prochaska’s transtheoretical weight, and controlling the use of
model. tobacco, alcohol, and other drugs.
7. Discuss the nurse’s role in health promotion. Health promotion is an important
8. Discuss how nursing process is applied to health promotion. component of nursing practice;
nurses must understand what health
promotion is to effectively prevent
illness and promote individual and
community health.
M08_KOZI2703_04_SE_C08.indd 120 17/03/17 10:57 AM

Chapter 8 Health Promotion 121
Development of An individual’s genetic Both physical and social,
Health-Promotion makeup, family history, the

processes of maturation
environments that
surround individuals and
Initiatives in Canada
and aging, and the shape behaviour,
physical or mental health positively or negatively,
challenges acquired over which they exert
during life variable control
Health promotion has been a practice dating back to
4000 BC with the Egyptians’ sewage disposal system,
feeding of the poor, and warnings about excessive alco- Biology Environment
hol consumption. Florence Nightingale was the very
first nurse to promote clean air and hygiene during the Lifestyle Health care
Crimean War in the 1800s. In the early 1900s, public organization
health movements in Canada focused on the control of Behaviour, which includes The human and physical
communicable diseases. At the turn of the twentieth cen- individual responses to resources that affect
tury, this work was exemplified by the Victorian Order internal stimuli or external access and provision of
conditions, as demonstrated health care services
of Nurses (VON) and by public health nurses promoting through the decisions by
nutrition and maternal and child health among the poor individuals that affect their
(Stamler & Yiu, 2016). See Chapter 1. risks and their subsequent
health status
Changing Focus in Public Health FIGURE 8.1 Lalonde’s health field concept.
(Post–World War II)
care organizations (see Figure 8.1). The concept marked a
Since World War II, continued advances in scientific shift from a medical approach to a behavioural approach
medicine and technology have led to marked improve- to health and put the emphasis on individuals’ responsi-
ment in health and mandatory public health measures, bility for their own health. Nevertheless, this approach
such as immunization, sanitation, water purification, and was heavily criticized for blaming people for their poor
the pasteurization of milk. These advances have led to health and failing to recognize the socioeconomic barri-
control of communicable diseases and prevented many ers to making healthy lifestyle choices.
illnesses and deaths. Union movements helped improve
working conditions and income. Economic improve-
ment also led to better housing and living conditions Epp Report (1986)
and improved nutrition. As Canadians enjoyed longer
life expectancy, chronic diseases (e.g., diabetes and heart By the mid-1980s, health promotion became a global dis-
disease), cancer, and accidents gradually replaced tuber- cussion, especially after the declaration of “Health for All
culosis, diarrhea, and influenza as the leading causes of by the Year 2000” by the World Health Organization (1978)
death. Public health practice began shifting its emphasis at the Alma-Ata conference in Russia. In 1986, Canada
from infection control to health-promotion activities hosted the first international conference on health promo-
by addressing risk factors, such as tobacco use, lack of tion in Ottawa and released Jake Epp’s (1986) Achieving
physical activity, and poor eating habits, that contribute Health for All: A Framework for Health Promotion
to various diseases (Stamler & Yiu, 2016). (Figure 8.2). Epp identified three health-promotion challenges:
1. Reducing inequities. Members of disadvantaged groups
have significantly shorter life expectancies, poorer
Lalonde Report (1974) health, and a higher prevalence of disability compared
With the passing of the Medical Care Act of 1966, with the average Canadian.
governments became responsible for financing a univer- 2. Increasing prevention. Various forms of preventable dis-
sal health care system with services that are accessible eases and injuries continue to undermine the health and
to all Canadians. In an effort to control the escalating quality of life of many Canadians.
health care costs, governments began to explore factors 3. Enhancing coping. Many Canadians suffer from various
that influenced the health of Canadians and evidence forms of chronic disease, disability, or emotional stress,
that supported health outcomes. This led to the first and they lack adequate community support to cope and
landmark health-promotion document in Canada, A live meaningful, productive, and dignified lives.
New Perspective on the Health of Canadians (Lalonde, 1974),
known as the Lalonde Report. Epp (1986) proposed three health-promotion mechanisms
Lalonde conceptualized the health field concept, to overcome these challenges:
which listed the four elements that determine health: 1. Self-care, or the decisions and actions individuals take
(a) biology, (b) lifestyle, (c) environment, and (d) health in the interest of their own health
M08_KOZI2703_04_SE_C08.indd 121 27/02/17 1:18 PM

Achieving Health
Aim
for All
Health Reducing Increasing Enhancing

Challenges Inequities Prevention Coping
Health-
Healthy
Promotion Self-Care Mutual Aid
Environments
Mechanisms
Implementation Fostering Public Strengthening Community Coordinating

Strategies Participation Health Services Healthy Public Policy
FIGURE 8.2 A framework for health promotion.

Source: © All rights reserved. Achieving health for all: A framework for health promotion. Health Canada, 1986. Adapted and reproduced with permission from the Minister of Health, 2016.
2. Mutual aid, or the actions people take to help one Health Promotion in Ottawa. This charter addresses the
another cope importance of a socioenvironmental approach to achiev-
3. Healthy environments, or the creation of conditions ing equity in health. It viewed health as a “resource for
and surroundings conducive to health everyday living” and identified the fundamental condi-
tions or prerequisites for health as peace, shelter, education,
Epp also suggested three key health-promotion implementation food, income, social justice, equity, sustainable resources,
strategies: and a stable ecosystem. The charter also stressed that
1. Fostering public participation
2. Strengthening community health services
3. Coordinating healthy public policy
Epp (1986) believed that decisions about health should
not belong exclusively to experts or governments. He
stressed the need for partnerships in health with all stakehold-
ers and the importance of public participation in implement-
ing health-promotion programs. As communities began to
see health as their prerogative, they took collective action
and led the healthy communities movement to improve social
and working environments. Such movement was first ini-
tiated in Toronto in 1984 and later spread worldwide
(Ontario Healthy Communities Coalition, n.d.).
Ottawa Charter for Health Promotion (1986)

The Ottawa Charter for Health Promotion (World
Health Organization, Health and Welfare Canada, &
Canadian Public Health Association, 1986), shown in FIGURE 8.3 The Ottawa Charter for Health Promotion.
Figure 8.3, was signed by delegates from 38 countries at Source: Reprinted from World Health Organization. The Ottawa charter for health promo-
tion, Health Promotion Emblem. Copyright © 1986. Retrieved from http://www.who.int/
the end of the 1986 First International Conference on healthpromotion/conferences/previous/ottawa/en/index4.html
M08_KOZI2703_04_SE_C08.indd 122 02/03/17 9:51 AM

individuals, government, and nongovernment sectors Chapter 7) were divided into five groups of population
must work in partnership for health. It outlined five health initiatives as follows:
health-promotion strategies and aims:
1. Social and economic environments: education, employment
1. Build healthy public policy—aim to make healthier and working conditions, income and social status, social
choices by adopting healthy public policy. support networks, and social environments
2. Create supportive environments—aim to generate safe, 2. Individual capacity and coping skills: healthy child develop-
stimulating, satisfying, and enjoyable living and working ment, biology and genetic endowment, gender
conditions. 3. Health services: health services
3. Strengthen community action—aim to empower 4. Physical environments: physical environments
communities to take ownership and control of their
5. Personal health practices: personal health practices and
own endeavours and destinies.
coping skills, culture
4. Develop personal skills—aim to assist people to make
informed choices so that they can have control over
their own health.
5. Reorient health services—aim to organize health, social, Population Health-Promotion
political, economic, and physical sectors by focusing on Model (1996)
the total needs of the individual.
Hamilton and Bhatti (1996) developed a population
health-promotion model, shown in Figure 8.5, to
Strategies for Population improve population health. The model integrated the
concepts of health-promotion strategies from the Ottawa
Health (1994) Charter for Health Promotion, the determinants of health
from the Strategies for Population Health, and the levels of
potential clients for intervention. These clients may be
With the severe global economic recession in the early individuals, families, communities, groups, or societies.
1990s, the need for all health services to demonstrate evi- This model presented four key questions for exami-
dence of health outcomes, accountability, cost-effectiveness, nation when implementing health-promotion actions:
and efficiency became more important than ever. The (a) what actions are being taken, (b) how these actions can
Canadian Institute of Advanced Research released a be implemented, (c) with whom the actions can be taken,
report, Strategies for Population Health: Investing in Health of and (d) why such actions are taken. It also emphasized
Canadians (Federal, Provincial, and Territorial Advisory the importance of research and evidence-based decision
Committee on Population Health, 1994). This report making.
sets the determinants of health at the centre of the frame-
work for population health (Figure 8.4) for planning action
to improve health. Evidence-based health outcomes
through research will be tracked and used to formu-
late public policy. The 15 determinants of health (see
Jakarta Declaration and Toronto Charter
for a Healthy Canada (1997–2002)
In the late 1990s, poverty, social and economic ineq-
uities, globalization, and environmental degradation
gained increasing recognition as threats to health. Social
Individual
Population
factors
determinants of health became the key themes in health-
Health Status
promotion discussions and resulted in the adoption of the
Determinants & 1997 Jakarta Declaration on Health Promotion
of Health
(WHO, 1997). Canada, together with other nations,
Personal Individual
health capacity and Collective affirmed social justice, equity, and sustainability as new
practices coping skills factors commitments for health promotion at the local, national,
Social and Physical Health and international levels. The Jakarta Declaration endorsed
economic environment services the Ottawa Charter for Health Promotion, as its principles
environment
were grounded in primary health care, social justice, and
Tools and Supports Foundations
for action community empowerment. It identified five priorities for
Research, information, and public policy
health promotion in the twenty-first century:
FIGURE 8.4 Framework for population health.

1. Promoting social responsibility for health
Source: © All rights reserved. Achieving health for all: A framework for health promotion. 2. Increasing investment for health development
Health Canada, 1986. Adapted and reproduced with permission from the Minister of
Health, 2016. 3. Consolidating and expanding partnerships for health
M08_KOZI2703_04_SE_C08.indd 123 25/02/17 2:00 PM

o
Wh
iety
Soc yst
em
to r/S ty
Sec uni
mm
Co ily
Inc
om Fam ual
e& ivid
So I n d nity
cia So mu
lS
up
cia
lS C om
po t en n
rt N atus gth Actio
tren ic
Ed e t S ubl
What
Wo uc wo yP
a t i rk a l t h
rkin o e y
How
Ph gC n ld H Polic
ysi on Bui ve
Bio c a d itio orti
log l Env ns S upp ts
Pe e n
rso y and ironm ativ me
na Ge ents Cre nviron
He & C Hea netil E kills
alt op lth cs o n al S
hy ing Pr ers
He Child Skill actic pP
s e v elo vice
s
a lth De e s D Ser
Ev C v re
id a el C a
• R enc re Ser opme Hea
lth
ng
e-B
es aki
vic nt n t
ea rie g
rnin
as es
r ch ed Reo nM a
io l Le
cis tia
•E De
va rien
lu ati xpe
on •E ns
Va tio
lu y
es u mp Wh
an s
d As
FIGURE 8.5 An integrated model of population health and health promotion.

Source: © All rights reserved. An integrated model of population health and health promotion. Public Health Agency of Canada, 2001. Adapted and Reproduced with permission from the
Minister of Health, 2016.
4. Increasing community capacity and empowering the interventions and strategies, (f) collaborating across sec-
individual tors and levels, (g) employing mechanisms for public
5. Securing an infrastructure for health promotion involvement, and (h) demonstrating accountability for
health outcomes. These elements cover a broad context
The 2002 Toronto Charter for a Healthy Canada (Raphael, of diseases and risk factors, and the framework supports
Bryant, & Curry-Stevens, 2004) further addressed the decision making for the desired health outcomes.
social determinants of health, their implications, and
policy development in such areas as early childhood
development, education, employment and working con-
ditions, food security, health care services, housing short- Health Goal for Canada
ages, income and its equitable distribution, social safety Nationally, Health Canada sets a health goal “for Canada
nets, social exclusion, unemployment, and job security. to be among the countries with the healthiest people in
the world” (Health Canada, 2014). It is committed to:
• Preventing and reducing risks to individual health and
A Population Health Approach: The the overall environment
Organizing Framework (2013) • Promoting healthier lifestyles
Initiated in 2006, the Public Health Agency of Canada • Ensuring high quality health services that are efficient
updated A Population Health Approach: The Organizing and accessible
Framework (2013), which focuses on eight elements essen-
• Integrating renewal of the health care system with
tial to improve the health of the population and reduce
longer-term plans in the areas of prevention, health
health disparities: (a) focusing on the health of the popu-
promotion, and protection
lation, (b) addressing the determinants of health and
their interactions, (c) basing decisions on evidence, (d) • Reducing health inequalities in Canadian society
increasing upstream investments to examine the root • Providing health information to help Canadians make
causes of a problem or a benefit, (e) applying multiple informed decisions (Health Canada, 2011)
M08_KOZI2703_04_SE_C08.indd 124 03/03/17 4:16 PM

Notably, Canada was once complimented as a world is not synonymous with health education. WHO (1998)
leader in health promotion. However, inequities in health defined health education as “consciously constructed
have been largely ignored because of various funding opportunities for learning designed to facilitate changes
priorities. There needs to be political and health care in behaviour towards a predetermined goal, and involv-
system leadership to invest adequately in disease preven- ing some form of communication designed to improve
tion and health promotion (Hancock, 2011). Ongoing health literacy, knowledge, and life skills conducive to
collaborative research in health promotion and translat- individual and community health” (p. 14). Health edu-
ing knowledge to practice must be fostered, and poli- cation, therefore, is a strategy of health promotion; it
cies must be established to address major health issues, is concerned with communication of information and
such as tobacco and drug use, obesity, mental health, fostering of motivation, skills, and confidence to take
poverty, early childhood development, diabetes, heart action to improve health.
disease, and Aboriginal health. Nurses must understand Central to health promotion is prevention. Leavell
the implications of various health-promotion initiatives and Clark (1965) described three levels of prevention dur-
for their practice. ing a course of disease progression (see Chapter 7 for
primary, secondary, and tertiary levels of prevention).
The notions of health promotion, health protection, and disease
prevention are significantly different. Pender, Murdaugh,
Defining Health Promotion and Parsons (2015) define health promotion as “behav-
iour motivated by the desire to increase well-being and
What, then, is health promotion? Health promotion actualize human health potential.” Health protection
is “a strategy that aims at informing, influencing, and involves activities focused on preventing, avoiding, or
assisting both individuals and organizations so that they minimizing injuries that individuals have little or no con-
will accept more responsibility and be more active in trol over and on preventable illnesses. Disease preven-
matters affecting mental and physical health” (Lalonde, tion is concerned with taking measures to prevent and
1974, p. 66). It involves any activity or program designed control common risk factors for diseases. Behaviours in
to improve the social and environmental living condi- both health protection and disease prevention are “motivated
tions that enhance people’s well-being (Labonte, 1992). by a desire to actively avoid illness, detect it early, or
Health promotion is also a process of enabling or empow- maintain functioning within the constraints of illness”
ering people to increase control over their health and to (p. 5). The major difference in these terms lies with the
improve their health by maximizing positive changes to underlying motivation for the individual behaviour (see
their physical, economic, social, and political environ- Table 8.1).
ments (Epp, 1986; Health Canada, 2005; WHO, 1984). Activities for health promotion, health protection,
Empowerment is a social action process “through and disease prevention are complementary processes
which people gain greater control over decisions and and are carried out for numerous reasons. For example,
actions affecting their health” (WHO, 1998, p. 16). suppose a 40-year-old male begins a program of walk-
Health promotion, therefore, is a philosophy, a process, ing five kilometres each day. If the goal of his pro-
and a multisectoral and sociocultural approach that gram is to decrease his risk of cardiovascular disease,
aims to enhance the health and well-being of individuals then the activity is considered disease prevention. By
and communities through policy formulation, supportive contrast, if the motivation for walking is to increase
environments, and health education. Health promotion his overall health and feeling of well-being, then it is
Table 8.1 Differences between Health Promotion and Health Protection and Disease Prevention
Health Promotion Health Protection and Disease Prevention
Aim To attain a higher level of wellness by modifying To increase resistance to harm by modifying
own behaviours and improving social, the environment to minimize preventable
environmental, and economic conditions illness or injury
Motivation Motivated by personal, positive desire for wellness Motivated by avoidance of harm or illness
Examples of • Stress management • Emergency responses

Activity Focus • Active living • Vehicle, water, food, and drug safety
• Nutrition • Infectious disease control
• Sexual health • Occupational health safety
• Injury prevention • Early detection of cancer (e.g., breast health)
• Smoking cessation • Health hazard investigation (e.g., chemical,
• Substance use and abuse radiation, and water)
• Responsible alcohol use
M08_KOZI2703_04_SE_C08.indd 125 30/01/17 1:36 PM

considered health-promotion behaviour. Health promo-

tion can be offered to all clients, regardless of their age Sites for Health-Promotion
or state of health. Age-specific health-promotion activi-
ties are discussed in Chapters 17 to 20. (See the Lifespan
Activities
Considerations box for examples of health-promotion
Health-promotion programs and activities can be offered
topics).
to individuals and families in their homes or in a com-
munity setting, such as schools, hospitals, or worksites.
Individual teaching or home visits can be costly, whereas
LIFESPAN CONSIDERATIONS group teaching is more cost-effective and can offer a set-
ting for socialization and peer support.
Community health-promotion programs are fre-
Health-Promotion Topics quently offered by health units, community health cen-
INFANTS tres, and nonprofit health agencies. These programs
Infant–parent attachment/bonding may include immunization, blood pressure screening,
Breast-feeding fire prevention information, bicycle safety programs for
Sleep patterns
children, and safe-driving campaigns for young adults.
School health-promotion programs serve as a foun-
Playful activity to stimulate development
dation for good health practices for children of all ages.
Immunizations
They are cost-effective and offer a convenient setting
Safety promotion and injury control
for health-promotion programs. The school nurse works
CHILDREN with teachers to plan and deliver information on vari-
ous health topics, such as basic nutrition, dental care,
Nutrition
activity and play, drug and alcohol use, domestic vio-
Dental checkups lence, child abuse, and issues related to sexuality and
Rest and exercise pregnancy.
Immunizations Worksite programs may address such issues as air
Safety promotion and injury control quality, accident prevention, back safety, blood pressure
screening, fitness information, and relaxation techniques.
ADOLESCENTS
Benefits to the employees can include an increased feel-
Communicating with teenagers ing of well-being, fitness, weight control, and decreased
Hormonal changes stress. Benefits to the employers can include an increase
Nutrition in productivity and better worker morale, decrease in
Exercise and rest absenteeism, and a lower rate of employee turnover,
Peer group influences all of which can help decrease business and health care
Self-concept and body image costs.
Sexuality Effective health-promotion activities should be
Safety promotion and accident prevention guided by models or conceptual frameworks for practice.
The rest of this chapter presents two common practice
ADULTS AND OLDER ADULTS models in health promotion, as well as the use of the
Adequate sleep
nursing process in health promotion.
Appropriate use of alcohol
Dental/oral health
Drug management
Exercise
Pender’s Health-Promotion
Foot health Model
Health screening recommendations
Hearing aid use Nola Pender’s revised health-promotion model (HPM),
Immunizations shown in Figure 8.6, considers the motivational source
Mental health for behaviour change that is based on how the cli-
Nutrition ent perceives the benefits of changing the given health
Physical fitness behaviour. Unlike the health belief model (see Chapter 7
Preventive health services for Rosenstock and Becker’s health belief model), the
Safety precautions HPM does not include “fear” or “threat” as a motivat-
Smoking cessation ing source for changing health behaviour (Pender et al.,
Weight control 2015). The variables in the revised HPM are described
in Figure 8.6.
M08_KOZI2703_04_SE_C08.indd 126 02/03/17 11:32 AM

Individual Behaviour-Specific Behavioural

Characteristics Cognitions Outcome
and Experiences and Affect
Perceived
benefits of action
Perceived Immediate competing

barriers to action demands
Prior (low control)
related and preferences
behaviour (high control)
Perceived
self-efficacy
Activity-related
affect
Commitment
Personal Health-promoting
to a
factor; behaviour
plan of action
biological, Interpersonal
psychological, influences
sociocultural (family, peers,
providers); norms,
support, models
Situational
influences;
options,
demand characteristics,
aesthetics
FIGURE 8.6 The health-promotion model (revised).

Source: Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2015). Health promotion in nursing practice (7th ed.) (pp. 345, 106–107). Reprinted and electronically reproduced by permission of
Pearson Education, Inc., New York, NY.
Individual Characteristics as family history. For instance, nurses could direct more
support and information to women with a strong family
and Experiences history of breast cancer by emphasizing the importance
The importance of an individual’s unique personal fac- of early detection and treatment and offering more hope
tors or characteristics and experiences depends on the for a cure. Helping to transform fear into hope through
target behaviour for health promotion. Personal factors early detection can make a difference in health attitudes
are categorized as biological (e.g., age, strength, bal- and behaviours.
ance), psychological (e.g., self-esteem, self-motivation),
and sociocultural (e.g., race, ethnicity, education, socio-
economic status). Some personal factors can influence Behaviour-Specific Cognitions
health behaviours, and some others, such as age, cannot and Affect
be changed. Prior related behaviour includes previous
Behaviour-specific cognitions and affect have major
experience, knowledge, and skill in health-promoting
motivational significance for acquiring and maintain-
actions. Individuals who received benefits from previ-
ing health-promoting behaviours, which can be modi-
ous health-promoting behaviours will engage in future
fied through nursing interventions. They include the
health-promoting behaviours. In contrast, a person with
following:
a history of barriers to achieving the behaviour remem-
bers the “hurdles” and will avoid making changes. • Perceived benefits of action: Anticipated benefits or out-
Nurses can assist by focusing on the positive benefits comes (e.g., physical fitness, stress reduction) affect the
of the behaviour, teaching how to overcome the barriers, person’s plan to participate in health-promoting behav-
and providing positive feedback for the client’s successes. iours and may facilitate continued practice. Prior posi-
Nursing interventions usually focus on factors that can be tive experience with the behaviour or observations of
modified, as well as those that cannot be changed, such others engaged in the behaviour is a motivational factor.
M08_KOZI2703_04_SE_C08.indd 127 21/02/17 10:26 AM

• Perceived barriers to action: A person’s perceptions about Immediate Competing Demands

available time, inconvenience, expense, and difficulty
performing the activity can act as barriers (imagined and Preferences
or real) to the individual’s commitment to a plan of Competing demands are those behaviours over which an indi-
action. vidual has a low level of control. For example, an unex-
• Perceived self-efficacy: This concept refers to the person’s pected work or family responsibility may compete with a
competencies in successfully carrying out the behav- planned visit to the health club, and not responding to this
iour needed to achieve a desired outcome, such as responsibility may cause a more negative outcome than
maintaining an exercise program to lose weight. Often, missing the exercise routine. Competing preferences are behav-
people who have serious doubts about their capabilities iours over which an individual has a high level of control;
decrease their efforts and give up, whereas those with however, this control depends on the individual’s ability to
a strong sense of efficacy exert greater effort to master be self-regulating or not give in. For example, a person who
problems or challenges. chooses a better-tasting high-fat food over a low-fat food
has given in to an urge based on a competing preference.
• Activity-related affect: The subjective feelings, such as
reaction to thinking about the behaviour, perceived
enjoyment, or unpleasant activities, that occur before,
during, and following an activity can influence whether
Behavioural Outcome
a person will repeat the behaviour or maintain the Health-promoting behaviour, the outcome of the health-
behaviour. A positive affect or emotional response to promotion model, is directed toward the client attain-
a behaviour is likely to be repeated, and behaviours ing positive health outcomes, such as improved health,
associated with a negative affect are usually avoided. enhanced functional ability, and better quality of life at
• Interpersonal influences: Interpersonal influences are all stages of development (Pender et al., 2015).
a person’s perceptions concerning the behaviours,
beliefs, or attitudes of others. Family, peers, and health
The Transtheoretical
care professionals are sources of interpersonal influ-
ences that can shape a person’s health-promoting
behaviours. Interpersonal influences include the
expectations of significant others, social support (e.g., Model: Stages of Health
emotional encouragement), and learning from obser-
vation or modelling.
Behaviour Change
• Situational influences: Situational influences have direct The Prochaska’s transtheoretical model (TTM)
and indirect effects on health-promoting behav- (Prochaska, Redding, & Evers, 2009), also known as
iours. They include perceptions of available options, change theory, is often used to promote positive behaviour
demand characteristics, and the aesthetic features of changes. The model views health behaviour change as a
the environment. An example of an individual’s per- cyclical phenomenon in which people progress through
ception of available options is easy access to healthy several stages. Take the “Leave the Pack Behind” (LTPB,
alternatives, such as vending machines and restaurants 2012) smoking cessation program as an example. In the
that provide healthful menu options. Demand charac- first stage, the person does not think seriously about
teristics can directly affect healthy behaviours through quitting smoke (changing a behaviour); by the time the
policies, such as a company regulation that mandates person reaches the final stage, he or she has successfully
that safety equipment be worn or that establishes a quit smoking (maintaining the change in behaviour). If
nonsmoking environment. Individuals are more apt to the person does not succeed in permanently quitting
adopt health-promotion behaviours if they are com- smoking (changing behaviour), relapse frequently occurs.
fortable in the environment versus feeling alienated. Figure 8.7 describes the six stages of change.
Environments that are considered safe as well as those
that are interesting are also desirable aesthetic features
that facilitate health-promotion behaviours. Precontemplation Stage
In the precontemplation stage, the person does not think
about changing behaviour within the future 6 months. They
Commitment to a Plan of Action may be uninformed or underinformed about the conse-
Commitment to a plan of action involves dedication and quences of the risk behaviours; or the person may have tried
the identification of specific strategies for carrying out changing and been unsuccessful and now feels that change is
and reinforcing a behaviour. Strategies are important hopeless. Individuals in this stage may be oblivious to their
because commitment alone often results in good inten- risk or tend to avoid reading, talking, or thinking about their
tions but not in the actual performance of the behaviour. high-risk behaviours (Prochaska, Redding, & Evers, 2009).
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Termination
– Copes without fear of relapse
Maintenance
– Strives to prevent relapse
– Integrates new behaviour into
lifestyle
Action
– Makes observable modifications
in lifestyle(s)
Relapse or Recycle
An opportunity to learn
from the experience and
renew efforts to change
Preparation
– Plans to take action in the
immediate future
– Has taken steps to begin the
behaviour change
Contemplation
– Acknowledges having a problem
– Intends to change
– Not ready to commit to action
Precontemplation
– Does not intend to take action
Figure 8.7 The transtheorectical model: Stages of change. The stages of change are rarely linear. It is more common for people to
recycle several times through the stages. The person who takes action and has a relapse (recycles through some or all of the stages)
is more apt to be successful the next time than the individual who never takes action.
Sources: Based on content from Prochaska, J. O., Norcross, J. C., & DiClimente, C. C. (1994). Changing for good. New York, NY: Harper Collins Publishers. Copyright 1994 by James O.
Prochaska, John C. Norcross, and Carlo C. DiClimente; Prochaska, J. O., Redding, C. A., & Evers, K. E. (2009). The transtheorectical model and stages of change. In K. Glanz, B. K. Rimer, &
F. M. Lewis (Eds.), Health behaviors and health education: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.
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Contemplation Stage The Nurse’s Role

During the contemplation stage, the person acknowledges
having a problem, seriously considers changing a specific in Health Promotion
behaviour, actively gathers information, and verbalizes plans
to change the behaviour in the near future (e.g., the next Nurses create opportunities to promote their clients’
6 months). The person, however, may not be ready to health. They can use a variety of programs (described
commit to action. Some people may stay in the contempla- below) to assist individuals and communities to adopt
tive stage for months or years before taking action. healthy behaviours.
Information dissemination is used to raise the
level of knowledge and awareness of individuals and
groups about health habits. It uses a variety of media
Preparation Stage to educate the public and raise their awareness about
The preparation stage occurs when the person intends the risks of particular lifestyle choices and about chang-
to take action in the immediate future (e.g., within the ing personal behaviours to improve their quality of
next month). Some people in this stage may have already life. Billboards, posters, brochures, newspaper features,
started making small behavioural changes, such as buy- books, health fairs, the media and the Internet, and com-
ing a self-help book. At this stage, the person makes the munity forums all offer opportunities for information
final specific plans to accomplish the change. dissemination on issues related to health promotion, such
as alcohol and drug abuse, driving under the influence
of alcohol, hypertension, and the need for immuniza-
tions. When planning information dissemination, the
Action Stage nurse considers such factors as culture and different age
The action stage occurs when the person actively imple- groups. Determining the best place and method to dis-
ments the behavioural and cognitive strategies of his or tribute information will increase effectiveness.
her action plan to interrupt previous health-risk behav- Health risk appraisal and wellness assessment
iours and adopt healthier ones. Relapses in behaviours programs are used to apprise individuals of the risk
are not unusual and need to be acknowledged. This stage factors that are inherent in their lives. These programs
requires the greatest commitment of time and energy. intend to motivate individuals to reduce specific risks and
to develop positive health habits. Wellness assessment
programs focus on more positive methods of enhance-
ment, in contrast to the risk-factor approach used in
Maintenance Stage health appraisal.
During the maintenance stage, the person strives to prevent Lifestyle and behaviour change programs
relapse by integrating newly adopted behaviours into his require the active participation of the individuals and are
or her lifestyle. This stage lasts until the person no longer geared toward enhancing their quality of life and extend-
experiences temptation to return to previous unhealthy ing their lifespan. Individuals generally consider lifestyle
behaviours, usually from 6 months to 5 years. Without a changes after they have been informed of the need to
strong commitment to maintenance, the person will relapse, change their health behaviours and have become aware
usually back to the contemplation or preparation stage. of the potential benefits of the process. These programs
are available on both group and individual bases, and they
address such issues as stress management, nutrition aware-
ness, weight control, smoking cessation, and exercise.
Termination Stage Environmental control programs address the
The termination stage is the ultimate goal, at which the continuing increase of contaminants of human origin
individual has complete confidence that the problem is that have been introduced into our environment. The
no longer a temptation or threat. It is as if he or she had amounts of contaminants that are already present in
never acquired the habit in the first place. Some behav- the air, food, and water will affect the health of occu-
iours may be terminated and may no longer require pants and descendants for several generations. The most
continual maintenance. common concerns of community groups are toxic and
These six stages are cyclical; people generally move nuclear wastes, dangers from nuclear power plants, air
through one stage before progressing to the next. However, and water pollution, and herbicide and pesticide use.
at any point, a person can relapse or recycle to any previ- Health-promotion activities involve collaborative
ous stage. In fact, the average successful self-changer recy- relationships with both clients and primary care provid-
cles through the stages several times before he or she exits ers. The role of the nurse in health promotion is to work
the cycle. Most individuals who relapse tend to return to with people, not for them. The nurse may act as advocate,
the contemplation stage. During this time, they may think consultant, teacher, or coordinator of services. For exam-
about what they have learned and plan for the next action. ples of the nurse’s role in health promotion, see Box 8.1.
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Lifestyle Assessment Lifestyle assessment

Box 8.1 The Nurse’s Role in Health
focuses on the personal lifestyle of the client, such as
Promotion
physical activity, nutritional practices, and stress manage-
• Model healthy lifestyle behaviours and attitudes ment, and habits, such as smoking, alcohol consumption,
• Facilitate client involvement and coordinating services and drug use, as they affect health. Lifestyle assessment
in the assessment, implementation, and evaluation of provides a basis for decisions related to desired behaviour
health goals and lifestyle changes.
• Teach clients self-care strategies to enhance fitness,
improve nutrition, manage stress, and enhance Spiritual Health Assessment Spiritual health
relationships is the ability to develop one’s inner nature to its fullest
• Educate clients to be effective health care consumers potential, including the ability to discover and articulate
• Guide clients’ development in effective problem solving a basic purpose in life; to learn how to experience love,
and decision making joy, peace, and fulfillment; and how to help oneself and
• Reinforce clients’ personal and family health-promoting others achieve the fullest potential (Pender et al., 2015).
behaviours Individuals’ spiritual beliefs can affect their interpreta-
• Advocate in the community for changes that promote a tion of events in their life, and therefore, an assessment
healthy environment
of spiritual well-being is a part of evaluating overall
health (see Chapter 46).
The Nursing Process Social Support Systems Review Through inter-

personal relationships, individuals and groups can
and Health Promotion provide comfort, assistance, encouragement, and infor-
mation. Social support fosters successful coping and
promotes satisfying and effective living. Social support
Nurses work with individuals, families, groups, and com- systems create an environment that encourages healthy
munities in diverse settings; they apply the nursing pro- behaviours, promotes self-esteem and wellness, and pro-
cess to assess clients’ health and assist them in setting vides feedback that the person’s actions will lead to
goals and plans and to take responsibility for positive desirable outcomes. Examples of social support systems
health changes. Refer to the section “Overview of the include family, peer support groups, computer-based
Nursing Process” in Chapter 23. See the Evidence- support groups, community organized support systems
Informed Practice box for an example of this process. (e.g., churches), and self-help groups (e.g., Alcoholics
Anonymous, Weight Watchers). The nurse can evaluate
the adequacy of the client’s social support systems by
Assessing asking if clients have had a source of support in the past
Components of this assessment are the health history and 5 years or more, and, if necessary, make a plan with them
physical examination, lifestyle assessment, spiritual health for exploring other options for enhancing the support
assessment, social support systems review, health risk system. It is also important to understand how various
assessment, health beliefs review, and life stress review. subgroups in Canada may define social support. (Refer
to Chapter 11).
Health History and Physical Examination
Health history and physical examination (discussed in Health Risk Assessment (HRA) A health risk
Chapter 28) provide guidelines for detecting any existing assessment (HRA) is an assessment and educational
problems. Medical history, age, gender, race, ethnicity, tool that indicates a client’s risk for disease or injury dur-
and culture of the individual must be considered when ing the next 10 years by comparing the client’s risk with
collecting data. For example, an environmental safety the mortality risk of the corresponding age, gender, and
assessment and immunization history must be appropri- racial group. The objectives of most HRAs are twofold:
ate to the person’s age and gender. Also, when doing a
nutritional assessment, the nurse must consider how age, 1. To assess risk factors that may lead to health problems
lifestyle, and cultural practices influence the dietary and 2. To change the health behaviours that place the client at
activity patterns of a client. (See Chapter 40 for more risk of developing an illness
information on nutrition assessment.)
The HRA includes a summary of the person’s health
Physical Fitness Assessment The nurse assesses risks and lifestyle behaviours with educational suggestions
several components of the body’s physical functioning: on how to reduce the risk. Risk factors are features
muscle endurance, flexibility, body composition, and car- that can cause a client to be susceptible to developing
diorespiratory endurance. There are specific guidelines for a specific health problem, such as cancer. An at-risk
obtaining measurements and the optimal values for men, aggregate refers to a subgroup within the community or
women, and children. Older adults need to be monitored population that is at greater risk of illness or poor recov-
carefully for fatigue during strength and endurance tests. ery. Occupational health nurses often use HRA to identify
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those at risk and subsequently plan interventions aimed to promotion, illness or disease prevention, and personal
decrease illness, absenteeism, and disability. growth. When the nurse and the client conclude that the
client has positive health functioning, such as adequate
Health Beliefs Review Assessment of clients’ health
nutrition or effective coping, the nurse can use this infor-
care beliefs reveals how much the clients believe or
mation to help the client reach a higher level of function-
perceive they can influence or control health through
ing. Some examples of wellness diagnoses are as follows:
personal behaviours. Locus of control is a measurable
concept that can be used to predict which people are • Health-seeking behaviours
most likely to change their behaviour. Some cultures • Effective breast-feeding
have a strong belief in fate: “Whatever will be, will be.”
• Anticipatory grieving
An example is teaching about diabetes control, which
often requires many lifestyle changes in diet and exercise, • Readiness for enhanced parenting
and close control of blood glucose levels to prevent com-
plications. If the person believes he or she has no control
over the outcome, it is difficult to motivate the client to Planning
make the necessary changes. Awareness of these differ-
ences in beliefs can provide a better indication of readi- Health-promotion plans should be mutually developed
ness and motivation on the part of the client to engage according to the needs, desires, and priorities of the
in healthy behaviours. client. The client chooses the health-promotion goals;
the frequency, duration, and course of actions; and
Life Stress Review Abundant literature and a vari- the method of evaluation. As a resource person, an
ety of stress-related tools are available to measure the adviser, and a counsellor, the nurse provides informa-
impact of stress on mental and physical well-being. High tion, emphasizes the importance of small steps in making
levels of stress are associated with an increased possibil- behavioural changes, helps identify sources of support,
ity of illness. (See the section “Concept of Stress” in and assists the client to set realistic and measurable goals.
Chapter 12.) Thomas Holmes’s Life Change Index Scale
rates 43 life events on the degree of stress each produces. Steps in Planning Pender et al. (2015) outline sev-
This life stress scale can be accessed online at www. eral steps in the process of planning health promotion,
dartmouth.edu/~eap/library/lifechangestresstest.pdf. which are carried out jointly by the nurse and the client
(see Box 8.2 for an example of an individualized health-
Validating Assessment Data Following the collec- promotion plan):
tion of assessment data, the nurse and the client jointly
review the client’s current health practices and attitudes. 1. Review and summarize the data from the assessment. The nurse
This allows for validation of the information by the cli- discusses with the client a summary of the data collected
ent and may increase his or her awareness of the need from the various assessments (e.g., physical health and
to change behaviour. The nurse and the client should fitness, nutrition, sources of stress, spirituality, health
consider the following: practices).
2. Reinforce strengths and competencies. The nurse and the client
• Any existing health problems
come to a consensus about areas in which the client is
• Perceived degree of control over health status doing well and areas that need work.
• Level of physical fitness and nutritional status 3. Identify health care goals. The client selects two or three top-
• Illnesses for which the client is at risk priority personal goals, prioritizes them, and reviews
• Health beliefs, cultural and spiritual practices behaviour change options. The decision may be to focus
on a single goal or a number of complementary goals
• Current health practices and coping skills
together.
• Sources of stress and ability to handle stress
4. Identify behavioural or health outcomes. For each of the
• Social support systems selected goals or areas in step 3, the nurse and the cli-
• Client’s strengths and needs ent determine what specific behavioural changes are
needed to bring about the desired outcome. For exam-
ple, to reduce the risk of cardiovascular disease, the
Analzying client may need to change a number of behaviours,
Wellness nursing diagnoses, or strength-oriented diag- such as stopping smoking, losing weight, and increasing
noses, provide a clear focus for planning interventions activity level.
and can be applied at all levels of prevention. For those 5. Develop a behaviour change plan. A successful program of
jurisdictions where diagnosis is not part of a nurse’s change is based on client ownership of the behaviour
role, the term would generally be nursing analysis or well- changed (Pender et al., 2015). Clients may need help
ness assessment. Wellness diagnoses are particularly use- in examining value–behaviour inconsistencies and in
ful for healthy clients who require teaching on health selecting behavioural options that are most appealing
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Box 8.2 Example of an Individual Disease-Prevention and Health-Promotion Plan
Designed for: James Moore

Home Address: 714 George Street
Home Telephone Number: 519-222-3333
Occupation (if employed): Building services supervisor
Work Telephone Number: 519-445-6666
Cultural Identification: African Canadian
Birth Date: 3/14/59 Date of Initial Plan: 1/15/2015
Client strengths Satisfactory peer relationships, spiritual strength, adequate sleep pattern
Major risk factors Elevated cholesterol, mild obesity, sedentary lifestyle, moderate life
change, multiple daily hassles
Nursing analysis Deficient Diversional Activity
(derived from assessment Imbalanced Nutrition: More Than Body Requirements
of functional health patterns)
Nursing analysis Caregiver Role Strain (elderly mother)
Medical diagnoses (if any) Mild hypertension
Age-specific screening recommendations Blood pressure, cholesterol, fecal occult blood, malignant skin lesions,
depression
Desired behavioural and health outcomes Become a regular exerciser (3×/week), lower my blood pressure, reduce
weight to 75 kg
Personal Health Goals Selected Behaviours to Strategies/Interventions

(1 = highest priority) Accomplish Goals Stage of Change for Change
1. Achieve desired body • Begin a progressive • Planning Counterconditioning
weight walking program • Action (eating four fruits and • Reinforcement management
• Decrease caloric intake four vegetables daily; using • Client contracting
while maintaining good low-fat dairy products for • Stimulus control
nutrition last 2 months) • Cognitive restructuring
2. Decrease risk for Change from high-sodium Contemplation • Consciousness raising

hypertension-related to low-sodium snacks • Learning facilitation
disorders
3. Learn to manage stress Attend relaxation classes and Contemplation • Contemplation

effectively use home relaxation tapes • Consciousness raising
• Self-revaluation
• Simple relaxation therapy
4. Increase leisure-time Join a local bowling league Contemplation • Support system

activities enhancement
Source: Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2015). Health promotion in nursing practice (7th ed.) (pp. 106–107). Upper Saddle River, NJ: Pearson Education Inc.
Reprinted and electronically reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.
and that they are most willing to try. The client’s priori- should be explored and used to reinforce the client’s
ties will reflect personal values, activity preferences, and efforts to change his or her lifestyle. All people experi-
expectations of success. ence barriers, some of which can be anticipated and
6. Reiterate the benefits of change. The benefits will probably planned for, thereby increasing the chances for the
need to be reiterated repeatedly, even though the cli- change to occur.
ent is committed to the change. The health-related and 8. Determine a time frame for implementation. Setting a time
non–health-related benefits should be discussed with frame helps the client target when to develop the
the client as central motivating factors. needed knowledge and skills for implementation of a
7. Address environmental and interpersonal facilitators and barri- new behaviour. The time frame may be several weeks or
ers to change. Environmental and interpersonal factors months. Scheduling short-term goals and rewards can
and available resources that support positive change offer encouragement to achieve long-term objectives.
M08_KOZI2703_04_SE_C08.indd 133 30/01/17 1:36 PM

Clients may need help to be realistic and to deal with

one behaviour at a time. EVIDENCE-INFORMED
9. Formalize commitment to behaviour change. Commitments PRACTICE
to changing behaviours are usually verbal, but
increasingly a formal, written behavioural contract How to Promote Breast Screening
is being used to motivate the client to follow through Programs among Immigrant Women
with selected actions. Motivation to follow through is
provided by a positive reinforcement or reward stated This study investigated the breast-screening experiences
in the contract. Contracting is based on the belief that of Arabic, Chinese, South Asian, and Vietnamese immi-
all people have the potential for growth and the right grant women residing in an urban city in Canada, within
a peer health educator program from 2008 to 2011. Two
of self-determination, even though their choices may public health nurses and five immigrant women facilita-
be different from the norm. tors led 10 focus groups with a total of 82 immigrant
women, aged 40 years and older. Themes identified
were learning about breast health, access to social sup-
port, perceptions of screening and health services, and
Implementing ways to improve programming. Other emerging findings
Self-responsibility is emphasized in making plans to included the need to understand immigrant women’s
change the behaviour. Depending on the client’s needs, information needs on cancer screening services, their
perceptions of health and prevention, and the transporta-
the nursing strategies may include supporting, teaching,
tion and language barriers they experienced to access
consulting, coordinating, facilitating, counselling, and health services.
modelling to enhance behaviour change.
NURSING IMPLICATIONS: To meet the health promotion
needs of immigrant women, nurses must consider the
PROVIDING AND FACILITATING SUPPORT The focus of
sociocultural context of their clients, work collabora-
providing support is on the desired behaviour change. tively with peer health educators and other commu-
The nurse must be nonjudgmental when offering sup- nity partners, and use multiple intervention strategies
port, whether on an individual basis or in a group set- to reduce disparities in and barriers to health care
ting. The nurse may also facilitate the development of services.
support networks for the client, such as family members Source: Crawford, J., Frisina, A., Hack, T., & Parascandalo, F. (2015). A Peer Health
and friends. Educator Program for Breast Cancer Screening Promotion: Arabic, Chinese, South
Asian, and Vietnamese Immigrant Women’s Perspectives. Nursing Research and
Practice. doi: 10.1155/2015/947245.
Individual Counselling Sessions Counselling sessions
may be routinely scheduled as part of the plan to support
the client’s decision making with regard to the health-
promotion plan. These sessions may be provided if the provided to groups, individuals, or communities. The
client encounters difficulty carrying out interventions or health-promotion topics must be based on the health needs
meets insurmountable barriers to change. of the people. Specific health-promotion goals must be set
and outcomes evaluated after the program implementation.
Telephone or Computer Counselling Telephone or
computer counselling may be provided to the client to Enhancing Behaviour Change To help clients succeed
answer questions, review goals and strategies, and reinforce in implementing behaviour changes, the nurse needs to
progress. This form of support can be useful and conve- understand the stages of change and effective interventions
nient for the busy client who may not have the time for that focus on moving the individual through the stages of
regular in-person sessions. change. Figure 8.8 provides suggested strategies for help-
ing clients, depending on their individual stage of change.
Group Support Group sessions provide an opportunity
Nurses can use the stage of change to recognize a client’s
for participants to learn from the experiences of others in
readiness to change and assist the client to the next stage
changing behaviour. Regular group contacts give individu-
of change.
als a renewed commitment to their goals.
Harm Reduction Harm reduction is a health-
Facilitating Social Support Social networks, such as
promotion approach that aims to minimize harm or
family and friends, can facilitate or impede the efforts
reduce the negative consequences of risk behaviour by
directed toward disease prevention and health promo-
keeping people as safe and healthy as possible in their
tion. The nurse’s role is to communicate the client’s
current lifestyle realities (Canadian Nurses Association
needs and goals, and assist the client to assess, modify,
[CNA], 2011). The nurse provides the needed knowl-
and develop the social support necessary to achieve the
edge, skills, resources, and support to those who are at
desired change.
risk, to reduce the harm done to those engaging in these
Providing Health Education Health education pro- behaviours and to the overall community. Examples of
grams on a variety of health-promotion topics can be harm reduction are the Prevent Alcohol and Risk-related
M08_KOZI2703_04_SE_C08.indd 134 21/02/17 10:26 AM

Precontemplation Contemplation Preparation Action Maintenance Termination
Assess confidence, Ask client if he or Continue to Continue to Continue positive Inform client of
importance, and she would like discuss pros and discuss benefits reinforcement of criteria for
readiness for information cons of behaviour with client. desired behaviour. terminators
change. and about what. change. (versus lifetime
Continue positive Continue to maintainers):
Discuss positive Assist client Provide support reinforcement. remind client of - a new self-image.
and negative to increase and guidance for previous - no temptation in
aspects of awareness of the client to Encourage successes. any situation.
behaviour to behaviour by - set a date to client to - solid confidence.
assist the person - determining begin action. - substitute healthy Encourage client - a healthier
to consider specific behaviour(s) - tell family and responses for to know the lifestyle.
changing. client wants friends of the problem behaviours danger signs,
to change. intended change (e.g., exercise, and which are
Provide inform- - performing self- and advise them relaxation). usually the result
ation in a caring, evaluation of how they can be - modify environ- of overwhelming
nonthreatening present view of self helpful. ment to reduce stress or
manner. versus future view - create a plan of stimulus to a pro- insufficient
of self without the action. blem behaviour coping skills.
behaviour. - make change a (e.g., remove ash-
- reflecting on the priority. trays from home).
behaviour (e.g., - monitor behaviour
"Why do I want Remind client of (e.g., food journal).
to smoke?") past successes. - plan rewards.
- examining the pros
and cons of change.
FIGURE 8.8 Strategies to promote behavioural change for each stage of change.
Sources: Data are from Prochaska, J. O., Redding, C. A., & Evers, K. E. (2002). The transtheorectical model and stages of change. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health
behaviors and health education: Theory, research, and practice (3rd ed.). San Francisco, CA: Jossey-Bass; Prochaska, J. O., Norcross, J. C., & DiClimente, C. C. (1994). Changing for
good. New York, NY: HarperCollins Publishers. Copyright 1994 by James O. Prochaska, John C. Norcross, and Carlo C. DiClimente; Rollnick, S., Mason, P., & Butler, C. (1999). Health
behavior change: A guide for practitioners. Edinburgh, UK: Churchill Livingstone; Saarmann, L., Daugherty, J., & Riegel, B. (2000). Patient teaching to promote behavioral change.
Nursing Outlook, 48(6), 281–287.
Trauma in Youth (PARTY) programs, to promote respon- continue with the plan, reorder priorities, change strategies,
sible drinking, and the needle exchange program, to pre- or revise the health-promotion contract.
vent the spread of acquired immunodeficiency syndrome
(AIDS) or hepatitis C.
Some nurses may experience value conflicts and be
concerned that they are not providing health-promoting Promoting Canadians’
behaviours with this approach. Regardless, they need
to recognize that clients have rights to accessible, non- Health
judgmental, and noncoercive treatments (see the section
“Ethical Decision Making” in Chapter 5) and that pre- Canada has been at the forefront of influencing health
vention activities are best aimed at people engaging in promotion. Canadian nurses must understand the histori-
high-risk behaviours (CNA, 2011). cal development of health promotion and its significant
contributions nationally and internationally. Although
Role Modelling Through observing a role model during health promotion has shown effectiveness from local to
the early stages of learning and change, the client acquires international levels, broader challenges remain; and there
ideas for behaviour and coping strategies for specific prob- needs to be a “revoluntionary transformation in the politi-
lems. The nurse and the client should mutually select role cal and healthcare leadership” (Hancock, 2011, p. 266).
models with whom the client can identify and whom he or The goal of nursing is to promote clients’ health and to
she respects. Nurses need to have a philosophy and lifestyle reduce inequities in health. Canadian nurses must, there-
that demonstrate good health habits and serve as models fore, possess the necessary knowledge and skills in health
of wellness for their clients. promotion to address the social determinants of health,
to promote positive behaviour change in their clients, and
to develop healthy public policies at the community level.
Through the use of the nursing process (see the section
Evaluating “Overview of the Nursing Process” in Chapter 23), nurses
Evaluation of the plan is an ongoing, collaborative effort work with individual clients of all ages, families, groups,
between the nurse and the client, both during the attain- and communities and help them attain the highest level of
ment of short-term goals and after the completion of long- functioning (see the section “Health” in Chapter 7 and the
term goals. During evaluation, the client may decide to Lifespan Considerations box).
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LIFESPAN CONSIDERATIONS
FACTORS AFFECTING HEALTH PROMOTION be role models for their children by eating well and exercising
AND ILLNESS PREVENTION regularly.
In Canada, national obesity rates continue to rise. Between ADULTS AND OLDER ADULTS
1981 and 2009, less than 1 in 11 children and more than
1 in 4 adults in Canada were obese. The obesity rate is now In older adults, health promotion and illness prevention are
roughly doubled across all age groups and tripled for youth, important, but often the focus is on learning to adapt to and live
aged 12 to 17 years (Canadian Institute for Health Information with increasing changes and limitations. Maximizing strengths
& Public Health Agency of Canada, 2011). In 2013, the num- continues to be of prime importance in maintaining optimal
ber of Canadians between the ages of 18 and 54 years who function and quality of life. Factors to be aware of that might
were overweight or obese increased. Between 2011 and indicate a need for additional information or resources include
2012, the percentage of men who were overweight increased the following:
by 40.2%; the weight for women has remained stable since • An increase in physical limitations
2003 (Statistics Canada, 2014). • Presence of one or more chronic illnesses
CHILDREN • Change in cognitive status
Obesity and overweight in children contribute to long-term • Difficulty in accessing health care services because of
health problems, such as heart disease and diabetes mel- transportation problems
litus. Healthy eating habits and adequate exercise patterns • Poor support system
form the basis for healthy growth and prevention of excessive • Need for environmental modifications for safety and to
weight gain in children. It is the responsibility of parents and maintain independence
caregivers to provide children with healthy food choices and • Attitude of hopelessness and depression, which decreases
an environment that makes eating a pleasure. Adults must the motivation to use resources or learn new information
Case Study 8
Mr. W., a 50-year-old professional, has pneumonia and is cur-
2. Each contact between a nurse and a client is an
rently being treated with antibiotics. He smokes two packs of
opportunity for health promotion. On the basis of
cigarettes a day. Following this bout of pneumonia, he voices his
the knowledge or key concepts listed above, what
concern about his smoking and wonders if he should try to quit
question(s) would you ask Mr. W.?
again. He states, “I’ve tried everything, and nothing works. The
longest I last is about 1 month.” He admits to 3. In which stage of change relating to his cigarette
being 13 kg overweight and states that he and smoking would you place Mr. W.? What strategies
his wife have started walking for 30 minutes could you, as the nurse, consider?
every evening. His wife has also started mak-
ing low-fat meals. He is concerned that if he Visit MyNursingLab for answers and explanations.
quits smoking, he will gain more weight.
1. What information or knowledge is important for the nurse

to remember when assisting a client to advance to the
next stage of change?
KE Y TERM S
Achieving Health for All: A environmental control health protection information
Framework for Health programs p. 130 p. 125 dissemination
Promotion p. 121 harm reduction p. 134 health risk p. 130
at-risk aggregate p. 131 health education p. 125 appraisal p. 130 Jakarta Declaration
disease prevention p. 125 health field concept p. 121 health risk on Health
empowerment p. 125 health promotion p. 125 assessment p. 131 Promotion p. 123
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lifestyle and behaviour Ottawa Charter Prochaska’s transtheo- spiritual health p. 131
change programs for Health rectical model p. 128 wellness assessment
p. 130 Promotion p. 122 risk factors p. 131 programs p. 130
lifestyle population social support p. 131 wellness nursing
assessment p. 131 health-promotion social support diagnoses p. 132
locus of control p. 132 model p. 123 systems p. 131
C hapter Highl ig hts

• Canada is a world leader in health promotion and has (c) preparation, (d) action, (e) maintenance, and (f) termi-
taken a sociocultural approach to examining what deter- nation. If a person is not successful in changing behav-
mines health. iour, relapse occurs. At any point in these stages, people
• Key documents have influenced health promotion in can move to any previous stage. An understanding of
Canada: the Lalonde Report, the Ottawa Charter for Health these stages enables the nurse to provide appropriate
Promotion, Achieving Health for All, the Jakarta Declaration on nursing interventions.
Health Promotion, the Toronto Charter for a Healthy Canada, • The nurse’s role in health promotion is to act as a facilita-
and Health Goal for Canada. tor of the process of assessing, planning, implementing,
• Health promotion is defined as client behaviour directed evaluating, and understanding health. Nurses seek oppor-
toward developing well-being and actualizing human tunities to strengthen the profession’s influence on health
health potential. Health protection is client behaviour promotion, disseminate information that promotes an
geared toward preventing illness, detecting it early, or educated public, and help individuals and communities to
maintaining function. change long-standing adverse health behaviours.
• Health-promotion activities are directed toward develop- • A complete and accurate assessment of the individual’s
ing client resources that maintain or enhance well-being. health status is basic to health promotion. Assessments or
Health-protection activities are geared toward preventing reviews of a client’s spiritual health, social support, health
specific diseases, for example, immunization to prevent beliefs, and life stress are also important because they
poliomyelitis. affect a person’s health.
• Nurses play a critical role in promoting health through • Organizing assessment data from individual and family
programs that focus on (a) information dissemination, assessments enables the nurse to identify client strengths,
(b) health appraisal and wellness assessment, (c) lifestyle recognize self-care abilities, and enhance health-promotion
and behaviour change, and (d) environmental control goals to help the client reach a higher level of functioning.
programs. These programs can be carried out in homes, • Health-promotion activities are mutually planned and
schools, community centres, hospitals, and worksites. directed according to the client’s needs, desires, and
• Pender’s health-promotion model depicts the multi- priorities.
dimensional nature of persons interacting with their • The nurse provides ongoing support and supplies addi-
interpersonal and physical environments as they pursue tional information and education to help individuals
their health goals. The major motivational variables that change their lifestyles or health behaviours.
are modifiable through nursing interventions include • During the evaluation phase of the health-promotion
perceived benefits of action, perceived barriers to action, process, the nurse assists clients in determining whether
perceived self-efficacy, activity-related affect, interpersonal they will continue with the plan, reorder priorities, or
influences, and situational influences. revise the plan.
• Prochaska et al. proposed a six-stage model for health • As role models for their clients, nurses should develop
behaviour change: (a) precontemplation, (b) contemplation, attitudes and behaviours that reflect healthy lifestyles.
NCLE X- st yl e practic e qui z

1. In which health-promotion document were the social 2. According to the Public Health Agency of Canada (PHAC),
determinants of health and the concepts of social jus- what is a current health-promotion priority for Canadians?
tice, equity, and sustainability affirmed as essential com- a. Basing decisions on evidence and increasing
ponents of health promotion? upstream investments
a. Epp Report b. Developing personal skills and orienting health care
b. Ottawa Charter for Health Promotion services
c. Lalonde Report c. Developing population health models
d. Jakarta Declaration d. Creating new determinants of health
M08_KOZI2703_04_SE_C08.indd 137 30/01/17 1:36 PM

3. What nursing activity is the best example of a health 7. If a client fails to follow the information or teaching
promotion initiative? provided, how should the nurse respond?
a. Immunizes grade 7 girls with the human papilloma a. Give up, since the client does not want to change his
virus (HPV) vaccine behaviour
b. Runs a weight reduction program for adults at risk b. Tell the client that he must follow nursing
for diabetes mellitus instructions
c. Collaborates with an employee group to develop a c. Act as the role model for the client so that he can
wellness walking program imitate the expected behaviour
d. Writes a blog for adolescents on healthy eating d. Assess what the barriers are and allow the client to
determine what he can or will do
4. What is the best way for the nurse to promote adoption
of safe sexual practices in a group of adolescents? 8. What is the best example of a wellness diagnosis?
a. Provide condoms a. Imbalanced nutrition: less than body requirement
b. Encourage abstinence related to nausea, as evidenced by decreased body
weight
c. Teach ways to prevent pregnancy
b. Potential for enhanced mental health in adoles-
d. Teach safe sex practices cents in the local high school, related to their
expressed desire to learn about an antibullying
5. Which statement reflects the contemplation stage of campaign
behaviour change?
c. Ineffective parental role performance related to
a. “I currently do not exercise 30 minutes three times heavy child-care responsibilities, as evidenced by
a week and do not intend to start in the next mother stating she feels overwhelmed
6 months.”
d. Readiness for enhanced self-health management
b. “I have tried several times to exercise 30 minutes
three times a week but am seriously thinking of try- 9. A client is very worried about how his business is
ing again in the next month.” doing while he is hospitalized. He spends much time
c. “I currently do not exercise 30 minutes three times on the phone and with colleagues instead of resting.
a week, but I am thinking about starting to do so in What should the nurse do first to promote the client’s
the next 6 months.” health?
d. “I have exercised 30 minutes three times a week a. Assess the client’s physiological needs
regularly for more than 6 months.” b. Assess the client’s perception of his health status
6. A female client is 20 kg overweight. She previously c. Discuss with the client plans for the needed behav-
attended two programs that guaranteed weight loss. ioural change
Although she lost some weight, she gained it back and d. Eliminate stress and distraction by offering the client
more after each program. She tells the nurse, “I was just a private room
born to be fat. I don’t have the willpower.” According
to Pender’s health-promotion model, the nurse should 10. Which source of data would indicate whether the per-
focus on which behaviour-specific cognition and affect son has an increased chance of acquiring a specific
variables for this client? disease?
a. Perceived barriers to action a. Lifestyle assessment
b. Perceived self-efficacy b. Health risk appraisal
c. Interpersonal influences c. Health beliefs review
d. Situational influences d. Health education
Re f erences
Canadian Institute for Health Information & Public Health Epp, J. (1986). Achieving health for all: A framework for health promotion.
Agency of Canada. (2011). Obesity in Canada: A joint report from the Ottawa, ON: Health and Welfare Canada.
Public Health Agency of Canada and the Canadian Institute for Health Federal, Provincial, and Territorial Advisory Committee on
Information. Ottawa, ON: Her Majesty the Queen in Right of Population Health. (1994). Toward a healthy future: Second report on
Canada. Retrieved from http://www.phac-aspc.gc.ca/hp-ps/hl- the health of Canadians. Ottawa, ON: Minister of Public Works and
mvs/oic-oac/assets/pdf/oic-oac-eng.pdf. Government Services Canada.
Canadian Nurses Association. (2011). Harm reduction and currently Hamilton, N., & Bhatti, T. (1996). Population health promotion: An
illegal drugs: Implications for nursing policy, practice, education and research: integrated model of population health and health promotion. Ottawa, ON:
Discussion paper. Ottawa, ON: Author. Health Canada, Health Promotion and Development Division.
Community Health Nurses of Canada. (2011). Canadian commu- Hancock, T. (2011). Health promotion in Canada: 25 years of
nity health nursing: Professional practice model and standards of practice. unfulfilled promise. Health Promotion International, 26(S2), 263–267.
Retrieved from http://www.chnc.ca/documents/CHNC- Health Canada. (2005). Health protection and promotion. Retrieved from
ProfessionalPracticeModel-EN/index.html. http://www.hc-sc.gc.ca/sr-sr/activ/protection/index_e.html.
M08_KOZI2703_04_SE_C08.indd 138 30/01/17 1:36 PM

Health Canada. (2011). About Health Canada: About mission, values, education: Theory, research, and practice (4th ed.) (pp. 97–121). San
activities. Retrieved from http://hc-sc.gc.ca/ahc-asc/activit/about- Francisco, CA: Jossey-Bass.
apropos/index-eng.php. Public Health Agency of Canada. (2013). A population health approach:
Health Canada. (2014). About Health Canada: What is Health Canada’s The organizing framework. The Canadian Best Practices Portal.
goal? Retreived from http://www.hc-sc.gc.ca/ahc-asc/index- Retrieved from http://cbpp-pcpe.phac-aspc.gc.ca/population-
eng.php. health-approach-organizing-framework/.
Labonte, R. (1992). Determinants of health: Empowering strategies for Raphael, D., Bryant, T., & Curry-Stevens, A. (2004). Toronto
nursing practice. Vancouver, BC: Registered Nurses Association of charter outlines future health policy directions for Canada and
British Columbia. elsewhere. Health Promotion International, 19(2), 269–273.
Lalonde, M. (1974). A new perspective on the health of Canadians. Stamler, L., & Yiu, L. (2016). Community health nursing: A Canadian
Ottawa, ON: Government of Canada. perspective (4th ed.). Toronto, ON: Pearson Canada.
Leave the Pack Behind. (2013). LTPB final report: Working together to Statistics Canada. (2014). Overweight and obese adults (self-reported),
achieve smoke-free campuses, 2012–2013. Retrieved from https:// 2013. Retrieved from http://www.statcan.gc.ca/pub/
www.leavethepackbehind.org/pdf/12-13%20LTPB%20Final%20 82-625-x/2014001/article/14021-eng.htm.
Activity%20Report.pdf. World Health Organization. (1978). The declaration of Alma-Ata.
Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in Geneva, Switzerland: Author.
the community (3rd ed.). New York, NY: McGraw-Hill. World Health Organization. (1984). Health promotion: A discussion
Ontario Healthy Communities Coalition. (n.d.). Origins of the document on the concepts and principles. Copenhagen, Denmark: WHO
healthy communities movement and the OHCC. Retrieved from Regional Office for Europe.
http://www.ohcc-ccso.ca/en/origins-of-the-healthy-communities- World Health Organization. (1997). The Jakarta declaration on health
movement-and-the-ohcc promotion. Geneva, Switzerland: Author.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2015). Health World Health Organization. (1998). Health promotion glossary.
promotion in nursing practice (7th ed.). Upper Saddle River, NJ: Geneva, Switzerland: Author. Retrieved from http://www.who.
Prentice Hall. int/healthpromotion/about/HPG/en/.
Prochaska, J. O., Redding, C. A., & Evers, K. E. (2009). The World Health Organization, Health and Welfare Canada, &
transtheoretical model and stages of change. In K. Glanz, Canadian Public Health Association. (1986). Ottawa Charter for
B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health Health Promotion. Geneva, Switzerland: WHO.
M08_KOZI2703_04_SE_C08.indd 139 30/01/17 1:36 PM

Chapter 9
The Canadian Health
Care System
Updated by
Donna M. Wilson, RN, PhD
Professor, Faculty of Nursing, University of Alberta
A
LEARNING OUTCOMES
After studying this chapter, you will be able to health care system is
1. Outline the history of the Canadian health care system as a major the sum of health care
component of Canada’s social safety network. services provided by all
2. Describe the five criteria of the Canada Health Act (1984). individuals and organizations that
aim to meet the health care needs
3. List the essential elements of the patient’s Bill of Rights and the
social values underpinning it and Canada’s universal publicly of target populations. In Canada, the
funded health care system. health care system is a major contrib-
4. Define the value of urgency-of-need determinations for gaining utor to the well-being of its citizens
access to health care services. and Canada as a whole. Although
5. Describe the functions and purposes of each health care sector. other comparisons can be made,
the Canadian health care system is
6. Differentiate primary, secondary, tertiary, and quaternary health
care services. often used to define Canada against
other countries where health care is
7. Report on social, political, technological, and other main factors
that impact health care delivery and health care system reform. neither as advanced nor as acces-
sible to their citizens. Even though
8. Identify the complementary but distinct roles and functions of
other health care professionals and para-professionals, and the health care in Canada is considered
significance of interdisciplinary health care teams. an essential public service, it is also
9. Describe models of nursing care. “big business.” It is a major source

of employment and a major compo-
10. Outline the contributions of nurse practitioners, clinical nurse
specialists, nurse managers, nurse researchers, and nursing nent of government spending, since
sociopolitical action for engendering beneficial health care and Canada’s health care system is pri-
health care system changes. marily publicly funded. Traditionally,
this health care system is expected
to provide care for acutely ill and
injured persons. However, health
promotion, illness prevention, tech-
nological advancements that permit
earlier detection of and intervention c
M09_KOZI2703_04_SE_C09.indd 140 17/03/17 10:58 AM

Chapter 9 The Canadian Health Care System 141
c for health problems, and an increase in chronic illnesses and an aging population are changing the
health care system. The roles of nurses are also changing in response to health care and health care
system developments and because nurses have formulated and implemented beneficial nursing,
health care, and health care system reforms.
History Today, a comprehensive range of programs are

in place, although many are no longer universal. The
Canadian health care system is one exception. It was
Canada’s large health care system did not emerge sud- designed as a universal program through the federal
denly or without precedent. The British North America Hospital Insurance and Diagnostic Services Act (1957),
Act (1867) established Canada as a country and laid which brought uniform coverage for these services across
out the respective jurisdictions of the federal and pro- Canada. The 1966 Medical Care Act extended this cov-
vincial governments. Responsibility for health, educa- erage to include physician services. In 1984, the Canada
tion, and social services was delegated to the provinces. Health Act was passed, in large part to ensure universal
Canada was growing through immigration, high birth health care accessibility for all citizens through outlawing
rates, and industrialization, with the population increas- extra-billing and other co-payments or user charges for
ingly urbanized. Poor housing and sanitation, crowded insured health care services. Each province and territory
living conditions, poverty, and a volatile economy con- today has a health care insurance plan that continues
tributed to high rates of morbidity and mortality. In to be governed by the Canada Health Act. This Act
response, public health legislation was enacted to deal provides for cost sharing, whereby the Government of
with infectious diseases, maternal and child health, work- Canada pays a proportion of the provincial or territorial
place safety, and environmental sanitation. Churches costs of provided health care, on the condition that five
and charities provided hospital care (as they did before criteria are met: public administration, compre-
Confederation), and voluntary organizations emerged. hensiveness, universality, portability, and acces-
Some of these organizations serve the Canadian pub- sibility (Table 9.1).
lic today (e.g., Victorian Order of Nurses, Canadian Even though Canada’s social safety network was
Mental Health Association). Municipal governments also developed to meet the needs of individuals requir-
became involved, often to assist poverty stricken or ill ing assistance and to address societal values of com-
persons. The union movement and fraternal brother- passion and equity, many social, economic, and other
hoods established benevolent funds, which members developments, including rising costs and demands for
contributed to and could access if unable to work. These services, have challenged each program. In response,
funds were the precursors to today’s employment insur- the provinces and territories have been restructuring
ance program and workers’ compensation. their programs, including their health care systems.
The two World Wars (1914–1918 and 1939–1945) Although redevelopments have more often been done
were instrumental in highlighting the importance of a to accommodate evidence-based practice and techno-
social safety network. Many injured soldiers returned logical developments, these changes have allowed health
with disabilities, needing health care and other assis- care to be delivered in new ways with better outcomes.
tance. These wars also created a demand for services For instance, surgical and diagnostic developments have
for soldiers’ widows, children, and parents, all having resulted in most people receiving care in day surgery
lost their main source of support. Rural municipalities or outpatient clinics. Only a decade ago, these people
were given power by the Government of Canada to would have been admitted to hospital for a few days or
levy taxes to pay for local physician services (through even weeks. Over 90% of all surgeries now are done in
the Municipality Act, 1916) and then hospital services day surgery clinics, and well over 90% of all diagnostic
(through the Municipal Medical and Hospital Services tests are done on an ambulatory or outpatient basis.
Act, 1939). In 1927, the federal government implemented More accurate diagnostic tests and new medicines are
a cost-sharing pension program for older persons in need. also reducing the need for surgery, and complication
The Family Allowance Act (1945), however, was the first rates and recovery times are much better with the newer
universal social program in Canada. It provided every laparoscopic and laser surgery methods.
Canadian family with a stipend for each child regardless Another major development factor has been chang-
of family income. Other universal programs that formed ing views of health, with 12 health determinants consid-
the Canadian social safety network include Old Age ered highly important for preventing illnesses and injuries,
Security (through the Old Age Security Act, 1952) and and maintaining or improving health. Intersectoral col-
the Canada Pension Plan, which came into force in 1966. laboration, long-range planning, and public participation
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TABLE 9.1 Canada Health Act
1. Public administration To satisfy the criterion respecting public administration, the health care insurance plan of each
province or territory “must be administered and operated on a non-profit basis by a public authority
appointed or designated by the government of the province; the public authority must be respon-
sible to the provincial government for that administration and operation; and the public authority
must be subject to audit of its accounts and financial transactions by such authority as is charged
by law with the audit of the accounts of the province.”
2. Comprehensiveness To be eligible for federal cash transfer payments, the health care insurance plan of each province
or territory “must insure all insured health services provided by hospitals, medical practitioners or
dentists (i.e., such as in the case of surgical-dental services that require a hospital setting) and,
where the law of the province so permits, similar or additional services rendered by other health
care practitioners.”
3. Universality Under the universality criterion, “the health care insurance plan of a province must entitle one hun-
dred percent of the insured persons of the province to the insured health services provided for by
the plan on uniform terms and conditions.”
4. Portability To satisfy the criterion of portability, “the health care insurance plan of a province must not impose
any minimum period of residence in the province, or waiting period, in excess of three months
before residents of the province are eligible for or entitled to insured health services; must provide
for and be administered and operated so as to provide for the payment of amounts for the cost of
insured health services provided to insured persons while temporarily absent from the province on
the basis that (i) where the insured services are provided in Canada, payment of health services is
at the rate that is approved by the health care insurance plan of the province in which the services
are provided, unless the provinces concerned agree to apportion the cost between them in a dif-
ferent manner, or (ii) where the insured health services are provided out of Canada, payment is
made on the basis of the amount that would have been paid by the province for similar services
rendered in the province, with due regard, in the case of hospital services, to the size of the hospi-
tal, standards of service and other relevant factors; and must provide for and be administered and
operated so as to provide for the payment, during any minimum period of residence, or any wait-
ing period, imposed by the health care insurance plan of another province, of the cost of insured
health services provided to persons who have ceased to be insured persons by reason of having
become residents of that other province, on the same basis as though they had not ceased to be
residents of the province.”
5. Accessibility The accessibility criterion is designed to ensure that residents of a province or territory have rea-
sonable access to “insured hospital, medical, and surgical–dental services on uniform terms and
conditions, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or
extra-billing) or other means” (e.g., discrimination on the basis of age, health status, or financial
circumstances). In addition, the health care insurance plan of the province or territory must provide
reasonable compensation to physicians and dentists for the insured health care services they pro-
vide; and payment to hospitals to cover the cost of insured health care services.
Note: Since 1984, slight changes through reinterpretation of the act have occurred. These changes and health care system developments are outlined each year in Health Canada’s
Canada Health Act Annual Report.
Source: © Adapted and reproduced with the permission of the Minister of Public Works and Government Services Canada, 2003. Health Canada assumes no responsibility for any errors
or omissions which may have occurred in the adaptation of its material. Canada Health Act is available at http://laws-lois.justice.gc.ca/eng/acts/C-6
are strategies being used to create more equitable dis- disadvantaged by this shift from public to private fund-
tribution of scarce and costly resources and services. ing. The corresponding shift from public control and
Efforts are being made to curb costs and make more public delivery of services to private for-profit or not-
effective use of health care personnel and infrastructure for-profit providers affects all Canadians. One concern
through such initiatives as regionalization and the con- is inaccessibility of health care information, as public
tinued shift of what was hospital-based care to families services are openly and fully reported, whereas private
and community agencies, such as extended care facilities health care providers do not have the same obligation.
and hospices.
Increasingly, Canadians are paying out of pocket or
contributing to supplementary insurance plans that cover
uninsured or extra health care services, such as physio- Rights and Health Care
therapy; prescription drugs and home care supplies;
vision, hearing, and dental care; and complementary Although health care is widely considered a right by citizens
or alternative therapies. These costs can be consid- of Canada, an important patients’ rights, or clients’
erable, with low-income Canadians disproportionately rights, movement began in the late 1960s. Its broad goal
M09_KOZI2703_04_SE_C09.indd 142 02/03/17 9:52 AM

was to improve the quality of health care, largely by making February 6, 2016) assisted death for competent grievously
the health care system and health care professionals more and irremediably ill adults who autonomously consent to
aware of and responsive to client needs and interests. At that the termination of their life. Client requests for illegal or
time, individuals wanted self-determination and control over criminal acts cannot be carried out (CNPS, 2015).
their own bodies when ill. Informed consent, confidentiality It is understood now that adults have the right to
of information, and the right of the patient to accept or verbally or in writing refuse treatment, even when it is
refuse treatment are all accepted and influential aspects of lifesaving; the right to review their health care records
self-determination now. The need for concern about rights and have them explained; and the right to receive
continues, however, because of patient vulnerability and publicly funded health care when it is appropriate for
the ongoing uncertainty coupled with differing judgments them. In addition, they have the right to be informed of
regarding the expected or probable outcomes of health resources that can be used to resolve a dispute or griev-
care. Timely access to health care has also become a clients’ ance and of health care agency policies and practices
rights concern. Although legal opinions have indicated that that relate to their care, treatment, and responsibili-
Canadians do not actually have a “right” to health care, ties, including any extra charges or out-of-pocket costs
Section 7 of the 1982 Canadian Charter of Rights and associated with these care options. Furthermore, they
Freedoms could be interpreted as outlining the rights or have the right to have options explained when hospital
entitlements of persons waiting for health care. care is no longer appropriate and to expect a reason-
At the heart of clients’ rights is the need for cli- able continuity of care both within and across health
ents and care providers to respect each other. Although care settings. Clients can also refuse to participate in
nurses have the Canadian Nurses Association Code of research studies.
Ethics (CNA, 2008), mandating and supporting their Nurses and other health care professionals are obliged
respect for clients, provincial and territorial governments to advise patients of their rights to make informed choices
across Canada are developing legislation or policy docu- about their health and health care. Most clients should
ments to indicate that citizens should be able to expect be asked about advance directives (i.e., instructions such
timely access to safe, high-quality health care. as Do Not Resuscitate in the event of cardiac or respira-
Although many comparisons reveal that Canada has tory arrest), and this information must be placed on their
a top-performing health care system, ill people are fre- health care record. Details about advance directives are
quently unable to assert their rights as they would if they provided in Chapter 48.
were healthy. Asserting rights requires energy, mental If a person lacks decision-making capacity, such as
competency, knowledge about their health problem and in the case of being a minor, very ill, or temporarily or
care options, an underlying awareness of their rights, and permanently mentally incompetent, his or her rights
organizational support for them to exercise these rights. can be exercised by a designated surrogate or proxy
In 1972, the Consumers’ Association of Canada first decision maker. Nurses are often advocates for clients in
published the Consumer Rights to Health Care. Their 1989 these and other situations. Nursing organizations, such
version is outlined in Table 9.2. The consumer move- as the CNA, have also been advocates for the rights
ment was also important for helping initiate legislation of individuals and for the good of Canadian society
on advance directives. All adults in Canada have the through lobbying governments and through the devel-
legislated right now to make a statement about their care opment of documents to unite nurses and influence
preferences, such as through a living will or a personal public policy, such as their 2015 Joint Position Statement –
directive, preferences that should be adhered to by all Practice Environments: Maximizing Outcomes for Clients, Nurses
health care organizations and health care professionals, and Organizations.
if permitted by law. Another illustration of consumer
rights is the 2015 Supreme Court ruling to allow (after
Categories of Health Care

TABLE 9.2 Consumer Rights
• Right to be informed Health care services are commonly categorized accord-
• Right to be respected as the individual with a major ing to type and level. In Canada, health care services are
responsibility for his or her own health care also categorized on the basis of urgency of need.
• Right to participate in decision making affecting his or her
health
• Right to equal access to health care regardless of the indi-
vidual’s economic status, gender, age, creed, ethnic origin Types of Health Care
and location
Four types of health care services are often described:
Source: Alberta Consumers’ Association. (1989). Consumer rights in relation to health (a) health promotion and illness prevention, (b) illness
care, Consumers’ Association of Canada. Retrieved from http://www.albertaconsumers.
org/submissions/Consumer%20Rights%20and%20Responsibilities%20in%20Health%20
diagnosis and treatment, (c) rehabilitation and health
Care%20(CAC%201989)%202010.pdf. restoration, and (d) hospice–palliative or end-of-life
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care. These types can be linked to the levels of preven- these services. However, community-based organizations
tion, as discussed in Chapter 7. are increasingly providing diagnostic and treatment ser-
vices. For example, community health centres may offer
HEALTH PROMOTION AND ILLNESS PREVENTION In
chronic illness services (e.g., diabetes mellitus or schizo-
1979, the World Health Organization (WHO), one of
phrenia). Diagnostic technologies, such as laboratory and
the most influential organizations globally, asserted that
radiology services, can be found in many community set-
“health is a basic human right and a worldwide social goal
tings now. Walk-in clinics provide a wide range of services,
… essential to the satisfaction of basic human needs and
usually without appointment.
the quality of life; and … to be attained by all people.”
The WHO emphasized that the main target of govern- REHABILITATION AND HEALTH RESTORATION Restor
ments and the WHO should be “the attainment by all ing people with illnesses and injuries to more optimal levels
citizens of the world by the year 2000 of a level of health of health and functioning is a process of assisting clients to
that will permit them to lead a socially and economically function adequately in the physical, cognitive, social, and
productive life” (p. 7). The overall goal then and as stated vocational areas of their lives. The goal of rehabilitation is
in subsequent WHO documents was to ensure health for to help people return to their previous level of health and
all individuals globally in part through increased access self-care capabilities or to the highest level they are capable
to health care services. This goal is evident in a series of of given their health status. Often, the aim is for the person
Canadian documents that emphasize health and wellness, to become independent, although achieving this aim is
as opposed to illness care: Marc Lalonde’s (1974) A New impossible for some. If the person is hospitalized, reha-
Perspective on the Health of Canadians, the Ottawa Charter for bilitation begins there and may continue in a subacute care
Health Promotion (World Health Organization, Health and unit, rehabilitative hospital, or nursing home. Increasingly,
Welfare Canada, & Canadian Public Health Association, with outpatient care and short hospital stays, rehabilitation
1986), Jake Epp’s (1986) Achieving Health for All: A Framework is taking place at home. Rehabilitation can occur through
for Health Promotion, and Roy Romanow’s (2002) Building on such simple means as resuming self-care activities, but some
Values: The Future of Health Care in Canada. (See Chapter 8 clients need specialized rehabilitative treatment, such as
for additional discussion on health promotion.) occupational therapy and physiotherapy.
Many Canadian groups and individuals now rec-
HOSPICE–PALLIATIVE AND END-OF-LIFE CARE The
ognize the advantages of staying healthy and avoiding
term hospice–palliative care refers to the provision
illness. Health-promotion programs address the deter-
of compassionate care or symptom relief to the dying
minants of health, including more positive social, eco-
(see Chapter 48). Some nurses and other professionals
nomic, and physical environments. Health promotion
specialize in hospice–palliative care. Nurses who special-
features the important role that all people have in actively
ize in hospice–palliative care may become credentialed;
maintaining or improving their own health. Health care
they are recognized as having advanced competencies in
services stress health promotion, such as public health
hospice–palliative care nursing through the CNA desig-
clinics, where community health nurses offer a wide range
nation CHPCN(C): Certified in Hospice and Palliative
of wellness programs; home care programs, where nurses
Care Nursing (Canada).
work to maintain or improve the health of disabled and
Currently, around 30% of decedents (persons who have
at-risk clients; and primary care clinics or primary care
died) in Canada received specialized hospice–palliative
networks, where interdisciplinary health care teams work
care services in hospital palliative care units, hospices,
to enhance wellness.
or elsewhere. The remaining decedents typically would
The health care system also offers programs for
have received some assistance from nurses and others who
illness and injury prevention. These may be directed
are not hospice–palliative care specialists. Increasingly,
at the client or the community and involve such practices
family members are providing end-of-life care in the
as providing immunizations, identifying risk factors for
home, with home care nurses helping at times. Some dying
illnesses (e.g., dietary habits or blood lipid levels for car-
processes, however, such as those associated with a long
diovascular disease), and helping people take measures to
decline in health through advanced aging and/or progres-
prevent acute and chronic illnesses. Prevention programs
sive chronic illness, require much more support in a con-
help reduce the incidence of illness, injury, and disability,
tinuing care facility (i.e., a nursing home or long-term care
such as through mandating helmets for children riding
facility). Nurses are a major provider of both specialized
bicycles. Environmental protective measures have been
hospice–palliative care and basic end-of-life care, as they
legislated by governments, often after being lobbied by
help dying people and family members in all care settings.
citizens’ and health care provider groups. (For a discus-
sion on further issues of safety, see Chapter 32.)
ILLNESS DIAGNOSIS AND TREATMENT Traditionally,
the greatest emphasis of Canada’s health care system
Levels of Health Care
has been on the diagnosis and treatment of illnesses. Health care services can also be categorized accord-
Physicians’ offices and hospitals are the main settings for ing to the complexity or level of the services provided:
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TABLE 9.3 Levels of Health Care Classified by Increasing 3. Elective: A nonurgent health problem is one that pro-
Complexity gresses slowly, if at all, or may resolve without health
care intervention. Knee and hip replacements are
Primary care (first contact Health promotion
point) common elective procedures. It normally takes many
Preventive care (e.g., immuni-
zations, prenatal or well-baby
years until a joint replacement requiring major sur-
clinics) gery is indicated. Waiting for this surgery for a few
Health education
weeks is not usually a problem, as the health condition
progresses slowly, if at all. Waiting for surgery also
Environmental protection and
allows time to make living or other arrangements, as
risk assessment
postoperative recovery is often many weeks in length.
Early detection and treatment
A high proportion, around 50%, of people who are
(e.g., physician office nursing
and telehealth nursing)
booked for elective surgeries or diagnostic tests do
not have these procedures performed. Unfortunately,
Long-term care
many do not call to cancel their booked appointments,
Emergency room care leaving gaps in operating room and other schedules,
Secondary care (care from Diagnosis and treatment unless someone else can quickly fill in.
specialist following referral) (complex)
This determination of need, although clients find
Tertiary (settings of highly Acute care (e.g., medical, it difficult to understand as they want to have their
specialized skills, technol- surgical, critical care nursing)
health problem immediately diagnosed and addressed,
ogy, supports) Care in hospital palliative care is important for ensuring health care system efficiency
units or hospices and containing health care costs. People who have emer-
Rehabilitation gent and elective health care needs have their names
Quaternary (highly special- Transplantation nursing added to a wait list, with the level of urgency of their
ized care centres) need included. These people have booked tests or treat-
ments, in contrast to over half of all hospital inpatients
who are admitted through the emergency department
for immediate care. People with urgent health problems
are sent directly to the emergency department, diag-
primary, secondary, tertiary, or quaternary. Table 9.3 nostic imaging clinic, or operating room, with arrange-
outlines the levels of care and the kinds of services that ments often being made while they are in transit for
may be provided by nurses at these levels. Nurses have a immediate care.
key role in providing health care, whether in the hospital One example of a system for classifying the type and
or the community. Planning for nursing services must be severity of illnesses is the Canadian Triage and Acuity
approached with the four levels of care in mind. Scale, widely used across Canada to ensure that people of
all ages receive appropriate emergency department care
(Canadian Association of Emergency Physicians, 2015).
Categories of Need for Health Care At times, this scale is used to illustrate inappropriate
use of emergency departments. Recently, the Canadian
Although all Canadians can access the health care system
Institute for Health Information (CIHI, 2014a) reported
if they require any of the insured services available, an
that 47% of Canadians visiting an emergency depart-
assessment of the urgency of their need is the major defin-
ment did so because they could not get an appointment
ing criterion in Canada affecting the speed at which health
with their primary care provider.
care is provided. Physicians and nurse practitioners, as well
Wait listing has been a longstanding method in
as triage nurses in emergency departments, must deter-
Canada of ensuring appropriate access to health care
mine how urgent each presenting person’s need for health
and the effective use of expensive and sometimes scarce
care is. Different systems of classifying illnesses exist, but
health care resources. Although quality of life may be
most are oriented to identifying whether the person has
influenced while waiting for emergent or elective diag-
one of three categories of need:
nostic tests, surgery, or other treatments, the health of
1. Urgent: This health problem requires immediate treat- the individual is not normally impacted. However, con-
ment to save a life or prevent serious complications, such siderable concern over waiting too long for health care
as in cases of myocardial infarction (heart attack) or a has arisen. This concern is valid when the health of an
cardiovascular accident (stroke). individual or family caregiver is negatively impacted by
2. Emergent: This health problem is one where diagnostic the wait. For instance, if the delay is too long in obtain-
and often treatment services are required in the next ing a joint replacement and the affected person develops
few days or weeks, such as when there is a possibility of a secondary health problem because of that delay, such
cancer or another condition that could become serious as depression or bed sores, then the wait clearly was too
in the near future. long. A growing number of research investigations and
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other attempts at tracking wait times and identifying For instance, a person can become ill, undergo many
appropriate waits for select health care services have diagnostic tests to diagnose a type and stage of can-
been conducted. This work is ongoing, with many dif- cer, have ongoing blood work and other examinations,
ferent approaches in use now to reduce wait times. The receive monthly chemotherapy treatments, and then
2003 First Ministers’ Accord on Health Care Renewal 2 weeks of daily radiation for pain reduction and never
and the 2004–2014 plan have had some impact across once be a hospital inpatient. Traditional nursing roles
Canada in reducing wait lists and wait times. A CIHI and responsibilities have changed and are continuing
(2011b) report revealed that 8 out of every 10 patients to change in response to this considerable shift of client
across Canada received care within benchmarked time- care out of inpatient hospital beds.
lines. A more recent CIHI (2014b) report showed that Clients, particularly those with severe or chronic
wait times for priority procedures were not improving in incurable health conditions requiring various forms of
all provinces, with some patients waiting longer than the care over an extended time, often receive their care
recommended timeframes, likely because the number of through a number of health care organizations. This
procedures performed has risen. care and the location of this care will depend on their
Despite wait lists, the vast majority of Canadians care needs, availability of family or friends to assist them,
needing health care can get same-day service; they may number and type of services or care agencies within
call a telehealth line to talk to a nurse for health care their community, supplementary insurance coverage,
advice or see a health care provider in a physician’s or and many other potential factors. To address the health
nurse practitioner’s office, primary care clinic, or hospi- and health care needs of an entire population, a wide
tal emergency department. Blood work and radiography range of health care organizations have been established
or other common diagnostic tests will often be done that in Canada.
same day. Furthermore, same-day service is provided if
the health problem is urgent and also, in many cases,
when it is emergent.
Public Health
Public health, a subset of community health, includes
Types of Health Care services that focus on promoting health and preventing
illness. Depending on the needs of people in the commu-
Organizations and Care nity, public health offices may offer immunization pro-
grams; well-baby clinics and prenatal health programs;
Settings cancer screening and screening for other conditions,
such as communicable and genetic diseases; education
In Canada, there are numerous health care organizations and support for persons living with chronic mental or
and varying care settings. Some organizations provide physical illnesses; school health education programs to
many services; for example, a general hospital provides prevent teenage pregnancy and other common age-
a wide range of inpatient and ambulatory care services, based health issues, such as sports injuries; alcohol, drug,
including emergency room services. Some of these ser- and gambling addiction detection and abuse services;
vices can also be obtained through community-based water and air testing services; restaurant inspections; and
agencies. For example, specialized hospice–palliative care so on. In some areas, the local public health office is also
can be provided in a hospital, the home, or another the site where people can request home care services for
community setting, such as a hospice or long-term care people who need assistance in the home and where home
facility. The term continuum of care refers to care care employees report to work.
given in a variety of settings from the onset of the health Public health services are provided through govern-
challenge to the point where the recipient no longer ment departments established at the local, regional (in
requires care. regionalized provinces), provincial or territorial, and
A client can be categorized as either an inpatient federal levels. Although their aims have considerable
or an outpatient. An inpatient is admitted to hospital similarity, the health programs and services at the fed-
and expected to remain for 1 or more days of care. eral, provincial or territorial, regional, and local rural or
With technological and other advances, hospital stays urban levels vary according to the public health needs of
now average 7 days. A client who is an outpatient simi- the people over whom they have jurisdiction.
larly requires health care but does not stay more than At the federal level, Health Canada is responsible for
a few hours in the hospital or clinic. The majority of “helping Canadians maintain and improve their health,
diagnostic tests and treatments, including around 90% while respecting individual choices and circumstances,”
of surgical procedures, are done on an outpatient basis with the goal “for Canada to be among the countries
now. Although this shift to ambulatory care has greatly with the healthiest people in the world” (Health Canada,
increased the efficiency of the health care system, this 2014). Public health is the primary focus of its various
shift has major implications for clients and their families. branches and agencies. Health Canada is also charged
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with providing health care services directly to First Nations other health care services, some differences exist. Some
and Inuit peoples. The federal government also adminis- provinces, for instance, have established agencies specifi-
ters a number of veterans’ health services in Canada and cally for drug, alcohol, and gambling addictions.
has other departments that directly or indirectly support Regional health departments and local agencies tra-
the health and well-being of Canadians. In 2004, the ditionally have responsibility for developing programs
influential Public Health Agency of Canada (PHAC) was and providing the services that meet the health needs
created by the federal government “to promote and protect of people living in or travelling through a defined geo-
the health of Canadians through leadership, partnership, graphical area, by providing the necessary staff and facil-
innovation and action in public health” (PHAC, 2015). ities to carry out these programs, continually evaluating
This agency is expected to “promote health, prevent and the need for and effectiveness of their programs, and
control chronic diseases and injuries, prevent and con- monitoring changing health needs. Client and service
trol infectious diseases, prepare for and respond to public utilization information collected at this level is crucial for
health emergencies, serve as a central point for sharing provincial or territorial and federal monitoring of public
Canada’s expertise with the rest of the world, apply inter- health and the efficacy of services.
national research and development to Canada’s public Nurses work at all levels of public health service,
health programs, and strength international collaboration as direct care providers, care coordinators, department
on public health and facilitate national approaches to pub- managers, and policymakers. Nurses who are certified
lic health policy and planning” (PHAC, 2015). It is respon- in community health nursing have met specific eligibil-
sible for such issues as infectious diseases, chronic diseases, ity requirements, passed a written examination, and
travel health, food safety, immunizations and vaccines, met a national standard of competency in community
emergency preparedness and response, health promotion, health nursing. In Canada, expertise in this speciality
injury prevention, laboratory biosafety and biosecurity, is recognized with the initials CCHN(C)—Certified in
and surveillance systems (e.g., for blood safety) and oversees Community Health Nursing (Canada)—granted by the
the Centre for Immunization and Respiratory Infectious CNA. (See Chapters 1 and 2 for more information on
Diseases, the Centre for Communicable Diseases and certification and competency, and Chapter 14 for more
Infection Control, the Centre for Emergency Preparedness information on public health nursing.)
and Response, the National Microbiology Laboratory, and
the Centre for Food-borne, Environmental, and Zoonotic
Infectious Diseases. Home Care
Since 2000, the federal minister of health has
been responsible for the Canadian Institutes of Health Home care services are provided to people outside hos-
Research, Canada’s main agency for funding and direct- pitals and continuing care facilities who need temporary
ing health research. Thirteen institutes are charged with or permanent assistance with health care needs, such as
fostering needed research. One of these is the Institute complex dressing changes, or with activities of daily liv-
of Population and Public Health. Research conducted ing, such as bathing. Home care is traditionally provided
through this institute is commonly oriented toward health to older as well as younger persons with disabilities.
promotion and illness prevention. Nurses are often prin- Earlier discharge of clients from hospital is a more recent
cipal investigators and research team members, as well as purpose. The home has become a common health care
institute board members and members of the scientific delivery site. In addition, the scope of services offered
teams that judge the quality and importance of the many in the home has broadened. Home care organizations
research proposals that are submitted in competition for now provide a wide range of comprehensive care to cli-
funding. Much intergovernmental communication and ents with acute, chronic, and terminal illnesses. Nurses
program coordination occurs among Health Canada, the and nursing aides or assistants are the most common
Public Health Agency of Canada, and provincial or ter- home care workers (Wilson, Birch, Cohen, MacLeod,
ritorial health departments. Contact is at the political or Mohankumar, & Williams, 2011). See Chapter 14.
top level through the elected and appointed federal and
provincial or territorial ministers of health and chief pub-
lic health officer as well as at the front lines through the Community Health Centres and Primary
ongoing work of the many nurses and other personnel
hired to support their organization’s mandate. Provincial Care Clinics
and territorial health departments are as broadly oriented Community health centres and primary care clinics are
as the federal health department is toward public health found in many Canadian communities, providing a wide
and thus to supporting both health and wellness through range of ambulatory health promotion, diagnostic, and
health promotion and effective health care, although treatment services. These facilities normally offer medi-
their mandates are confined to policies and programs or cal, nursing, nutrition, social work, and at times basic
services on a provincial or territorial basis. Although all laboratory and radiological services. Some provide ser-
provinces and territories have similar public health and vices to people who require minor surgical procedures
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that can be performed outside hospitals. These centres Nurse Practitioner Offices
offer three main advantages: (a) They are more acces-
sible to clients and thus help them obtain necessary and Nurse practitioner offices are now being opened in
timely health care; (b) they are more holistic in their Canada as places for first contact between clients and
approach to health and illness, as they typically focus on the health care system (NP-led clinics, 2010). As in phy-
more than just the single presenting health problem and sician offices, a wide range of diagnostic and treatment
symptoms; and (c) they free up costly and scarce hospital services are normally offered. Health promotion is a key
services for clients who are more seriously ill. Nurses difference, as nurse practitioners focus on wellness. Some
working here may have basic or advanced nursing educa- nurse practitioners specialize in certain areas, such as
tion. Nurse practitioners and clinical nurse specialists are services to older people. These offices tend to be situated
often needed for their specialized knowledge and skills. in regions where health care needs are not being met
adequately, such as in areas with sparse populations and
chronic shortages of family physicians (CNA, 2009b).
Physician Offices
In Canada, the family physician’s office was the tradi- Specialist Clinics
tional setting where first contact between clients and the The term specialist clinic refers to a health care organiza-
health care system occurred. A limited set of medical tion that is situated either in a hospital or community set-
services is provided by physicians in their offices, usually ting. Most provide a distinct or specialized set of health
in keeping with the fee-for-service schedule of payments services, such as physiotherapy or education and ongoing
that is negotiated by medical groups with their provincial care for patients with diabetes mellitus. If based in a
or territorial health departments. Although the majority hospital, these clinics are also called outpatient or ambu-
of family and specialist physicians have their own offices latory care clinics, normally serving people not currently
or work with several other physicians in a group prac- admitted to hospital as inpatients. Nurses in these clinics
tice, the trend now is toward community health centres have a wide range of functions, in keeping with their
and primary care clinics, where physicians work with an education and their specific level of skills and knowledge.
interdisciplinary team comprising nurse practitioners,
nurses, and other health or social service professionals.
Clients most often go to physician offices for ill-
ness diagnosis and treatment, routine health monitoring, Occupational Health Clinics
and ongoing chronic illness management. Medication The occupational health clinic or office is gaining impor-
prescriptions, either new or refills, are a common out- tance as a common setting for employee health care.
come of visits to physician offices, along with referrals Employee health has long been recognized as signifi-
for laboratory and other diagnostic tests and referrals cant to workplace productivity. Today, more companies
to medical or other specialists. An increasing criticism encourage workplace wellness by providing on-site exer-
against physician offices is that they are merely reac- cise facilities and through the coordination or provision
tive to health problems and do not address the broader of a wide range of health-promotion activities.
aim of health care, which is to prevent illnesses through Community nurses in occupational health settings
improving health and through better management of have a variety of roles. Worker safety has been a tra-
chronic health problems to prevent acute episodes of ditional concern of occupational health nurses. Today,
illness. nursing functions in occupational health may include
Nurses employed in physician offices have many roles work safety and health education; immunizations; and
and responsibilities. Some nurses carry out traditional pre-employment and annual employee health screening
functions, including client registration, preparing clients for tuberculosis, hearing loss, and vision or eye problems.
for examination, obtaining information, and providing Other functions may include screening for health prob-
information to clients and other persons or organiza- lems, such as hypertension and obesity; assessing disabil-
tions. Other functions may include obtaining specimens, ity and readiness to return to work; providing workplace
assisting with procedures, and providing some treatments. discord counselling and crisis intervention; and planning
Nurse practitioners and clinical nurse specialists may be preretirement or retirement programs. Managers are
employed to provide primary care to clients in stable realizing that occupational health clinics can be a signifi-
or unstable health. Nurse practitioners diagnose health cant factor in attracting and retaining staff.
conditions that require intervention, plan and provide In Canada, occupational health nurses are typi-
this intervention or make referrals to other professionals cally registered nurses. They may also have a certifi-
(CNA, 2009), and typically prescribe medications. Nurse cate, diploma, or degree in occupational health and
practitioners and clinical nurse specialists (although their safety from a college or university. Nurses certified in
scope of practice is more limited) are expected to have a occupational health nursing have met specific eligibil-
holistic and wellness orientation to their care. ity requirements, passed a written examination, and
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met a national standard of competency in occupational Hospitals in Canada have undergone many changes
health. In Canada, expertise unique to this specialty over time. One of the most common changes since
is recognized with the initials COHN(C)—Certified in the mid-1990s has been a reduction in the number of
Occupational Health Nursing (Canada)—granted by the inpatient beds, offset by an increase in outpatient and
CNA. (See Chapters 1 and 2 for more information on day surgery services. Some hospitals provide innovative
certification and competency.) services, such as daycare for those who are terminally ill
and nutrition classes. Some have established alternative
birth centres to facilitate birthing to be a normal and
Hospitals natural life event. Within some provinces and territories,
regional health authorities have been given the respon-
Hospitals traditionally have provided a broad range of sibility for needed changes and for the overall planning
services for persons who are ill, injured, or dying. Most and provision of health care services in their region. In
hospitals are open to any person needing health care. others, the provincial or territorial government and local
However, military hospitals provide care only to military hospital or health care boards are responsible for operat-
personnel and their dependants. Although hospitals are ing, planning, and policymaking for hospitals.
chiefly viewed as institutions that provide health care, Another change relates to clientele. Most patients
they have other functions, such as being a resource for admitted to hospitals today are seriously ill and require
research and for nursing education. complex nursing and other care on an inpatient basis;
Hospitals can be classified by the services they provide. others less ill are treated on an outpatient or ambulatory
General hospitals admit clients requiring a variety of ser- basis. With the increasing acuity (or severity) of illness
vices; most often these are emergency, medical, surgical, among hospital inpatients, hospitals have become com-
obstetric, pediatric, and psychiatric or mental health ser- plex care centres. Hospital nurses consequently need to
vices. Hospitals are becoming more specialized, however, have advanced assessment and other skills and knowledge.
such as when one hospital becomes the maternal or child Nurses in hospitals have multiple responsibilities,
centre, with no other hospitals in that region offering these including coordinating patient care, assessing and moni-
services. Some hospitals offer only a specialty service, com- toring client health, providing a wide range of direct
monly psychiatric or pediatric care. care services, conducting research studies, orienting new
Hospitals are usually described as acute or chronic staff, and educating staff for continuing competency.
care (i.e., auxiliary) facilities. An acute care hospital pro- Management roles are often fulfilled by nurses, with
vides assistance to clients who are acutely ill and who need nurses having responsibility for a hospital or a hospital
short-term hospitalization, for example, a few hours or unit or department, increasingly as top-level executives.
days. Increasingly, with health care advances, acute care
clients are requiring only a few hours of observation fol-
lowing surgery, other treatments, and major diagnostic Telehealth
procedures. Chronic care or auxiliary hospitals provide
Telephone health care advice is now common across
care for extended periods, sometimes for the remainder
Canada. Telehealth nurses are often experienced nurses
of a person’s life.
who ask key questions to elicit needed information and
The variety of health care services that each hospital
then supply appropriate answers to the wide range of
provides usually depends on its expected duties, as well
persons calling in with health concerns. These nurses
as its size and location. Hospitals vary considerably in
advise callers how to manage nonurgent situations at
size, from small rural hospitals with only a few inpatient
home and how and when to seek appropriate medical
beds to large urban hospitals with as many as 1000 beds.
or hospital care. Telehealth services are typically avail-
Large urban hospitals typically have a wide range of inpa-
able 24 hours a day, 7 days a week. Hospital emergency
tient services, a large capacity emergency department,
department visits are reduced with the use of telehealth,
advanced diagnostic equipment and laboratories, day sur-
which benefits those who do not need to travel there as
gery units, pharmacy services, intensive care and coro-
well as those who need care in emergency departments.
nary care services, and different outpatient clinics. Some
large hospitals also have ultra-specialized or quaternary
services, such as spinal cord injury or burn units, organ
transplantation programs, oncology services, and kidney
Rehabilitation Centres
dialysis units. Small rural hospitals are often limited to Rehabilitation centres can be half-way houses, stand-
some inpatient beds, basic radiological and laboratory ser- alone hospitals, or special units in hospitals and other
vices, and first-response emergency services. The number sites. Rehabilitation centres have an important role in
of services that a rural hospital provides is related to the helping clients recuperate. Drug and alcohol rehabilita-
educational and practice qualifications of the hospital’s tion centres, for example, help clients free themselves
staff and physicians, the number of people who rely on from chemical dependence and assist them to return
it for health care, and its distance from an urban centre. home and function to the best of their abilities. Today,
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the concept of rehabilitation is applied to all injuries,

illnesses (physical and mental), and addictions. Nurses EVIDENCE-INFORMED PRACTICE
in rehabilitation centres generally plan and coordinate
client treatments. This type of nursing often requires What Are the Concerns of Rural
specialized skills and knowledge.
Persons with Advanced Cancer and of
Their Families?
Continuing Care Facilities
In this study, the researchers were trying to understand how
Continuing care facilities provide skilled nursing care and older rural patients with advanced cancer manage transitions
personal care for people who have chronic illnesses or during their care. Based on individual interviews with six rural
disabilities and are unable to care for themselves. These patients, ten bereaved family members, twelve rural health
facilities are often called nursing homes, long-term care facilities care professionals, and four focus groups, four themes
were identified. The first was community connectedness and
or, in British Columbia, complex care facilities. These facili-
isolation—where participants noted that they did feel con-
ties often become home to the clients living there, who nected to their community and supported by it but also felt
are referred to as residents. Because long-term disability isolated, especially during certain parts of the illness process.
occurs most often among seniors, continuing care facili- This was increased if the participant was geographically
ties have services that are largely oriented to the needs distant from others. The second theme was lack of acces-
of older people. New types of continuing care facilities sibility to care—especially if care was required after hours
are emerging, such as assisted living facilities, lodges, and or if they lived long distances from treatment centres. The
third identified theme was communication and information
daycare centres for people who do not need 24/7 support.
issues—where participants identified not knowing what was
Another type is subacute care for those who have been going to happen as the disease progressed, and health care
inpatients in hospitals and no longer need acute care but workers reported that sometimes patients and families were
require additional rehabilitation before returning home. struggling and the health care worker had not been notified
Nurses working in extended care facilities could that they needed help. The fourth theme, independence and
have a wide range of responsibilities. Some provide dependence, reflected the patients’ desire to remain inde-
nursing care when necessary, such as medication admin- pendent as well as their realization that they needed help as
more care was required.
istration, whereas others plan and coordinate care and
rehabilitation activities or manage the facility. NURSING IMPLICATIONS: Although independence and
community support are valued by patients and their
families, nurses need to be alert to changing needs
Hospice–Palliative Care Services during the progression of a terminal disease.
Source: Based on Duggleby, W. D., Penz, K., Liepert, B. D., Wilson, D. M.,
Long ago, a hospice was a place for travellers to rest. This Goodridge, D., & Williams, A. (2011). “I am part of the community but. . . .” The
term has currently come to mean a homelike health changing context of rural living for persons with advanced cancer and their families.
Rural and Remote Health, 11, 1733.
care facility that is designed specifically for dying people
(see Chapter 48 for more information on hospice care).
Hospice–palliative care, more broadly, is a type of end-
people cope with an immediate crisis and provide guidance
of-life care that may be offered in any setting, such as a
and support to prevent further crises.
home, nursing home, or hospital. Its central concept is
Nurses working in crisis centres need crisis communica-
not saving life but improving or maintaining quality of life
tion and counselling skills. These nurses must immediately
until death. Cicely Saunders, a nurse who later became a
identify the person’s problem, offer assistance to help the
physician and the founder of St. Christopher’s Hospice in
person cope or obtain needed help, and perhaps later direct
London, England, believed that for dying people, physi-
the person to resources for ongoing support.
cal and social environments are as important as medical
interventions. Nurses who work in hospice–palliative care
may or may not have advanced education and prepara- Mutual Support and Self-Help Groups
tion for this important work. A growing number of nurses
are obtaining CHPCN(C) designation. (See the Evidence- Canada has hundreds of support or self-help groups that
Informed Practice box on the concerns of rural persons focus on nearly every health problem or life crisis that
with advanced cancer and of their families.) people may experience. Such groups arose largely because
people felt their needs were not being met by the health
care system. Alcoholics Anonymous, which was formed in
Crisis Centres 1935, served as the model for many of these groups.
Crisis centres provide emergency support to clients. These
centres operate out of a community organization or hospi-
tal, and most provide 24-hour telephone service. Some also
Providers of Health Care
provide direct counselling to people at the centre or in their The providers of health care, collectively referred to
homes. The primary purpose of a crisis centre is to help as the health care team, are health care personnel from a
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Table 9.4 Roles of Select Health Care Team Members
Clinical nurse specialists (CNSs) CNSs provide expert nursing care and play a leading role in the development
of clinical guidelines and protocols. They promote the use of evidence, provide
expert support and consultation, and facilitate system change.
Dentists Dentists diagnose and treat diseases, conditions, and disorders of teeth, the
mouth, and surrounding tissues and structures.
Dietitians or nutritionists Dietitians plan, implement, and manage individual nutritional support and food
service programs.
Laboratory/radiologic technologists These paraprofessional workers assist or complete diagnostic tests—often
laboratory or radiology tests.
Nurse practitioners Nurse practitioners (NPs) diagnose and treat human illness and assist in rehabili-
tation, with their role expected to be holistic and health promotive.
Occupational therapists The primary goal of occupational therapists is to enable people to participate in
activities of daily living.
Paramedical technologists; emergency These first-response health care personnel deliver on-site first-aid to ill or injured
medical and ambulance attendants persons and transport them to hospitals.
Pharmacists Pharmacists dispense medications and help people understand and use their
medications safely to achieve the desired health outcomes. In some provinces,
pharmacists can renew and alter prescriptions.
Physicians Physicians diagnose and treat human illnesses and assist rehabilitation after the
onset of disease or injury.
Physiotherapists Physiotherapists or physical therapists are professionals who analyze and
address the impact of injuries, diseases, or disorders on movement and physi-
cal functioning.
Respiratory therapists Respiratory therapists assist in the diagnosis and treatment of lung disorders.
Social workers Social workers seek to improve the social health and well-being of individuals or
families.
Source: Adapted from the Canadian Institute for Health Information. (2006). Health personnel trends in Canada, 1995 to 2004. Ottawa, ON: Author. Reprinted by permission of CIHI.
variety of disciplines who coordinate their knowledge appropriate, effective, and mistake-free health care. As
and skills to assist patients (clients or residents), families, a result, they desire more information and services.
select population groups, and whole communities. The These factors and many others are affecting the health
choice of personnel for a particular individual or group care system. Box 9.1 summarizes historical trends in the
client depends on the needs of the client or patient. The development of the Canadian health care system.
roles of the categories of nurses are found in Chapter 1;
Table 9.4 defines the roles of other needed health care
providers. Alternative care providers, such as chi- Advancements in Technology
ropractors, herbalists, naturopaths, acupuncturists, and
many others, offer services that are not typically listed as and Evidence-Based Care
medically necessary to qualify for provincial and territo- With more research being done, scientific knowledge is
rial health care insurance coverage, although it could rapidly increasing. Improved diagnostic and treatment
be argued that these providers are also health care team procedures, more highly sophisticated equipment, and
members. knowledgeable health care professionals create better
outcomes for all clients. New medications are continu-
ally being developed to prevent or treat chronic and
Factors Impacting the acute health problems. The higher prevention, cure, and
remission rates with cancer are but one example of the
Health Care System life-saving impact of these advancements.
Surgical procedures involving the heart, lungs, brain,
People now have greater knowledge about their health and other organs that were nonexistent 10 years ago are
and health care. In the past, physicians and nurses made possible today. Recovery following major surgery has
necessary health care decisions; today, people usually also improved in terms of health outcomes and speed of
want to be involved in these decisions, if not be solely recovery. Laser, laparoscopic, and microscopic procedures
responsible for them. People also have higher expec- have streamlined the treatment of illnesses that required
tations from health care. Canadians want up-to-date, major surgery not long ago. Nonsurgical techniques and
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Box 9.1 Trends in Canadian Health Care System

Fact Implications for Nursing Practice
The five criteria of the Canada Health Act are the cornerstone of the Nurses need to understand the five criteria and how
Canadian health care system. the health care system operates to deliver effective
quality care.
The Canadian health care system has evolved into its present form. Then and now, nurses have been system and client
Saskatchewan, in 1947, was the first province to establish universal advocates to ensure that the health care needs of
hospital insurance. Ten years later, the Canadian government passed people are understood and met.
legislation to permit the federal government to share the cost of provincial
hospital insurance plans. By 1961, all provinces and territories had public
insurance plans providing comprehensive coverage for in-hospital care.
Canada’s total health care and per capita (per person) expenditures are Nurses have a responsibility to be fiscally aware and
higher compared with other developed countries. to advocate for economic accountability. Specific
cost-containing initiatives have been implemented
to improve efficiencies and contain costs. All health
care providers are involved in these initiatives.
Federal reform initiatives have included the Commission on the Future of Nurses need to lead, participate in, and understand
Health Care, chaired by Roy Romanow; the Standing Senate Committee government health care initiatives.
on Social Affairs, Science and Technology (the Health of Canadians–the
Federal Role), chaired by Michael Kirby; and the 2004–2014 Accord to
shorten wait times.
medications have made some surgeries unnecessary. A care system. This cost is offset, however, by the cost
prime example is gallbladder removal, which used to be a savings that result from health care advancements.
major surgical procedure involving a 10-day hospital stay Unfortunately, it is much easier to cost out the price of
and a high probability of wound infections and pneumo- a new diagnostic machine than to calculate the savings
nia. Although gallbladder disease is still very common in that arise from preventing some illnesses and successfully
Canada, it can now be treated either with medications to treating others earlier.
dissolve gallbladder stones or through laparoscopic gall-
bladder removal, a day surgery procedure. Day surgery
has many advantages; an inpatient hospital bed is not Economics
required; recovery at home is improved; and hospital-
acquired, or nosocomial, infections are avoided. Paying for health care has been an issue for governments,
With this shift out of hospital, some direct and indi- particularly since 1966 when the Medical Care Act (the
rect costs have been passed to the individual or family. precursor of the 1984 Canada Health Act) was passed,
These include the cost of medications and supplies that containing a promise of 50/50 cost sharing between the
would be provided at no charge if hospitalized. Lost federal and provincial governments. The health care sys-
time from work is an indirect cost, as family members tem, then and now, is greatly affected by the country’s
normally are needed for transportation purposes and financial status. The economic recessions of the 1970s and
for providing both pretreatment and post-treatment care 1990s, as well as the 2008–2009 recession, increased con-
in the home. Family caregiving may be long term, with cerns about escalating health care costs. Canada’s health
informal caregiver burden increasingly linked to health care costs have increased considerably since 1966, and
issues for family members who provide ongoing care for they continue to increase above inflation. Many factors
contribute to this, including the cost of not doing more to
chronically ill or dying loved ones.
prevent illnesses and injuries and the high cost of deliver-
The use of computers, which has improved client
ing health care across Canada. Although 80% of citizens
care and has helped store and retrieve large volumes of
live in or near urban centres, where economies of scale
information, is commonplace in health care organiza-
reduce costs, 20% of citizens live in rural and remote areas
tions now. Health research is also greatly advanced, and
across 95% of Canada’s land surface.
the knowledge gained is important for improvements in
Other reasons for this cost increase include the
evidence-informed practice and for the education of new
following:
health care professionals.
Technological advances and specialized treatments • The costs of drugs, supplies, and physician services have
or procedures come with a high price tag for the health risen substantially.
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• Inflation continually increases all costs, including health Recognition of the cultural and ethnic diversity of
care provider wages. Canada is increasing. A series of CNA position state-
• Existing equipment and facilities become obsolete or in ments have been developed, including Promoting Cultural
need of repair and replacement. Competence in Nursing (CNA, 2010), which acknowledges
the increasingly diversity among clients. Health care pro-
• Additional space, sophisticated equipment, and spe-
fessionals and organizations are meeting the challenges
cially trained personnel to use and maintain equipment
presented by persons speaking different languages and
are required to provide modern evidence-informed
having different customs and health care practices and
care.
beliefs. For example, more organizations are providing
• The population has grown, with more people needing opportunities for staff to increase their cultural knowl-
health care services. edge and sensitivity.
• Health care system inefficiency exists, including mini-
mal home care and extended care services to permit
more care outside of hospitals. Problems in Distribution of Services
• Changes in illnesses have occurred; more clients have Two problems in the distribution of health care ser-
multiple chronic illnesses that need ongoing care, and vices across Canada exist: (a) uneven distribution and
widespread obesity is causing many health problems. (b) increased specialization. In some areas, particularly
inner city and remote or rural locations, the numbers of
Health care system initiatives to contain costs are
health care professionals and services available locally
undertaken by various provincial and territorial govern-
are insufficient to meet the health care needs of individu-
ments and health regions. One such initiative, the Lean
als, families, and communities. Rural and remote clients,
project of the Saskatchewan Ministry of Health (2015),
such as Inuit and other northern residents, often need
attempts to “put the needs and values of patients and
to travel long distances to obtain needed services. Even
families at the forefront and uses proven methods to
if there is a local hospital, small hospitals usually do not
continuously improve the health system. It is unique in
offer surgical, birthing, and many other services; this
that it engages and empowers employees to generate and
may be because of personnel and equipment shortages
implement innovative solutions, and to fundamentally
or health care specialization.
improve the patient experience on an ongoing basis”
Health care is continually becoming more special-
(para 1). System efficiencies to improve the patient expe-
ized, with cancer care and many other health care ser-
rience and contain costs are the goals of the program.
vices provided only in a few larger organizations, where
Similar initiatives now exist in most health regions.
greater frequency of care delivery helps ensure cur-
rent knowledge and competent practice. Because of
the highly specialized techniques and new knowledge
Growth and Demographic Changes that have emerged with research, an increasing num-
In 1966 and 1984, when the two acts that sequentially ber of health care personnel provide only specialized
formed our health care system were passed, the popula- services. They may be highly specialized technicians
tion of Canada was 20 million and 26 million, respectively. or technologists with narrow and exacting jobs, such
Today, there are 35.5 million Canadians, each of whom can as orthotic technologists, biomedical electronic tech-
be expected to see a physician or nurse practitioner at least nologists, and nuclear medicine technologists. Increased
once a year. Approximately 9% of Canadian citizens of all specialization is evident also among nurses, physicians,
ages will be admitted to hospital for inpatient care per year, and other health care professionals. This specialization,
and half will require ambulatory care in emergency depart- although beneficial, contributes to fragmentation of care
ments or outpatient clinics (Health Canada, 2015). and other concerns. To a client, it may mean receiving
The characteristics of the Canadian family have care from five to thirty different health care profession-
also changed considerably in the past few decades. The als in the hospital and many more over the course of
numbers of single-parent families and alternative family a terminal or treatable illness. Having to deal with this
structures have increased markedly. Most single-parent seemingly endless stream of personnel can cause confu-
families are headed by women, many of whom work in sion. It can also lead to errors.
low-paying jobs; they typically require assistance with Providing safe care is very important. The Canadian
daily childcare or when a child is sick at home. Divorce Patient Safety Institute was established by Health Canada
continues to be common, with more divorced or never- in 2003 as an independent not-for-profit organization,
married persons entering old age without the assurance operating collaboratively with health care professionals
of assistance from spouses or children. Considerable and organizations, regulatory bodies, and governments
geographical mobility means that family members may to build and advance a safer health care system for
not be close by to help. The birthrate continues to be low, Canadians (Canadian Patient Safety Institute, 2012).
with immigration needed to maintain population levels Nursing has contributed to these efforts, such as through
of young and working-age persons (CIHI, 2011a). the CNA (2009a) position statement entitled Patient Safety.
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Accreditation Canada (2013) is another key national earlier detection and proactive management of health
nongovernmental organization that, since 1958, has problems. These programs are often used by women, as
worked “with health care organizations to help them they are more likely to live longer.
improve quality, safety, and efficiency” for “the best Indeed, people aged 85 years and older are among
possible care and service.” This organization has health the fastest-growing population groups. This age group
care excellence as its aim. Clients are also more aware is more likely to need assistance to accomplish activities
of patient safety issues because of media attention, with of daily living. Only 7% of older people, mostly those
health care organizations expected to have safety policies aged 85 years and older, live in continuing care facili-
and safe workplace practices in place. ties (CIHI, 2011a). Chronic illnesses are more prevalent
with aging, although more than three-quarters of older
Canadians rate their health as good, very good, or excel-
Access to Health Care lent (Statistics Canada, 2012). Considerable concern
exists with regard to the use of health care services by
Not all population groups in Canada have equitable seniors, despite 84.7% of the Canadian population being
access to health care. Rural and remote residency has younger and potentially as likely to need health care. For
been associated with higher rates of risk factors, illnesses, instance, the most common reason for hospitalization
and death; and reduced access to health care (CIHI, in Canada is childbirth. Other age-based differences in
2006). Low education and income are other major health care needs are evident; 80% of all persons who
factors associated with greater health care needs and require end-of-life care are older, and older people have
higher utilization, as well as poorer health care outcomes higher rates of home care utilization and longer hospital
(CIHI, 2010). Access to, and thus use of, available health stays when admitted to hospital.
care services is adversely affected by poverty. Although
Canadians do not have to pay to see a physician or to
receive hospital care, taking a day off from work for Women’s Health
health care could mean a day without pay for someone in
a minimum-wage job. The transportation costs to access The women’s movement has been instrumental in chang-
health care and the costs of out-of-hospital care are also ing health care practices. Examples are the provision of
disproportionately higher for persons with low incomes. childbirth services in more relaxed settings, such as birth-
Limited government assistance may be available, but its ing centres, and the provision of overnight facilities for
eligibility varies considerably across provinces and ter- parents of children admitted to hospital. Traditionally,
ritories. (See Chapter 15 for more information on rural many health care concerns that are unique to women,
health care.) both young and old, have been overlooked; with rising
concern, for instance, that heart disease among women
is often not detected. One of Health Canada’s responses
in this area is the Gender-Based Analysis initiative, which
Population Aging and Aging recognizes the variety of factors that contribute to gen-
among Older Adults der differences in health and health care needs, as well
as providing evidence of the effects of gender on the
Not only is the number of older Canadians increasing
determinants of health (Health Canada, 2010).
from 4.8 million in 2010 to an anticipated 10.4 million
by 2036 (Statistics Canada, 2009), but so also is the
percentage of Canadians aged 65+. By 2030, when all
members of the large “baby boom” generation (those
Homeless Populations
born between 1945 and 1964) will have reached age 65 The growing number of homeless individuals and fami-
years, 25% of the population will be older persons com- lies is a health problem, too. The homeless differ from
pared with the 2013 rate of 15.3% (Statistics Canada, people who are poor. The homeless are often socially
2014). Although much concern exists about their health isolated, lack any type of permanent residence, and are
care utilization, older people are increasingly healthy often disaffiliated from family. Because of the conditions
and active into advanced old age. They fulfill many in which homeless people live (e.g., temporary shelters,
important responsibilities through volunteering, holding tents, cars, or on the street), existing illnesses are often
political office, heading boards or corporations, caring exacerbated and new health challenges, such as frost
for grandchildren or ill family members and friends, and, bite, malnutrition, and injuries, often emerge.
increasingly, staying in the workforce (CIHI, 2011a). The Factors contributing to homelessness include the
feeling of being useful is important for a person’s health. high cost of housing and the change from inpatient
Special programs are being designed in communities so to outpatient mental care services. Limited access to
that the talents and skills of this group are not lost to health care services is another significant contributor to
society. Other programs, such as seniors’ daycare, are poor health. Tuberculosis, for instance, is more common
being designed for health-promotion purposes and for among homeless people.
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Evidence-Informed Practice coordinating, implementing, and evaluating care for indi-

viduals after hospital discharge over their lifetimes.
It is sometimes said that over half of all health care Nurse case managers may be hired by a hospital
practices are not research based and that, instead, prac- or another health care organization, such as a home care
tices that have developed in response to needs have been agency. They may coordinate care for a specific client
refined over time. Nurses are rapidly addressing this population, such as clients with chronic obstructive lung
issue, with many nurse researchers seeking to prove that disease or mental health problems, or for all persons
current nursing or health care practices are safe and receiving long-term home care. A critical component of
effective or that the new alternatives are better. their role is communication and collaboration with other
health care professionals and the client to achieve optimal
immediate and long-term outcomes.
Climate Change Case management can be used as a cost-containment
Evidence of climate change, broadly referred to as global strategy, as hospital avoidance and earlier discharge from
warming, is also growing, including information on the hospital reduce health care costs. Case managers often
varied impacts of climate change. Although distinct use critical pathways to track each client’s progress.
weather-related emergencies, such as the 2011 tsunami A critical pathway, which is a plan or tool for the man-
in Japan, cause considerable health impacts to those aged care of a client, specifies assessments, interventions,
directly and indirectly affected, global health is being treatments, and outcomes for specific health-related con-
affected by the daily effects of increased greenhouse ditions across time. Critical pathways are also called
gases. Unfortunately, we can expect to see more pandem- interdisciplinary care plans, anticipated recovery plans, and action
ics, heat waves, and violent weather with unchecked cli- plans. These plans can be developed for most surgical
mate change. Other less visible, but serious, impacts from procedures, and for other emergency care, trauma care,
increased greenhouse gases should also be of concern, and additional health-related interventions. They are
such as rising rates of asthma and chronic obstructive usually used for high-volume case types or situations
lung disease. with relatively predictable outcomes. These pathways are
designed in collaboration with members of the health
care team who are involved in managing each case type,
Leadership and the pathways are considered best practices as they
are based on a body of evidence. It is important to exer-
Another important influence on the health care system is cise clinical judgment, however, when applying standard
leadership by elected and appointed persons, as well as protocols and to refrain from using them as a check-
nurses and others who advocate for beneficial reforms. list for all clients. Critical pathways are presented in
Reform task forces and commissions are often initiated Chapter 23 and later chapters.
by governments, although they do not always lead to
change. Increasingly, leaders are using visions of health
promotion and sustainable health care coupled with
evidence from research to plan policy and programs that Patient-Focused Care
incrementally change the Canadian health care system. Patient-focused care (also called client-centred care) is a
delivery model that emphasizes the importance of the client’s
needs and interests. The supposition is that if health care
Contemporary Frameworks is more directly aimed at determining and meeting client
needs there will be more successful treatment and possibly
for Care cost savings. For instance, many terminally ill people refuse
to continue with life-supporting treatments. Their needs and
A number of newer client care approaches support con- interests are paramount over those of families who may want
tinuity of care and cost-effectiveness. Continuity of care continued treatment.
across organizations and care providers is important, as Cross-training, the development of multiskilled work-
is cost-effectiveness. ers who can perform tasks or functions normally done by
more than one discipline, illustrates patient-focused care.
For example, an unlicensed health care worker may be
Case Management taught to obtain a 12-lead electrocardiogram (ECG), or
individuals who are already certified in one occupation
The term case management describes a range of models can take on a second certification, such as nurses provid-
of integrated health care services. Case managers may also ing medical laboratory and x-ray technology, respiratory
be referred to as patient navigators or care managers. Nurses therapy, and physical or occupational therapy. The blur-
are commonly hired for this type of work. Case managers ring of role boundaries is making collaboration vital dur-
typically assume responsibility for assessing needs, planning, ing the design and implementation process. In addition,
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many health care professionals have shared skills in terms decision making (within and across disciplines), and
of assessment, intervention, and evaluation. Relying on fosters respect for the contributions of all providers”
the assessments of other providers, where appropriate, (Health Canada, 2005, p. 1).
can avoid duplication of effort and improve team func-
tion for better patient care.
Another initiative to foster patient-focused care
is interprofessional collaboration, which has Models for the Delivery
long been a topic of importance in the practice and
educational arenas. In light of the need for interdis- of Nursing
ciplinary teamwork, Health Canada developed the
Interprofessional Education for Collaborative Patient-Centred Contemporary configurations for the delivery of nursing
Practice (IECPCP) initiative in 2005. “Collaborative include collaborative arrangements, such as managed care,
patient-centred practice is designed to promote the case management, and patient-focused care discussed ear-
active participation of several health care disciplines lier. Frequently, delivery methods comprise components of
and professions. It enhances patient, family, and more than one configuration. Box 9.2 describes the most
community-centred goals and values, provides mecha- common nursing care delivery methods used in acute care
nisms for continuous communication among health and other settings: case method, functional method,
care providers, optimizes staff participation in clinical team nursing, and primary nursing.
Box 9.2 Nursing Delivery Methods Used in Health Care Settings

Case method • One nurse is assigned to and is responsible for the comprehensive care of one or more
assigned clients over the course of a shift.
Functional method • This method focuses on the jobs to be completed (e.g., vital signs, medication
administration).
• Personnel with less preparation than professional nurses perform less complex care.
• The person assigning work has authority and responsibility, normally the charge nurse or
the team leader.
Team nursing • The collective delivery of care to clients through a nursing team that is led by a profes-
sional nurse.
• The team consists of registered nurses, often working with licensed practical nurses,
unlicensed assistive personnel, such as nurse aides, and possibly psychiatric nurses and
others.
Primary nursing • One nurse is responsible for the care of select clients, 24 hours a day, 7 days a week.
• Associates provide care when the primary nurse is not available.
Case Study 9
Rebecca Konapinski is leaving hospital after major surgery. She
is leaving with a drain that will stay in place for
2. How might Rebecca’s family and friends provide health
care services to her?
10 days. It is obvious she is apprehensive and
worried about who will change her dressing 3. How would a nurse provide health care to her?
when she gets home. Her children are young,
and her husband travels a great deal. Visit MyNursingLab for answers and explanations.
Critical Thinking Questions
1. What is meant by continuum of health care service

delivery?
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Key Terms
accessibility p. 141 dentist p. 151 interprofessional physiotherapist p. 151
alternative care diagnosis p. 144 collaboration p. 156 portability p. 141
providers p. 151 dietitian p. 151 laboratory/radiologic primary nursing p. 156
case management p. 155 end-of-life care p. 144 technologist p. 151 public administration
case managers p. 155 functional method nurse practitioner p. 151 p. 141
case method p. 156 p. 156 nutritionist p. 151 rehabilitation p. 143
clients’ rights p. 142 health care system occupational therapist respiratory therapist
clinical nurse specialist p. 140 p. 151 p. 151
(CNS) p. 151 health promotion p. 144 paramedical social worker p. 151
comprehensiveness health restoration p. 143 technologist p. 151 team nursing p. 156
p. 141 hospice–palliative care patient-focused care treatment p. 144
continuum of care p. 144 p. 155 universality p. 141
p. 146 illness and injury pharmacist p. 151
critical pathways p. 155 prevention p. 144 physician p. 151
C hapter Highl i g hts

• The health care system has developed into a large, • Health care must coordinate their skills to assist clients.
complex organization comprising a wide variety of orga- Their mutual goal is to restore and promote client health.
nizations, services, and health care providers. At the heart This coordination also occurs when hospice–palliative
of this system is the client. care is provided.
• Health care should be considered a right of the citizens • The many factors affecting health care delivery include
of Canada. consumers’ rights, women’s health, an increasing popula-
• Health care services can be categorized as primary, second- tion, advances in knowledge and technology, economic
ary, tertiary, or quaternary and grouped by type of service: factors, fragmentation of care, increased costs, health care
(a) health promotion and illness prevention, (b) diagnosis of the homeless, problems in distribution of health services,
and treatment, (c) rehabilitation, and (d) hospice–palliative demographic changes, and access barriers to health care.
and end-of-life care. • A number of nursing care delivery models can be used,
• Hospitals provide a wide variety of inpatient and outpa- including the case method, functional method, team nurs-
tient services. Hospitals can be categorized as acute care ing, and primary nursing.
or extended care centres. Many other settings, such as • Health care costs are escalating and becoming a signifi-
clinics, offices, and daycare centres, also provide health cant factor in the provision of universal health care in
care. Canada.
N CLE X- st yle pr actice qui z

1. A young woman from Ontario was vacationing in British 2. A client is diagnosed with a condition requiring a blood
Columbia when she was injured. She was given imme- transfusion. The client declines the transfusion because
diate treatment in the nearest hospital and was not of his religious beliefs. Which right is exemplified in this
charged anything for her treatment though she lives out scenario?
of province. This practice demonstrates which of the five a. To be informed
Canada Health Act criteria?
b. The right to choice
a. Comprehensiveness
c. Right to consumer education
b. Universality
c. Public Administration d. The right to health care
d. Portability
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3. Which types of health care services have traditionally expectations regarding the care and delivery of
been emphasized within the Canadian health care health services.
system?
d. Advancements in technology have decreased the
a. Diagnosis and treatment of illnesses amount of time spent in hospital and concurrently
b. Rehabilitation and health restoration decreased care requirements from community health
agencies and individual clients.
c. Health promotion and illness prevention
d. Hospice–palliative and end-of-life care 7. What BEST describes team nursing?
a. Delegation of tasks to other members of the health
4. Which of these examples is considered a primary health care team
care service? b. Planning and delivery of care for a group of clients
on a 24/7 basis
a. A visit to an orthopedic specialist
c. Fragmentation of nursing care duties
b. Screening for cervical cancer
d. First point of contact for most clients within the
c. Emergency room care health care system
d. Diagnostic imaging
8. A client requires a surgical procedure and has been
5. Part of the responsibility of a registered nurse is to placed on a wait list. What is the client’s urgency of
understand the role of health care personnel involved in care category?
the different dimensions of client care. An experienced a. Urgent
registered nurse is working on a busy cardiology ward. A b. Emergent
client on the team is being discharged home with a pre-
scription for eight new cardiac drugs to add to his health c. Elective
care regime. Which health care provider might best be d. Diagnostic
suited for the role of medication interaction screening
and education? 9. There has been a shift from inpatient hospital care to
care in ambulatory or community arenas. What has
a. Registered nurse resulted from this change?
b. Pharmacist a. An increase in out-of-pocket expenses
c. Social worker b. A decrease in the availability of treatments requiring
d. Physician sophisticated equipment
c. A reduced requirement for professional nurses to
6. Which statement is true regarding societal and demo- work in hospitals
graphic factors affecting the Canadian health care d. A decrease in the number of extended care facilities
system? required for the population
a. Most older people in Canada are no longer inde-
pendent, with the majority living in extended care 10. Which is an example of an illness and injury prevention
facilities. program?
b. Reduced access to health care by the rural popula- a. Analysis of motor vehicle collisions
tions in Canada is a factor associated with higher b. Use of occupational protective equipment
rates of rural illness and premature death. c. Teaching crutch walking in an ambulatory care clinic
c. Canadians are realizing the health care system may d. Support group for women with breast cancer
not meet all their needs and therefore have lower
Re f e r e nc e s
Accreditation Canada. (2013). Corporate overview. Retrieved from Canadian Institute for Health Information. (2011a). Health care in
https://www.accreditation.ca/corporate-overview. Canada: A focus on seniors and aging. Retrieved from https://secure.
Canada Health Act. R.S., 1984, c. C-6. cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf.
Canadian Association of Emergency Physicians. (2015). Canadian Canadian Institute for Health Information. (2011b). Wait times in
triage and acuity scale (CTAS). Retrieved from http://caep.ca/ Canada—A comparison by province, 2011. Retrieved from http://
resources/ctas. secure.cihi.ca/cihiweb/products/Wait_times_tables_2011_en.pdfh.
Canadian Institute for Health Information. (2006). How healthy are Canadian Institute for Health Information. (2014a). Sources of
rural Canadians? Retrieved from https://secure.cihi.ca/free_ potentially avoidable emergency department visits. Retrieved from
products/rural_canadians_2006_report_e.pdf. https://secure.cihi.ca/free_products/ED_Report_ForWeb_EN_
Canadian Institute for Health Information. (2010). Hospitalization Final.pdf.
disparities by socio-economic status for males and females. Retrieved from Canadian Institute for Health Information. (2014b). Wait times for
https://secure.cihi.ca/free_products/disparities_in_hospitalization_ priority procedures in Canada, 2014. Retrieved from https://secure.
by_sex2010_e.pdf. cihi.ca/free_products/2014_WaitTimesAiB_EN.pdf.
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Canadian Nurses Association. (2008). Code of ethics. Ottawa, ON: Lalonde, M. (1974). A new perspective on the health of Canadians.
Author. Ottawa, ON: Government of Canada.
Canadian Nurses Association. (2009a). Position statement: Patient safety. NP-led clinics: Ontario leads the way. (2010). Canadian Nurse Journal,
Retrieved from http://www.cna-nurses.ca/CNA/documents/pdf/ 106(9), 30–35.
publications/PS102_Patient_Safety_e.pdf. Public Health Agency of Canada. (2015). About the agency. Retrieved
Canadian Nurses Association. (2009b). Position statement: The nurse from http://www.phac-aspc.gc.ca/about_apropos/index-eng.php.
practitioner. Retrieved from https://www.cna-aiic.ca/~/media/ Romanow, R. J. (2002). Building on values: The future of health care in
cna/page-content/pdf-en/ps_nurse_practitioner_e.pdf ?la=en. Canada. Retrieved from http://publications.gc.ca/collections/
Canadian Nurses Association. (2010). Position statement: Promoting Collection/CP32-85-2002E.pdf.
cultural competence in nursing. Retrieved from http://www.cna-aiic. Saskatchewan Ministry of Health. (2015). Saskatchewan Health Care
ca/~/media/cna/page-content/pdf-en/ps114_cultural_ Management System: Lean initiative. Retrieved from http://www.
competence_2010_e.pdf ?la=en. saskatchewan.ca/government/health-care-administration-and-
Canadian Nurses Association. (2015). Joint posi- provider-resources/saskatchewan-health-initiatives/lean.
tion statement-practice environments: Maximizing outcomes for Statistics Canada. (2009). 2006 census: Portrait of the Canadian
clients, nurses and organizations. Retrieved from http:// population in 2006, by age and sex: Findings. Retrieved from http://
www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ www12.statcan.ca/census-recensement/2006/as-sa/97-551/
practice-environments-maximizing-outcomes-for-clients-nurses- index-eng.cfm.
and-organizations_joint-position-statement.pdf ?la=en. Statistics Canada. (2012). Social participation and the health and well-
Canadian Nurses Protective Society. (2015). Update: The Supreme being of Canadian seniors. Retrieved from http://www.statcan.gc.ca/
Court ruling on physician-assisted death. The Canadian Nurse, pub/82-003-x/2012004/article/11720-eng.htm.
111(4), 22–24. Statistics Canada. (2014). Population projections: Canada, the provinces and
Canadian Patient Safety Institute. (2012). Retrieved from http:// territories, 2013 to 2063. Retrieved from http://www.statcan.gc.ca/
www.patientsafetyinstitute.ca/English/Pages/default.aspx. daily-quotidien/140917/dq140917a-eng.htm.
Epp, J. (1986). Achieving health for all: A framework for health promotion. Wilson, D. M., Birch, S., Cohen, J., MacLeod, R., Mohankumar,
Ottawa, ON: Health and Welfare Canada. D., & Williams, A. (2011). Home care developments in the
Health Canada. (2005). Interprofessional education for collaborative patient- Canadian province of Alberta with regionalization. Global Journal
centred practice. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/ of Health Science, 3(1), 3–9.
hhr-rhs/strateg/interprof/index-eng.php. World Health Organization. (1979). Formulating strategies for health for
Health Canada. (2010). Health portfolio sex and gender-based analysis all by the year 2000. Geneva, Switzerland: Author.
policy. Retrieved from http://www.hc-sc.gc.ca/hl-vs/pubs/women- World Health Organization, Health and Welfare Canada, &
femmes/sgba-policy-politique-ags-eng.php. Canadian Public Health Association. (1986). Ottawa charter for health
Health Canada. (2014). About Health Canada. Retrieved from http:// promotion. Ottawa, ON: Canadian Public Health Association.
www.hc-sc.gc.ca/ahc-asc/index-eng.php.
Health Canada. (2015). Canada Health Act annual report. Retrieved
from http://www.hc-sc.gc.ca/hcs-sss/pubs/cha-lcs/2014-cha-lcs-
ar-ra/index-eng.php.
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Chapter 10
Environmental and
Global Health Nursing
Updated by
Olive Wahoush, RN, MSc, PhD (McMaster); Iris Mujica, RN, MSc, PhD(s)
(McMaster); and Michael G. Ladouceur, RN, BScN, MPH (McMaster)
McMaster University
T
LEARNING OUTCOMES
After studying this chapter, you will be able to his chapter will help you
1. Describe the main factors related to environmental health: climate understand the evolu-
change, global warming, air pollution, water, and sanitation. tion and characteristics
2. Describe how environmental factors affect health in Canada. of environmental and global health.
Environmental health and global
3. Examine the changes in population health over time and between
countries, including lifespan differences and epidemiologic health are both important and rel-
transition. evant to nurses in Canada, even if
4. Distinguish between global health and international health. they never travel out of Canada. It is
already clear that climate change and
5. Summarize the ways in which countries are organized and current
theories of development in relation to global health. changes in the global economy exert
powerful effects on Canadians and
6. Discuss the relevance of the Sustainable Development Goals in
reducing poverty and fostering development across the world. Canada. Environmental and global
health are not static fields; each is a
7. Describe the features of four main issues of global health and
explain how they relate to life in Canada. rapidly changing and dynamic inter-
face of many factors that impact how
8. Describe the role of nursing in global health and the importance of
educating nurses in global health issues. we live and work now and in the
future. We present definitions of key
terms, history, and development of
these broad fields of health and intro-
duce the idea of transitions for nations
and populations in each section.
Joachim Wendler/Shutterstock
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Chapter 10 Environmental and Global Health Nursing 161
Environment and Health limits the normal reflection of the sun’s rays back into the
upper atmosphere, which is necessary to maintain the nor-
mal cycles of the earth’s temperature. Global warming has
Environmental factors exert significant influence on been increasing more rapidly since the 1970s. Some pat-
human health in all countries, including Canada. Cli- terns of change may last a decade or two, whereas others
mate change, access to safe water, sanitation, and indoor may persist and become permanent without interventions
and outdoor pollution are perhaps most important, as for change (Birn, Pillay, & Holtz, 2009b).
they are major factors in the deaths and burden of illness Global warming effects vary. For instance, warming
for millions of adults and children annually. is greatest over land, highest over high northern latitudes,
Almost 25% of all diseases and 23% of all deaths and least over the Southern Ocean and northern part of
are caused by environmental factors. The most vul- the North Atlantic (Pachauri & Reisinger, 2007). Predicted
nerable are those who experience unequal access to changes include increased frequency of tropical storms and
health care resources or have specific vulnerabilities, for heat waves, with precipitation increasing in some regions
example, children, Indigenous peoples, people who live and decreasing in others. These changes will impact how
in poverty, and those who live on small islands and in and where people live and ultimately their health (Patz,
rural or isolated communities (Griffiths & Winant, 2007; Frumkin, Holloway, Vimont, & Haines, 2014).
World Meteorological Organization [WMO], 2013; Over time, changes in temperature and weather
World Health Organization [WHO], 2015a). patterns will change land use; rising seas levels will cause
Young children are particularly vulnerable to ill- loss of coastal plains and small islands; and populations
nesses and death related to environmental factors because will be displaced and forced to migrate. Forest clearance,
children breathe, eat, and drink more in proportion to accompanied by changing weather patterns, will cause
body size compared with adults (Prüss-Üstün & Corvalán, vectors of diseases, such as rats, ticks, flies, and mos-
2006). Globally, a third of illnesses and death in child- quitoes, to migrate, bringing old diseases to new areas
hood are caused by environmental factors and by toxins, and giving rise to new diseases. West Nile virus infection
sometimes resulting in permanent developmental damage. is an example of a new disease in Canada.
Climate Change Health Effects of Climate Change

Climate change and its effects are now well documented
Climate change is implicated in 13 million deaths world-
(Balbus, 2010; Pachauri & Reisinger, 2007; WMO,
wide annually and a significant portion of disease bur-
2013), and reasonable estimates of future effects are pos-
den. Globally, increasing millions will suffer malnutrition,
sible (Prüss-Üstün & Corvalán, 2006). Climate change
death, and injuries related to extreme weather. In 2003,
occurs when long-term weather patterns change.
an extreme heat wave in Europe caused an estimated
Changes noted in weather patterns over the past few
70 000 deaths; such events are expected to be the norm
decades include global warming, increased rainfall in
by 2050. Diarrheal diseases associated with warmer tem-
some regions, prolonged periods of no rainfall in others,
peratures and cardiorespiratory problems related to poor
extreme storm systems, and rising sea levels. Possible
air quality will increase, and other diseases will emerge
effects of climate change are presented in Table 10.1.
in new regions; malaria and Dengue fever have already
Global warming is caused by increases of “green-
extended into new regions and higher altitudes (WHO,
house gases,” primarily carbon dioxide, methane, and
2009a). Changes in disease patterns require vigilance
nitrous oxide. Their emissions vary widely by country
from public health systems so that early identification
(see Table 10.2). It is important to understand that some
can lead to effective management for population health.
countries with lower per-capita rates of carbon produc-
tion have, in fact, the largest total rate because they have
very large populations. Others with very high per-capita
rates have a low total rate, as their national population is
Solutions for Climate Change
quite small in global terms (see Table 10.3). Both mea- Three potential solutions for climate change are pro-
sures provide direction for carbon reduction activities. posed: (a) adaptation, (b) mitigation (actions taken to
Greenhouse gases are produced from human activity reduce the effects), and (c) reducing emissions from
in industry, power generation, vehicle use, agriculture, and deforestation and forest degradations (REDD); these
deforestation (Birn, Pillay, & Holtz, 2009a). Burning fos- solutions will be effective if widely adopted and imple-
sil fuels is the principal source, and deforestation adds to mented (McMullen & Jabbour, 2009; United Nations
the accumulation of greenhouse gases, as trees are essen- Environment Program [UNEP], 2015).
tial for their absorption. Greenhouse gases cause global Adaptation includes actions to live with climate
warming as they form a layer above the earth’s atmo- changes and to identify shifts in disease patterns. Exam-
sphere. Radiation from the sun penetrates these gases ples of adjusting to climate change include changing the
and warms the earth. The greenhouse gas layer, however, timing of the planting season, matching types of crops
M10_KOZI2703_04_SE_C10.indd 161 21/02/17 5:23 PM

TABLE 10.1 Examples of Possible Impacts of Climate Change Caused by Changes in Extreme Weather and Climate Events
Examples of Major Projected Impacts by Sector*
Likelihood of Future
Trends for Twenty-
M10_KOZI2703_04_SE_C10.indd 162
162 UNIT TWO
Phenomenon and First Century Using Industry, Settlement Projections,

Direction of Trend SRES Scenarios Agriculture, Forestry Water Resources Human Health Ecosystems, and Society
Land areas, warmer Virtually certain c Crops in colder Effects on water resources THuman mortality from less T Energy demand for heating
TCold days and nights environments relying on snowmelt; cold exposure c Demand for cooling
cHot days and nights T Crops in warmer effects on some water c Poor air quality in cities
environments supplies T Disruption to transport because of snow; ice
c Insect outbreaks effects on winter tourism
Warm spells/heat Very likely T Crops in warmer c Water demand; water c Risk of heat-related mor- TQuality of life for people in warm areas with-
waves; more often over regions as a result of quality problems (e.g., tality, especially for older out appropriate housing; impacts on the very
land areas heat stress algal blooms) adults, chronically sick, very young and poor
c Danger of wild fire young, and socially isolated
Heavy precipitation Very likely Damage to crops, soil T Quality of surface and cRisk of deaths, injuries Disruption of settlements, commerce, trans-
events erosion, inability to cul- groundwater; contamina- cInfectious, respiratory, and port, and societies because of flooding; pres-
Contemporary Health Care in Canada
c Frequency over most tivate land as a result of tion of water supply; water skin diseases sures on urban and rural infrastructures, and
areas waterlogged soils scarcity may be resolved. loss of property
cArea affected by Likely Land degradation; More widespread water T Risk of food and water Water shortage for settlements, industry, and
drought T Yields as a result of stress shortages societies
crop damage and failure c Risk of malnutrition T Hydropower generation potential
c Livestock deaths c Risk of water- and food- c Possibility for population migration
c Risk of wild fire borne diseases
cIntense tropical Likely Damage to crops; Power outages causing c Risk of deaths, injuries, Disruption by flood and high winds
cyclone activity windthrow (uprooting) of disruption to public water water- and food-borne Loss of risk coverage in vulnerable areas by
trees; damage to coral supply diseases; post-traumatic private insurers
reefs stress disorder c Potential for population migrations and loss
of property
c Incidence of extreme Likely Salinization of irrigation T Freshwater availability c Risk of deaths and injuries Similar to tropical cyclones above
high sea level (excludes water, estuaries, and as a result of saltwater by drowning in floods
tsunamis) freshwater systems intrusion c Migration-related health
effects
*Note: These projections do not take into account any changes or developments in adaptive capacity. SRES, Special Report on Emissions Scenarios.
Source: Adapted from Pachauri, R. K., & Reisinger, A. (2007). Climate change: Synthesis report: Fourth assessment report of the Intergovernmental Panel on Climate Change. (Fourth Assessment of the Intergovernmental Report on Climate Change No. 2011).
Geneva, Switzerland: IPCC.
21/02/17 5:23 PM
TABLE 10.2 Top 10 Countries in Total Carbon Emissions in TABLE 10.3 Top 10 Countries Based on Per-Capita Rates
Kilotonnes, 2011 of Carbon Emissions, 2011
Country Kilotonnes Country Tonnes per Capita

China 9 019 518 Qatar 44.0
United States 5 305 570 Trinidad & Tobago 37.2
India 2 074 345 Kuwait 29.1
Russian Federation 1 808 073 Brunei Darussalam 24.0
Japan 1 187 657 United Arab Emirates 20.0
Germany 729 458 Aruba 23.9
Canada 485 463 Luxembourg 20.9
Iran 586 599 Bahrain 18.1
United Kingdom 448 236 Australia 16.5
Korea (South) 589 426 United States 17.0
Source: World Bank. (2015). CO2 emissions (kt). Retrieved from http://data.worldbank. Source: World Bank. (2015). CO2 emissions (kt per capita). Retrieved from http://data.
org/indicator/EN.ATM.CO2E.PC. worldbank.org/indicator/EN.ATM.CO2E.PC.
planted regionally to suit new temperature and rainfall and although MDG targets were met in 2010 with
patterns, and new establishing standards for insulation of more than 90% of the global population able to access
buildings to protect against extreme cold or heat. Health safe drinking water, more than 600 million people in
care system adaptations include implementing heat and rural areas, Sub-Saharan Africa, and East and Southeast
cold alert protocols and early identification of new pat- Asia do not have access to safe drinking water (UNEP,
terns in disease. Successful adaptation results in reduced 2012a). However, this issue is also prevalent in Canada,
vulnerability to climate change. as evidenced by 94 First Nations communities having
Mitigation focuses on reducing greenhouse gas emis- been issued boil water advisories (Health Canada, 2016).
sions. Actions include switching to cleaner, renewable Almost 94% of diarrheal diseases are related to unsafe
energy sources, such as solar power and wind power. drinking water. Water comes from two main sources: (a)
Reducing deforestation will decrease emissions from wood surface sources, such as pools and rivers, and (b) ground-
burning and help maintain the earth’s capacity to absorb water sources, such as wells. Surface water sources are
greenhouse gases, particularly carbon dioxide. Deforesta- easily contaminated and should not be used without
tion is an ongoing challenge, as national and corporate treatment. Groundwater sources are more protected,
interests are heavily invested in clearing forests to access as water is filtered by soil and other layers until it is
mineral and other resources. Climate change is created trapped by impervious bedrock. Groundwater may be
locally but exerts its effects globally, so remediation efforts accessed through springs or wells, which are often sus-
must start locally but extend globally to halt or reverse ceptible to contamination. Deep or bore wells are much
climate change. Successful actions will require intersectoral safer sources of water; however, specialized equipment is
and intergovernmental collaborations and sharing of infor- required to construct them (UNEP, 2015).
mation and resources. Future health care needs will include Contamination of water may also involve toxic sub-
managing heat exposure, old infectious diseases in new stances, such as fertilizers and pesticides from agricul-
locations, and malnutrition, as well as disaster planning. ture, dioxins, or polycyclic aromatic hydrocarbons, which
are a result of fires or petroleum production. All are
associated with risks to health and to diseases, such as
Water and Sanitation cancer; these substances have been found in the breast
milk of women living near a contaminated water source
Safe and clean drinking water and sanitation, a human (Kim et al., 2014). Water is vulnerable to contamina-
right essential to the full enjoyment of life and all other tion at many points through animal or human feces at
human rights (UNEP, 2013; WHO, 2015b), are impor- the source (surface water), chemical runoff from nearby
tant for health and are closely linked. Water supplies are industries and farms (groundwater), and improper puri-
often contaminated when effective sanitation measures fication procedures. Contaminated water supply results
are not used to dispose of human waste. Sanitation sys- in ongoing illness in children and adults, and death, as
tems can be compromised by flooding that overruns pit occurred in Milwaukee (Wisconsin) in the United States
latrines, septic tanks, or piped sewage systems. (1993) and in Walkerton (Ontario) in Canada (2000).
Safe water is essential for health, access to safe The principles of safe drinking water are prevention
drinking water is a key target of Millennium Develop- of contamination, water treatment, and clean storage for
ment Goal 7 (MDG 7) (Prüss-Üstün & Corvalán, 2006), use. The best source of water for drinking is piped from
M10_KOZI2703_04_SE_C10.indd 163 21/02/17 5:23 PM

a central clean supply either to individual households particularly among children, older adults, and those with
or to community centres where people can easily access compromised health.
water for their use. Globally, indoor pollution is primarily caused by the
Sanitation is the treatment and disposal of waste use of biofuels for cooking and heating in homes with inad-
products, making them safe for public health. Sanitation equate ventilation (Markovic & Abubaker, 2014; WHO,
is divided into two main activities: (a) wastewater treat- 2014a). Biofuels include wood, coal, and dried animal
ment and (b) solid waste disposal. Wastewater treatment dung. Women and young children are the most commonly
is the management of human sewage; solid waste man- affected, and the rates of acute and chronic respiratory ill-
agement includes garbage collection and disposal. The nesses among them are high. Other causes of indoor pollu-
MDG 7 target of reduction by half the world population tion include tobacco smoke, industrial processes, and toxic
without sustainable access to means for sanitation will chemicals in paint, wood finishes, and cleaning chemicals.
not be met. More than 2.5 billion people, most living A few approaches are already bringing about reduc-
in Africa, Asia, and the Pacific regions, still do not have tions in indoor pollution. Simple, inexpensive, improved
access to those means (UNEP, 2012b; WHO, 2015b). cooking stoves are being distributed in many developing
The safe disposal of human feces to prevent contami- countries to reduce indoor pollution among most of the
nation of soil and water is important to reduce the spread affected population. Smoking is prohibited in public set-
of diarrheal disease, intestinal nematodes, and hook- tings in many developed and developing countries. Paints
worms. These parasites cause malnutrition and anemia and wood finishes are produced without noxious chemi-
in infected individuals. Parasites may be ingested in soil or cals, and use of safety filtration masks is encouraged.
in uncooked food that is contaminated. Sanitary disposal Outdoor pollution is more pervasive and causes
of human waste is achieved through the use of a latrine, chronic obstructive pulmonary disease (COPD) and can-
septic tank, or piped system to a sewage treatment plant. cer. Outdoor pollution is produced largely by industry,
The simplest is storage, usually in a pit latrine or outhouse; emissions from vehicles, power generation, and such nat-
the mostly solid waste is stored until the pit is full, at which ural events as volcanic eruptions. Air quality varies sig-
time the solids must be removed or a new pit must be nificantly across cities and regions; plans are now being
prepared. Improvements have been made to privacy and put in place to try to reduce short-lived climate pollutants
ventilation (WHO, 2015b). Septic tanks are often used in worldwide (UNEP, 2012b; UNEP, 2014; WMO, 2013).
rural communities around the world; they handle larger Controls on car emissions, garbage burning, and
quantities of human waste and are efficient and effective industrial exhausts are important strategies for improv-
over longer periods. They work well in low-density housing air quality, especially in light of the rapidly expand-
ing locations and require very little maintenance (Markle, ing airline industry and the increasing use of automobiles
Fisher, & Smego, 2007). The most efficient method of worldwide. Cleaner fuels are more important than ever
managing human waste comprises collection systems and if outdoor air quality is to be improved and sustained.
treatment plants. The raw sewage is processed through a Environmental factors are interactive and difficult
number of disinfection procedures, allowing the fluid con- to separate for independent actions and may have effects
tent to be returned to surface water supplies and the solids far from their sources. Their effects are pervasive and
to be further processed for use as crop fertilizer. affect many millions of people globally, usually those
Solid waste management (garbage removal and dis- who are already vulnerable because of their age, loca-
posal) is also important, and in many communities across tion, or income. Successful resolution of these problems
the developing world, this means collecting these materi- requires intersectoral and intergovernmental coopera-
als and burning them, even when they create toxic fumes tion and collaboration. Nurses and other health care
and smoke. In many countries, sorting garbage into vari- professionals have roles and responsibilities as citizens
ous components for recycling is an important diversion and professionals working for global health in health
strategy to reduce landfills that pose a risk for harmful promotion, illness prevention, and public health.
substances leaking into surrounding soil and water tables.
Access to safe drinking water and sanitation systems
is important in promoting human health. Globally, chil-
dren, Indigenous peoples, and those living in rural and
remote areas or in urban slums are most at risk of living
Global Health versus
with inadequate access to safe drinking water or sanita- International Health:
What Is the Difference?
tion, predisposing them to illness.
For many decades, the terms “international health,”

Air Pollution “health geography,” and “tropical medicine” were used
Indoor and outdoor air pollution causes respiratory to describe this growing field (Brown, Cueto, & Fee,
illnesses, cancers, and millions of deaths annually, 2006). Although “international health” is still very much
M10_KOZI2703_04_SE_C10.indd 164 21/02/17 5:23 PM

in use, those engaged in international work are increas- Unfortunately, poverty and political strife have resulted in
ingly using the term “global health” to characterize their undermining these improvements. As of 2013, the aver-
field of activity. age life expectancy of a person in Afghanistan is 61 years,
The term international health literally means in Zimbabwe 59 years, and in Guatemala 72 years. The
“health status among nations” and has emphasized dif- estimation of healthy life expectancy at birth is on aver-
ferences among countries rather than their common- age 10 years less for all six countries indicated (WHO,
alities. It is historically a concept more focused on the 2015a). Longevity in Africa has been severely limited by
control of epidemics in developing countries that require the ongoing human immunodeficiency virus/acquired
nation-to-nation solutions, such as foreign aid and medi- immunodeficiency syndrome (HIV/AIDS) pandemic.
cal missionary work, rather than on collective action. For example, the life expectancy for a Ugandan man
The term global health refers to health issues and has decreased from 47.4 years (1980–1985) to 39.7 years
concerns that typically transcend national borders, class, (1985–1990) to 38.9 years (1995–2000) (WHO, 2015a).
race, ethnicity, and culture (Brown et al., 2006). This Globally, populations seem to be trading one set of dis-
term acknowledges the ongoing process of integration of eases for another. In many countries, improved socioeco-
national economies, societies, and cultures and empha- nomic and public health conditions that led to a reduction
sizes the commonality of health issues that require col- in infectious disease-related morbidity and mortality have,
lective action. It has been defined as “the area of study, however, resulted in the introduction of lifestyle-related
research and practice that places a priority on improving diseases, such as obesity, coronary artery disease, hyperten-
health and achieving equity in health for all people world- sion, and other diseases related to excessive eating, smok-
wide” (Koplan et al., 2009, p. 1995). The term “global” ing, alcohol consumption, and illicit drug use. Scientific,
is also associated with the growing importance of actors social, cultural, economic, and political factors all contrib-
beyond governmental or intergovernmental organiza- ute to the overall wellness of a community, whether local
tions and such agencies as the media, internationally or international. The impact of disease-oriented medical
influential foundations, nongovernmental organizations, care on the overall health status of a country is relatively
and transnational corporations (Macfarlane, Jacobs, & small compared with the collective contributions made
Kaaya, 2008). by improved living conditions, including better nutrition,
The major international agency for health is the sanitation, housing, education, and income.
World Health Organization (WHO). Other important
agencies are the United Nations Development Pro-
gram (UNDP, 1992) and the World Bank, which are Epidemiological Transition
introduced later in this chapter. A major initiative for
improved global health is the United Nations Millen- According to a theory advanced by Omran in 1971,
nium Declaration, which includes the globally endorsed an epidemiological transition occurs as a country
Millennium Development Goals (Patel & Prince, 2010). (See undergoes the process of “modernization” from Third-
Weblinks placed online for the Canadian Nurses Associa- World to First-World conditions (Omran, 2005). Accord-
tion [CNA] position statement.) ing to the theory, the development of cleaner water and
better nutrition drastically improves the chances of child
survival and average life expectancy; this, in turn, subse-
quently leads to declines in fertility rates and produces a
Global Health: A Historical Perspective shift from infectious diseases to chronic and degenerative
The collective personal health of a population is defined diseases as the major causes of morbidity and mortality.
as public health. At the turn of the twentieth century,
the life expectancy for a citizen living in Canada was
47 years for a male and 50 years for a female, and the five
leading causes of death were (a) influenza and pneumo-
Classification of Countries
nia, (b) tuberculosis, (c) diarrhea and enteritis, (d) heart For purposes of thinking globally, one can say that
disease, and (e) stroke (Norris & Williams, 2000). The there are approximately 200 countries in the world.
median lifespan for persons residing in the less developed This denominator of 200 is a useful way to think of
regions of the world was even lower, and most public proportions; for example, the G20 countries comprise
health problems were largely caused by infections. Now, only 10% of the world’s nation states. There are many
more than 100 years later, the health of populations ways of organizing or classifying countries, depending
globally has dramatically improved. In 2013, the aver- on who is doing the classifying. Traditional methods
age Japanese was stated to be living as long as 84 years, include national income (GDP), level of development,
the average Canadian 82 years, and the average Costa and geography. Such terms as “Western World,” “First
Rican 79 years (WHO, 2015a). Even in impoverished World” and “Third World” are well known. The term
parts of Africa, Asia, and Latin America, tremendous “developing country” is generally used to describe a
public health gains were seen in the twentieth century. nation state with a more feudally organized society, more
M10_KOZI2703_04_SE_C10.indd 165 21/02/17 5:24 PM

World population
arranged by
income Distribution of income
The richest fifth receives 82.8%

Richest
of total world income
9.9% of income
Each horizontal band

represents an equal fifth 4.2% of income
of the world’s people
2.1% of income
Poorest 1.0% of income
The poorest fifth receives

1.0% of total world income
FIGURE 10.1 Champagne glass distribution of income for world populations.

Source: Ortiz, I., & Cummins, M. (2011). Global inequality: Beyond the bottom billion—a rapid review of income distribution in 141 countries.
UNICEF Social and Economic Policy Working Paper (p. 6). New York, NY: UNICEF.
agriculture-based economy, or low level of material well- quintiles (20% increments) (Conley, 2008). In 2014, the
being. There is no international definition for the term richest fifth of the world’s population received 82.7%
“developed country,” and levels of development can vary of the total world income, whereas the poorest fifth
widely even within the so-called developed countries received merely 1.4%. A mere 1% of the world’s adults
(e.g., population groups that do not share in the prosper- owned 48.2% of global assets, whereas the bottom half
ity of the mainstream or pockets of underdevelopment of the world’s population owned just 1% of total wealth
within a country). Many of these terms are perceived (Global Wealth Report, 2014). Almost half the world
as stereotyping, so some have suggested a classification population (>3 billion people) lived on less than $2.50 a
based on a North–South geographical axis—the North day (Chen & Ravallion, 2008). Nearly one in four people
being home to all members of the G8 wealthiest democ- (1.44 billion) lived on less than $1.25 per day, whereas,
racies and the South being everyone else. Wealth is an in 2007, the world’s 358 billionaires had assets exceeding
important means of providing health care services to a the combined annual incomes of countries with 45% of
population as well as creating a healthy environment. As the world’s people (UNDP, 2010).
the world becomes more economically, politically, and
socially integrated, debates on global health are focusing
on equity and justice regardless of income, economic Countries Organized by Religion
system, or geographical location. Human behaviour is a major determinant of the health
of individuals and groups, and religious belief is a major
influence of human behaviour. Thus, it is useful to
Nation States Classified by Income understand how the world’s principal religions and spiri-
tual traditions (defined by the number of adherents) can
For analytical purposes, the World Bank’s main criterion for
be arranged by geography and historical origin. Abra-
classifying its 187 member states is gross national income
hamic religions originated in the Middle East, Indian
(GNI) per person per year. On the basis of the GNI index,
religions in India, and Far Eastern religions in East Asia.
every country is classified by the World Bank as high-
Another group with supraregional influence are African
income, middle-income (subdivided into lower-middle and
diasporic religions, which have their origins in Central
upper-middle), or low-income (World Bank, 2011). In addi-
and West Africa.
tion, there are two elite groups classified as major indus-
trialized democracies (the G8) and the world’s top major
economies (the G20). Canada belongs to both groups.
With respect to the distribution of the world’s
Countries Organized by Language
wealth, Figure 10.1 provides a dramatic illustration of There are more than 2700 languages in the world. Some
“the champagne glass distribution” arranged by income of the top languages by population are the six official
M10_KOZI2703_04_SE_C10.indd 166 21/02/17 5:24 PM

languages of the United Nations: Arabic, Chinese (Man-

darin), English, French, Russian, and Spanish. English Theories of Development
is currently one of the most widely spoken and written
languages worldwide. The impact of colonialism and The observation that some countries are wealthier (and
the continued influence of Western powers have contrib- healthier) than others has spawned a host of theories to
uted to making European languages dominant in many explain such differences; a few of the better known ones
parts of the world. are presented in Table 10.4.
TABLE 10.4 Theories of Development
Theory of Development Period Salient Features

Colonialism 15th–20th • Sovereignty over the colony is claimed by the metropole or “mother coun-
centuries try,” and the social structure, government, and economics of the colony are
changed by the colonists.
• European nation states (e.g., England, France, Spain, Portugal, Belgium,
Netherlands, etc.) established colonies on other continents (Africa, Asia, Latin
America) for trade.
• A set of unequal relationships between the metropole and the colony and
between the colonists and the Indigenous population has been cited as an
explanation for extreme variation in health status among countries and certain
groups within countries.
Neocolonialism Post–World War II • Colonialism by other means, such as economic arrangements, military, or
(1945–1960) technological influences.
• Based on unequal relationships and interference in the politics of weaker
countries by stronger countries.
• Certain forms of foreign aid have amounted to neocolonialism.
• Has also been used as a label to describe governmental social policy or
attitude toward certain groups within countries.
Modernization Theory 18th century– • Used to explain the process of improvements made within societies.
present day • Looks at internal dynamics while referring to social and cultural structures and
the adaptation of new technologies.
• Assumes that with assistance, “traditional” countries and societies can be
brought to “development” in the same manner that wealthier countries have
(e.g., from hunting and gathering, to subsistence farming, to an industrial
revolution, to the knowledge economy).
• Criticized by communist ideologies, world systems theorists, globalization
theorists, and dependency theorists, among others.
Linear Stages of Growth 1960s–1980s • Developed by Walt W. Rostow, an American economist.
(also called Rostow’s • Economic modernization occurs in five fairly linear stages of varying lengths:
Stages of Growth) (a) traditional society, (b) preconditions for takeoff, (c) takeoff, (d) drive to
Model (Rostow, 1960) maturity, and (e) age of high mass consumption (Todaro & Smith, 2009a).
• Economic “takeoff” must initially be led by a few individual sectors, such as
agriculture, transportation, and manufacturing.
• Criticized by Marxists, who push for economic self-reliance and development
of all sectors equally, including the education and health sectors.
Dependency Theory 1970s–present • Resources flow from a “periphery” of poor and underdeveloped states to a
day “core” of wealthy states, enriching the latter at the expense of the former (Dos
Santos, 1971).
• Poor states are impoverished and rich ones enriched by the way poor states
are integrated into the “world system.”
• The task in helping underdeveloped areas out of poverty is to accelerate them
along a supposed common path of development, by such means as invest-
ment, technology transfers, and closer integration into the world market.
• Opposes free market economists and modernization theorists.
• “Underdeveloped” countries need to reduce their connectedness with the
world market so that they can pursue a path more in keeping with their own
needs, less dictated by external pressures (Todaro & Smith, 2009b).
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Regardless of which theory of development is used around the world. Gender inequality persists, and access
to explain why some countries are wealthier or health- to primary education is still a challenge in many countries.
ier than others, the inevitable fact is that the world is Carbon dioxide emissions have increased, and water scar-
becoming increasingly more integrated and that there city is projected to increase worldwide. Conflict remains
has been an overall improvement in measures of global the main threat to human development contributing to
health. increased poverty rates in affected countries. More work
is needed in addressing disparities across the world and
as part of the post-2015 development agenda; the UN
Globalization has devised 17 Sustainable Development Goals
(SDGs) for the period of 2015–2030 (United Nations,
Globalization can be defined as the process of interna- 2014a; United Nations, 2014b; United Nations, 2015).
tional integration arising from the exchange of worldviews, The SDGs replaced the MDGs, which expired at the end
ideas, information, products, pathogens, trade, finance, of 2015, and SDGs will be applied not only to developing
and people. This integration requires a shift in public countries but to all countries of the world. See Table 10.5.
health thinking from a singular focus on “international The government of Canada continues its commit-
health” (the higher disease burden in poor countries) to a ment to the MDGs and the recently approved SDGs
more nuanced analysis of “global health,” in which health
risks in both poor and rich countries are seen as having TABLE 10.5 Sustainable Development Goals
inherently global causes and consequences. This implies
a moral imperative for national governments, especially 1. End poverty in all its forms everywhere.
those of wealthier nations, to take greater account of 2. E
nd hunger, achieve food security and improved nutri-
global health and its social determinants in all their foreign tion and promote sustainable agriculture.
policies (Labonté, Mohindra, & Schrecker, 2011). 3. E
nsure healthy lives, and promote well-being for all at all
ages.
4. E
nsure inclusive and equitable quality education, and
Sustainable promote lifelong learning opportunities for all.

5. A
chieve gender equality, and empower all women and
Development Goals girls.
6. E
nsure availability and sustainable management of water
and sanitation for all.
In the year 2000, all of the state members of the United
Nations approved the United Nations Millennium Dec- 7. E
nsure access to affordable, reliable, sustainable, and
laration, which asserted that all individuals have the right modern energy for all.
to dignity, equality, freedom, a basic standard of living 8. P
romote sustained, inclusive, and sustainable economic
that includes freedom from hunger and violence, and growth; full and productive employment; and decent
work for all.
encourages tolerance and solidarity. Among the several
commitments stated in the declaration was the commit- 9. B
uild resilient infrastructure, promote inclusive and sus-
ment to significantly reduce poverty and promote devel- tainable industrialization, and foster innovation.
opment by reducing economic and social conditions 10. Reduce inequality within and among countries.
in the world’s poorest countries. Eight Millennium 11. M
ake cities and human settlements inclusive, safe, resil-
Development Goals (MDGs) were identified to oper- ient, and sustainable.
ationalize this priority area between 1990 and 2015. The 12. Ensure sustainable consumption and production patterns.
eight MDGs are: 13. T
ake urgent action to combat climate change and its
1. Eradicate extreme poverty and hunger impacts.
14. C
onserve and sustainably use the oceans, seas, and
2. Achieve universal primary education
marine resources for sustainable development.
3. Promote gender equality and empower women
15. P
rotect, restore, and promote sustainable use of ter-
4. Reduce child mortality restrial ecosystems, sustainably manage forests, combat
5. Improve maternal health desertification, halt and reverse land degradation, and
halt biodiversity loss.
6. Combat HIV/AIDS and tuberculosis
16. P
romote peaceful and inclusive societies for sustainable
7. Ensure environmental sustainability development, provide access to justice for all, and build
8. Build partnership for development effective, accountable, and inclusive institutions at all levels.
To date, progress has been achieved for many of 17. S

trengthen the means of implementation, and revitalize
the global partnership for sustainable development.
the MDGs worldwide, but this progress has been uneven
Source: Adapted from United Nations. (2014a). Press release-UN General Assembly’s
across all countries. Approximately 800 million people Open Working Group proposes sustainable development goals. Retrieved from https://
still suffer from hunger and live in extreme poverty sustainabledevelopment.un.org/content/documents/4538pressowg13.pdf.
M10_KOZI2703_04_SE_C10.indd 168 21/02/17 5:24 PM

(UN, 2014a) and will continue working with the UN in

the achievement of the post-2015 agenda, particularly
in the areas of maternal, newborn, and child health and
job creation/sustainable economic growth and account-
ability (Department of Foreign Affairs Trade and Devel- Aspirations
opment [DFATD], 2015a).
CAPACITY BUILDING In health, capacity building aims Strategies
e
at developing new structures, approaches, or values to
r
ltu
Cu
address the health challenges of the population (Crisp, Organiztional skills
Swerissen, & Duckett, 2000) and is defined by WHO
(2016) as the “development and strengthening of human
Human Systems and Organizational
and institutional resources” (para 3). Capacity build- resources infrastructure structure
ing is a long-term, continual process of development
that involves all stakeholders in a population and uses a
country’s human, scientific, technological, and organi- Aspirations: An organization’s mission, vision, and overarching
zational resources and capabilities. For capacity build- goals, which collectively articulate its common sense of purpose
and direction
ing to be successful, the interventions must be addressed
at the individual, institutional, and societal levels and at Strategy: The coherent set of actions and programs aimed at fulfill-
ing the organization’s overarching goals
both the local and international levels. Individually, people
Organizational Skills: The sum of the organization’s capabilities,
build capacity by enhancing existing knowledge and skills, including performance measurement, planning, resource manage-
a need addressed by nurses’ educator roles. Education ment, and external relationship building
and health are closely related in development; as people Human Resources: The collective capabilities, experiences,
become more knowledgeable about their health, they are potential and commitment of the organization’s board, management
more able to care for themselves, and thus the burden of team, staff, and volunteers
disease is reduced (Todaro & Smith, 2012). Systems and Infrastructure: The organization’s planning, decision-
making, knowledge management, and administrative systems, as well
At institutional and societal levels, capacity building as the physical and technological assets that support the organization
can be achieved by strengthening existing organiza- Organizational Structure: The combination of governance, organi-
tions, through supporting the development of sound zational design, interfunctional coordination, and individual job descrip-
policies, organizational structures, and effective methods tions that shapes the organization’s legal and management structure
of management. Both governmental and nongovern- Culture: The connective tissue that binds together the organization,
mental organizations (NGOs) have active roles in global including shared values and practices, behaviour norms, and, most
important, the organization’s orientation toward performance.
capacity building, and many health organizations are in
international partnerships for health sustainability. The FIGURE 10.2 Capacity building framework.
key is that people, organizations, and societies develop Source: All rights reserved and used with permission. This figure was taken from the report
partnerships in pursuit of the same goal and use a frame- “The Effective Capacity Building in Nonprofit Organizations,” Copyright 2001, Venture
Philanthropy Partners (VPP), which was prepared for VPP by McKinsey & Company.
work to aid their success (see Figure 10.2).
SUSTAINABILITY Similar to capacity building, the con-
degradation. Alleviation of poverty is a major hurdle
cept of sustainability in global health refers to the
to achieve sustainability and is considered a major
long-term maintenance of developed programs in a
cause of both local and global health problems (Bell
society. Sustainable development, as described by the
& Morse, 2008; Lusigi, 2008). Sustainability of health
United Nations World Commission on Environment
is important for reducing mortality, morbidity, and dis-
and Development (WCED) is “development that meets
ability, especially in poor and marginalized populations,
the needs of the present without compromising the
and is achieved through specific strategies that target
ability of future generations to meet their own needs”
health issues and create health systems that unfold over
(WCED, 1987). People’s basic needs include food, shel-
time (Yang, Farmer, & McGahan, 2010). Nurses are
ter, health, and protection, and when available resources
frequently involved in such initiatives both locally and
are inadequate to meet any of these needs, a condi-
globally through various initiatives.
tion of absolute underdevelopment occurs. Thus, to
achieve sustainable development, a process of change SOCIAL JUSTICE The concept of social justice is
must be consistent with future and present needs of the based on the principles of equity, equality, and respect
population. for human rights. It is broadly concerned with the equi-
The main dimensions of sustainable development table bearing of burdens and reaping of benefits in soci-
are environmental (water, land, atmosphere, and waste), ety (Drevdahl, Dorcy, & Grevstad, 2001).
economic, and social (UN, 2014b; UN, 2015). These In health care, the focus of social justice is the alloca-
indicators address several interrelated global issues, tion of health care resources and equitable access to these
such as poverty, inequality, hunger, and environmental resources, as well as the broader determinants of health.
M10_KOZI2703_04_SE_C10.indd 169 25/02/17 2:32 PM

The disparity in health status of virtually all populations 2015), and more than 51 million are refugees (UNHCR,
in terms of their socioeconomic status, gender, race or 2013). Migration brings many benefits to the receiv-
ethnicity, and geographical location makes it necessary to ing countries, such as new ideas, skills, and resilience.
identify and intervene within these determinants. Migrants stimulate local economies as they establish
The field of nursing actively supports the value of themselves in their communities.
social justice in health through national and interna- There are a few important distinctions among
tional nursing associations’ mandates. The Canadian migrants. Voluntary migrants move for many reasons,
Nurses Association (CNA) Code of Ethics states the follow- primarily to improve their circumstances. Significant
ing: “Nurses uphold principles of equity and fairness to numbers of business class or skilled workers, including
assist persons in receiving a share of health services and health care professionals, migrate to other countries
resources proportionate to their needs and in promoting to improve their opportunities (Dumont & Widmaier,
social justice” (CNA, 2008); social justice is an expected 2010). Forced migrants include refugees and asylum
value and action of practice (CNA, 2010). seekers, who are unable to remain in their country of
origin because they are at risk from war, persecution, or
natural disasters. They are usually not able to return to
their homeland until significant changes occur.
Major Issues The 1951 Refugee Convention establishing the United
in Global Health Nations High Commission for Refugees (UNHCR) stated

that a refugee is someone who:
Major issues in global health are related to the circum- … owing to a well-founded fear of being persecuted for
stances in which people live, their behaviour, and the reasons of race, religion, nationality, membership of a
environment. These factors, the determinants of health, particular social group or political opinion, is outside the
were described more than 30 years ago, when public country of his nationality, and is unable to, or owing to
health and primary health care were identified as the such fear, is unwilling to avail himself of the protection
best approaches to improve health in Canada (Lalonde, of that country. (UNHCR, 2012)
1974). These ideas were reaffirmed by the declaration
of Alma Ata a few years later (1978), which added that
The majority of refugees (more than 80%) live in
health is a fundamental human right and called on gov-
neighbouring countries to their country of origin (Baba
ernments, the WHO, and others to act (WHO, 1978).
Fall et al., 2009; UNHCR, 2012). Canada is a destina-
The Commission on Social Determinants of Health
tion or receiving country for immigrants and refugees.
(CSDH) described the impact of the social determi-
This means that nurses and health care professionals will
nants of health and the link to health inequities within
care for people with different beliefs and expectations
and between nations (CSDH, 2008).
and whose needs will relate to their migration history.
Evidence suggests that access to health care (Gagnon,
The poor health of the poor, the social gradient in health
2004; Wahoush, 2009) and health vary by immigration
within countries, and the marked health inequities between
status (Gagnon et al., 2007; Newbold, 2005; Newbold,
countries are caused by the unequal distribution of
2009). Nurses in Canada must be proficient in provid-
power, income, goods, and services, globally and nation-
ing culturally competent care for diverse populations (see
ally, the consequent unfairness in the immediate, visible
Chapter 11) and understand the additional impact of
circumstances of people’s lives—their access to health
migration on expectations for health.
care, schools, and education, their conditions of work and
leisure, their homes, communities, towns, or cities—and
their chances of leading a flourishing life.
Indigenous Peoples
These differences in health status of populations are
areas for action; many examples of successful change Indigenous peoples, or Aboriginal populations, are
and ongoing problems are presented in the report of described by the WHO as
the Commission for the Social Determinants of Health
(Marmot & Friel, 2008). … communities that live within, or are attached to,
geographically distinct traditional habitats or ancestral
territories, and who identify themselves as being part of
a distinct cultural group, descended from groups present
Migration in the area before colonists arrived, modern states were
In global terms, migration means the movement of created and current borders defined. They generally main-
people, usually from one country to another. It is increas- tain cultural and social identities, and social, economic,
ing, and at present, there are an estimated 232 million cultural and political institutions, separate from the main-
international migrants worldwide (UN Population Fund, stream or dominant society or culture. (WHO, 2011a)
M10_KOZI2703_04_SE_C10.indd 170 21/02/17 5:24 PM

This description does not mention the forcible dis- Co-operation and Development) average (Gurria, 2008).
placement that is characteristic of many Indigenous Globally, Indigenous peoples, recent immigrants, and
populations, resulting in loss of land and sometimes women, especially those in single-parent households, are
catastrophic lifestyle changes (Truth and Reconcilia- most at risk of low income and the associated risks of
tion Commission of Canada, 2015). Globally, there are poor living conditions and homelessness. They are also
approximately 350 million Indigenous peoples living in less likely to move out of poverty.
more than 70 countries. They are often marginalized
and experience poorer health compared with the gen-
eral population. For example, infant mortality is almost
always higher among Indigenous populations (Phillips,
Food Security
Morrell, Taylor, & Daniels, 2014; WHO, 2014b). The WHO (2011b) considers that food security exists
Although Indigenous populations around the world are “when all people at all times have access to sufficient,
diverse, they experience similar health issues and deter- safe, nutritious food to maintain a healthy and active life.”
minants of health (Gracey & King, 2009). Many live Food security is based on three pillars: (a) food availability,
in isolated communities with limited access to services, or having sufficient amount of food available on a con-
water, and sanitation, and experience inadequate nutri- sistent basis; (b) food access, or having sufficient amount of
tion and housing and poverty. resources, both physical and economic, to obtain appro-
In Canada, Indigenous peoples include First priate and nutritious food; and (c) food use, or the appro-
Nations, Inuit, and Métis. Like many other Indigenous priate use of available food based on knowledge of basic
populations, they experience poorer health compared nutrition and adequate water and sanitation. If one of
with the general population. Suicide, diabetes, and pre- these three pillars is affected, then food security is at risk.
mature deaths occur more frequently than in the general There are many factors that jeopardize food security in
population (Gracey & King, 2009; WHO, 2011a). Infant the world, including climate and weather, conflict, natural
mortality among Aboriginal populations in Canada is disasters, living in remote locations, and health emergen-
significantly higher than among the general Canadian cies. Despite all these factors, poverty is still the major
population (Smylie, Deshayne, & Ohlsson, 2010), and contributor to food insecurity, leading to hunger and
the rates of infant mortality vary significantly across the malnutrition. About 795 million people are undernour-
globe. ished globally because of extreme poverty. This, how-
ever, is down by 167 million over the last decade, and is
216 million less than in 1990–1992 (Food and Agriculture
Organization [FAO], 2015). In Canada, about 1.1 million
Poverty and Inequality households were reported to have experienced food inse-
Poverty is a complex concept that has been defined in curity each year between 2007 and 2012. This comprises
many ways; in this chapter, poverty means more than about 8% of adults and 5% of children in the entire popu-
low income. The World Bank defines extreme poverty lation. The territories had higher rates of food insecurity
as having an average daily consumption of $1.25 or compared with the provinces. Among the territories, Nun-
less; this means living on the edge of subsistence (World avut had the highest rate at 36.7%, and Nova Scotia had
Bank, 2015). Globally, poverty rates are declining, but the highest rate among the provinces at 11.9% (Statistics
the improvements are not universal, and the propor- Canada, 2015). Nurses, both locally and globally, often
tion of those living in deep poverty remains largely care for patients who have suffered malnutrition.
unchanged (Chen & Ravallion, 2008). Between 1980 and Food safety is also important in maintaining health.
2011, almost half the population in Sub-Saharan Africa Food can become contaminated with biological and
lived in extreme poverty, whereas in Southeast Asia, chemical agents, causing adverse effects on health. Cur-
extreme poverty was significantly reduced from 80% to rently, the most common threats to food safety are pesti-
20%. Poverty is implicated in the death of more than cides; industrial chemicals and metals; allergens; bacteria,
10 million children annually. Children growing up poor viruses, and parasites; natural toxins; veterinary drugs;
face many challenges that have negative consequences and food additives. That is why it is important that food
for their health in adulthood and their future earning safety regulatory agencies, such as the Canadian Food
power, which affects their living standard, health, and Inspection Agency (CFIA), in Canada ensure that food is
well-being, as well as the material circumstances of their safe for consumption (Chassy, 2010).
future children.
In developed countries, income inequality is more
damaging to health and well-being than low income
alone (Marmot, Friel, Bell, Houweling, & Taylor, 2008).
Disasters
Income inequality, which was reduced in many countries Disasters are situations in which the normal infrastruc-
during the mid-1990s, is increasing again, and in Canada, ture is severely disrupted on a large scale, necessitating
it is now above the OECD (Organisation for Economic external help to enable people to live their lives in safety
M10_KOZI2703_04_SE_C10.indd 171 02/03/17 10:59 AM

and health. Many die at the time of the disaster, and oth- women still exist in many societies, often with men enjoy-
ers die later because of longer-term impacts of disease ing better health compared with women. Yet women
and contamination from the event. Natural disasters live longer than men in almost every country. This
are often climate related. They include storm systems, means that life expectancy is not the best measure of
such as typhoons that cause severe and extensive floods, health when exploring gender issues. Measuring gender
and extreme weather conditions, such as heat waves or inequalities is difficult, but two measures that assess dif-
earthquakes (United Nations Office for the Coordination ferent but complementary aspects of gender are widely
of Humanitarian Affairs, 2015). The March 2011 earth- used: (a) the Gender Inequalities Index (GII) and (b) the
quake in Japan is an example of how a natural disaster Social Institutions and Gender Index (SIGI).
can have a significant impact that goes well beyond The GII compares outcomes for women against
national borders, as the resulting tsunami damaged a those for men within a nation (Klugman, 2010); the score
nuclear power plant, causing radiation leakage into the represents women’s loss of potential for human develop-
air and seawater. ment in comparison with men within the same country.
During a disaster, disruption of normal services This new experimental measure includes features of
includes access to clean water, sanitation, school or work, reproductive health, empowerment, and labour market
and health care services. Organizations providing help on participation at national levels, comparing men and
a large scale include national governments, International women on these aspects of life. The world average GII
Red Cross, Save the Children, Oxfam International, score is 0.56, which means that 56% of potential human
and Médecins Sans Frontières. Initial activities focus on development is lost because of discrimination against
providing temporary shelter, clean water, and latrines women; the score for Canada is 0.289 (Klugman, 2010;
and on assessment of the extent of damage and need for Varkey & Gupta, 2005).
help in the immediate period as well as the longer term. In contrast, the SIGI is a measure of gender equal-
Disaster relief teams are multidisciplinary and often ity. Developed by the OECD (Branisa, Klasen, & Zeigler,
include nurses along with other health care professionals, 2009), SIGI employs different indicators or factors at
logistics support personnel, engineers, skilled workers, the root of gender inequity. These factors include mea-
and volunteers, all of whom may be at risk as they pro- sures of civil liberty, decision-making power, exposure
vide care in the disaster setting. The Disaster Assistance to violence, preference for male offspring, and owner-
Response Team (DART) includes 200 members of the ship rights. Scores range from 0 to 1; a lower number
Canadian forces, who arrive quickly and establish mech- indicates less discrimination against women compared
anisms for safe drinking water, shelter, safety, and urgent with higher scores. In 2009, using this scale, the OECD
health care and eventually leave to allow space for other reported that Paraguay (0.00248) had the lowest and
personnel engaged in longer-term relief activities. Sudan (0.67781) had the highest level of discrimination
against women (OECD, 2010).
These measurements are significant, as they pro-
vide a mechanism to evaluate changes over time and to
Infectious Diseases and Surveillance compare countries. Understanding what each measure
In global health terms, monitoring disease outbreaks and includes and using more than one will present a clearer
threats to public health is a priority for the global com- picture of gender equity and inequality.
munity; 194 countries have committed to implementing
global rules to improve global health security. This moni-
toring is called surveillance. The International Health
Regulations (IHRs) developed these rules after the severe Women’s Health
acute respiratory syndrome (SARS) outbreak in Canada. Women in low-income countries face high levels of
An international example is the global monitoring of the mortality associated with poor nutrition, unsafe water,
H1N1 virus (WHO, 2008). The Public Health Agency poor sanitation, smoke from solid-fuel stoves, and lack of
of Canada (PHAC) is responsible for the implementa- care during pregnancy and childbearing (Temmerman,
tion of the IHRs and leads the Emergency Preparedness Khosla, Bhutta, & Bustreo, 2015a; WHO, 2015a; WHO,
Response in Canada (PHAC, 2015). 2015b).
Many of the causes of death and illness in the
childbearing years, such as HIV/AIDS, complications
of pregnancy and childbirth, and vesicovaginal fistula,
Gender are preventable with simple improvements in care during
Gender may not relate to the distinction of the biologi- and after pregnancy (Lester, Benfield, & Fathalla, 2010).
cal sex of the individual alone but refers to the socially Risks to women’s health have negative consequences for
constructed roles, behaviour, activities, and attributes their children, families, and communities. Poor nutrition,
that a particular society considers appropriate for men infectious diseases, and limited access to health care are
and women (WHO, 2009b). Inequities between men and associated with low-birth-weight infants, and women in
M10_KOZI2703_04_SE_C10.indd 172 21/02/17 5:24 PM

low-income countries often experience all three. Low-

birth-weight infants have increased risk of death or poor EVIDENCE-INFORMED
health in the long term. Almost all (98%) of the more PRACTICE
than a half million maternal deaths occur in 68 priority
countries, with little progress on improvements to date Is the Provision of Essential Newborn
(Lester et al., 2010). The most common causes of mater-
nal death, such as hypertension, hemorrhage, and sepsis,
Care (ENC) Training to Midwives a
relate primarily to reproductive health, but chronic dis- Cost-Effective Intervention to Reduce
eases are increasingly responsible for premature death of Neonatal Mortality in Zambia?
women (Chou, Daelsmans, Jolivet, Kinney, & Say, 2015).
Interventions to achieve sustainable reduced rates of The authors (2011) conducted a cost-effectiveness analysis
maternal mortality are illustrated in Box 10.1, along with to evaluate whether the training of midwives who worked
in first-level (primary care, low-risk) health facilities in Zam-
four prenatal checks. In low-income and middle-income
bia and participated in the WHO ENC (Essential Newborn
countries, almost three-quarters of pregnant women had Care) course on 7-day neonatal mortality was effective in
reducing early neonatal mortality (ENM) rates. Eighteen
college-trained midwives were certified as ENC instructors
after a 5-day ENC training-of-trainer course. The course
BOX 10.1 WHY INVESTING IN WOMEN’S AND included universal precautions, routine neonatal care, resus-
CHILDREN’S HEALTH MAKES SENSE citation, prevention of hypothermia, early and exclusive
breast-feeding, “kangaroo care,” small infant management,
To reduce poverty and improve a country’s overall danger signs, and recognition of illness. These instructors
well-being: were responsible for training a total of 123 midwives in each
• Research confirms that a health system that delivers of the 18 delivery clinics in two urban areas. The effect of
reproductive health care is a strong system that delivers training was calculated by comparing ENM rates before
for everyone. and after ENC training. It was found that all-cause 7-day
• A woman’s poor health often pushes her family further neonatal mortality decreased from 11.5/1000 to 6.8/1000
into poverty. live births after ENC training. This was indicative of 97 lives
• Children born to women who have had at least 5 years of being saved.
education are 40% more likely to live past age 5 years. NURSING IMPLICATIONS: The WHO developed the
To enable families to thrive: ENC course, as neonatal deaths in the first 7 days are
significantly higher in developing countries than in
• A mother’s death or disability greatly raises the chances
the developed world. Nurses in developing countries
her newborn and her other children will die before age
5 years. benefit from this type of training, as they are often the
first health care team member that expecting mothers
• Women connect their families and communities, instilling would see in a care facility. In addition, this training-
cultural and social values.
the-trainer approach allows for knowledge transfer to
• It helps women and children to realize their fundamental occur between nurses and nursing students.
human rights.
Source: Based on Manasyan, A., Chomba, E., McClure, E. M., Krzywanski, S., &
• Women’s health and children’s health are inextricably Carlo, W. A. (2011). Cost-effectiveness of essential newborn care training in urban
linked to meeting the other Millennium Development first-level facilities. Pediatrics, 127(5), e1176–e1181. DOI: 10.1542/peds.2010-2158
Goals (MDGs).
The principal strategies to reduce maternal mortality include

the following:
at least one antenatal check, but this rate drops to less
• Improved nutrition and education of girls—improved than half for pregnant women in Sub-Saharan Africa.
physical health, growth, and development
Births attended by a skilled birth attendant increased
• Gender equality and women’s empowerment—enables
choices by women
from 41% to 65.7% from 1996 to 2008 but varied with
the much lower rates in Eastern Africa (33.7%), Western
• Reducing adolescent pregnancies—deferred age of mar-
riage and access to contraception Africa (41.2%), and South Central Asia (46.9%) (WHO,
• Promoting access to contraception—enables birth spac-
2009b; WHO, 2009c). Millennium Development Goal 5
ing, reduces unwanted pregnancies, and limits unsafe (MDG 5), to improve women’s and children’s health, is
abortions part of a global strategy, with its term ending in 2015.
• Skilled birth attendants—evidence-based practice pro- Although there have been significant improvements in
moted via the Integrated Management of Pregnancy and the health of women and children, more needs to be
Childbirth (IMPAC) done to sustain progress past the end of the MDG term
• Postbirth care for mother and infant (Temmerman, Khosla, Laski, Matthews, & Day, 2015b).
Progress is also hampered by the shortage of skilled
Source: Ki-Moon, B. (2010). Investing in our common future: Global strategy for health care providers (doctors, nurses, and midwives).
women’s and children’s health. Retrieved from http://www.who.int/pmnch/topics/
maternal/201009_globalstrategy_wch/en/index.html. See the Evidence-Informed Practice box on the provision
of essential newborn care (ENC) training to midwives.
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The WHO estimates that approximately 700 000 mid- BOX 10.3 SUMMARY OF INTERVENTIONS
wives are needed to achieve the goal of skilled care at KNOWN TO REDUCE CHILD MORTALITY IN
every birth. Migration of skilled health care providers to CHILDREN UNDER 5 YEARS
urban settings, to the private sector, or out of the country
further hampers progress. Some countries have demon- • Care during pregnancy, during birth, and after birth by a
strated that improvements are possible. skilled health care provider
• Early initiation of breast-feeding, that is, within 1 hour of
birth
Child Health • Exclusive breast-feeding for the first 6 months of life
• The introduction of nutritionally adequate and safe com-
Risks to newborn health are highest during the first plementary foods at 6 months, together with continued
month after birth; deaths during this time occur most breast-feeding for up to 2 years and beyond
often when mothers have limited access to skilled health • Immunization programs
care during pregnancy, during birth, and after birth. • Sleeping under mosquito nets treated with insecticide
Improved maternal care improves outcomes for new- • Use of oral rehydration salts and zinc supplements for
borns. Globally, most deaths among children less than diarrheal diseases
5 years old are caused by infections and malnutrition • Hand washing and hygiene (safe disposal of feces)
(see Box 10.2). • Reduction of indoor pollution
Worldwide, improvements reduced mortality rates in • Prompt care by a skilled health care provider
this age group from 91 to 43 per 1000 live births in 2015. • Improved standards and delivery of care through the Inte-
Almost two-thirds of these 8 million deaths in 2008 grated Management of Childhood Illness (IMCI) available
were caused by infectious diseases (WHO, 2011c). In the to children under 5 years, with specific emphasis on com-
period 1990–2009, only three regions—Sub-Saharan mon diseases in the region (WHO, 2016)
Africa, Southeast Asia, and Oceania—failed to achieve
reductions of more than 50% in child mortality (WHO,
2011c).
Data on infants or children in marginalized groups,
such as refugees and Indigenous or Aboriginal popula-
tions, are limited. Evidence suggests that children in countries, but some others are still lagging behind. Suc-
these groups are at additional risk of poor health and cess in reducing child mortality to meet MDG 4 requires
premature death (see Box 10.3). additional efforts to accelerate progress (Ki-Moon, 2010;
The Integrated Management of Childhood Illness Were et al., 2015). Renewed efforts are needed to sustain
(IMCI) program strengthens the capacity of health care improvements beyond the MDGs.
providers, families, and communities to support child
health and development and reduce child mortality, ill-
ness, and disability (Rowe, Rowe, Holloway, Ivanovska,
Muhe, & Lambrechts, 2008). Nurses and Global Health
Child health and deaths among children under 5 years
old represent a significant loss of potential for human Nurses have many roles in global health. Information
development (UN IGCME, 2015). Effective low-cost in this section describes the relevance of nursing and
interventions have reduced child mortality rates in some nursing organizations to global health and provides sug-
gestions from our collective knowledge and experience as
practitioners, educators, researchers, and nursing leaders
in global and international health settings.
BOX 10.2 SUMMARY FACTS ABOUT National and international nursing organizations
MORTALITY IN CHILDREN UNDER 5 YEARS have emphasized the importance of addressing global
health issues in clinical practice (CNA, 2008; Inter-
• Approximately half of all deaths in children under 5 years national Council of Nursing [ICN], 2007). The CNA
occur in five countries: India, Nigeria, Democratic Repub-
lic of Congo, Pakistan, and China.
(2009) endorses the principles of primary health care,
whereby essential health care in the form of health pro-
• Girls are more at risk of early death compared with boys
(because of selective abortion and infanticide). motion and illness prevention is universally accessible to
• One-third of deaths are caused by pneumonia (18%) and
the entire population. The CNA also considers global
diarrhea (15%). health a fundamental right; therefore, nurses have the
• Almost half of mortality (40%) in those under age 5 years right and responsibility to learn about the root causes
occurs within the first month after birth. of inequity in global health and be actively involved
• The majority of deaths (70%) in those under age 5 years in developing solutions. Furthermore, although there
occurs within the first year of life. is no defined set of competencies needed for nurses to
practise safely and ethically in the global health context,
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there has been an emphasis on cultural competence as Preparing to Work in Global Health
a key component of global health (CNA, 2008; Regis-
tered Nurses Association of Ontario [RNAO], 2007). Nurses interested in working in global health need to con-
Indeed, the CNA’s competencies for entry level practice sider their motivation and the assets that they may bring
for registered nurses recommend that an entry level reg- to the job and share with others. Skills and knowledge
istered nurse “Demonstrates knowledge about emerging in nursing and the ability to prioritize, make decisions,
community, population and global health issues and and work with limited technologies are all important,
research” (CNA, 2014, p. 7). as are general abilities, such as being able to drive and
Currently, the migration of nurses is a growing phe- speak or understand languages other than one’s own.
nomenon globally, and there is a need to ensure the avail- Nurses work overseas as volunteers, nurses, or support
ability of well-trained nurses in all health care settings to staff in some projects where their roles are often flexible
meet patients’ needs in diverse cultural and geographical and multi-tasked. Country reports are available from the
areas (WHO, 2006). Nurses should be active participants Department of Foreign Affairs, Trade and Development
in the development of clinical practice guidelines that (DFATD, 2015b) and the Central Intelligence Agency
ensure comprehensive global health care. (CIA) World Fact Book (CIA, 2015).
Case Study 10
Following the civil war in Somalia in the 1990s, Canada accepted
large numbers of Somali refugees. The first wave of families was
2. What are some of the barriers that you would expect
Somali refugees might face in Canada?
settled in two large urban cities (Toronto and Vancouver), and
these families tended to group together socially and geographi- 3. What sorts of health problems would you expect to find
cally. Some administrators in charge of resettlement felt that in a cluster of Somali refugee families?
allowing the development of small ghettos was hindering the 4. Which level(s) of government is/are responsible for the
assimilation of refugees into Canadian society. Consequently, health and well-being of refugees and asylum seekers in
the next wave of Somali refugees was dispersed throughout the Canada?
country to small towns—in many cases, only one or two fami-
lies per town. However, when an evaluation of the resettlement Visit MyNursingLab for answers and explanations.
program was carried out a year later by qualified, independent
evaluators, it was found that the separated families had poorer
scores in English skills and had higher rates
of health and adjustment problems and work
absenteeism, compared with families in con-
centrated communities. The administrators
were puzzled by these results.
1. How would you satisfactorily explain the results to the

administrators?
K EY TERM S
capacity building p. 169 food security p. 171 Millennium Development social justice p. 169
climate change p. 161 global health p. 160 Goals (MDGs) p. 168 surveillance p. 172
colonialism p. 167 Indigenous peoples natural disasters p. 172 sustainability p. 169
environmental factors p. 170 pollution p. 164 Sustainable
p. 161 international health poverty p. 171 Development Goals
environmental health p. 165 safe water p. 163 (SDGs) p. 168
p. 160 international sanitation p. 164 vectors of disease
epidemiological nursing p. 170 social determinants p. 161
transition p. 165 migration p. 170 of health p. 170
M10_KOZI2703_04_SE_C10.indd 175 21/02/17 5:24 PM


• International organizations agree that climate change is freedom from hunger and violence, and encourages toler-
the most significant environmental challenge and that ance and solidarity.
multiple actions are needed to cope with climate change • Seventeen Sustainable Development Goals (SDGs) have
and to reduce carbon emissions now and in the future. been instituted as part of the post-2015 development
• Access to clean water and sanitation, which is impor- agenda to address disparities not only in developing
tant for human health, has improved globally. However, nations but in all countries across the world.
people living in rural and remote areas or in inner-city • Capacity building, sustainability, and social justice are
low-income areas face increased risks to their health in important for development to occur.
many regions of the world because they continue to have
limited or no access to safe drinking water or appropriate • Theories of development, such as colonialism, moderniza-
sanitation. tion, and linear stages of growth, have attempted to explain
how economic growth occurs in countries around the world.
• Pollution continues to reduce indoor and outdoor air
quality and is associated with increased risks of respira- • Globally, major issues include the health of migrants and
tory and other illnesses. Indigenous peoples, and issues of poverty and inequality.
• There is a difference between international health and • Women’s and children’s health and mortality have
global health. International health focuses on the study of improved globally, but some regions have not experienced
disease burden within and between nation states, whereas such improvements. Unacceptable mortality rates in some
global health relates to the study of the improvement of regions require focused efforts to accelerate the rate of
health, reduction of disparities, and protection against improvement.
health risks in both rich and poor countries that are seen • National and international nursing organizations have
as having inherently global causes and consequences. emphasized the importance of addressing global health
• The United Nations Millennium Declaration asserts issues in clinical practice.
that all individuals in the world have the right to dignity, • Global health education in nursing has become important
equality, freedom, a basic standard of living that includes in the Canadian undergraduate nursing curriculum.

1. What year is the target for the achievement of the 4. Which of the following is the GREATEST contributor
Sustainable Development Goals (SDGs)? to food insecurity?
a. 2015 a. Food contamination
b. 2030 b. Poverty
c. 2018 c. Population overcrowding
d. 2050 d. Lack of proper food storage
2. Which of the following BEST describes the process of 5. A nurse educator gave a presentation on the differ-
economic development from traditional society, through ences between international health and global health
economic “takeoff,” initially led by a few individual to a group. What statement by a session participant
sectors, such as agriculture, transportation, and manu- demonstrates a clear understanding of the term global
facturing, and ending in mass consumption? health?
a. The neocolonial theory a. “The term means health status among countries.”
b. The only “reasonable development path” for poor b. “The focus is on the control of epidemics in develop-
countries ing countries.”
c. Rostow’s linear stages of growth theory c. “Emphasizes improving health and achieving equity
d. How “underdeveloped” countries can increase their in health for all people worldwide.”
connectedness to world markets d. “Is the organized efforts of society to keep people
healthy, prevent injury and illness.”
3. Which environmental situation would exert the greatest
potential to cause human disease and/or death? 6. Which of the following exemplifies one of the eight
a. A woman in Nepal uses biofuel for cooking Millennium Development Goals (MDGs)?
b. Contamination of surface water in Northern India a. Young women are encouraged to join national police
c. Forced migration of people from Syria of Timor-Leste.
d. West Nile viral infection in Canada b. In rural Cambodia, backyard fish farms are established.
M10_KOZI2703_04_SE_C10.indd 176 21/02/17 5:24 PM

c. Canada supports the South African Trust to educate d. Relying on the expertise of professional occupational
men on human immunodeficiency virus/acquired trainers in Canada prior to departure
immunodeficiency syndrome (HIV/AIDS).
d. A rural district in Lesotho gets light through solar 9. An unnamed country has a Gender Inequality Index
panel instillation. score of 0.446. What does this mean?
a. Women are almost 45% less powerful than women
7. What has sometimes caused catastrophic lifestyle in other countries.
changes in Indigenous (Aboriginal) populations?
b. Women earn almost 45% less than men.
a. Education
c. Almost 45% of human development potential is lost.
b. Economic assistance
d. Women have almost 45% more power than men.
c. Migration
d. Forcible displacement 10. What is the BEST definition for the term “epidemio-
logical transition”?
8. A student nurse is working with a nongovernmental a. This occurs when a country moves from Third-
organization (NGO) on a community development World to First-World conditions.
project with women and children in Indonesia. Which
would be a key capacity-building intervention? b. It is the long-term maintenance of developed pro-
grams in a society.
a. Sitting with families at a community feast upon arrival
c. This is the movement of people from one country to
b. Leading a consultation with prominent community another.
members
d. This occurs when Indigenous peoples are forced to
c. Reflecting on the motivation for undertaking this integrate with the dominant culture.
opportunity
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Chapter 11
Safe Cultural Caring
Updated by
Holly Graham, RN, PhD, R.D. Psychologist (Provisional)
Assistant Professor, College of Nursing, University of Saskatchewan
I
LEARNING OUTCOMES
After studying this chapter, you will be able to n this chapter, we
1. Describe the concept of culture and its impact on the nursing explore the diverse ele-
process. ments of Canadian
2. Describe the unique world views that all peoples (i.e., Indigenous, culture. We examine culture as a
non-Indigenous, immigrants) in Canada have that impact their concept and discuss using a cul-
health practices. tural safety lens to guide nursing
3. Differentiate among cultural awareness, cultural sensitivity, and practice. Cultural awareness, sen-
cultural competence and describe the process of working toward sitivity, competence, and safety are
cultural safety. then applied to primary care and
4. Describe how the seven characteristics of culture pertain to health promotion. Cultural compe-
nursing. tence is linked increasingly to reduc-
5. Discuss Srivastava’s (2008) ABCDE model of cultural competence. ing health disparities among racial,
6. Describe guidelines for culturally sensitive, competent, and safe ethnic, and underserved populations
health care. (Lipson & Desantis, 2007). Thus, it is
7. Describe four cultural barriers to cultural sensitivity and safety, and imperative that Canadian nurses be
identify ways to overcome them. informed, become culturally sensi-
8. Analyze the different health views of culturally diverse clients: tive, and work toward cultural com-
traditional healing, biomedical, and holistic. petence to safely care for the diverse
9. Explain how the determinants of health influence the health and ethnic and Indigenous populations in
well-being of an individual. Canada.
10. Individualize client care to facilitate culturally sensitive, competent, The demographic profile of
and safe care, based on a holistic cultural assessment. Canada has been changing over
the past several decades, creating
a greater racial and ethnic diver-
sity. All health care providers must
understand the intricate relationship
between cultural and ethnic beliefs
and values, and the ways in which c
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c these concepts impact the context of health care services both delivered (by providers) and received
(by those in need of care) (Escallier, Fullerton, & Messina, 2011). Initially, cultural competence was
perceived as a moral and ethical imperative; however, there is increasing evidence stressing the
importance of cultural competence when addressing disparities in health care quality and outcomes
(Srivastava, 2008). Thus, nurses can directly impact health disparities by improving health care
services.
Canada’s Cultural Mosaic and Nova Scotia. They then moved westward into
Ontario, the Prairie provinces, and British Columbia.
With the defeat of French General Montcalm by British
It is important to understand the history of the peoples General Wolfe in 1769, Canada became a British col-
in Canada to truly comprehend and appreciate their ony. By 1891, Canada’s population growth was small
diverse ethnic and cultural origins. Examining the his- compared with that in the United States. Canada’s pop-
torical context and national policies of Canada that ulation of 4.8 million was distributed unevenly across
affect Indigenous peoples, immigrants, and refugees pro- its vast territory, with the majority concentrated in
vides to nurses an insight into the evolution of Canada’s Ontario, Quebec, and the Atlantic region. With the
cultural mosaic and ultimately lays the foundation to completion of the transcontinental railway in 1885, all
think critically about providing culturally competent and of Canada became accessible, from the east coast to the
culturally safe care. west coast. In addition, the dispossession of Indigenous
Indigenous communities, peoples and nations are those which, land rights through the signing of the seven numbered
having a historical continuity with pre-invasion and pre- treaties in the 1870s enabled the federal government to
colonial societies that developed on their territories, consider open up the west to agricultural settlement. The clos-
themselves distinct from other sectors of the societies now ing of the American frontier meant that Canada could
prevailing in those territories, or parts of them. They form at attract immigrants from the United States, Britain, and
present non-dominant sectors of society and are determined Europe.
to preserve, develop and transmit to future generations their During the twentieth century, three major migra-
ancestral territories, and their ethnic identity, as the basis of tions helped shape the present composition of the
their continued existence as peoples, in accordance with their Canadian population. The first occurred between 1901
own cultural patterns, social institutions and legal systems. and 1912, when almost 3 million people arrived, mainly
(United Nations Permanent Forum on Indigenous from Britain and northern European countries. By 1911,
Issues, 2007, p 12) immigrants accounted for 22% of the population, com-
pared with 13% in 1901. Between 1919 and 1931, only
In this chapter, the term Indigenous will be used to 1.2 million immigrants arrived in Canada. This decline
refer to the three groups of Aboriginal peoples who are occurred for several reasons: Canadians were involved in
recognized by the Canadian Constitution: Indians (First social policies that influenced the character of the coun-
Nations), Métis, and Inuit (Health Canada, 2009). In try, including its immigration policy; the years between
general, the Government of Canada and some organiza- World Wars I and II were a period of immigration
tions use the term Aboriginal, whereas other organizations restriction and reduction; the Canadian government
use Indigenous. increased sanctions with regard to certain immigrant
Canada has a long history of emigration and immi- groups; and the war-torn conditions of Europe left
gration; individuals from diverse backgrounds and cultures many individuals without the means to emigrate to
have come to Canada and called it home. The Indigenous other countries.
peoples were the original inhabitants of North America. The second group of immigrants came after World
Indigenous peoples and their traditional teachings main- War II, when hundreds of thousands of people in Europe
tain that they are the first peoples of Canada and have were displaced from their homelands or were refugees.
existed here from the very beginning. Despite colonization More than 1 million immigrants arrived in Canada
and numerous attempts to totally assimilate Indigenous between 1946 and 1955, with most of them still coming
peoples, they remain as distinct in language, culture, and from Britain and other European countries. The third
ethnicity as more recent immigrants to Canada. major migration began in 1977 and continues today.
Early in the seventeenth century, Europeans estab- Between 2001 and 2006, more than 1 million immigrants
lished settlements primarily in Quebec, New Brunswick, were accepted into Canada.
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Chapter 11 Safe Cultural Caring 183
In proportion to its population, Canada permits by 2031 the median age of the population will be
about twice as many immigrants as does the United 44 years.
States. Consequently, the proportion of foreign-born • In 2006, the median age of Canada’s workforce
individuals in Canada is more than 20%, whereas the increased to 41.2 from 39.5 in 2001. This rise is espe-
proportion in the United States is 12.5%. Only Australia cially strong in the percentage of workers who are more
rivals Canada in its proportion of first-generation immi- than 55 years of age, which increased to 15.3% from
grants: 22.2% (Chui, Tran, & Maheux, 2007). Statistics 11.7% in 2001.
Canada projects that by 2030, immigration may be the
• Chinese languages are the most common languages spo-
only source of population growth in Canada (Chui,
ken at home, after English and French.
Tran, & Maheux, 2007).
New immigrants tend to settle in geographical areas • Aboriginal people are a young and urban popula-
that have other persons from their homeland; in a new tion. The median age of the Aboriginal population is
country, the presence of those from a familiar linguistic, 24.7 years, 14 years younger than the non-Aboriginal
religious, and cultural background makes the transition population.
to a new way of life easier. The vast majority (97.2%) of • Older Canadians are shaping the national demograph-
immigrants entering Canada between 2001 and 2006 ics. Between 2001 and 2006, the population older than
(Chui, Tran, & Maheux, 2007) settled in urban areas, 80 years increased by 25%. Statistics Canada projects
with more than half in the large cities of Toronto, that the number of seniors (65 years of age and older)
Montreal, and Vancouver. could outpace the number of children younger than
Historical events and immigration patterns and 15 years of age within the next 10 years.
policies have shaped the ethnocultural composition of • The increase in visible minority populations has out-
Canada. In the beginning, as a consequence of coloni- paced the natural population increase, increasing by
zation, Canada was dominated by French and British 27.2% compared with the total population increase
cultures. These two groups remain unassimilated by of 5.4%. In 2006, visible minorities accounted for
each other. Indigenous peoples were also not completely 16.2% of the population, compared with 11.2% in
assimilated, even though numerous government policies 1996.
attempted to do that. Today, Canada is a multicultural
• Since the end of World War II, a substantial pro-
nation, in which a plethora of languages, religions, belief
portion of immigrants, in excess of 500 000 in total,
systems, values, and life patterns prevail.
have been refugees, coming from Hungary in 1956;
Czechoslovakia in 1968; Southeast Asia, the Middle
East, South and Central America, Africa, and, more
Demographic Profile recently, from Bosnia and Somalia.
According to the 2006 census, there are 1 172 785 • Discerning whether an individual is an immigrant or a
individuals who have identified as being Aboriginal. refugee—that is, whether the person’s move to Canada
From the individuals who have self-identified as being was a choice or a forced decision—is a consideration in
Aboriginal, there are 698 025 North American Indians, providing culturally safe care.
389 780 Métis, and 50 480 Inuit.
In terms of the whole population, the results of
the 2006 census (Chui, Tran, & Maheux, 2007; Martel
& Caron-Malenfant, 2007a, 2007b; Statistics Canada,
Language
2008a, 2008c, 2008d, 2015) identify the following During each of the census periods, Canadians have been
points: asked to identify their mother tongue, defined as “the
first language that a person learned at home in child-
• Canada’s population has more than doubled in the past
hood and still understands” (Statistics Canada, 2012a).
50 years, from just over 14 million in 1951 to just over
In 2011, for the first time, questions regarding language
35 million in 2016.
were asked of the entire population, and more than
• The People’s Republic of China was the main source 200 languages were reported, including Aboriginal lan-
country of immigrants to Canada in 2001 and again in guages. English was the most commonly spoken language
2006. In 2006, 14% of recent immigrants came from at home (66%), and 21% of the population reported that
China, and India accounted for 11.6%, followed by the French was most commonly spoken at home (Statistics
Philippines (7%) and Pakistan (5.2%). Six of the top 10 Canada, 2012b). One in five of the population in 2006
countries of origin of all newcomers in the 2006 census was an allophone (i.e., mother tongue other than English
were in Asia and the Middle East. or French). Of the allophone population, 56% iden-
• Canada’s national median age reached an all-time tified an Asian language as the mother tongue, with
high of 39.5 years in 2006, rising steadily since 1966. speakers of Tagalog (from the Philippines) showing the
Statistics Canada’s demographic projection is that greatest increase since 2006 (Statistics Canada, 2012b).
M11_KOZI2703_04_SE_C11.indd 183 08/02/17 5:31 PM

Also, in 2011, over 200 000 Canadians reported hav- histories of intergenerational family violence and abuse;
ing an Aboriginal language as mother tongue. These histories of involvement with foster care; unhealthy
persons were most often living in Quebec, Manitoba, or coping, and social and life skills; emotional numbness;
Saskatchewan (Statistics Canada, 2012c). anger toward authority figures; low self-esteem from
According to the 2006 census, 81% of the new deep-rooted feelings of humiliation, shame, and aban-
immigrants who had arrived in the previous 5 years donment; and disconnection from family and culture
were unable to speak in either one of the two official (Chansonneuve, 2005). There are unequivocal dispari-
languages (Corbeil & Blaser, 2007). This situation has ties between Indigenous and non-Indigenous peoples
put a strain on certain services, such as English or in Canada related to income, employment, education,
French language training and translation services, and housing, health, and mental health (Health Canada,
has posed challenges in the delivery of health care. 2005; Statistics Canada, 2010). Ermine, Sinclair, and
Statistics Canada (Schellenberg & Maheux, 2007) con- Jeffery (2004) asserted that “despite the unpalatable
ducted a longitudinal survey of immigrants to Canada, nature of colonial history . . . Indigenous people expe-
and 32% of immigrants who sought employment rience those realities daily. While it may be difficult to
in Canada identified language as a major barrier to read about the realities of Indigenous peoples, it is with-
employment. out a doubt more difficult to live those realities” (p. 9).
The Truth and Reconciliation Commission (TRC)
of Canada was formed in 2008 with the vision to
“reveal the truth about the residential schools, and
Indigenous Peoples establish a renewed sense of Canada that is inclusive
It is important to understand how contact with colo- and respectful, and that enables reconciliation” (TRC
nizers changed every aspect of life for the Indigenous Commission of Canada, 2012, p. 2). Prime Minister
peoples. As a result of colonization, the Indigenous Harper offered a full apology on behalf of Canadians
peoples of Canada lost their language, autonomy, self- for the Indian Residential Schools system on June 11,
determination, ability to practise their cultural and spiri- 2008. The TRC (2012) hoped to engage Indigenous
tual beliefs, and, most importantly, connection with their peoples and Canadians by acknowledging the experi-
identity. With the occurrence of epidemics, the social, ences and the ongoing legacy of the residential school
economic, political, cultural, and community structures era on Indigenous people’s health and well-being. This
were severely disrupted and, in some cases, annihilated. acknowledgement and understanding form part of the
Within the residential school system, Indigenous children effort to achieve the ultimate goal of reconciliation and
were subjected to physical, mental, emotional, religious, renewed, inclusive relationships between Indigenous
and sexual abuses. These practices that were legally peoples and non-Indigenous peoples, based on mutual
enforced by non-Indigenous peoples have contributed respect and understanding.
to the current health disparities between the Indigenous The Calls to Action highlight the following areas of
and non-Indigenous peoples in Canada (Chansonneuve, Indigenous health and well-being: child welfare, educa-
2005; Chartrand & McKay, 2006; Wesley-Esquimaux & tion, language and culture, health, and justice. As a result
Smolewski, 2004). of the TRC Calls to Action (2015), Universities Canada,
The negative consequences of colonization, spe- representing 97 universities across Canada, has adopted
cifically the epidemics and the residential school expe- a set of principles outlining its “shared commitment” to
riences, led to cultural discontinuity, which has been enhancing educational opportunities for Indigenous stu-
linked to high rates of mental illness, alcoholism, suicide, dents, specifically ensuring that all students take courses
and violence in many communities (Kiramayer, Brass, & in Indigenous studies. The University of Saskatchewan
Tait, 2000). The First Nations adults who were surveyed hosted the first National forum in November 2015 for
by the Regional Health Survey (2002–2003) believed universities to respond to the TRC’s Calls to Action
that their parents’ attendance at residential school had (2015).
negatively affected the parenting they received as chil- The changing face of Indigenous peoples is illus-
dren. Also, even if only one of the parents had attended trated in Figure 11.1.
a residential school, the chances of the children think-
ing about committing suicide in their lifetime were
higher. At a 5-day retreat for those who had expe-
rienced residential school abuse in eastern Ontario,
Visible Minorities
participants reported the continued negative impact In Canada, non-British and non-French immigrants
on themselves, their families, their communities, and remained on the fringes of mainstream society until
their clients (Chansonneuve, 2005). These participants the middle of the twentieth century. The 2006 census
attributed to the residential school legacy the high rates collected information on members of visible minor-
of suicide, family violence, addictive and self-destructive ity groups in Canada, defined as “persons, other than
behaviours, mental illness and emotional disorders; Aboriginal people, who are non-Caucasian in race, or
M11_KOZI2703_04_SE_C11.indd 184 08/02/17 5:31 PM

TABLE 11.1 Visible Minority Population, by Place of Origin,

1996 Census and 2006 Census
1996 Census 2006 Census

Total population 28 528 125 31 241 030
Visible minority population 3 197 480 5 068 095
South Asian 670 590 1 262 865
Chinese 860 150 1 216 565
Black 573 860 783 795
Filipino 234 195 410 700
Latin American 176 970 304 245
Arab/West Asian 244 665 422 245
Southeast Asian 172 765 239 935
Korean 64 835 141 890
Japanese 68 135 81 300
Multiple visible minority 61 575 133 120
Visible minority 69 745 71 420
(not included elsewhere)
Pearson Education, Inc.
Source: Statistics Canada. (2001). Total population by visible minority population for
Canada, 1996. Retrieved from http://www.statcan.ca/english/census96/feb17/vmcan
.htm; and Statistics Canada. (2009). 2006 Census of Population. Retrieved from http://
www40.statcan.gc.ca/l01/cst01/demo50a-eng.htm.
FIGURE 11.1 This photograph represents three generations

of Plains Cree people from the Thunderchild First Nation,
Saskatchewan: grandmother, mother, and granddaughter. Canada’s Multicultural Policy
The multicultural policy in Canada was initiated in
non-white in colour” (Statistics Canada, 2008b). In 2006, 1971 as a guideline for federal government policy, and
over 5 million persons identified themselves as members it reflects the evolving nature of Canadian society.
of visible minority groups, representing 16.2% of the However, it is important to note that Canada did have
Canadian population. The numbers of visible minorities previous policies of assimilation and/or colonization
have steadily increased over the past 25 years. Indeed, that focused on the absorption of people into a dominant
visible minorities represented 4.7% of Canadians in culture. In Canada, an example of assimilation would
1981, 9.4% in 1991, 11.2% in 1996, 13.4% in 2001, and be the forced integration of Indigenous peoples into
16.2% in 2006. Ontario is home to more than half the the European-Canadian culture. Assimilation was an
visible minority population (Statistics Canada, 2008c). explicit policy of the Canadian government that led to
The increase in the visible minority population has the removal of Indigenous children from their homes
been five times the increase in the general population and families and their subsequent institutionalization
since 2001 (Statistics Canada, 2008c). The largest vis- in residential schools. Colonization has shaped and
ible minority population was reported to be the South continues to influence families around the globe. The
Asian group (4% of total population), followed by the purpose of assimilation or colonization is to impose
Chinese (3.9%) and blacks (2.5%). Other visible minor- the values, attitudes, beliefs, or practices of a dominant
ity groups included Filipinos (8.1%), Latin Americans group in society on a minority group. Through colonial
(6%), Arabs (5.2%), Southeast Asians (4.7%), West rule, many cultures have had to cope with the imposition
Asians (3.1%), Koreans (2.8%), and Japanese (1.6%) of Christian-European family norms and with the values
(see Table 11.1). of their colonizers.
The Toronto, Montreal, and Vancouver census met- In 1988, the Multiculturalism Act was passed,
ropolitan areas (CMAs) were home to 68.9% of recent guaranteeing multiculturalism as a legal entity and
immigrants in 2006. Between 2001 and 2006, higher pro- affirming its importance to Canada. As a policy pro-
portions of recent immigrants chose to settle in smaller moting tolerance and diversity, multiculturalism was to
CMAs. Fully 16.6% of newcomers in 2006 settled in be the opposite of assimilation, which means loss of
the CMAs of Calgary, Ottawa-Gatineau, Edmonton, those characteristics that distinguish a group from the
Winnipeg, Hamilton, and London. In 2001, by compari- culture that surrounds it. Canada has been called a
son, 14.3% of newcomers lived in these CMAs (Statistics mosaic or an ethnically plural society because of the way it
Canada, 2008c). has absorbed immigrants. It has supported people in
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Box 11.1 Canadian Legislation Affecting Multiculturalism in Canada
Year Legislation/Legislative Event

1960 The Canadian Bill of Rights barred discrimination by federal agencies on the grounds of race, national origin, colour,
religion, or gender.
1961 Changes to Canada’s Immigration Act meant that fewer immigrants were European, and the mix of source countries
shifted to nations in southern Europe, Asia, and the West Indies.
1969 The Official Languages Act was enacted to protect minority language rights.
1971 The federal government announced its policy of multiculturalism, which encouraged people to retain their cultural beliefs
and practices.
1982 The Canadian Charter of Rights and Freedoms considered multiculturalism to be constitutional and protected equality
rights without discrimination (in particular based on race, national or ethnic origin, colour, religion, gender, age, or mental
or physical disability). Section 27 explicitly states that the Charter will be interpreted in a manner consistent with the
preservation and enhancement of the multicultural heritage of Canadians.
The Canada Act replaced the British North America Act as Canada’s constitution and also recognized the three
main groups of Indigenous peoples in Canada: First Nations, Métis, and Inuit.
1984 The Canada Health Act established principles of accessibility, comprehensiveness, universality, portability, and public
administration to ensure health care for all Canadians, regardless of health, location, or social/economic status.
1986 The Employment Equity Act was established to achieve equality in the workplace so that no persons would be denied
employment opportunities or benefits for reasons unrelated to ability; it established the principle that employment equity
means more than treating persons in the same way but also requires special measures and the accommodation of
differences; it identified four groups thought to experience disadvantage in employment: women, Aboriginal peoples,
persons with disability, and persons in a visible minority
1991 The Broadcasting Act established the requirement for the Canadian broadcasting system to appropriately reflect the
diversity of cultures in Canada.
2015 Final report of the Truth and Reconciliation Commission is released.
retaining a distinct sense of cultural identity. This is in Many parts of culture (e.g., health and illness practices;
contrast to the “melting pot” of the United States, where attitudes about touch, territory, and privacy; childbirth;
immigrants are assimilated into the mainstream of that and death and dying practices) affect nursing practice.
culture. (See Box 11.1 for a summary of Canadian legis- Religious and spiritual beliefs are part of cultural
lation on multiculturalism in Canada.) values and can influence dietary restrictions, family plan-
The ethnocultural profile of Canada today shows ning, the use of blood transfusions, and death-related
a nation that has become increasingly multiethnic and practices, such as autopsy, organ donation, cremation,
multicultural. This portrait is diverse and varies from and prolonging life. Understanding the unique val-
province to territory, city to city, and community to com- ues and belief systems of particular religious groups is
munity. Immigration over the past 100 years has shaped important in providing culturally safe care. For exam-
Canada, with each new wave of immigrants adding to ple, many Orthodox Jews believe in prolonging life as
the nation’s ethnic and cultural composition. Half a cen- much as possible and do not believe in cremation; some
tury ago, most immigrants came from Europe; now most Indigenous peoples practise traditional healing methods,
are from several parts of Asia. The number of visible such as use of the sweat lodge; many Jehovah’s Witness
minority groups in Canada is growing. Canadians listed followers will not accept blood transfusions; and many
more than 200 ethnic groups in their answers to the 2006 Jewish and Muslim dietary practices prohibit eating
census question on ethnic ancestry, reflecting a varied pork or pork products. These are just a few examples;
and rich cultural mosaic (Statistics Canada, 2008c). however, in providing culturally safe care, the important
nursing action is to conduct a cultural assessment on all
clients (Indigenous, non-Indigenous, immigrants) and
Culture as a Concept ask the client about his or her preferences.
Components of Culture Cultures are complex. Characteristics of Culture Culture exhibits the
Their facets relate to all aspects of life: language, art, following characteristics:
music, values systems (beliefs, morals, rules), spirituality
and religion, philosophy, family roles and organization, • Culture is learned. It is neither instinctive nor innate. It is
patterns of behaviour, childrearing practices, rituals or learned through life experiences from birth.
ceremonies, recreation and leisure activities, festivals and • Culture is taught. It is transmitted from parents,
holidays, nutrition, food preferences, and health practices. extended family, and peers to children over successive
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generations. Verbal and nonverbal communication Diversity refers to the fact or state of being differ-
patterns transmit culture. ent. Many factors account for differences; race, gender,
• Culture is social. It originates and develops through peo- sexual orientation, culture, ethnicity, socioeconomic sta-
ple’s interactions in families, groups, and communities. tus, educational attainment, religious affiliation, ability,
marital status, age, and so on. Diversity, therefore, occurs
• Culture is adaptive. Customs, beliefs, and practices change
not only between cultural groups but also within a cul-
as people adapt to the social environment and as their
tural group.
biological and psychological needs change. For example,
The term ethnic refers to a group of people who
the idea of the extended family still exists; however, the
share a common and distinctive culture. Although eth-
means by which families interact and communicate has
nicity has sometimes been used to identify race, Giger
been transformed, despite large geographical distances,
and Davidhizar (2004) suggest that ethnicity is “a com-
by the World Wide Web, which facilitates instant visual
mon social and cultural heritage that is passed on to
and verbal communication.
successive generations” (p. 67). The characteristics of the
• Culture is shared. This is true to varying degrees. Even group give an individual a sense of cultural identity.
though values, beliefs, and traditions may be shared, Other factors that help define ethnicity may include
unique differences still exist for each individual within religion and the geographical background of the family.
a cultural group. Race is a controversial term. For some people, the
• Culture is difficult to articulate. Members of a specific cul- definition of race includes having common characteris-
tural group often find it difficult to explain their own tics, such as skin colour, bone structure, facial features, hair
culture. Many of the values and behaviours are habitual texture, and blood type. The American Anthropological
and are carried out subconsciously. Association (AAA) statement on race defines it as an
• Culture exists at many levels. Culture is most easily identi- idea created by Western Europeans following exploration
fied at a visible level. Rituals (e.g., funerals), dress, and across the world to account for differences among people.
celebrations are visual cues to culture that are easily It has been used to refer to groupings of people accord-
revealed. Often, it is more difficult to find out about ing to common origin or background and associated
the more abstract concepts, such as values, beliefs, and with perceived biological markers. No races, in fact, exist
traditions. among humans except the human race. Ideas about race
are culturally and socially transmitted and form the basis
of racism, racial classification, and often complex racial
identities (AAA, 1998). The Human Genome Project has
discovered that humans are 99.9% genetically alike and
Definitions and Concepts that the genetic variations related to geography or ances-
try do not correlate with the socially constructed racial
Related to Culture classifications; that is, there are no genetically discrete
races. In fact, there is greater genetic variability within
The terms culture, diversity, ethnicity, and race are often used a racial category than among the various categories.
interchangeably, but they are not synonymous. Culture Although it is now recognized that there is no scientific
is defined as “the learned, shared, and transmitted val- merit to the concept of race, race remains an important
ues, beliefs, norms, and lifeway practices of a particular social construct, whereby social meanings are attached
group that guide thinking, decisions, and actions in pat- to perceived physical differences, resulting in inequality
terned ways” (Leininger, 1988, p. 158). Because cultural among racial groups. Culture should not be confused with
patterns are learned, it is important for nurses to note either race or ethnic group. Race, culture, and ethnic origin are
that all members of a particular group may not share three distinct terms, which are often inappropriately used
identical cultural experiences. For example, generations interchangeably.
have different appreciations of music according to expo-
sure within their peer group—swing from the 1940s, jive
from the 1950s, rock and roll from the 1960s, and so
on. Large cultural groups often have cultural subgroups
Considerations
or subsystems. A subculture usually comprises people
who have a distinct identity and yet are also related to a
for Culturally Safe
larger cultural group. Nursing Practice
The term bicultural “is used to describe a person
who crosses two cultures, lifestyles, and sets of values” Similar to giving ethical care, nurses must consider cul-
(Giger & Davidhizar, 2004, p. 67). For example, a young tural and ethnic factors in themselves and others in pro-
man whose father is Cree and whose mother is European viding quality nursing care. A group’s world views shape
Canadian may maintain his traditional Cree heritage while its health culture—the values, beliefs, and practices it
also being influenced by his mother’s cultural values. holds about health promotion, disease prevention, illness
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treatment, and the expectations that guide the nurse–client Canadians (see the Evidence-Informed Practice box).
encounter. The Canadian health care system is rooted in Western
People who belong to the same ethnic group may biomedical principles, in which outcome is oriented
have little in common in their lifestyles, beliefs, and val- toward the effective diagnosis and treatment of disease.
ues. For example, a Canadian of East Indian ancestry Clients from a nondominant culture may view nurses of
could be a third-generation Canadian who cannot speak the predominant culture as a threat to their traditional
a word of the ancestral mother tongue, a recently arrived ways of dealing with health care concerns and therefore
lawyer from New Delhi, or an ethnic refugee from a not reveal their traditional forms of treatment. In addi-
small mountain village in northern India. tion, ethnic minority immigrants may not be able to read
Health care providers must understand the over- and write in either official language of Canada. Written
arching influence of the determinants of health that instructions from a nurse may be misunderstood or not
also influence health inequities and disparities (Public fully understood.
Health Agency of Canada [PHAC], 2010; Raphael, Escallier, Fullerton, and Messina (2011) contended
2006). For example, socioeconomic status, length of time that cultural competence is really nursing competence.
in Canada, educational level, age, gender, and country The “real issue in a clinical event is individualized patient
of origin will influence the perspectives of health and care—which is the signature of contemporary nursing—
health behaviours. However, some genetically acquired which has been repackaged by the medical profession
biological traits, such as differences in skin pigmentation, as ‘culturally competent’ care” (p. 185). Essentially, the
body build, and metabolism, can have a bearing on a various cultural assessments are simply strategies
person’s health. For example, individuals who trace their for eliciting the patient’s understanding of his or her
ancestry to black racial groups of Africa, among others, illness, individualizing his or her care, and improving
are predisposed to a genetic blood condition known as communication.
sickle-cell anemia. Before presenting a cultural safety lens, it is neces-
It is important for nurses to explore the cultural sary to elaborate on the diversity of the health beliefs
and ethnic beliefs and the health care practices of all and practices, family patterns, communications styles,
space and time orientation, nutritional patterns, pain
responses, and death and dying practices of Canadians.
Evidence-Informed
Practice
Health Beliefs and Practices
The scientific or biomedical health belief is based
How Do Contemporary néhiyawak on the belief that life and life processes are controlled by
physical and biochemical processes that can be manipu-
(Plains Cree) Describe miyo- lated (Andrews & Boyle, 2003). The client with this view
mahcihoyān (Well-Being)? will believe that illness is caused by germs, viruses, bac-
teria, or a breakdown of the human machine, the body.
Given the negative history of research with Indigenous peo-
ples, there has been a shift to new research paradigms as This client will expect a pill, treatment, or surgery to
a result of the “decolonizing agenda that has a principal cure health problems.
goal, the amelioration of disease and the recovery of health From an Indigenous perspective, the holistic
and wellness for Indigenous populations” (Ermine, Sinclair, health belief approaches health and well-being from
& Jeffery, 2004, p. 9). Research guidelines and policies a perspective that takes into consideration interconnect-
now reflect a greater sensitivity to Indigenous knowledge edness, interrelatedness, balance, and harmony within
and to the rights of Indigenous peoples and their commu-
an individual and extends outward into the commu-
nities. Graham-Marrs (2011) explored what improved the
mental health and well-being of the Plains Cree people from nity (Hart, 2002). Many Indigenous peoples of North
Thunderchild First Nation and what they perceived as nec- America and South America use the medicine wheel
essary to attain optimal mental health and well-being. Each to symbolize these concepts. For example, the medicine
step of the research process was intended to benefit the wheel teaches that there are four aspects to an individu-
participants, the same way the nursing process is expected al’s well-being—the physical, the mental or intellectual,
to benefit clients. the emotional, and the spiritual (Mussell, 2005). See
Nursing Implications: Through research such as Figure 11.2.
this, nurses can begin to understand how cultural per- The concept of yin and yang in the Chinese culture
spectives influence clients’ views of health and health and the hot–cold theory of illness in many Spanish
challenges. cultures are examples of holistic health beliefs. When a
Source: Based on Graham-Marrs, H. A. (2011). Narrative descriptions of miyo- Chinese client has a yin (cold) illness, the treatment may
mahcihoyān (well-being) from a contemporary néhiyawak (Plains Cree) perspective include a yang (hot) food (e.g., hot tea). For example, a
(Doctoral dissertation). Saskatoon, SK: University of Saskatchewan.
Chinese client who has been diagnosed with cancer, a yin
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older family members to prevent or treat colds, fevers,

indigestion, and other common health problems. People
Spiritual continue to use chicken soup as a treatment for the flu.
a sense of Why do individuals use these traditional healing
connectedness with methods? Traditional medicine, in contrast to biomedi-
other creations of the cal health care, is thought to be more humanistic. The
Great Spirit consultation and treatment often takes place in the
Intellectual Physical community of the recipient, frequently in the home of
concepts, air, water the healer. The healer often prepares the treatments,
ideas, food, for example, teas to be ingested, poultices to be applied,
Will clothing,
thoughts, or charms or amulets to be worn. It is important for
habits, shelter, the nurse to be mindful that these amulets or culture-
discipline exercise, specific items may be placed under their pillow to
sex assist with the healing process; thus, it is essential to
Emotional
recognition, acceptance, ensure that these items are kept intact and remain in
understanding, love, place throughout the person’s hospitalization. A fre-
privacy, discipline, limits quent component of treatment is some ritual practice
on the part of the healer or the client to cause healing to
occur. For example, Indigenous peoples may participate
in a sundance as part of their healing process. Because
FIGURE 11.2 Medicine Wheel. traditional healing practices are culturally based, they
Source: Mussel, W. J. (2005). Warrior caregivers: Understanding the challenges
and healing of First Nations men (p. 115). Ottawa, ON: Aboriginal Healing Foundation. are often more comfortable and less frightening for
the client.
It is important for the nurse to obtain information
about traditional healing practices that may have been
disease, will want to eat foods considered to have yang used or are currently in use when the client is seeking
properties. Western medical treatment. Often, clients are reluctant
What is considered hot or cold varies considerably to share traditional medicine with health care profession-
across cultures. In many cultures, the mother who has als for fear of being laughed at or rebuked. The nurse
just delivered a baby should be offered warm or hot should remember that treatments once considered to be
foods and kept warm with blankets because childbirth is traditional treatments, including acupuncture, therapeu-
seen as a cold condition. Conventional scientific thought tic touch, and massage, are now being investigated for
recommends cooling the body to reduce a fever. The their therapeutic effect. However, herbal remedies may
physician may order liquids for the client and cool com- interact with cardiac medications, for example, with
presses to be applied to the forehead, the axillae, or the deleterious effects on a person’s health, ranging from
groin. Galanti (2004) stated that many cultures believe discomfort to death.
that the best way to treat a fever is to “sweat it out.”
Clients from these cultures may want to cover up with
several blankets, take hot baths, and drink hot beverages.
Giger and Davidhizar (2004) stated that the nurse must
Family Patterns
keep in mind that a treatment strategy that is consistent The family is the basic unit of society. Cultural values
with the client’s beliefs may have a better chance of can determine communication within the family group,
being successful. For example, the Latin American client the norm for family size, and the roles of specific family
who avoids spicy foods when experiencing a stomach dis- members. In some families, the man is considered the
turbance may be eating foods consistent with the bland provider and decision maker. The woman may need to
diet that is normally prescribed by physicians. Nurses consult her family before making decisions about her
must also use evidence and critical thought to determine medical treatment or the treatment of her children.
if the cultural practice may have some negative aspects, Some families are matriarchal; that is, the mother or
as with, for instance, the parent who bundles a child with grandmother is viewed as the leader of the family and is
fever to keep him very warm. usually the decision maker. The nurse needs to identify
People who have limited access to scientific health who has the authority to make decisions in a client’s
care or strong cultural beliefs may turn to traditional family. If the decision maker is someone other than the
medicine or healing. Traditional medicine is defined client, the nurse needs to include that person in health
as those beliefs and practices relating to illness preven- care discussions.
tion and healing that are derived from cultural tradi- The value placed on children and older people within
tions rather than from modern medicine’s scientific base. a society is culturally derived. In some cultures, older
Many students might recall special teas or cures used by people are considered the holders of the culture’s wisdom
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and are, therefore, highly respected. Responsibility for of various ethnic and cultural backgrounds is critical
caring for older relatives is determined by cultural prac- to providing culturally competent, safe nursing care.
tices. In many cultures, older relatives who cannot live A therapeutic nurse–client relationship is grounded in
independently often live with a married son or daughter meaningful communication between the nurse and the
and his or her family. client. Cultural variations in both verbal and nonver-
Cultural gender-role behaviour may also affect nurse– bal communication can require the development of a
client interaction. In some countries, men dominate and communication plan that incorporates the client as an
women have little status. Men from these countries may informed partner in care.
be unwilling to accept instruction from a female nurse or
physician but are receptive to the same instruction given by VERBAL COMMUNICATION The most obvious cultural
a male health professional. Some cultures have a prevail- difference is in verbal communication: vocabulary, gram-
ing concept of machismo, or male superiority. Machismo matical structure, voice qualities, intonation, rhythm,
requires that the adult man provide for and protect his speed, pronunciation, and silence (Giger & Davidhizar,
family, including extended family members. The woman 2004). In North America, the predominant language
is expected to maintain the home and raise the children. is English; however, immigrant groups who speak
Cultural family values may also dictate the extent English still encounter language differences because
of the family’s involvement in the hospitalized client’s English words can have different meanings in differ-
care. In some cultures, the nuclear family as well as the ent English-speaking cultures. Similarly, great differences
extended family will want to visit for long periods and exist between the French spoken in Canada and that
participate in care. In other cultures, the entire clan may spoken in France. In Canada, the French language has
want to visit and participate in the client’s care. This evolved, assimilating Indigenous and English terms. In
can cause concern on nursing units with strict visiting Quebec, New Brunswick, and other places, nurses must
policies. The nurse should evaluate the benefits of fam- meet the French language requirements for practice and
ily participation in the client’s care and modify visiting need to be aware of the language diversity that exists
policies, as appropriate. within the province.
Naming systems in many cultures differ from those Initiating verbal communication may be influenced
in North America. In some cultures (e.g., Japanese and by cultural values. The busy nurse may want to complete
Vietnamese), the family name comes first and the given nursing admission assessments quickly. The client, how-
name second. One or two names may or may not be ever, may be offended when the nurse immediately asks
added between the family and given names. Other personal questions. In some cultures, it is believed that
nomenclature may be used to delineate sex and child social courtesies should be established before business or
or adult status. For example, in traditional Japanese personal topics are discussed. Discussing general topics
culture, adults address other adults by their surname can convey that the nurse is interested in the client and
followed by san, meaning Mr., Mrs., or Miss. An example has time for the client. This enables the nurse to develop
is “Maurakami san.” The children are referred to by a rapport with the client before progressing to more per-
their first names followed by kun for boys and chan for sonal discussion.
girls. Traditionally, most Sikhs and Hindus are given Verbal communication becomes even more difficult
three names. Some Hindus may have a personal name, when an interaction involves people who speak dif-
a complementary name (such as the father’s first name), ferent languages. Both clients and health care profes-
and then a family name. Sikhs usually have a personal sionals experience frustration when they are unable to
name, the title Singh for men and Kaur for women, and communicate verbally with each other. For clients who
then the family name. Names by marriage also vary. have limited knowledge of English, the nurse should
In Central America, a woman who marries retains her avoid slang words, medical jargon, and abbreviations.
father’s name and also takes her husband’s. For example, Augmenting spoken conversation with use of gestures
if Louisa Viccario marries Carlos Gonzales, she becomes or pictures can increase the client’s understanding. The
Louisa Viccario de Gonzales. The connecting de means nurse should speak slowly, in a respectful manner, and
“belonging to.” Nurses need to become familiar with at a normal volume. Speaking loudly does not help the
appropriate ways to address clients. client understand and may be offensive. The nurse must
also frequently validate the client’s understanding of
what is being communicated. The nurse must be wary
of interpreting a client’s smiling and nodding to mean
Communication Style that the client understands; the client may only be try-
Communication and culture are closely interconnected. ing to please the nurse while not understanding what is
Through communication, culture is transmitted from being said.
one generation to the next, and knowledge about the For the client who speaks a different language, an
culture is transmitted within the group and to those interpreter may be necessary. Galanti (2004) noted that
outside the group. Effective communication with clients cultural rules often dictate who can discuss what with
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Box 11.2 Using an Interpreter and other health care personnel can use pictures and
in Nursing Practice gestures to augment verbal communication.
Nurses who speak a second language may be asked
When using an interpreter, nurses should use the following to interpret for others. Some nursing schools and health
guidelines: care institutions do not permit nursing students to inter-
• Be sure to obtain client consent to use an interpreter or pret consent for a procedure. The student should check
for any other arrangement for communication.
the institution’s policy before agreeing to interpret for
• Avoid asking a member of the client’s family, espe- institutional staff and physicians.
cially a child or spouse, to act as interpreter. Some
clients, not wanting family members to know about Nurses and other health care providers must remem-
their problems, may not provide complete or accurate ber that clients for whom English is a second language
information. may lose command of their English when they are in
• Avoid complex language or medical jargon, as the client stressful situations. Clients who have used English com-
may have limited understanding of vocabulary in English fortably for years in social and business communication
related to health problems. may forget and revert to use of their primary language
• Be aware of differences in gender, age, dialect, and when they are ill or distressed. It is important for the
religion; it is preferable to use an interpreter of the same nurse to assure the client that this is normal and to pro-
sex as the client to avoid embarrassment and faulty
translation of sexual matters. mote behaviours to facilitate verbal communication.
• Avoid an interpreter who is politically or socially incom-
Nonverbal Communication To communicate effec-
patible with the client. For example, a Bosnian Serb
may not be the best interpreter for a Muslim, even if he tively with culturally diverse clients, the nurse needs to
speaks the language. be aware of two aspects of nonverbal communication
• Address the questions to the client, not to the interpreter. behaviours: (a) the meaning of the nonverbal behaviours
• Ask the interpreter to interpret as closely as possible the to the client and (b) the meaning of the behaviour in the
words used—the interpreter’s role is to be the voice of client’s culture. It is not required that the nurse be knowl-
the client. edgeable about the nonverbal behaviour patterns of all
• Speak slowly and distinctly. Do not use metaphors—for cultures; however, before assigning meaning to nonverbal
example, “Does it swell like a grapefruit?” or “Is the pain behaviour, the nurse must consider the possibility that
stabbing like a knife stab?” the behaviour may have a different meaning for the
• Observe the facial expressions and body language that client and the family. Furthermore, to provide safe and
the client assumes when listening and talking to the
interpreter.
effective care, nurses who work with specific cultural
groups should learn more about cultural behaviour and
• Ask the interpreter to share any insights about the client;
however, be sure these are perceived as insights and communication patterns within these cultures.
not as facts or the client’s actual beliefs. Nonverbal communication can include the use of
• Explain to the client and the interpreter that all com- silence, touch, eye movement, facial expressions, and
munication is confidential—no client information will be body posture. Some cultures are quite comfortable with
disclosed to anyone. long periods of silence, whereas others consider it appro-
• Write down key points, directions, and/or appointment priate to speak before the other person has finished talk-
times so they are not confused or forgotten. ing. Many people value silence and view it as essential
• Ask the client to repeat, in his or her own words, all to understanding a person’s needs. Some cultures view
instructions and information. silence as a sign of respect, whereas to other people,
• Determine from the interpreter whether or not any silence may indicate agreement (Giger & Davidhizar,
aspects of the interaction were difficult. 2004).
Touching involves learned behaviours that can
have both positive and negative meanings. In the North
American culture, a firm handshake is a recognized form
whom. Guidelines for using an interpreter are shown in of greeting that reflects cordiality (Giger & Davidhizar,
Box 11.2. Whenever possible, professional health care 2004). In some European cultures, greetings may include
interpreters should be used. a kiss on one or both cheeks along with the handshake. In
Interpreters should be objective individuals who some societies, touch is considered magical, and because
can provide accurate interpretation of the client’s infor- of the belief that the soul can leave the body on physi-
mation and of the health care professional’s questions, cal contact, casual touching is forbidden. Vietnamese
information, and instructions. Many institutions that are Canadians may find touching of the head or shoulders
located in culturally diverse communities have interpret- to be anxiety producing because of such a belief (Giger
ers available on staff or maintain a list of employees who & Davidhizar, 2004). Nurses should, therefore, touch
are fluent in other languages. Embassies, consulates, eth- a client’s head only with permission. The sex of the
nic churches, ethnic clubs, or telephone companies may person touching and being touched often has cultural
also be able to provide interpretation services. Nurses significance.
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Cultures dictate the forms of touch that are appro- may physically withdraw or back away if the nurse is
priate for individuals of the same sex and opposite sex. perceived as being too close. During care, the nurse will
In many cultures, for example, a kiss is not appropriate need to explain to the client why there is a need to be
for a public greeting between persons of the opposite close. To assess the lungs with a stethoscope, for example,
sex, even those who are family members; however, a kiss the nurse needs to move into the client’s intimate space.
on the cheek is acceptable as a greeting among individu- In these circumstances, the nurse should first explain the
als of the same sex. The nurse should watch interaction procedure and await permission to continue.
among clients and families for cues to the appropriate Residents in long-term care facilities or patients
degree of touch in that culture. The nurse can also assess who are hospitalized for an extended time may want to
the client’s response to touch when providing nursing personalize their space. They may want to arrange their
care, for example, by noting the client’s reaction to the room differently or control the placement of objects on
physical examination or a bath. their bedside cabinet or overbed table. The nurse should
Facial expression can vary among cultures. Giger be responsive to clients’ needs to have some control over
and Davidhizar (2004) stated that Italian, Jewish, African their space. When there are no medical contraindica-
American, and Spanish-speaking persons are more likely tions, clients should be permitted and encouraged to
to smile readily and use facial expression to commu- wear their own clothing and have objects of personal
nicate feelings, whereas Irish, English, and northern significance. Wearing cultural dress or having personal
European people tend to have less facial expression and and cultural items in the environment can increase self-
are less open in their response, especially to strangers. esteem by promoting not only the client’s individuality
Facial expressions can also convey a meaning opposite to but also his or her cultural identity.
what is felt or understood.
Eye movement during communication has cultural
foundations. In Western cultures, direct eye contact is
regarded as important and generally shows that the other Time Orientation
is attentive and listening. It conveys self-confidence, Time orientation refers to an individual’s focus on the past,
openness, interest, and honesty. Lack of eye contact may the present, or the future. Most cultures combine all
be interpreted as secretiveness, shyness, guilt, or lack of three time orientations, but one orientation is more
interest. Other cultures may view eye contact as impolite likely to dominate. The North American focus on time
or an invasion of privacy. Body posture and gesture are tends to be directed to the future, emphasizing time and
also culturally learned. Finger pointing, the “V” sign schedules (Galanti, 2004). Nursing students know what
with the index and middle fingers, and the thumbs-up times they must be in class or clinical. They know what
sign have different meanings. For example, the “V” sign courses they will take in future semesters. Other cultures
means victory in some cultures, but it is an offensive ges- may have a different concept of time. Members of
ture in other cultures (Galanti, 2004). First Nations communities may be perceived as being
Communication is an essential part of establishing present oriented and not being concerned about the
a relationship with clients and their families. It is also future. Other values, such as family and community, may
important for developing effective working relationships override or come into conflict with European views or
with health care colleagues. To enhance their practice, orientations with regard to time. For example, going to
nurses can observe the communication patterns of cli- class or to a medical appointment may take a backseat
ents and colleagues and be aware of their own commu- if a family member becomes ill, as the first obligation is
nication behaviours. always to family and community. Often, no explanation
is given, perhaps because none is expected within the
Indigenous culture.
The culture of nursing and health care values time.
Space Orientation Appointments are scheduled, and treatments are pre-
Space is a relative concept that includes the individ- scribed with time parameters (e.g., changing a dressing
ual, the body, the surrounding environment, and objects once a day). Medication orders include how often the
within that environment. The relationship between the medicine is to be taken and when (e.g., digoxin 0.25 mg,
individual’s own body and objects and persons within a once a day, in the morning). Nurses need to be aware of
space is learned and is influenced by culture. For instance, the meaning of time for clients. Giger and Davidhizar
in Western societies, people tend to be territorial, as (2004) stated that when caring for clients who are “pres-
reflected in such phrases as “This is my space” or “Get ent oriented,” it is important to avoid fixed schedules.
out of my space.” In Western cultures, spatial distances The nurse can offer a time range for activities and treat-
are defined as the intimate zone, the personal zone, and ments. For example, instead of telling the client to take
the social and public zones. The size of these areas may digoxin every day at 10 a.m., the nurse might tell the
vary with the specific culture. Nurses move through all client to take it every day in the morning, or every day
three zones as they provide care for clients. The client after getting out of bed.
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Nutritional Patterns context of their own culture. If the client does not com-
plain of pain, it should not be assumed that the client is
Most cultures have staple foods, that is, foods that are not experiencing pain. The nurse must be aware of what
plentiful or readily accessible in the environment. For conditions are likely to cause pain and offer clients pain
example, the staple food of most Asians is rice; of Italians, relief, as appropriate.
pasta; and of Eastern Europeans and North Americans, Treatment for pain may also vary with culture. In
wheat. Even clients who have been in Canada for several European Canadian cultures, medication is typically used
generations often continue to eat the foods of their cul- for pain relief. In other cultures, heat, cold, relaxation, or
tural homelands. other techniques and treatments may be used.
Food-related cultural behaviours can also include
decisions such as whether to breast-feed or bottle-feed
infants and when to introduce solid foods to them. Food
can also be considered part of the remedy for illness. Death and Dying Practices
Foods classified as “hot” foods may be used to treat ill- Death is a universal experience, and all people want to
nesses that are classified as cold illnesses, as noted earlier. die with dignity. Various cultural and religious tradi-
For example, corn meal (a hot food) may be used to treat tions and practices associated with death, dying, and
arthritis (a cold illness). Each cultural group defines what the grieving process help people cope with these expe-
it considers to be hot and cold entities, if those concepts riences. Nurses are often present through the client’s
are part of their culture. dying process and at the moment of death, especially
Religious practice associated with specific cultures also when it occurs in a health care facility. Knowledge of
affects diet. Some Roman Catholics avoid meat on certain the client’s religious and cultural heritage helps nurses
days, such as Ash Wednesday and Good Friday, and cer- provide individualized care to the client and the family,
tain Protestant denominations prohibit meat, tea, coffee, even though the nurses themselves may not participate in
or alcohol. Both Orthodox Judaism and Islam prohibit the family’s rituals associated with death. It is important
the ingestion of pork or pork products. Orthodox Jews for the nurse to ask the family if any special customs
observe kosher customs, eating certain foods only if they or practices are required prior to, during, and after the
are inspected by a rabbi and prepared according to Jewish death of the client.
dietary laws. For example, eating milk products and meat Dying in solitude is unacceptable in most cultures.
products at the same meal is prohibited. Some Buddhists, In many cultures, people prefer a peaceful death at
Hindus, and Sikhs are strict vegetarians. The nurse must home rather than in the hospital. Some ethnic groups
be sensitive to such religious dietary practices, and ask may request that health care professionals not reveal the
clients how they enact these practices in their daily lives. prognosis to dying clients. They believe the person’s last
days should be free of worry and pain. People in other
cultures prefer that a family member (preferably a male
in some cultures) be told the diagnosis so that the client
Pain Responses can be tactfully informed by a family member accord-
It has been demonstrated that beliefs about and responses ing to client and family preferences. Nurses also need to
to pain vary among ethnic and racial groups. Cultural determine whom to call and when as the client’s death
response to pain must be viewed in relation to both the draws near.
actual perception of pain and the meaning or signifi- Beliefs and attitudes about death, its cause, and
cance of pain to the client and family. In some cultures, the soul also vary among cultures. Unnatural deaths, or
pain is considered a punishment for bad deeds; the “bad deaths,” are sometimes distinguished from “good
individual is, therefore, expected to tolerate pain with- deaths.” In some cultures, the death of a person who
out complaint to atone for sins. In other cultures, self- has behaved well in life is considered less threatening
infliction of pain is a sign of mourning or grief. In other because that person will be reincarnated into a good life.
groups, pain is anticipated as a part of the ritualistic Beliefs about preparation of the body, autopsy,
practices of passage ceremonies and, therefore, tolerance organ donation, cremation, and prolonging life can
of pain signifies strength and endurance. In some cul- be closely allied to the person’s religion. Autopsy, for
tures, boys especially are taught “to take pain like a man” example, may be prohibited, opposed, or discouraged
and that “big boys don’t cry,” while in other cultures, the by followers of Eastern Orthodox religions, Muslims,
expression of pain elicits attention and sympathy. Jehovah’s Witnesses, and Orthodox Jews. Some religions
Galanti (2004) noted that nurses and clients may prohibit the removal of body parts and dictate that all
assess pain differently. Nurses and physicians may under- body parts be given appropriate burial. Organ donation is
estimate or overestimate (and treat accordingly) their prohibited for Jehovah’s Witnesses and Muslims, whereas
client’s pain in relation to the client’s expression of pain Buddhists in North America consider it an act of mercy
and both the client’s and the nurse’s cultural contexts. and encourage it. Cremation is discouraged, opposed, or
Client responses to pain should be assessed within the prohibited by the Mormon, Eastern Orthodox, Islamic,
M11_KOZI2703_04_SE_C11.indd 193 08/02/17 5:31 PM

and Jewish faiths. Hindus, in contrast, prefer crema-

tion and cast the ashes into what they consider a holy ABC(DE) of Cultural Competence
river. Prolongation of life is generally encouraged; however,
some religions, such as Christian Science, are unlikely AFFECTIVE
to use medical means to prolong life, and the Jewish EQ
T
EN
faith generally opposes prolonging life after irreversible UI
M
TY
N
O
brain damage. Recent changes to Canadian law allow DYNAMICS OF
R
VI
EN
for medical assistance in dying; this decision between a DIFFERENCE
client and the physician is clearly influenced by cultural BE
VE
TI
HA
practices and beliefs around death. In the case of a ter-
NI
VI
G
OU
CO
RA
minal illness, Buddhists may permit euthanasia. L
Nurses also need to be knowledgeable about the cli-

ent’s death-related rituals, such as last rites and adminis-
tration of Holy Communion, chanting at the bedside, and Figure 11.3 Srivastava’s (2008) ABC (and DE) Model
other rituals, such as special procedures for washing, dress- of Cultural Competence.
ing, positioning, and shrouding the dead. For example, Source: Srivastava, R. (2008). PowerPoint slide from the Canadian Federation of Mental
Health Nurses Conference Presentation. Toronto, ON: Author. Reprinted by permission
certain people may want to retain their native customs, in of Rani Srivastava.
which family members of the same sex wash and prepare
the body for burial and cremation. Muslims customarily
turn the body to face Mecca. Nurses need to ask fam-
behaviour is risky. Cultural safety takes into consid-
ily members about their preferences and verify who will
eration power relations and the uniqueness of human
carry out these activities. Burial clothes and other cultural
beings and avoids stereotyping.
or religious items are often important symbols for the
Cultural competence requires acknowledg-
funeral. For example, those of the Mormon faith are often
ing the fundamental ethnocentrism of contemporary
dressed in their temple clothes. The nurse must ensure
Western health care and the differences in the way
that any ritual items present in the health care agency are
patients and families respond to illness and treatment
given to the family or to the funeral home.
(Escallier, Fullerton, & Messina, 2011). Cultural compe-
tence is “the process in which the health care provider
continuously strives to achieve the ability to effectively
Providing Culturally
work within the cultural context of a client, individual,
family, or community (Campinha-Bacote, 1998, p. 6).
Safe Care Srivastava’s (2008) ABC (and DE) model of cultural

competence (see Figure 11.3) provides a comprehensive
context to guide safe nursing care for the diverse popula-
Leininger (1991) produced one of the first models of cul- tions in Canada. Srivastava’s (2008) ABCDE approach
tural care diversity and universality (see MyNursingLab to cultural competence is based on assumptions and
for the model). Since the development of Leininger’s concepts that provide a way of viewing a complex issue:
sunrise model, several other models have been devel-
oped. All of these models address similar elements of A 5 Affective domain
culture pertinent to nursing care. Some focused on B 5 Behavioural domain
broad concepts, such as an emphasis on understand- C 5 Cognitive domain
ing of personal biases, prejudices, values, and beliefs, D 5 Dynamics of difference
combined with an understanding of power, trust, and E 5 Equity and Environment
equity (Srivastava, 2007); others emphasized learning
the practices and beliefs that are attributed to particular The first three domains have been described exten-
cultures (Purnell & Paulanka, 2005). Some others intro- sively in the literature. The affective domain of cul-
duced notions of time, space (Giger & Davidhizar, 2004; tural competence is demonstrated by cultural awareness
Spector, 2004), and communication (Andrews & Boyle, and sensitivity and is viewed as a vital first step in the
2003). Although these models have elements in common, cultural competence journey. Cultural awareness is
each model emphasizes slightly different attributes that the self-examination and in-depth exploration of one’s
can guide the nurse to assess patient, family, or commu- own cultural and professional backgrounds. This pro-
nity culture. However, health care providers should use cess involves the recognition of one’s biases, prejudices,
these models in conjunction with a cultural safety lens to and assumptions about individuals who are different
avoid a checklist approach. The assumption that check- (Campinha-Bacote, 2002). Without being aware of the
lists and learning about rituals and practices in general influence of one’s own culture or professional values,
will provide insight into the complexity of social human there is a risk that the health care provider may engage
M11_KOZI2703_04_SE_C11.indd 194 08/02/17 5:31 PM

in cultural imposition. Cultural imposition is the ten- Guidelines for Best Practices
dency of an individual to imposing their beliefs, values,
and patterns of behaviour on another culture (Leininger, Several national and provincial nursing groups have
1978). Cultural sensitivity is the respect and appre- developed position statements and best practices for
ciation for cultural behaviours based on an understand- delivery of appropriate cultural care. Examples are
ing of the other person’s experience and perspective. the Canadian Nurses Association (CNA, 2010) Position
This domain reflects an intentional respect for cultural Statement: Promoting Cultural Competence in Nursing; the
differences and having an accepting attitude. To develop RNAO (2007) Best Practice Guideline: Embracing Cultural
this awareness and sensitivity requires openness, criti- Diversity in Health Care: Developing Cultural Competence; and
cal self-reflection, and experience (Srivastava, 2008). In the Aboriginal Nurses Association of Canada (2009)
addition, the Registered Nurses’ Association of Ontario Cultural Competence and Cultural Safety in Nursing Education:
(RNAO, 2007) reminds health care providers that a A Framework for First Nation, Inuit and Métis Nursing. The
focused commitment to learning from and about oth- College of Nurses of Ontario’s (2008) Practice Guideline for
ers and critical self-reflection will develop one’s cultural Culturally Sensitive Care emphasizes the following elements
sensitivity. for providing culturally sensitive care:
The behavioural domain of cultural competence 1. Being culturally knowledgeable. It is impossible to possess
is typically described as the cultural skill that enables in-depth knowledge about all cultures; however, it is pos-
health care providers to learn about clients’ cultural val- sible to have a general understanding of how cultures
ues, beliefs, and practices to determine the most appro- can affect health practices and beliefs.
priate goals and interventions (Srivastava, 2008).
2. Being client centred. Client-centred care requires that
The cognitive domain addresses the need for
nurses recognize the client’s culture, the nurse’s own cul-
knowledge-based care. The nature of knowledge required
ture, and how both affect the nurse–client relationship.
for cultural competence is not clear (Srivastava, 2008).
Each client is unique and requires individual assessment
Srivastava suggests that health care providers assess the
and planning.
extent to which the issues involved can be categorized as
(a) unique to the individual, (b) reflective of the broader 3. Being self reflective. Self-reflection is a fundamental ele-
culture, and (c) reflective of cultural processes in general. ment of providing culturally sensitive, competent, and
Ideally, health care providers would learn the rituals, cus- safe care. Nurses may fall into the trap of thinking they
toms, and practices of the major cultural groups within know a culture or what is best for the client, or nurses
the geographical location where they practice. might impose their beliefs and values on the client.
Understanding the dynamics of difference Understanding the self as distinct from others in the
is a key attribute of cultural competence. Given the broadest sense is critical in the provision of culturally
“significant influence that minority group or marginal- safe care.
ized status can have on healthcare quality and outcomes, 4. Recognizing potential conflict between the culture of the nurs-
there is merit in highlighting this attribute as a separate ing profession’s values and beliefs and client cultural values
domain” (Srivastava, 2008, p. 31). Cultural competence and beliefs. The nursing profession itself has a culture
in this domain requires health care providers to acknowl- that can come into conflict with the cultural values
edge and understand the impact of systemic oppression, and beliefs of clients. When beliefs and values come
discrimination, and racism. In addition, these dynamics into conflict, it is the nurse’s role to reflect on her or
of difference occur at multiple levels: (a) client–clinician, his professional beliefs and values and to offer the
(b) client–system, (c) clinician–colleagues, and (d) clini- treatment or therapy in a way that meets the client’s
cian–system. Dynamics of difference recognize the impact goal of care.
of both marginalization and privilege (Srivastava, 2008).
5. Facilitating client choice. This is part of the nurse’s role in
“E” represents equity and environment. Equity
providing quality care. The client’s choice is the best
focuses on “equality of outcomes and means that people
approach. If this choice places the client or others at
with unequal need require different or differential treat-
risk, the nurse is responsible to mediate between client’s
ment to achieve identical results” (Srivastava, 2008,
wishes and protection of others.
p. 32). By keeping the concept of equity as a desired
goal for cultural competence, health care providers are 6. Incorporating client’s cultural preferences. Adding cultural
reminded to “identify and address the unique needs and preferences into the client’s nursing care plan can
barriers for each patient” (Srivastava, 2008, p. 32). The facilitate the client’s physical, emotional, and spiritual
environment—that is, the practice setting—also plays health.
an important role in supporting health care providers 7. Accommodating client cultural beliefs and practices. This
to effectively deliver culturally competent care to their approach should be based on a cultural assessment as
clients. For example, interpreter services may need to be part of the overall assessment and individualization of
accessed for care in the home. the client’s care based on these preferences.
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Barriers to Cultural Sensitivity and Safety power resulting from policies and practices of organi-
zations and institutions. Deliberate discrimination in
Many factors can be barriers to providing culturally sen- Canadian history has created inequalities between racial
sitive or culturally safe care to clients and their support groups, specifically, within the Indigenous peoples of
people. These issues can also affect communication and Canada (Office of the Treaty Commissioner, 2008).
working relationships with other health care personnel. Racism is a form of discrimination related to ethnocen-
Ethnocentrism, stereotyping, prejudice, and discrimina- trism, in which a person believes that race is the primary
tion are some of these elements. determinant of human traits and capacities and that
Ethnocentrism refers to the view that the beliefs racial differences result in an inherent superiority of a
and values of one person’s own culture are superior to particular race.
those of other cultures. In health care, ethnocentrism
can include the view that the only valid health care
beliefs and practices are those held by the professionals Implementing Best Practices
in the health care system. Nurses who take a transcul-
tural view, however, value their own beliefs and practices
for Safe Cultural Caring
while respecting the beliefs and practices of others. It It is important for nurses to be culturally sensitive and
is important for nurses to realize that although many to convey this sensitivity to clients, support people, and
people of diverse racial and religious backgrounds have other health care personnel (HCP). It is essential for
combined their traditional health practices with Western all HCP to recognize the power of their words. Words
health practices, other people may be unable or unwill- create perceptions, influence thoughts, and affect the
ing to do so. quality of all interpersonal relationships (Beebe, Beebe,
Most people are gradually exposed to their culture’s Redmond, Geerinck, & Salem-Wiseman, 2015). Some
beliefs, values, and practices over a period of years, ways to do so include the following:
starting at birth. Ethnocentrism is thought to result
• Always address clients by their last names (e.g., Mrs.
from lack of exposure or knowledge of other cultures.
Aylia, Dr. Rush) until they give you permission to use
Ethnorelativity is the ability to appreciate and respect
other names. In some cultures, the more formal style
the viewpoints of other cultures.
of address is a sign of respect, whereas the use of first
Stereotyping occurs when the assumption is
names may be considered disrespectful. It is important
made that all members of a culture or ethnic group are
to ask clients how they want to be addressed.
alike. For example, a nurse may assume that all Italians
express pain volubly or that all Chinese people like rice. • When meeting a person for the first time, introduce your-
Stereotyping may be based on generalizations unrelated self by your full name and explain your role in the person’s
to reality. For example, research indicates that Italians health care. This approach helps establish a relationship
are likely to express pain verbally; however, a particular and provides an opportunity for clients and nurses to
Italian client may not verbalize pain. Stereotyping that learn the pronunciation of one another’s names.
is unrelated to reality can be either positive or negative • Be genuine with people, and be open and honest about
and is frequently an outcome of racism or discrimina- your lack of knowledge about their culture.
tion. Nurses need to realize that not all people of a • Use language that is culturally sensitive; for example,
specific group have the same health beliefs, practices, use terms such as gay, lesbian, bisexual, transgendered, or two-
and values. It is, therefore, essential to identify a specific spirited rather than homosexual; do not use man or mankind
client’s beliefs, needs, and values, rather than assuming when referring to a woman; African Canadian is preferred
they are the same as those attributable to the larger cul- by some over black, and Latin American is preferred over
tural group. Hispanic. Asian is more acceptable than Oriental (Eliason,
Prejudice is a strongly held opinion about some 1993). In Canada, use the term Aboriginal or Indigenous to
topic or group of people. A prejudice may be positive or refer to First Nations, Inuit, and Métis, or ask the person
negative. A positive prejudice often stems from a strong what term they prefer.
sense of ethnocentrism (Eliason, 1993). Prejudice may
• Find out what clients know about their health problems,
also derive from ignorance or misinformation. Types
illnesses, and treatments. Assess whether this informa-
of negative prejudice include ageism, which is negative
tion is congruent with the predominant health care
attitudes toward older adults; sexism, which is negative
culture. If the beliefs and practices are incongruent,
attitudes toward women; and homophobia, which is
establish whether this will have a negative effect on cli-
negativism toward lesbian women and gay men.
ent health.
Discrimination refers to the differential and
negative treatment of individuals on the basis of their • Do not make any assumptions about any client.
race, ethnicity, gender, or other group membership. • Respect the client’s values, beliefs, and practices, even if
Institutional discrimination refers to the uneven they differ from your own or from those of the predomi-
access by group membership to resources, status, and nant culture. It is important to respect the client’s rights
M11_KOZI2703_04_SE_C11.indd 196 02/03/17 11:41 AM

to hold these beliefs and for the client to feel safe in the Box 11.3 Guide for Health Care
nurse–client relationship. Professionals Working with Indigenous
• Show respect for the client’s support people. In some Peoples
cultures, men in the family make decisions affecting the
According to the Society of Obstetricians and
client, whereas in some other cultures, women make the
Gynaecologists of Canada (2000) and the Indigenous
decisions. Physicians Association of Canada (2011), health care
• Make a concerted effort to earn the client’s trust, but do professionals should
not be surprised if it develops slowly or not at all.
• Have a basic understanding of the appropriate names
According to National Aboriginal Health with which to refer to the various groups of Indigenous
Organization (NAHO, 2008), cultural safety refers to what peoples in Canada
is felt or experienced by a client when a health care • Have a basic understanding of the current sociodemo-
provider communicates with the client in a respectful, graphics of Indigenous peoples in Canada
inclusive way, empowers the client in decision-making, • Familiarize themselves with the traditional geographical
and builds a health care relationship wherein the client territories and language groups of Indigenous peoples
and the provider work together as a team to ensure • Understand the connection between historical and
maximum effectiveness of care. Remember, “it is impos- current government practices toward First Nations/Inuit/
sible to become an authority on your own culture(s), let Métis peoples (including, but not limited to, colonization,
alone someone else’s, and it is counter to the concept of residential schools, treaties, and land claims) and the
cultural safety, where differences within cultures, not just resultant intergenerational health outcomes
between them, is acknowledged and respected. What • Recognize that the current sociodemographic challenges
cultural safety asks us to do when we face a nursing situ- facing many Indigenous individuals and communities
ation outside of our sphere of cultural experience is to have a significant impact on health status
‘ask’” (Hughes & Farrow, 2006, p. 13). • Recognize the need to provide health care services for
Indigenous peoples as close to home as possible
• Have a basic understanding of governmental obligations
Cultural Assessment and policies regarding the health of Indigenous peoples
in Canada
Students in Canadian nursing programs are expected to • Recognize the need to support Indigenous individuals
learn about cultural diversity, and all nurses are expected and communities in the process of self-determination
to provide safe care, regardless of the culture of the
Source: Adapted from Smylie, J. (2000). Policy statement: A guide for health profes-
client. The CNA (2010) believes that cultural compe- sionals working with Aboriginal peoples. Journal of Obstetrics and Gynaecology
tence is the application of knowledge, skills, attitudes, Canada, 22(12), 1056–1061.
or personal attributes required by nurses to maximize

respectful relationships with diverse populations. The
underlying values for cultural competence are inclusiv-
ity, respect, valuing differences, equity, and commitment assessment is important; how and when questions are
(CNA, 2010). asked require sensitivity and clinical judgment. Trust
All phases of the nursing process are affected by the must be established before clients can be expected to
client’s and the nurse’s cultural values, beliefs, and behav- volunteer and share sensitive information. The nurse,
iours. As the client’s culture and the nurse’s culture come therefore, needs to spend time with clients, introduce
together in the nurse–client relationship, a unique cul- some social conversation, and convey a genuine desire to
tural environment is created that can improve or impair understand their values and beliefs.
the client’s outcome. Self-awareness of personal biases Before a cultural assessment begins, the nurse should
can enable nurses to develop modifying behaviours or determine the client’s language and the client’s degree of
(if they are unable to do so) to remove themselves from fluency in English. The nurse can also learn about the
situations where care may be compromised. Nurses can client’s communication patterns and space orientation
become more aware of their own culture through values by observing both verbal and nonverbal communication.
clarification (see Chapter 5). As an example, Box 11.3 For example, does the client do the speaking or defer
provides recommendations for working with Indigenous to another? What nonverbal communication behaviours
clients. does the client exhibit (e.g., touching, eye contact)? What
A thorough cultural assessment provides a nurse significance do these behaviours have for the nurse–client
with the necessary information and understanding of interaction? What is the client’s proximity to other people
how a client’s cultural beliefs and practices will impact and objects within the environment? How does the client
the nursing process and ultimately the client’s health react to the nurse’s movement toward him or her? What
outcome. A cultural assessment takes time and usually cultural objects within the environment have importance
needs to extend over several sessions. The process of for health promotion or health maintenance?
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Box 11.4 Examples of Open-Ended Questions for a Cultural Assessment
Cultural Affiliation healthy (e.g., wearing amulets, religious or spiritual practices)?

How do you know when you are healthy?
I am interested in learning about your cultural heritage. Can
you tell me about your cultural group, where you were born, Illness Beliefs and Care Practices
and (if appropriate) how long you have lived in this country?
What kinds of things do you do to treat illness? Do
Beliefs about Current Illness you use traditional healers (shaman, curandero, priest,
spiritualist, minister, or monk)? In your culture, who
Tell me about your problem. What name do you give it? What
determines when a person is sick? How would you
do you think has caused it? Why did it start when it did? What
describe your past experiences with cultural healers and
does your sickness do to your body? How severe is the sick-
Western health care professionals? What special remedies
ness? What do you fear most about your sickness? What are
are generally used for the illness you have? What remedies
the chief problems your sickness has caused for you person-
are you currently using (e.g., herbal remedies, potions,
ally, for your family, and at work?
massage, wearing of talismans, copper bracelets, or
Communication charms)? What remedies have you used in the past, and
which did you find helpful? What remedies or treatments
What languages do you speak at home? What languages are are you considering now, and how can we help? Is the
you most comfortable speaking? In what language(s) can you care we are giving you what you think it should be? How
read and write? How would you like us to address you — by would you like us to care for you?
your first name? by your last name? Would you like an inter-
preter? (if appropriate) Family Life and Support System
Health Care Practices I would like to learn about your family. Who are the members
of your family? What family duties do women and men usually
What kinds of things do you do to maintain health? For exam- perform in your culture? Whom do you consult when making
ple, what types of food do you eat to maintain health? What health care decisions (e.g., another family member, cultural or
foods do you eat during illness, and how is food prepared? religious leader)? Who will be able to help you during and after
What other activities do you or your family do to keep people treatment? Do you need help to contact these people?
Sources: Based on Andrews, M. M., & Boyle, J. S. (2003). Transcultural concepts in nursing care (4th ed.). Philadelphia, PA; Lippincott; Kleinman, A., Eisenberg, L., & Good, B. (1978).
Culture, illness and care. Annals of Internal Medicine, 88, 251–258; Rosenbaum, J. N. (1991). A cultural assessment guide: Learning cultural sensitivity. Canadian Nurse, 88, 32–33;
and Waxler-Morrison, N., Anderson, J., & Richardson, E. (Eds.). (1990). Cross cultural caring: A handbook for health professionals in Western Canada. Vancouver, BC: University of
British Columbia (UBC) Press.
To obtain cultural assessment data, the nurse uses condition to identify changes in health state and to rec-
broad statements and open-ended questions that encour- ognize impending crises before they become irreversible
age clients to express themselves fully (see Box 11.4 for may be all that is realistically achievable. At a time of
examples). The important principle to remember when crisis, the nurse may then have the opportunity to rene-
conducting an assessment is that “the client is the teacher gotiate the original care approach.
and expert regarding his or her culture, and the nurse is Safe cultural caring is challenging. It requires
the learner” (Rosenbaum, 1995, p. 188). At this stage, discovery of the meaning of the client’s behaviour,
the nurse draws no conclusions but obtains information flexibility, creativity, and knowledge to adapt nursing
from the client. interventions. For example, a culturally sensitive nurse
Many cultural assessment tools are available. The knows that a Chinese woman who has just given birth
nurse needs to use a tool appropriate to the situation and refuses to eat fruits and vegetables, refuses to drink
and adapt it, as required. For example, a nurse in an the cold water at her bedside, stays in bed, and refuses
emergency department of an urban hospital may need a to take sitz baths, baths, or showers needs to increase
different format from that required by a nurse working her yang forces. The nurse will discuss this assess-
in a home care setting. Nurses need to ensure they collect ment with the client, make plans to adapt nursing
enough basic cultural data to identify patterns of behav- interventions accordingly, recognizing that it is the cli-
iour that may either facilitate or interfere with a nursing ent’s (or family’s) right to make his or her own health
strategy or treatment plan. care choices. Nurses also need to identify community
When a client chooses to follow only cultural prac- resources that are available to assist clients of diverse
tices and refuses all prescribed medical or nursing inter- cultures. Cultural competence is an ongoing process,
ventions, nursing goals for the client need to be adjusted. is multifaceted, and requires a personal and organiza-
Anderson, Waxler-Morrison, Richardson, Herbert, and tional commitment to enhance the health outcomes for
Murphy (1990) pointed out that monitoring the client’s all Canadians (Srivastava, 2008).
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Case Study 11
Rose Maniwaki is a 65-year-old Indigenous person with a history to the clinic. Rose’s granddaughter is extremely overweight—and,
of diabetes. She was diagnosed with gestational diabetes during given her family history, at high risk for diabetes.
her first pregnancy in her early twenties. She has had six pregnan- Through her involvement at the community health centre and
cies and, during each, her diabetes was significantly aggravated. interactions with the traditional healers, Rose has begun to become
She is now clinically obese (175 cm tall and weighs 110 kg), has more active in the community and has joined a women’s drum-
type II diabetes, and is fully insulin dependent. Her diabetes is ming group. She has found the regular gatherings of her drumming
extremely difficult to control. She has had her right foot amputated group, comprising women of varying ages, to be very helpful in
below the knee and has had a prosthesis since age 60 years. She her struggle with alcoholism and depression. Her drumming group
has osteoarthritis, osteoporosis, and high blood pressure. performed the opening welcome at an evening heart health talk
Rose is a widow. Her husband died in his forties as a result held in her community for First Nations women, and during that
of uncontrolled diabetes and alcoholism. She lives in a small, event, Rose discovered that diabetes is a major risk factor.
poorly insulated, mouldy, overcrowded, two-bedroom house in a As a result of her experiences at the community health centre
First Nations community in northern Ontario. After her husband’s and in her drumming group, Rose has become
death, she raised her children by herself on social assistance and involved in self-governance and has joined
is now raising five grandchildren so that her daughter can attend a group in the local band office, particularly
nursing school in a community 400 km away. Two of Rose’s focusing on health issues, such as diabetes,
other children are dead—one from suicide, the other from a car alcoholism, and depression.
accident caused by drunk driving. Her other surviving children
have left northern Ontario, and she has had little or no contact
with them. Rose is also struggling with alcoholism. CRITICAL THINKING QUESTIONS
Rose experiences depression and takes Prozac to help with
her health problems and sense of loss. The medication does not 1. Using the nursing process, develop a plan of care for
help very much. Rose is also taking sleeping pills. Rose attended Rose and her family (assessment, nursing diagnosis,
residential school from age 6 to 13 years and, therefore, is not as planning, intervention, and evaluation; see Chapter 23).
connected to her family and community as she might have been a. How would you integrate holistic health beliefs into
otherwise. She has had trouble relating to her culture and its your nursing care plan for Rose and her family?
values. However, there is a new community health centre with a
traditional circular healing room, where traditional healers as well
b. How would you integrate your knowledge of coloniza-
tion and residential schools into the care for Rose and
as a nurse practitioner, nurses, community health representa-
her family?
tives, a nutritionist, and a social worker are available. Rose has
been coming to the health centre on a more or less regular basis c. How would you integrate Rose’s newly discovered
and has found herself drawn to the traditional healers. appreciation of traditional healing into her care plan?
Rose has come to the health centre because she is experienc- d. As a health care provider, what questions would you
ing breakdown of her stump, which is cracked and painful and ask Rose about her family, her community, and her
is draining pus. The nurse practitioner advises her that she may diabetes?
need to travel south to the hospital if the infection persists. Rose e. How would you integrate your knowledge of the
has no other family members in the community and worries about determinants of health into her care plan?
who would care for her grandchildren if she has to fly out for hos-
pital care. Rose has brought one of her granddaughters with her Visit MyNursingLab for answers and explanations.
KEY TERM S
affective domain p. 194 cultural competence environment p. 195 prejudice p. 196
assimilation p. 185 p. 194 equity p. 195 race p. 187
behavioural domain cultural identity p. 187 ethnic p. 187 racism p. 196
p. 195 cultural safety p. 194 ethnicity p. 187 scientific or
bicultural p. 187 cultural sensitivity ethnocentrism p. 196 biomedical health
cognitive domain p. 195 ethnorelativity p. 196 belief p. 188
p. 195 culture p. 187 holistic health belief stereotyping p. 196
colonization p. 185 culture-specifics p. 189 p. 188 subculture p. 187
cultural assessments discrimination p. 196 institutional traditional medicine
p. 188 diversity p. 187 discrimination p. 196 p. 189
cultural awareness dynamics of Multiculturalism Act
p. 194 difference p. 195 p. 185
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• Canadians come from a variety of ethnic and • Health beliefs and practices, family patterns, communica-
cultural backgrounds, and many Canadians retain tion style, space and time orientation, nutritional patterns,
at least some of their traditional values, beliefs, and pain response, and death and dying practices influence
practices. the relationship between the nurse and the client, who
• Many groups in Canada are bicultural; that is, they have individual cultural backgrounds.
embrace two cultures: their original ethnic culture and • When assessing a client, the nurse considers the client’s
the Canadian culture. cultural values, beliefs, and practices related to health and
• An individual’s ethnic and cultural background can health care. All clients require an individualized cultural
influence beliefs, values, and practices. assessment.
• Personal characteristics also modify an individual’s • Self-reflection and awareness is a critical component of
cultural values, beliefs, and practices. providing culturally safe health care.
N CLE X- ST YLE PRACTICE QUI Z

1. What factor has caused Canada’s population to more a. Immediately pack up the equipment and tell her that
than double in the past 50 years? the nurse will be back later
a. Immigration b. Explain that nurses are very busy and that this is the
b. Longer life expectancy only time that her morning care can be done
c. Higher birthrates c. Discuss with the client when she would like to do her
morning care and plan to do it then
d. Immunization
d. Tell the client that if she does not do it now, she will
2. A nurse is starting a new job in a community health set- have to wait until tomorrow
ting where many of the clients have a different culture
from the nurse’s own. According to Srivastava’s ABCDE 6. A nurse is assigned to care for an Aboriginal man.
model of cultural competence (Srivastava, 2008), which In keeping with his traditions, he would like to do
action by the nurse would best satisfy the affective a “smudge,” that is, ignite a very small quantity of
domain of the model? tobacco that he keeps in a pouch with him at all times.
What should the nurse do?
a. Set goals for nursing interventions
a. Consult spiritual care and request for an Elder to
b. Discuss the impact of discrimination with the clients
visit him
c. Ensure an interpreter is available for all client interactions
b. Inform him that lighting fires in the hospital is
d. Self-reflect on own values and beliefs about culture against the law
c. Insist that he give the nurse his tobacco, since
3. What is the focus of cultural safety? smoking is bad for him
a. Transcultural nursing theories d. Ask him what a “smudge” is and why he wants to do it
b. Cultural awareness
c. Cultural competence 7. What is the most important aspect of providing
d. Self-reflection and power culturally competent nursing care?
a. The client feels safe in the nurse–client relationship.
4. Which of the following is an example of stereotyping? b. The nurse feels that everything has been done to
a. Holding a strong opinion against an individual or make the client like him or her.
group of individuals c. The nurse has learned something about a new culture.
b. Giving preferential treatment based on gender, social d. The clients’ preferences are as important as the nurse’s.
class, or ethnicity
c. Assuming that all members of a group are alike 8. A nurse, who speaks and understands only English,
d. Seeing one’s own group as being superior to another is assigned to care for a client who does not speak or
understand English. The client is accompanied by his
5. A nurse is about to begin assisting a young woman from young grandson, who appears to be about 8 years of
a Middle Eastern country with her morning care, when age. What would be the best course of action for the
the client suddenly appears to be very uncomfortable nurse to take?
and asks if the care can be done later. What should the a. Find an older member of the family to act as an
nurse do to provide culturally sensitive care? interpreter
M11_KOZI2703_04_SE_C11.indd 200 08/02/17 5:31 PM

b. Request a professional health care interpreter c. Explain to the client that time is very important in
c. No additional help is necessary—the grandson will Western or Canadian culture
be a sufficient interpreter d. Offer to get her a watch so she can keep track of
d. Use nonverbal methods of communication, such as the time
drawing pictures or gesturing
10. A nurse is assigned two clients who have had abdomi-
9. A nurse is working in a community agency, and one of nal surgery. One client is constantly complaining about
the clients is consistently late for appointments. This is pain and the other client does not tell the nurse he is
very distressing to the nurse, who is very busy and can- experiencing pain; however, his facial expressions and
not always accommodate the client when she does even- body language suggest that he is in pain. What should
tually turn up. The nurse is aware that not all cultures the nurse do?
have the same time orientation as Western cultures, that a. Assess the client’s pain within the context of the
is, to be on time and to keep their scheduled appoint- client’s culture
ments. However, the nurse is not sure whether this is the b. Treat each client equally and according to Western
only reason for the lateness. What should the nurse do? beliefs and values
a. Tell the client that he or she is very busy and that the c. Insist that the client who is more vocal about his
client should let the nurse know in advance if she is pain express his discomfort in more acceptable
going to be late for the appointment ways
b. Ask the client why she is late for appointments and d. Ask their physicians to increase their doses of
ask if the nurse can assist her to keep the scheduled analgesic
appointments
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Chapter 12
Individual Care
Updated by
Professor and Associate Dean, College of Nursing, University of Nebraska Medical Centre
N
LEARNING OUTCOMES
After studying this chapter, you will be able to urses assess and plan
1. Explain the relationship of individuality, self-concept, and holism to health care for individu-
nursing practice. als. Care of the individual
2. Compare and contrast the elements of individuality and self- is enhanced when the nurse under-
concept. stands the concepts of individual-
3. Describe the essential aspects of assessing role relationships. ity, self-concept, and holism. While
assessing the individual, the nurse
4. Identify six common factors that can make an individual more
vulnerable to some health problems and describe a nursing also needs to assess the influences of
implication for each. others through relationships. For exam-
5. Describe the possible effects of illness on an individual and his or ple, the beliefs and values of clients
her relationships with others. and the support they receive come,
6. Identify Maslow’s five categories in the hierarchy of human needs. in large part, from the family and are
reinforced by the community. Thus, an
7. Discuss how a nurse might use the three selected types of
theories to begin to assess an individual’s health needs. understanding of family dynamics and
the context of the community assists
the nurse in planning care. For addi-
tional information on the family and
community, see Chapters 13 and 14.
To assist clients toward health, nurses
must understand them as individuals.
The nurse uses knowledge of individu-
ality, holism, and self-concept, along
with theories of development, human
needs and systems in the context of
the client’s situation, whoever the cli-
ent may be (individual, family, group,
community, or population).
Application of knowledge to the
individual is known as client-centred
care and is the centrepiece of the c
M12_KOZI2703_04_SE_C12.indd 203 17/03/17 11:08 AM

c profession and of this text. As outlined in Chapter 1, the individual recipient of care may be called
a patient, resident, or client. This terminology has been a topic of some controversy, with several
organizations using both patient and client in their published documents. For example, we might talk
about patient safety, or client-centred care. Wing (1997) surveyed individuals attending a back pain
clinic and contended that the majority of individuals seeking care preferred to be called patients. He
made the point that the health care professional should follow the person’s lead and use the ter-
minology preferred by the individual. In this text, we have chosen to refer to the individual seeking
care, especially within an acute care setting, as a patient, and the person living in a long-term care
setting as a resident. We have referred to individuals receiving care in community settings as clients.
Throughout this chapter, the term “client” is used to encompass patients, clients, and residents, and
the content discussed can be applied to all. Sometimes, concepts that are developed for individuals
can be applied to communities, and vice versa, and so more than one term may be used to describe
the concept. It is also important to remember, as you read this chapter, that you are an individual and
are influenced by the same factors as are your clients. Nurses’ relationships with clients are affected
by their own individuality, and thus, it is very important for nurses to be self-aware to ensure that they
are focused on client issues, practices, and beliefs rather than their own.
Concept of Individuality and collectively. For example, Canadian society’s view of

homosexuality, both socially and legally, has changed
To help clients attain, maintain, or regain an optimal significantly within the past decades. Those changes may
level of health, nurses need to understand clients as affect how each (nurse and client) approaches the other.
individuals. Each individual is a unique being who is When providing care, nurses need to focus on the
different from every other human being, with a differ- client within both a total care and an individualized care
ent genetic makeup, life experiences, and environmental context. In the total care context, the nurse considers all
interactions. Even identical twins, with all their similari- the principles and areas that apply when taking care of
ties, are individual persons. any client of that age and condition. In the individual-
Aspects of individuality include the person’s total ized care context, the nurse becomes acquainted with the
character, self-identity, and perceptions. The person’s client as an individual, referring to the total care prin-
total character encompasses behaviours, emotional states, ciples and using the principles that apply to this specific
attitudes, values, motives, abilities, habits, and appear- person at this time. For example, a nurse who is advising
ances. The person’s self-identity encompasses perception the mother of a preschooler understands that the child’s
of self as a separate and distinct entity, alone and in desire to explore the world is a developmental stage that
interactions with others. Identity is often threatened by all preschoolers experience. However, the preschooler
actual or perceived alterations in wellness. Some changes diagnosed with attention deficit disorder with hyperac-
are minor and may be considered merely inconveniences; tivity may have an increased risk of accidents and inju-
others can compromise existence in profound ways. The ries when interacting with the environment because of
person’s perceptions encompass the way the person inter- impulsivity and poor self-control.
prets the environment or situation, directly affecting how Each individual has a concept of his or her own self.
the person thinks, feels, and acts in any given situation. This self-concept is one’s mental image of oneself. A
Nurses’ and clients’ perceptions determine their positive self-concept is essential to a person’s mental and
subjective realities at the time of their interaction. physical health. Individuals with a positive self-concept
Differences can exist in the two views of reality that will are better able to develop and maintain interpersonal
influence communication and acceptance of each other, relationships and resist psychological and physical illness.
and whether the client’s health care needs are being met. They have greater control of their environments and
Sometimes, the views of nurses and clients differ because are better able to accept or adapt to changes over their
of their own unique experiences. Nurses also need to lifespan. Individuals who have a poor self-concept may
take into consideration the views of reality of the society express feelings of worthlessness, self-dislike, or even
in which both the client and the nurse reside, individually self-hatred. They may feel sad or hopeless and may lack
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Chapter 12 Individual Care 205
energy to perform the simplest of tasks (Kraus, Chen, accepting constructive feedback. Self-awareness is,
& Keltner, 2011). Nurses have a responsibility to assess however, dependent on the congruence between how
clients who have a negative self-concept to identify the individuals view themselves, and how others view them
possible causes, and to help them develop a more positive and their behaviours. For instance, persons who perceive
view of themselves. themselves to have excellent communication skills may
be surprised to learn that others may not view their skills
so positively.
In the role of the caregiver, the self-aware nurse is
Self-Concept able to suspend judgment and focus on the needs of the
client, even if they differ from the needs or perceptions
Self-concept involves all the self-perceptions—appearance, of the nurse. When conflicts arise, the nurse can analyze
values, and beliefs—that influence behaviour and are his or her reactions through introspection and by ask-
referred to when using the words I or me. Self-concept ing questions such as the following:
influences the following: • Why do I react this way (fear, anger, anxiety, annoyance,
worry)?
• How one thinks, talks, and acts
• Can I change the way I respond to this situation to affect
• How one sees and treats another person
the client’s reaction in a helpful way?
• Choices one makes
• What feedback have I received, and how can I respond
• Ability to give and receive love to it?
• Ability to take action and to change things
Self-concept has four dimensions in development or
construction: Formation of Self-Concept
1. Self-knowledge: insight into one’s own abilities, nature, A person is not born with a self-concept; rather, it devel-
and limitations ops as a result of social interactions with others. See
Chapter 17, “Concepts of Growth and Development,”
2. Self-expectation: what one expects of oneself; may be
for a discussion on the development of self-concept,
realistic or unrealistic expectations
including Erikson’s stages of development, Piaget’s cog-
3. Social self: how a person is perceived by others and nitive developmental stages, and Havighurst’s develop-
society mental tasks. According to Erikson (1963), throughout
4. Social evaluation: the appraisal of oneself in relationship life, people face developmental tasks associated with
to others, events, or situations eight psychosocial stages. The development of a healthy
self-concept is dependent on the success of accomplish-
People who value “how I perceive me” above “how
ing these developmental tasks. Inability to complete
others perceive me” can be described as me-centred. They
developmental tasks may lead to a poor self-concept.
try to live up to their own expectations and compete only
Table 12.1 lists behaviours that indicate successful or
with themselves. In contrast, strongly other-centred people
unsuccessful accomplishment of developmental tasks.
have a need to live up to the expectations of others, com-
Self-concept development comprises three broad
paring, competing, and evaluating themselves in relation
steps:
to others. They tend to have difficulty asserting them-
selves and fear disapproval. The positive self-concept, 1. The infant learns that the physical self is separate and
therefore, is me-centred and is formed with limited refer- different from the environment.
ence to others’ opinions. The nurse’s awareness of her or 2. The child internalizes others’ attitudes toward self.
his own self-concept helps in the accurate assessment and
3. The child and the adult internalize the standards of
promotion of positive self-concept with clients. Nurses
society toward self.
who possess a positive self-concept are better able to
understand the needs, desires, feelings, and conflicts of The term global self refers to the collective beliefs
their clients and are more likely to help clients meet their and images a person holds about the self, which develops
needs (Eckroth-Bucher, 2010; Miskelly & Duncan, 2014). over time (Bosson & Swann, 2009; van Soest, Wichstrøm,
Self-awareness is the relationship between a per- & Kvalem 2015). It is also a person’s frame of refer-
son’s own perception of self in comparison with others’ ence for experiencing and viewing the world. Some of
perceptions of him or her. Self-awareness in a nurse is these beliefs and images represent statements of fact, for
crucial for the development of therapeutic nurse–client example, “I am a woman”; “I am a father”; “I am short.”
relationships. A nurse needs to look inward at personal Others refer to less tangible aspects of self, for instance,
beliefs, attitudes, motivations, strengths, and limitations “I am competent”; “I am shy.”
(Richards, Campenni, & Muse-Burke, 2010). A nurse Each separate image and belief has a bearing on
gains self-awareness through working with others and self-concept. The various images and beliefs people hold
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TABLE 12.1 Examples of Behaviours Associated with Erikson’s Stages of Psychosocial Development
Behaviours Indicating Behaviours Indicating

Stage: Developmental Tasks Positive Resolution Negative Resolution
Infancy: trust versus mistrust Requesting assistance and expecting to Being unable to accept assistance
receive it Refusing to provide a person with personal
Expressing belief of another person information
Sharing time, opinions, and experiences Restricting conversation to superficialities
Toddlerhood: autonomy versus Accepting the rules of a group but also Failing to express needs
shame and doubt expressing disagreement when it is felt Not expressing one’s own opinion when
Expressing one’s own opinion opposed
Easily accepting deferment of a wish Overly concerned about being clean
fulfillment
Early childhood: initiative versus Starting projects eagerly Verbalizing fear about starting a new project
guilt Expressing curiosity about many things Apologizing and being very embarrassed over
Demonstrating original thought small mistakes
Imitating others, rather than developing
independent ideas
Early school years: industry Completing a task once it has been started Not completing tasks started
versus inferiority Working well with others Not assisting with the work of others
Using time effectively Not organizing work
Adolescence: identity versus Asserting independence Failing to assume responsibility for directing
role confusion Planning realistically for future roles one’s own behaviour
Establishing close interpersonal relationships Failing to set goals in life
Accepting the values of others without question
Early adulthood: intimacy Establishing a close, intimate relationship Remaining alone
versus isolation with another person Avoiding close interpersonal relationships
Making a commitment to that relationship, Withdrawing from sexual relationships
even in times of stress and sacrifice
Accepting sexual behaviour as desirable
Middle-aged adults: generativity Being willing to share with another person Talking about oneself instead of listening to
versus stagnation Guiding others others
Establishing a priority of needs, recognizing Showing concern for oneself in spite of the
both self and others needs of others
Being unable to accept interdependence
Older adults: integrity versus Using past experience to assist others Demanding unnecessary assistance and
despair Maintaining productivity in some areas attention from others
Accepting limitations Procrastinating and being apathetic
Not accepting changes
about themselves are not equal in weight and promi- Self-concept in these areas influences the choices
nence, but they constitute the core self-concept to the people make and perceptions they have about their
person’s identity, for example, “I am very smart”; “I am health. Persons with a strong positive self-concept about
female.” Images and beliefs that are less important to appearance are likely to value healthy behaviours and
the person are on the periphery, for example, “I am left- take action to maintain the health of their skin, hair, and
handed”; “I am not athletic.” muscle tone. Persons with negative self-concepts may
People are thought to base their self-concept on how be less proactive about health-promotion and illness-
they perceive and evaluate themselves in these areas: prevention activities.
• Vocational performance Maintaining and evaluating one’s self-concept is an
• Intellectual functioning ongoing process. Events or situations may change one’s
self-concept over time. For instance, new students entering
• Personal appearance and physical attractiveness a nursing program initially may have difficulties seeing
• Sexual attractiveness and performance themselves as competent health care professionals. Over
• Being liked by others time, and through education and practice experience, they
come to see themselves in this way. As one ages, engaging
• Ability to cope with and resolve problems
in social activity is key to maintaining one’s self-concept
• Independence and possibly enhancing one’s identity (Borrero & Kruger,
• Particular talents 2015; Lodi-Smith & Roberts, 2010). Having a self-concept
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includes how we see ourselves and how we are seen by

others. The ideal self is how we should be or would EVIDENCE-INFORMED
prefer to be. The ideal self is the individual’s perception PRACTICE
of how one should behave based on certain personal stan-
dards, aspirations, goals, and values. Adults usually hold Does a Child’s Death Impact Parental
some thoughts about their perceived self, how they see
themselves versus how they are seen by others. A discrep-
Self-Identity?
ancy between the ideal self and the perceived self can be Recognizing that the parental self-identity of a nurturing, pro-
an incentive to self-improvement. However, when the dis- tecting, responsible person could be negatively impacted fol-
crepancy is great, low self-esteem can result. lowing the death of a child, these authors interviewed parents
The increased use of the Internet, e-mail, instant mes- 6, 12, and 18 months following the death of their children as
saging, video gaming, and cell phones by today’s generation a result of cancer. Twenty-six parents from 18 families par-
ticipated in the first two interviews, and 18 parents at the
can negatively impact on the development of self-concept and final interviews. In the semi-structured interviews, parents
self-esteem. Digital technology and cyberspace interactions were asked about the illness, treatment, and death and
tend to create social isolation without actual face-to-face con- then about how these experiences had influenced them in
tacts and may exert a negative influence on the development terms of their relationships and daily life. Results indicated
of self-concept and self-esteem (Faulkner, Carson, & Stone, that parents tended to experience identity reintegration or
2014; Jackson, vonEye, Fitzgerald, Zhao, & Witt, 2010). identity disintegration at each time period. Characteristics
Nurses, like other adults, view themselves on the basis of reintegration included positive reframing, awareness of
personal growth and purpose, and focusing on surviving
of both internal and external inputs acquired during their children. Characteristics of disintegration included negative
educational and subsequent work experience. The ability perceptions of social support, difficulty coping with the per-
to appraise one’s own strengths, the desire to follow in manence of death, and inability to envision their own future.
the steps of role models, and the feedback received from There were some specific demographic characteristics of
colleagues and clients are some of the influences on the the two groups and how they responded to the death. What
nurse’s self-concept. made this study unique was that it documented parents’
responses over time. Some of the parents who had dem-
onstrated reintegration within the first year had responses
indicating disintegration at the 18-month mark.
Components of Self-Concept
NURSING IMPLICATIONS: These results suggest that
Self-concept has four components in expression: (a) per- bereavement issues continued and sometimes resur-
sonal identity, (b) body image, (c) role performance, and faced later than the 1-year mark after death. This
(d) self-esteem. research highlights the need for continued support
within the grieving process for longer than 1 year.
Source: Based on O’Conner, K., & Barrera, M. (2014). Changes in parental self-
Personal Identity identity following the death of a child to cancer. Death Studies, 38(6), 404–411. doi:
10.1080/07481187.2013.801376
Personal identity is the conscious sense of individuality
and uniqueness that is continually evolving throughout of personality. Furthermore, the individual sees himself
life. People often view their identity in terms of name, gen- or herself as a unique person. For example, as Canadian
der, age, race, ethnic origin or culture, occupation or roles, society is becoming more accepting and adolescents are
talents, and other situational characteristics (e.g., marital becoming more open and are disclosing their sexual ori-
status and education). One common identity is that of entation, their sense of self may be negatively impacted
parent. The Evidence-Informed Practice box outlines how when exposed to homophobic terms. To build a sense of
self-identity can change as circumstances change. school community where diversity is celebrated, schools
Personal identity also includes beliefs and values, need to establish and enforce anti-homophobia policies
personality, and character. For instance, is the person and reinforce respectful interpersonal relationships and
outgoing, friendly, reserved, generous, or selfish? Personal interactions (Taylor & Peter, 2011).
identity thus encompasses both the tangible and factual,
such as name and gender, and the intangible, such as
values and beliefs. Identity is what distinguishes the self
Body Image
from others. The face that individuals show to the world The image of physical self, or body image, is how a person
may change with the audience or the event (e.g., work perceives the size, appearance, and functioning of the body
versus home); however, their personal identity encom- and its parts. Body image has both cognitive and affective
passes all their roles. aspects. The cognitive aspect is the knowledge of the physi-
A person with a strong sense of identity has inte- cal body; the affective aspect includes the sensations of the
grated body image, role performance, and self-esteem body, such as pain, pleasure, fatigue, and physical move-
into a complete self-concept. This sense of identity pro- ment. Body image is the sum of these attitudes, conscious
vides a person with a feeling of continuity and a unity and subconscious, that a person has toward his or her body.
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equally as important on attitude development. In addi-

tion, cultural and societal values also influence a person’s
body image.
All sources of media influence how individuals view
themselves and others. The “ideal” body image fre-
quently portrayed influences women’s and men’s percep-
tions of what constitutes a healthy, normal appearance.
Overweight women, in particular, are more at risk to
experience depression, engage in negative self-talk, and
develop an eating disorder in response to body image dis-
satisfaction (Sides-Moore & Tochkov, 2011). If a person’s
body image closely resembles that person’s body ideal,
the individual is more likely to think positively about the
physical and nonphysical components of the self. The
body ideal is greatly influenced by cultural standards.
For example, in North America, the fit, well-toned body
is admired. During adolescence, issues related to body
image are of paramount concern. For example, research-
ers are continuing to explore how positive and negative
body images may develop or change during adolescence
(Dion et al., 2015). Different parts of the body have dif-
ferent values for different people. Some parts of the body
have greater significance for different people compared
with other parts. For example, some women desire to
have larger breasts or some may be upset because of
greying hair or hair loss, but may place high importance
on other physical attributes.
Those with a healthy body image will engage in
Elena Dorfman/Pearson Education, Inc.
activities that make them look and feel better, includ-

ing their choice of leisure activities (Liechty, Sweinson,
Willfong, & Evans, 2015). These persons will take
responsibility to improve health at times of illness and
institute health-promoting activities. In contrast, persons
with an unhealthy body image may neglect activities
that are important to health, such as regular sleep and
a healthy diet.
FIGURE 12.1 Body image is the sum of a person’s conscious The individual who has a body image disturbance
and unconscious attitudes about his or her body. Persons do may ignore a body part that is significantly changed in
not always appear to themselves as they appear to others. structure by illness or trauma. Some individuals may
express feelings of helplessness, hopelessness, power-
lessness, and depression in relation to the body image
changes that occur over time. These feelings can be so
Body image includes clothing, makeup, hairstyle, intense that they contribute to self-destructive behaviour,
jewellery, tattooing, body piercing, and other things inti- such as eating disturbances, or suicide attempts. But in
mately connected to the person (Figure 12.1). It also today’s society, the option of cosmetic surgery is readily
includes body prostheses, such as artificial limbs, den- available. It has given female breast cancer survivors
tures, and hairpieces, as well as devices required for func- the option of breast reconstruction following mastec-
tioning, such as wheelchairs, canes, and eyeglasses. Past tomy and has contributed positively to reducing aging
and present perceptions and how the body has evolved anxiety in middle-aged women (Slevec & Tiggemann,
over time are part of body image. 2010). However, one may also argue that women need-
A person’s body image develops partly from others’ ing plastic surgery to “reduce aging anxiety” may reflect
attitudes and responses and partly from the individual’s their inability to accept their aging body and therefore
own exploration of the body. Body image develops in embrace a positive self-concept of healthy aging. Liechty,
infancy in response to how the parents or caregivers Ribeiro, Sveinson, and Dahlstrom (2014) noted that in
respond to the child with smiles, holding, and touching. their sample of older Canadian men, it was function,
The child’s exploration of his or her own body sensations rather than appearance, that influenced participants’
during breast-feeding, thumb sucking, and the bath are body image.
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Role Performance CLINICAL ALERT

People undergo numerous role changes throughout life. According to Maslow, if an individual’s love and belong-
A role is a set of expectations about how a person in a ing needs are met, he or she is more likely to achieve the need for
certain role should behave. Role performance refers self-esteem. Achieving this need is an important element in striving for
to how an individual fulfills the expected duties of a par- self-actualization.
ticular role. Role mastery means that the individual is
successful in meeting the expectations of that assigned
a decrease in self-esteem, and embarrassment. See the
role. Expectations or standards of behaviour of a role
Clinical Alert box on Maslow’s category of love and
are set by society, a cultural group, or a smaller group to
belonging needs and the assessment questions about role
which a person belongs. Each person usually has several
performance on page 214.
roles, such as husband, parent, brother, son, employee,
friend, nurse, and church member. Some roles are only
temporary. With the introduction of each new role, there
needs to be a period of role development, which
Self-Esteem
involves socialization into that particular role. For exam- Self-esteem is a person’s judgment of his or her own
ple, nursing students are socialized into nursing through worth, that is, how that person’s standards and perfor-
exposure to their professors, practice experience, classes, mances compare with those of others and with his or
laboratory simulations, and seminars. her ideal self. If a person’s self-esteem does not match
To act appropriately, people need to know who they the ideal self, then low self-concept results.
are in relation to others and what the societal expecta- Self-esteem comes in two types: (a) global and (b) spe-
tions for certain roles are. Nolan and Harold (2010) cific. Global self-esteem is how much a person likes
used the tenets of image congruity theory to study himself or herself as a whole. Specific self-esteem is
what attracted participants to certain job opportunities. how much a person approves of a certain part of himself
Results showed that prospective job seekers are attracted or herself. Global self-esteem is influenced by specific
to organizations with personalities they perceive as simi- self-esteem. For example, if a man places little value on
lar to their own actual and ideal self-concepts. his cooking skills, then how well or badly he cooks will
Role ambiguity occurs when people are unclear have little influence on his global self-esteem.
of role responsibilities and do not know what to do or Self-esteem is derived from the self and others. In
how to do it and are unable to predict the reactions of infancy, self-esteem is related to the caregiver’s evalua-
others to their behaviour. Ambiguity causes feelings of tions and acceptances. Later, the child’s self-esteem is
frustration and inadequacy leading to role failure, often affected by competition with others. As an adult, a per-
causing lowered self-esteem. son who has high self-esteem has feelings of significance,
Self-concept is also affected by role strain and role feelings of competence, the ability to cope with life, and
conflicts. Role strain occurs when people feel or are control over his or her destiny.
made to feel inadequate or unsuited to a role. Role The foundation for self-esteem is established during
strain is often associated with gender-role stereotypes. early life experiences, usually within the family structure.
For example, women in occupations traditionally held However, an adult’s level of overall self-esteem is affected
by men might be treated as having less knowledge and by what is happening in one’s life at any given time. Severe
competence than men in the same roles. stress related to prolonged illness or unemployment can
Role conflicts arise from opposing or incompat- substantially lower a person’s self-esteem. Individuals who
ible expectations of a role or position. In an interpersonal experience a disability or illness that is viewed negatively
conflict, people have different expectations about a par- by society may have lower self-esteem. People frequently
ticular role. For example, a grandparent may have dif- focus more on their negative aspects and less on their
ferent expectations from those of the mother about how positive aspects. It is important for them to recognize
she should care for her children. In an interrole conflict, both their strengths and weaknesses equally. Strategies for
one person’s or group’s role expectations differ from the enhancing self-esteem in self or others across the lifespan
expectations of another person or group. For example, are illustrated in the Lifespan Considerations box.
a woman working full time in a job may have a role
conflict if her husband expects her to handle all their
childcare problems. In a person–role conflict, role expecta- Factors That Affect Self-Concept
tions violate the beliefs or values of the individual fulfill-
ing the role. For example, a nurse in a family planning Major factors, such as stage of development, family and
clinic may be expected to advise couples about birth culture, stressors, resources, history of success and fail-
control methods that are inconsistent with the nurse’s ure, and illness, can impact an individual’s self-concept.
belief system regarding prevention or management of STAGE OF DEVELOPMENT During the various stages
unwanted pregnancy. Role conflict can lead to tension, of development, conditions affecting the development
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LIFESPAN CONSIDERATIONS: BUILDING OR ENHANCING SELF-ESTEEM ACROSS THE LIFESPAN

CHILDREN • Show appreciation for effort and contributions. Emphasize
the process, not just the result.
Children build strong self-esteem if they develop five basic
attitudes: (a) security and trust, (b) identity, (c) belonging, (d) pur- • Ask for their opinions and suggestions.
pose, and (e) personal competence. • Encourage participation in decision making in areas that
• Security and trust are developed early in life; for example, affect the adolescent. Show confidence in the teen’s judg-
infants should not be left “to cry it out,” but they should learn ments.
that they can rely on their parents to meet their needs promptly • Avoid comparison with others, and avoid ridicule or punish-
and consistently. With older children, trust and security are ment in front of others.
strengthened when adults spend time with them, listening, • Assist in the creation of realistic goals and standards.
playing, reading, or just being there. Both emotional and physi- • Adolescents often engage in volunteer activities in their
cal contacts, such as a hug, convey warmth and caring. schools or communities, which helps them identify their
• Identity is developed when children are allowed to explore strengths and find meaning in their activities. Knowing that
and experiment with the world around them and to express they have a purpose and are making a difference gives
themselves as unique individuals in that world. They should them strong self-esteem.
be given opportunities to practise who they are. Preschoolers,
for example, love to dress themselves and should be allowed ADULTS
to wear outlandish outfits (within limits of weather and safety)
if they choose to. Teenagers who try new hair colours and Nurses can use the following strategies to help adults enhance
styles, some of which may upset their parents, are engaging their self-esteem:
in a crucial developmental step. • Explore the meaning of self-esteem and how the client’s self-
• Belonging is essential for all humans, and having a sense esteem has influenced past behaviours and actions (and can
that others in your social network care about you, want influence present and future plans and decisions).
you there, and benefit by your contribution is important to • Assist the client in assessing the internal and external forces
healthy self-esteem. Children gain this sense of belonging contributing to or weakening his or her self-esteem.
by being included in activities, by being praised for their
• Act in ways that demonstrate belief that the client can cope
efforts and achievements, and by being valued by parents,
with the realities and demands of life and is worthy of expe-
siblings, caregivers, and other adults. Parents should make
riencing joy and happiness.
an effort to catch their children doing well and praise them
for it (e.g., “I like the way you share with your brother”). • Avoid comparisons with other people.
Children should also hear that they are valued just for being • Discourage statements about the self that are negative.
themselves (e.g., “I like doing things with you. Remember • Encourage the use of affirmations to enhance self-esteem with
when we went to the park? Wasn’t that fun?”). such statements as “I like myself” or “I am a valuable person.”
• Purpose and belonging are closely related. Children need • Encourage associations with positive, supportive people.
opportunities to participate in the family and their com-
• Make positive statements about the person’s past suc-
munity to discover what they can best contribute based on
cesses (major or minor).
their strengths and skills. For example, a mother might say,
“Leo (age 4) is our actor. He is wonderful with costumes • Help the person to make a list of his or her positive qualities
and can make any of us smile when he puts on a ‘play’ for and to review this list often.
his family.” Leo may never become an actor, but he knows • Suggest the person do things for others. Making a positive
he makes a significant contribution to his family’s well- contribution enhances positive feelings of self-worth.
being. He brings them joy.
• Personal competence grows as children identify and refine OLDER ADULTS
their skill sets. Children develop competence as they con-
The older adult who becomes increasingly dependent can
front and solve problems, face challenges, expand their
thinking, and are asked to do more than they think they develop low self-esteem. Old age is frequently accompanied by
can do. Adults must, however, provide children with sup- changes, such as reduced income, decline in physical health,
port, guidance, appropriate assistance, and constructive loss of friends and family, and retirement. In addition to those
feedback (including praise) to prevent the child from being actions listed above, nurses can use the following strategies to
overwhelmed. Too much frustration or uncertainty can lead help older adults enhance their self-esteem:
to giving up, avoidance, lying, bullying, and other antisocial • Encourage clients to participate in planning their own care.
behaviours. If adults help accomplish goals that are impor-
tant to children, then children are more likely to develop a • Listen carefully to their concerns.
sense of personal competence and independence. • Assist clients to identify and use their own strengths.
• Key ingredients for helping children develop high self-esteem • Encourage them to participate in activities in which they can
are love, acceptance, firmness, consistency, and the estab- be successful.
lishment of expectations. Such qualities provide children with a • Be respectful and address the client by name. Focus on the
safe, loving, supportive, and predictable world to live in. client’s strengths and knowledge.
• Encourage clients to stay connected with their memories
ADOLESCENTS through reminiscing by writing or recording an autobiogra-
Nurses can use the following strategies to help adolescents phy and through storytelling.
enhance their self-esteem: • Promote privacy and respect.
• Provide increasing levels of responsibility. Adolescents • Encourage creative activities to tap their resources.
need to experience successes and failures and the conse- Examples are music, art, quilting, and photography.
quences of their own behaviour. • Work with clients to establish achievable goals to bolster
• Encourage discussion about issues, including problems self-esteem.
and mistakes.
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BOX 12.1 STRESSORS AFFECTING

SELF-CONCEPT
Many stressors can interfere with a positive self-concept:
IDENTITY STRESSORS
• Change in physical appearance (e.g., facial wrinkles)
Golden Pixels LLC/Shutterstock
• Decline in physical, mental, or sensory abilities

• Inability to achieve goals
• Relationship concerns
• Sexuality concerns
• Unrealistic ideal self
BODY IMAGE STRESSORS

FIGURE 12.2 A child is often pulled in opposite directions by • Loss of body parts (e.g., amputation, mastectomy,
family and peer expectations. hysterectomy)
• Loss of body functions (e.g., from stroke, spinal cord
injury, neuromuscular disease, arthritis, declining mental
or sensory abilities, aging)
of self-concept change. For example, an infant requires
• Disfigurement (e.g., resulting from pregnancy, severe
a supportive, caring environment, while a child requires burns, facial blemishes, colostomy, tracheotomy)
freedom to explore and learn. An older adult’s self- • Unrealistic body ideal (e.g., a muscular configuration
concept is based on experiences and accomplishments in that cannot be achieved)
progressing through life’s stages.
SELF-ESTEEM STRESSORS
FAMILY AND CULTURE A young child’s values are largely
• Lack of positive feedback from significant others
influenced by the family and culture. In later years, peers
have a greater influence on the child and the sense of self. • Repeated failures
When the child is confronted with conflicting expectations • Unrealistic expectations
from family, culture, and peers, the child’s sense of self is • Abusive relationship
often confused (Figure 12.2). For example, an adolescent • Loss of financial security
is instructed by parents not to consume alcohol because
ROLE STRESSORS
he or she is underage, but some of their peers may drink
alcohol regardless of parental restrictions. • Loss of parent, spouse, child, or close friend
• Change in or loss of job or other significant role
STRESSORS Stressors can strengthen the self-concept • Divorce
as an individual copes successfully with problems.
• Illness
Conversely, overwhelming stressors can cause maladap-
• Ambiguous or conflicting role expectations
tive responses, including problematic substance use, with-
drawal, and anxiety if coping strategies fail. A person’s • Inability to meet role expectations
ability to handle stressors will largely depend on personal
resources. See Box 12.1 for examples of stressors that
may place a client at risk for problems with self-concept.
may see herself as less attractive, and the loss of a breast
RESOURCES An individual’s resources are internal and may affect how she acts and values herself. People respond
external. Examples of internal resources include con- to stressors, such as illness and alterations in function
fidence and values; external resources include a sup- related to aging, in a variety of ways. Acceptance, denial,
port network, sufficient finances, and organizations. withdrawal, or depression are common reactions.
Generally, the greater the number of resources a per-
son has and uses, the more positive is the effect on the Changes to Roles and Self-Concept during
self-concept. Illness The illness experience is a common example of
a time when normal or expected roles of an individual or
HISTORY OF SUCCESS AND FAILURE People who have family become suspended, temporarily altered, or per-
a history of failure often see themselves as failures. Those manently changed, leading to temporary or permanent
who have a history of success are more likely to have a changes in the self-concept. In 1951, Parsons described
positive self-concept. Likewise, people with a positive the “sick role” in terms of both what the ill person could
self-concept tend to find contentment in their level of expect and what was expected of the patient. Basically,
success, whereas having a negative self-concept can lead Parsons indicated that the ill person could and should
people to view their life situation as negative. remove himself or herself from normal social obligations
ILLNESS Illness and trauma can also affect the self- (e.g., work or parenting) as well as from the responsibil-
concept. A woman who has undergone a mastectomy ity for the situation (removed from blame for the illness
M12_KOZI2703_04_SE_C12.indd 211 27/02/17 10:30 AM

or health challenge). However, the person still had the as well as from a chronic illness view. In chronic illness,
responsibility to strive to get well and to cooperate in there is no recovery but only remission; chronic illness
that effort—that is, seek assistance and follow the profes- does not always lead to death or delay of death. If one’s
sional advice. In the hospital setting, this sick role often self-concept is influenced not only by personal beliefs
meant loss of autonomy and privacy. Health profession- and values but by others’ inspirations, including those
als sometimes viewed this work of the sick role as an of family and friends, the enormity of living with one or
affirmation of all the rules and regulations imposed on more chronic conditions for a large part of one’s life will
hospitalized patients and their families. The frequently be significant. Nurses need to consider this knowledge
unspoken aspects of the role were the tasks and attitudes as they assess and know themselves, their individual
of family members and other significant persons (e.g., patients and significant others, and the additional influ-
boss) in the patient’s life. These tasks included taking ences on their lives.
over some of the patient’s tasks, roles, and responsibili-
ties, as well as supporting the patient’s efforts to recover.
Concept of Holism
For more than two decades, a significant body of
research was completed that looked at the sick role and
how it might be affected by age, gender, culture, and a
host of other factors. For example, many cultures have Nurses are concerned with the individual as a whole,
behavioural expectations of women who have just given that is, with the complete, or holistic, person, not as an
birth, far beyond societal maternity leaves and child assembly of parts and processes. The terms holistic
care. Although the sick role is not as widely researched and holism are derived from the Greek word meaning
today, large remnants of the theory remain. For example, “whole.” The term holism itself was coined by Jan Smuts,
parents who bring a critically ill infant to the emergency a South African scholar and political leader, in his book
room are being “good parents” in that they sought pro- Holism and Evolution (Smuts, 1926). In holistic theory, a
fessional expertise. However, they are now expected to living organism is seen as an interacting, unified whole
temporarily hand over the parenting role to the emer- that is more than the mere sum of its parts. Viewed in
gency room staff, as these personnel are assumed to have this light, any disturbance in one part is a disturbance
greater knowledge and skill in terms of what is needed of the whole system or being (see Box 12.2). The social
for that infant in the immediate situation. Further, there determinants of health reinforce the concept of holism,
remains an expectation that those same parents will fol- and demonstrate clearly how the health status of an
low procedures and prescriptions, even if they are dif- individual is related to many factors, most of which are
ficult and painful, to aid in the recovery of their child. social factors. (See Chapter 7 for discussion of social
When Parsons wrote his work, diseases were more determinants of health.)
acute in nature, and the outcomes were more broadly When applied in nursing, the concept of holism
noted as recovery or death. Chronic disease was much emphasizes that nurses must keep the whole person in
less recognized; for example, type 2 diabetes was known mind and strive to understand how one area of concern
as “adult-onset diabetes” because it was never seen in relates to the whole person. The nurse must also consider
children. Twenty years later, there was some recognition the relationship of the individual to the external environ-
that Parsons’ work was not as helpful in terms of mental ment and to others. For example, in helping a man who
illness or in chronic conditions (Segall, 1976). Segall also is grieving over the death of his spouse, the nurse should
noted that the questions of which illnesses were, indeed,
part of the patient’s responsibility remain a topic of dis-
cussion still today in, for example, heart disease, obesity, BOX 12.2 FACTORS INFLUENCING THE
and human immunodeficiency virus/acquired immuno- IMPACT OF ILLNESS ON THE INDIVIDUAL
deficiency syndrome (HIV/AIDS). Holism can help nurses understand how different factors
Parsons’ work really was about relationships. and relationships can change the way illness affects an
Within this millennium, Parsons’ work is being revis- individual. Some of these factors are as follows:
ited. Shillings (2002) and Williams (2005) both wrote • The meaning of the illness to the individual
about the doctor–patient relationship. Shillings noted • The nature of the illness, which can range from minor
that with patients and families being much more edu- to life threatening
cated than in the past, physicians (and nurses) are not so • The duration of the illness, which ranges from short term
clearly the only ones with knowledge, thus changing the to long term
patient’s view of self and the dynamics of the relation- • The residual effects of the illness, including none to
ship. Williams echoed some of Shillings’ ideas and also permanent disability
noted the use of evidence-based medicine (and nursing), • The financial and social impact of the illness on the
which was less evident when Parsons completed his work. individual’s ability to work
Shillings also talked about trust in the professional rela- • The impact of the illness on the individual’s family
tionship, a critical element. Varul (2010) looked at these • The source of the individual’s identity and self-esteem
relationships and expectations from an economic view
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explore the impact of the loss on the whole person (i.e., on HEALTH APPRAISAL The health appraisal begins with a
the man’s appetite, rest and sleep patterns, energy level, complete health history. The health history is one of the
sense of well-being, mood, usual activities, family relation- most effective ways of identifying existing or potential
ships, and relationships with others). Nursing interven- health problems and the individual’s current methods
tions are directed toward restoring overall harmony, so of coping with these health issues (see Chapter 28). For
they depend on the man’s sense of purpose and meaning instance, the client may have modified his choice of food
of his life. Nursing theorists, such as Parse and Newman to cope with dental pain when chewing. If further evalu-
(see Chapter 4 for additional information), based their ation is indicated, a referral is made to the appropriate
theories on considering the whole person. health care professional. When the focus is on health,
the appraisal includes information on lifestyle behaviours
and health beliefs, with the recognition that the health
Assessment of the Individual issue may have effects on other aspects of the individ-
Every care encounter begins and continues with an assess- ual’s life. The person dealing with chest pain may have
ment of the patient, resident, or client (see Figure 12.3). changed her exercise and work behaviours significantly.
Assessment is also the first part of the nursing pro- The nurse uses data from the health appraisal to formu-
cess, which will be described in detail in Chapter 23. late a health profile. The health profile provides the data
Components of this assessment may include the health necessary to determine wellness or to establish a needs
history and physical examination, physical fitness assess- profile or a nursing diagnosis and to plan appropriate
ment, lifestyle assessment, health-risk appraisal, health nursing interventions to promote optimal health through
beliefs review, cultural assessment, spiritual health lifestyle modification.
assessment, social support systems review, and life-stress
review. In this section, some of the tools for assessment HEALTH BELIEFS To promote health, the nurse must
are introduced, with an emphasis on the assessment of understand the health beliefs of individuals. Health beliefs
the individual’s identity and self-concept. may reflect a lack of information or misinformation
Theerasakj/Shutterstock
Fotorobs/Shutterstock
Huntstock.com/Shutterstock
FIGURE 12.3 Nurses intervene to promote the health and well-being of

individuals of diverse ages and backgrounds.
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BOX 12.3 HEALTH-PROMOTING COPING coping mechanisms. The coping mechanisms individuals
MECHANISMS develop reflect their own resourcefulness. Many indi-
viduals modify their daily routines in order to cope with
The following coping mechanisms can be beneficial when symptoms of their conditions, such as the person who
they promote health: sleeps in a downstairs room as she is unable to climb
• Problem solving stairs because of shortness of breath. Individuals may
• Positive thinking use the same coping patterns rather consistently over
• A sense of personal control over own life time or may change their coping strategies when new
• Delayed gratification demands are made on them. Not all coping strategies
• Healthy behaviours (e.g., exercise, good nutrition) are positive and may result in other health issues, such as
• Social support relationships the person who uses alcohol to avoid dealing with some
emotional issues. See Chapter 47 for a more detailed
discussion on coping mechanisms.
Nurses working with individuals realize the impor-
about health or disease. For instance, a client diagnosed tance of assessing coping mechanisms as a way of deter-
with a back condition may believe that surgery is the only mining how individuals relate to stress. Also important
effective treatment, whereas health care professionals are the resources available to the individual. Internal
may prescribe exercises to improve the condition. The resources, such as knowledge, skills, effective commu-
client’s belief may limit his willingness to do the exer- nication patterns, and a sense of purpose, assist in the
cises. Clients’ beliefs also include folklore and practices problem-solving process. Age and the individual’s devel-
from different cultures. Many clients may have outdated opmental stage often bring with them experiences that
information about health, illness, treatment, and preven- may or may not support positive coping strategies. For
tion. The nurse is frequently in a position to assess the instance, an individual may seek the support of the local
client’s current health practices, give the latest informa- foodbank when he is unable to provide sufficient food for
tion or to correct misconceptions. For instance, a person himself because of financial issues. Another individual
who has a cultural background that includes traditional with the same issues may go without adequate food or
medicines for certain conditions may be using those seek the support of extended family. In addition, exter-
remedies, often without discussion with health person- nal support systems promote coping and adaptation.
nel. Those remedies may interact with other treatments
RISK FOR HEALTH PROBLEMS Risk assessment helps
prescribed for the condition. For additional information
the nurse identify individuals at higher risk than the gen-
on health beliefs, see Chapters 7, 8, and 11.
eral population of developing specific health problems,
COPING MECHANISMS Individual coping mechanisms such as a cerebrovascular accident, diabetes, or lung
are the behaviours individuals use to deal with stress cancer. The vulnerability of individuals to health prob-
or changes. Coping mechanisms can be viewed as an lems may be based on age, hereditary or genetic factors,
active method of problem solving developed to meet gender or race, cultural factors, sociological factors, and
life’s challenges. See Box 12.3 for some health-promoting lifestyle practices.
ASSESSMENT INTERVIEW
Role Performance
Use these questions as a base to construct questions to learn about the client’s roles:
FAMILY RELATIONSHIPS • Do you feel as if your family members are proud of you?
• Tell me about your family.
WORK ROLES AND SOCIAL ROLES
• What is your home like?
• How is your relationship with your spouse/partner/ • Do you like your work?
significant other? [if appropriate] • How do you get along at work?
• What are your relationships like with your other relatives? • What about your work would you like to change if you
• How are important decisions made in your family? could?
• What are your responsibilities in the family? • How do you spend your free time?
• How well do you feel you accomplish what is expected of • Are you involved in any community groups?
you? • Are you most comfortable alone, with one other person,
• What about your role or responsibilities would you like or in a group?
changed? • Who is most important to you?
• Are you proud of your family members? • Whom do you seek out for help?
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Developmental Factors Individuals at both ends of the can be minimized, or that the onset of certain dis-
age continuum are at risk of developing health problems. eases can be delayed through lifestyle modifications.
Young children lack the knowledge, skills, and experience Cancer, cardiovascular disease, type 2 diabetes, and
to establish a repertoire of coping strategies. Some older tooth decay are among lifestyle-related diseases. The
adults feel a lack of purpose and decreased self-esteem. incidence of lung cancer, for example, would be greatly
As an example, the older person experiencing significant reduced if people never smoked. Good nutrition, dental
body changes related to osteoporosis (humped back and hygiene, and use of fluoride—in the water supply, in
spinal twisting, resulting in the need for a walker) may toothpaste, or as topical supplements—have been shown
avoid social events outside the home, and thus experience to reduce caries (dental decay).
social isolation. These feelings, in turn, reduce his or her One of the most important lifestyle-related issues
motivation to engage in health-promoting behaviours, today is obesity. Obesity has become pandemic in Canada,
such as exercise or community and family involvement. leading to numerous negative health effects. Other impor-
tant lifestyle considerations are exercise, stress manage-
Hereditary Factors Individuals born into families with
ment, and rest. Today, nurses have the knowledge to
a history of certain diseases, such as diabetes or cardio-
prevent or minimize the effects of some of the main
vascular disease, are at greater risk of developing these
causes of disease, disability, and death. The challenge for
conditions. A detailed individual and family history,
health care professionals is to disseminate information
including genetically transmitted disorders, is essential
about prevention and to motivate individuals to make
to the identification of individuals at risk. These data are
lifestyle changes before the onset of illnesses.
used not only to monitor the health of individuals but
also to recommend modifications in lifestyle and health
IDENTIFYING AREAS OF STRENGTH A thorough assess-
practices that potentially reduce the risk, minimize the
ment looks at strengths as well as areas of weakness.
consequences, or postpone the development of geneti-
Even healthy people often perceive their problems and
cally related conditions.
weaknesses more easily than their assets and strengths.
Gender or Race Some individuals may be at risk of Individuals’ areas of strength contribute to their resil-
developing a disease by reason of gender or race. Males, ience in adversity and increase their abilities to address
for example, are at greater risk of having cardiovascular their health and social issues.
disease at an earlier age compared with females, and Resilience is “the process of adapting well in the face
females are at greater risk of developing osteoporosis, of adversity, trauma, tragedy, threats or significant sources
particularly after menopause. Although it is sometimes dif- of stress—such as family and relationship problems, seri-
ficult to separate genetic factors from cultural ones, certain ous health problems or workplace and financial stress-
risk factors seem to be related to race. Sickle-cell anemia, ors. It means ‘bouncing back’ from difficult experiences”
for example, is a hereditary disease predominantly affect- (American Psychological Association [APA], 2015, para 1).
ing people of African descent. Compared with the general A primary factor in resilience relates to having supportive
population in Canada, Indigenous or Aboriginal people relationships within and outside the family; resilience is
seem more susceptible to certain diseases, such as diabetes. also based on the encouragement and reassurance of oth-
Cultural Factors Culture creates an atmosphere that ers, such as nurses. Resilience is related to one’s capacity
influences the health beliefs and practices of an individual. to solve problems, communicate effectively, make realistic
To understand cultural factors, the nurse needs to explore plans and implement them, and manage strong feelings
with the individual his cultural practices relevant to his and emotions. Resilience is also related to a positive self-
health. To provide culturally sensitive care, nurses need to concept and confidence in one’s own abilities (APA, 2015).
recognize and understand a broad spectrum of cultural All of these skills can be enhanced through the client’s self-
values, beliefs, and practices but also the extent to which development and through teaching by nurses.
the individual adheres to those practices (see Chapter 11). Many individuals demonstrate high levels of per-
sonal resilience in their situations and the nurse’s role
Sociological Factors The individual’s health is influ- is to assist them to identify their skills and strengths for
enced by a variety of sociological factors, the most note- continued or enhanced personal coping.
worthy of which is poverty. Poverty is a major problem People with low self-esteem tend to focus more on
that affects the health of the individual. If an individual their limitations, be less aware of their strengths, and per-
is born into or grows up in a single-parent family headed ceive themselves as having many more problems. When
by a female, then the risk of poverty increases. Other a client has difficulty identifying personal strengths and
factors include the person’s roles within society, at work, assets, the nurse provides the client with a set of guidelines
and in the community, and personal interests and activi- or a framework for identifying such strengths (Box 12.4).
ties. (Refer to Chapter 7 for a discussion on the social (See Chapter 4 for a discussion on Strengths-Based Care.)
determinants of health.) Certainly within a therapeutic relationship, but even
Lifestyle Factors It has become clear that many dis- in the most casual or informal encounter, nurses can
eases are preventable, that the effects of some diseases employ strategies to enhance the individual’s self-esteem,
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BOX 12.4 FRAMEWORK FOR IDENTIFYING to identification of different client needs for nursing care.
PERSONALITY STRENGTHS Planned nursing interventions that are needed to assist the
individual to health and that enhance personal well-being
Note past, present, and anticipated future participation in are identified on the basis of this assessment. Evaluation
the following: determines whether the planned interventions have led to
• Hobbies and crafts the achievement of the established goals and outcomes.
• Expressive arts, such as writing, painting, sketching, or
music appreciation
• Sports and outdoor activities, including spectator sports
• Education, training, and related areas (including
self-education)
Applying Theoretical
• Work, vocation, job, or position Frameworks to Individuals
In addition, determine the following:
• Sense of humour and the ability to laugh at self and take A variety of theoretical frameworks provide the nurse
“kidding” with a holistic overview of health promotion for the indi-
• Health status, including healthy aspects of body function vidual across the lifespan. Major theoretical frameworks
and good health maintenance practices that nurses use in promoting the health of the individual
• Special aptitudes, such as sales or mechanical ability; are needs theories, developmental stage theories, and
having “a green thumb”; the ability to recognize and systems theories.
enjoy beauty; the ability to solve problems; a liking for
adventure or pioneering; perseverance and the drive
needed to get things done Needs Theories
• Relationship strengths, including the ability to make
people feel comfortable, the capacity to enjoy being with In needs theories, human needs are ranked on an ascend-
people, the ability to be aware of people’s needs and ing scale according to how essential the needs are for
feelings, and the ability to listen survival. Abraham Maslow, perhaps the most renowned
• Emotional strengths, including the capacity to give and needs theorist, ranks human needs on five levels in
receive warmth, affection, and love; the ability to control ascending order (Maslow, 1970):
anger and to feel and express a wide range of emotions;
and the capacity for empathy 1. Physiological Needs. Such needs as air, food, water, shelter,
• Spiritual strengths, such as faith, love of God, and hope. rest, sleep, activity, and temperature maintenance are
crucial for survival.
2. Safety and Security Needs. The need for safety has both
physical and psychological aspects. The person needs
contributing to a healthy outlook and perception of the
to feel safe, both in the physical environment and in
current situation. Some of the strategies nurses can use
relationships.
include the following:
• Encouraging clients to appraise the situation and 3. Love and Belonging Needs. The third level of needs in-
express their feelings cludes giving and receiving affection, attaining a place
in a group, and maintaining the feeling of belonging.
• Encouraging clients to ask questions
4. Self-Esteem Needs. The individual needs both self-esteem
• Providing accurate information
(i.e., feelings of independence, competence, and
• Becoming aware of distortions, inappropriate or unreal- self-respect) and esteem from others (i.e., recognition,
istic standards, and faulty labels in clients’ speech respect, and appreciation).
• Exploring clients’ positive qualities and strengths 5. Self-Actualization. When the need for self-esteem is
• Encouraging clients to examine more on positive satisfied, the individual strives for self-actualization,
self-evaluation than negative self-evaluation the innate need for a person to develop his or her
• Avoiding criticism maximum potential and realize abilities and qualities.
• Teaching clients to substitute negative self-talk (“I can’t (See Box 12.5.)
walk to the store anymore”) with positive self-talk (“I can CHARACTERISTICS OF BASIC NEEDS All people have
walk half a block each morning”). Negative self-talk rein- the same basic needs; however, a person’s perception of
forces a negative self-concept. a need varies according to learning and the standards
of his or her culture. For example, professional achieve-
ment may be important in one culture or subculture and
Nursing Process unimportant in another. People’s needs have the follow-
Nurses committed to individualized care involve the cli- ing characteristics:
ent in the nursing process, as discussed in Chapter 23. • People meet their own needs relative to their own pri-
Data gathered during an individual assessment can lead orities. For example, during a drought, a mother might
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BOX 12.5 MASLOW’S CHARACTERISTICS can be markedly altered if the need for oxygen is threat-
OF A SELF-ACTUALIZED PERSON ened by a respiratory obstruction.
According to Maslow, a self-actualized person has the Needs can be satisfied in healthy and unhealthy
following characteristics: ways. Ways of meeting basic needs are considered
• Is realistic and objective about life healthy when they are not harmful to others or to the
• Judges people correctly self, conform to the individual’s sociocultural values, and
are within the law. Conversely, unhealthy behaviour may
• Is perceptive and decisive
be harmful to others or to the self, does not conform to
• Has a clear notion of right and wrong
the individual’s sociocultural values, or is not within the
• Is usually accurate in predicting future events
law. People who satisfy their basic needs appropriately
• Appreciates art, music, politics, and philosophy are healthier, happier, and more effective than those
• Possesses humility and listens to others carefully whose needs are frustrated.
• Is dedicated to some work, task, duty, or vocation Throughout their lifetime, individuals strive to meet
• Is highly creative, flexible, spontaneous, courageous, needs. A person’s perception of a need and his or her
and willing to make mistakes response to satisfy a need can be influenced by ethno-
• Is open to new ideas cultural standards, by external and internal stimuli (e.g.,
• Is self-confident, has self-respect and self-control hunger), and by self-determined priorities (e.g., stopping
• Has low degree of self-conflict; personality is integrated smoking). Positive factors that affect the satisfying of
• Does not need fame needs are the presence of supportive relationships, a
• Is highly independent and desires privacy strong self-concept, and the satisfactory achievement of
• Can appear remote and detached developmental stages. For example, if an infant achieves
• Is governed more by inner directives than by society the developmental task of learning to trust, then the basic
needs of feeling loved and secure are readily resolved.
• Can make decisions contrary to popular opinion
Knowledge of the theoretical bases of human needs
• Is problem centred rather than self-centred
assists nurses in responding therapeutically to a c lient’s
• Accepts the world for what it is
behaviours and in understanding themselves and their
own responses to needs. Human needs serve as a frame-
Source: Based on Chapter 3, “The study of self-actualization,” from The Third Force:
The Psychology of Abraham Maslow, by Frank Goble. Copyright © 1970 by Thomas work for assessing behaviours, assigning priorities to
Jefferson Research Center. desired outcomes, and planning nursing interventions.
For example, an adult with poor self-esteem would have
difficulty becoming self-actualized. Therefore, nurs-
give up her share of water or food and risk starvation or ing interventions would focus on increasing the client’s
die so that her child can live. self-esteem.
• Although basic needs generally must be met, some
needs can be deferred. An example is the need for
independence. During an acute illness, the individual Developmental Stage Theories
may prefer to be somewhat dependent on health care
professionals and other caregivers and then resume the Developmental stage theories categorize a person’s
desire for independence after recovery. behaviours or tasks into approximate age ranges or in
terms that describe the features of an age group. The age
• A need can make itself felt by either external or internal
ranges of the stages do not take into account individual
stimuli. An example is the need for food. A person may
differences; however, the categories do describe charac-
experience hunger as a result of thinking about food
teristics associated with the majority of individuals at
(internal stimulation) or as a result of seeing a beauti-
periods when distinctive developmental changes occur
fully decorated cake (external stimulation).
and with the specific tasks that must be accomplished.
• A person who perceives a need can respond in several Because human development is highly complex and
ways to meet it. The choice of response is largely a result multifaceted, developmental stage theories describe only
of learned experiences, lifestyle, and the values of the one aspect of development, such as cognitive, psycho-
culture. For example, the professional woman who comes sexual, psychosocial, moral, or faith development. Stage
home from work feeling tired may meet the need for theories emphasize a definite, predictable sequence of
relaxation by walking around the park after dinner. Many development that is orderly and continuous. Each stage
people’s food choices at mealtimes and snack times are is affected by those stages preceding it and affects those
based on past experiences, lifestyle, and culture. stages that follow. For example, an adolescent who is
• Needs are interrelated. Some needs cannot be met unable to establish a stable sense of personal identity
unless related needs are also met. The need for hydra- may have difficulty in later developmental stages with
tion can be seriously altered if the need for elimination adult roles and career aspirations. See Chapter 17 for
of urine is not also met. Likewise, the need for security further information about developmental stages.
M12_KOZI2703_04_SE_C12.indd 217 27/02/17 10:30 AM

Developmental stage theories allow nurses to describe

the typical behaviours of an individual within a certain age o n al s y st e m s
N a ti
group, explain the significance of those behaviours, pre- t er r it o ri a l s
l and y st
i n cia em
dict behaviours that might occur in a given situation, and o v
m m u ity s y s t e m
n s
P r o s
provide a rationale to explain behavioural manifestations. C i ly s y st e m s
m
Fa
Individuals can be compared with a representative group id u al s y ste m
of people at the same age or stage. During care, the nurse’s d iv s
In a n s y ste m
knowledge of stage theories can be used in parental and rg sys s
la r t
O
client education, counselling, and anticipatory guidance.
em
C e ll
DNA
s
chains
Systems Theories
General systems theory explains the breaking of whole things
into parts and the working together of those parts in
systems. The theory explains the relationship between
wholes and parts, describes concepts about them, and
predicts how the parts will behave and react.
The basic concepts of systems theory were proposed
in the 1950s. One of its major proponents, Ludwig von
Bertalanffy (1968) introduced systems theory as a univer- FIGURE 12.4 A common system hierarchy.
sal theory that could be applied to many fields of study.
Systems theory is applied in health professions when
curricula are focused on body systems, such as the respi- physiological symptoms, such as sleeplessness, nausea, or
ratory, cardiac, or gastrointestinal system. Nurses are changes in cardiac function.
increasingly using systems theory to understand not only Systems come in two general types: closed and open.
biological systems but also systems in families, communi- A closed system does not exchange energy, matter, or
ties, and health care. General systems theory provides a information with its environment. An example of a closed
way of examining interrelationships and deriving princi- system is a chemical reaction that takes place in a test
ples. Systems theory can also be used in nursing theories tube. In reality, outside the laboratory, no closed systems
and curricula, such as Campbell’s UBC (University of exist. In an open system, energy, matter, and informa-
British Columbia) model (see Chapter 4). tion move into and out of the system through the system
A system is a set of interacting identifiable parts or boundary. All living systems, such as plants, animals,
components. A system can be an individual, a family, or people, families, and communities, are open systems,
a community. The fundamental components of a system since their survival depends on a continuous exchange of
are matter, energy, and communication. Without any energy. They are, therefore, in a constant state of change.
one of these, a system does not exist. The individual is Because humans are biopsychosocial beings, their
a human system with matter (the body), energy (chemi- biological, psychological, social, and spiritual compo-
cal or thermal), and communication (e.g., the nervous nents can be regarded as systems with hierarchical, inter-
system). The boundary of a system, such as skin in the related subsystems.
integumentary system in humans, is a real or imaginary The biological system can be subdivided into many
line that differentiates one system from another system subsystems, including the neurological, musculoskeletal,
or a system from its environment. respiratory, circulatory, gastrointestinal, and urinary sub-
Systems can be complex and, therefore, are often systems. Each subsystem can, in turn, be further subdi-
studied as subsystems. Each subsystem belongs to a higher vided. For example, the urinary system consists of the
system. In the individual or human system, the subsys- kidneys, the ureters, and the bladder; the circulatory
tems (or lower-level systems) are the organ systems, such system consists of the heart and blood vessels. The bio-
as the respiratory system and the digestive system; the logical system can also be subdivided into categories of
suprasystems are the family systems. See Figure 12.4 for a needs or functional health patterns or activities of daily
hierarchy of the human system. living, such as nutrition and hydration, sleep or rest,
Because all the parts of a system are interrelated, activity or exercise, and elimination.
the whole system responds to changes in one of its parts. The psychological, social, and spiritual systems are a
This interrelatedness is the basis for nursing’s holistic focus of research in several disciplines. Although the
view of the client. For example, a tumour in the liver interrelatedness of the systems is clearly evident, the
affects the whole individual; that is, the person may be explicit delineation of specific subsystems, the exact
nauseated, tired, or anxious. A psychological problem, relationships among them, and their influence on health
such as stress or anxiety, can also manifest itself in are still not well understood (Belar, 2003). Topics within
M12_KOZI2703_04_SE_C12.indd 218 27/02/17 10:30 AM

these systems include thinking, feeling, faith, empathy,

coping, hardiness, quality of life, self-efficacy, power,
and social support. Nurse researchers and theorists have Throughput
used research results on these topics as a basis for theory Input Output
processes
development and improving practice.
For its functioning, an open system depends on the
quality and quantity of its input, output, and feedback.
Input consists of information, material, or energy that
enters the system. After the input is absorbed by the
Feedback
system, it is processed in a way useful to the system. This
transformation is called throughput. For example, food
FIGURE 12.5 An open system with a feedback mechanism.
is input to the digestive system; it is digested (throughput)
so that it can be used by the body. Output from a system
is energy, matter, or information given out by the system and feedback maintain the system in a state of homeo-
as a result of its processes. Output from the digestive stasis or dynamic equilibrium. This premise directs
system is feces, nutrients, and caloric energy. the nurse to look at environmental factors influencing
Feedback is a process that enables a system to regu- the system and to plan nursing interventions to help the
late itself by redirecting the output of a system to affect client maintain homeostasis. For example, the individual
the input of the same system, thus forming a feedback who is experiencing severe anxiety may be taught a vari-
loop (Figure 12.5). Numerous examples of this feedback ety of stress management techniques.
mechanism are found within individual, family, and The family unit can also be viewed as a system. Its mem-
community systems. In the individual, for example, the bers are interdependent, working toward specific purposes
autonomic nervous system relies on a feedback system to and goals. Many families are described as open systems, as
balance the effects of the sympathetic and parasympa- they are continually interacting with and influenced by
thetic centres, which modify heart and respiratory rates. other systems in the community. Boundaries regulate the
In the family system, parents provide feedback to chil- input from other systems that interact with the family
dren to modify behaviour. In the community, laws, rules, system; they also regulate output from the family system to
and regulations guide the behaviour of citizens. the community or to society. Boundaries protect the family
Human systems theories assert that the individual is from the demands and influences of other systems. Open
an open system in constant interaction with a changing families are likely to welcome input from without, encour-
environment. People interact with the environment by aging individual members to adapt beliefs and practices to
adjusting themselves to it or adjusting it to themselves. meet the changing demands of society. Such families are
For instance, increasing environmental (societal) empha- more likely to seek out health care information and use
sis on physical activity has caused many Canadians to community resources. These families are adaptable and,
increase their own activity levels and to encourage family therefore, better prepared to cope with changes in lifestyle
members to do so as well. Constant input into the system needed to restore, maintain, or promote health.
Case Study 12
Aliyah is a young mother of three children and lives in Windsor,
Ontario. She has developed a severe arthritic condition that has
2. What areas of Aliyah’s identity are most at risk, and
why?
affected her ability to work and adequately care for her family.
Her illness has created a financial hardship for the family and has 3. When dealing with Aliyah’s physical problem, what other
strained their roles. She has given up her position as a secretary issues occurring in Aliyah’s life might you consider?
at an automotive plant. Aliyah and her husband have custody 4. Explore Aliyah’s situation from the perspective of
of their children from previous marriages, as Maslow.
well as a daughter together. She is reluctant to
5. What class of theories might you use to understand
seek assistance from outside sources because
Aliyah’s situation?
she fears interference from her ex-husband
concerning her children.
CRITICAL THINKING SKILLS
1. What type of assessment data might you collect?
M12_KOZI2703_04_SE_C12.indd 219 27/02/17 10:30 AM

KE Y TERM S
body image p. 207 holism p. 212 personal identity p. 207 role strain p. 209
boundary p. 218 holistic p. 212 resilience p. 215 self-awareness p. 205
closed system p. 218 ideal self p. 207 role p. 209 self-concept p. 204
core self-concept p. 206 input p. 219 role ambiguity p. 209 self-esteem p. 209
equilibrium p. 219 introspection p. 205 role conflicts p. 209 specific self-esteem p. 209
feedback p. 205 open system p. 218 role development p. 209 system p. 218
global self p. 205 output p. 219 role mastery p. 209 throughput p. 219
global self-esteem p. 209 perceived self p. 207 role performance p. 209

• Nursing involves viewing the client as an individual and • The nurse assesses four areas of self-concept: personal
in a holistic way. identity, body image, self-esteem, and role performance.
• To ensure holistic health care, the nurse considers all the • Because a positive self-concept is basic to health, one of
components of health (health promotion, health main- the nurse’s major responsibilities is to help clients whose
tenance, health education and illness prevention, and self-concept is disturbed to develop a more positive and
restorative–rehabilitative care) and recognizes that distur- realistic image of themselves.
bance in one part of a person affects the whole being. • A trusting client–nurse relationship is essential for the effec-
• A positive self-concept is essential to a person’s physical tive assessment of a client’s self-concept, for providing help
and psychological well-being. and support, and for motivating client behaviour change.
• Although each individual has unique characteristics, cer-
• A person’s self-perception can differ from the person’s tain needs are common to all people.
perception of how others see him or her and from the
ideal self, that is, how the person would like to be. • A variety of social, psychological, and nursing theoretical
frameworks provide the nurse with a holistic overview of
• Interactions with significant others create the conditions the health promotion of individuals and families across
that influence self-concept throughout life. the lifespan.
• When individuals are able to conceptualize the self, they • Maslow’s hierarchy of human needs consists of five
begin a lifelong process of deciding whether and to what categories: physiological (survival) needs, safety needs,
extent they are valuable and worthy. love and belonging needs, self-esteem needs, and self-
• Individuals who grow up in families whose members value actualization needs.
one another are likely to feel good about themselves. • People vary in how they rank their needs at any given
• Factors affecting self-concept include development, moment.
family and culture, stressors, resources, history of success • Needs satisfaction can be altered by illness, significant
and failure, and illness. relationships, self-concept, and developmental levels.

1. Which question by the nurse is best for assessing role 2. What dimension of individuality influences the way an
performance in a client? individual interprets the environment?
a. “Tell me about your family.” a. Self-identity
b. “What are your primary concerns about being dis- b. Total character
charged home?” c. Perceptions
c. “What can’t you do now that you could do before d. Values
the accident?”
d. “How do you see your responsibilities changing as a 3. A client who has metastatic cancer of the liver and is
result of this health event?” severely jaundiced asks the nurse to assist him in plan-
M12_KOZI2703_04_SE_C12.indd 220 27/02/17 10:30 AM

ning a cruise 9 months in the future. The nurse assesses a. Individual processes are detached from each other.
that he is using a coping mechanism. What is the pur- b. The reason for consulting the health care profes-
pose of coping mechanisms? sional is of primary importance.
a. Protect the person c. Each individual is more than the sum of his or her
b. Provide feedback parts.
c. Stimulate the endocrine system d. The individual and the immediate environment are
d. Change reality the focus of care.
4. A client had emergency surgery that resulted in a total 8. A client has been positive for human immunodeficiency
colectomy with the creation of an ileostomy 2 days ago. virus (HIV) for 5 years and was recently admitted to the
The client will not look at the stoma or participate in hospital with a confirmed diagnosis of Pneumocystis carinii
ostomy care. The nursing diagnosis for the client is: at [now known as Pneumocystis jirovecii]. The client tells the
risk for developing a negative self-concept in response to nurse that he notices people seem to avoid coming into
an unexpected body image disturbance. What nursing his room and that he is lonely. What strategy should the
intervention would be best for this client? nurse use to provide support to the client?
a. Encourage the client to find an ostomy support group a. Explain to him the reason he is isolated is because of
his susceptibility to infections.
b. Help the client to verbalize thoughts and feelings
b. Explain to him that people do not come into his
c. Have client watch an ostomy video to facilitate the room because they are afraid of getting HIV
teaching/learning process infection.
d. Assess the client for symptoms of depression and anxiety c. Ask him if any of his family can come to the hospital
to keep him company.
5. When a father prepares to leave for work in the morning,
his 3-year-old son starts to cry and scream. The father d. Spend time talking with him during and between
picks him up and delays leaving for a while. The child’s care activities.
behaviour most reflects which part of the family system?
9. Sarah, a friend, is trying to make some changes to her
a. Input lifestyle. The nurse supports her by giving positive feed-
b. Throughput back. What is the purpose of positive feedback?
c. Output a. Inhibits change
d. Feedback b. Stimulates change
c. Maintains homeostasis
6. Which activity would be most appropriate to facilitate a
child’s development of identity? d. Regulates change
a. A swim coach tells the child, “I like how hard you
worked in practice today.” 10. A nurse is doing health screening for toddlers at a well-
child health clinic. The nurse will use play as a strategy
b. Parents play board games with their child in the to engage the child during the health screening process.
evening after dinner Which theoretical framework would be most appropri-
c. A school-aged child wants to dye her hair pink ate for the nurse to use to complete the health screening
d. A child in Grade 7 volunteers to walk the dog for assessment?
older neighbours a. Needs
b. Developmental
7. A student nurse has recently learned about the use of
holistic thinking in nursing. What idea will help the stu- c. Systems
dent in preparing interview questions for a client? d. Health beliefs
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Chapter 13
Nursing Care
of Families
Updated by
Jean Hughes, RN, PhD
Associate Professor, Faculty of Nursing, Dalhousie University
W
LEARNING OUTCOMES
After completing this chapter, you will be able to henever concerns related
1. Define “family” in a way that accounts for diverse forms of to health and illness
structure and relationship. arise, both individual
2. Describe factors influencing a shift in nursing perspective from the persons and those who are involved
individual to the person in the context of the family. in their lives are affected. Usually
3. Outline historical developments in the history of family nursing. these are family members. Nurses
encounter family members in every
4. Discuss the impact of trends in health care services on family
involvement. practice setting, including home care,
community clinics, and hospitals. As
5. Propose possible family member expectations for their involvement
in care. health care services have shifted away
from institutional care with shorter
6. Analyze demographic trends in Canadian families that influence
health and family structure. hospital stays, family members are
increasingly called upon to provide
7. Identify questions to be posed during a genogram and ecomap
inquiry. care at home. Care can involve emo-
tional support, symptom monitoring,
8. Formulate questions aimed at exploring reciprocal influences
between health or illness and the family. and technical procedures, such as
dressing changes, dialysis, or intra-
9. Describe relational practices that foster a collaborative stance with
family members. venous therapies. Family members
can be a tremendous resource to
10. Explain five relational practices that can be integrated when
providing nursing care with families. nurses through their knowledge of
client preferences and usual patterns
of response to difficulties. However,
family members do not always hold
similar views about caregiving roles.
Nurses are challenged to invite and
respect all views of family members
and provide them with information
and emotional support. Nurses are c
M13_KOZI2703_04_SE_C13.indd 223 17/03/17 11:09 AM

c also challenged to involve family members in decision making, in ways that respect the rights and
wishes of clients, and help prepare family members with appropriate knowledge, skills, and supports
for caregiving roles.
What Is “Family?” any combination of two or more persons who are bound
together over time by ties of mutual consent, birth and/
or adoption, or placement and who, together, assume
Standards of family structure have shifted dramatically responsibilities for variant combinations of some of the
over the past three decades. Couples now often post- following:
pone childbearing while engaged in prolonged periods
of education or establishment of careers. Rising rates of • Physical maintenance and care of group members
divorce and remarriage have resulted in more blended • Addition of new members through procreation or
and lone-parent families. Increased family mobility has adoption
also shifted the roles of extended family members. These • Socialization of children
changes challenge definitions of family based on long-held
assumptions (see Box 13.1). Persons choosing to define • Social control of members
themselves as family may or may not be bound by blood • Production, consumption, distribution of goods and
or legal status. The following definition attempts to be services
open and respectful of the many different ways families • Affective nurturance—love
may organize themselves.
The Vanier Institute of the Family (2015) defines In contrast, Statistics Canada defined a census
family both in terms of the individuals and their roles—as family solely in terms of the individuals:
. . . a married couple and the children, if any, of either

BOX 13.1 TYPES OF FAMILIES IN TODAY’S or both spouses; a couple living common law and the chil-
SOCIETY dren, if any, of either or both partners; or, a lone parent
of any marital status with at least one child living in the
Family may be described in different ways according same dwelling and that child or those children. All mem-
to biological relatedness, cultural norms, social ties, bers of a particular census family live in the same dwell-
interactions, or proximity. Scholarly definitions often
ing. A couple may be of opposite or same sex. Children
focus on structure (e.g., biological or legal ties), function
(e.g., caretaking or financial support), or transactions
may be children by birth, marriage or adoption regard-
(e.g., creation of shared meaning through affective ties less of their age or marital status as long as they live in
or symbolic communication such as stories and rituals), the dwelling and do not have their own spouse or child
while lay definitions often blend the elements (Thompson, living in the dwelling. Grandchildren living with their
Seo, Griffith, Baxter, James, & Kaphingst, 2015). grandparent(s) but with no parents present also constitute
Some common types of “Family” include the following: a census family. (Statistics Canada, 2012)
• Traditional—both parents reside in the home with chil-
dren; mother assumes nurturing role, and father provides In clinical practice, it is important for the nurse to
economic necessities understand how members of a particular family identify
• Two career—both husband and wife are employed themselves in relation to each other. Who is in this family?
• Lone parent—one parent with child(ren) How do these family members view their relationships,
• Adolescent—an infant is born to adolescent parents priorities, concerns, responsibilities, and preferences? To
• Blended—existing families that join together to form a establish a therapeutic relationship with a family, nurses
new one need to be respectful of the ways that families define and
• Cohabiting—unrelated individuals or families who live describe themselves.
under one roof
• Adoptive—children are adopted by parent(s)
Family Nursing
• Mixed race—parents and/or children of different ethnicities
• Nuclear—parent(s) and child(ren) from same generation
• Mixed generation—parent(s) and child(ren) from several
generations Family nursing refers to relational practices that
• Gay or lesbian—same-sex couple involve family members in care, respond to their con-
cerns, or provide information and emotional support.
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Chapter 13 Nursing Care of Families 225
Care of family members calls for nursing practices to “thinking family” or “thinking interactionally.” This
that occur within conversation and relationship, across means that the nurse must forge a collaborative rela-
every health care setting. You will notice that the terms tionship not only with the patient but also with persons
patient and client are both used in this chapter, as nursing who are involved with the patient during the health care
care of families can occur in inpatient and community encounter. Involvement of family members helps the
settings. nurse better understand the meaning of illness to the
Each encounter with families in nursing practice patient and family and the possibilities for support dur-
affords a possibility for nursing of families. Family mem- ing recovery, health maintenance, or health promotion.
bers may be present when the home care nurse visits. There is growing evidence that patients and fami-
They may be at the bedside of an ill family member. The lies offer a unique perspective and key understanding
nurse may conduct a formal family assessment interview of patient needs, and can assist health professionals to
upon the patient’s admission to a facility. The nurse may discover unexpected outcomes (Locatelli et al., 2015). A
also be involved in a conference with family and other Cochrane review also shows that parents are significantly
health care team members to facilitate decision making, more satisfied with Care-By-Parent-Unit (CBPU) than
treatment planning, or discharge. In some situations, the with standard care and that costs were lower for CBPU
nurse has little or no direct contact with family members compared with standard inpatient care (Shields, Zhou,
of the individual client, yet the needs and concerns of Pratt, Taylor, Hunter, & Pascoe, 2012). In addition, evi-
family members may still be addressed in their absence. dence shows that family members who are included in
Although the individual is the focus of care, the the care of patients perceive significantly higher cogni-
extent to which family members are involved in health tive and emotional support from the nurses than family
care encounters varies. Many health care facilities now members who are not (Sveinbjarnardottir, Svavarsdottir,
provide structural supports to include family members & Wright, 2012).
and value their presence and contribution to care. These However, the mobilization of family theory to prac-
supports include open or flexible visiting policies, com- tice remains limited (Berger, Flickinger, Pfoh, Martinez,
fortable waiting rooms and access to overnight facilities, & Dy, 2014). Findings from a Canadian study report
refreshments, telephones, and increased access to infor- that family nursing is more likely to be implemented in
mation from health care professionals. Indeed, many clinical practice areas where patients experience seri-
agencies now have adopted a Patient and Family-Centered ous or life-threatening illnesses, staff are educationally
Care (PFCC) approach to the planning, delivery, and prepared, and there is ongoing mentorship and manage-
evaluation of health care that is grounded in mutually ment support for family nursing and less likely in areas
beneficial partnerships among patients, families, and with high patient turnover, such as acute medical-surgical
health care providers (Institute for Patient and Family- wards (St John & Flowers, 2009).
Centered Care [IPFCC], 2016). Core concepts of the Clearly, nurses need family theory to provide truly
IPFCC include the following: relevant care, given that the family is the fundamental
unit of society with norms, values, and roles distinct from
• Dignity and Respect. Health care practitioners listen to and
that of the individual (Dwairy, 2002). However, provid-
honour patient and family perspectives and choices.
ing staff development and management support in the
Patient and family knowledge, values, beliefs, and cul-
workplace to promote family-centred nursing practice is
tural backgrounds are incorporated into the planning
equally important. A Cochrane review found that inter-
and delivery of care.
ventions transferring patient-centred skills to providers
• Information Sharing. Health care practitioners communi- were effective across studies (Dwamena et al., 2012).
cate and share complete and unbiased information with Clearly, understanding how best to work with fami-
patients and families in ways that are affirming and use- lies is complex. Wright and Leahey (2013) described four
ful. Patients and families receive timely, complete, and theoretical frameworks that have contributed to their
accurate information to effectively participate in care family nursing work: (a) systems theories, (b) cybernet-
and decision making. ics theory, (c) communications theory, and (d) change
• Participation. Patients and families are encouraged and theory. Systems theories help nurses understand the
supported in participating in care and decision making family as a group of interconnected individuals (see
at the level the patient chooses. Chapter 12). Cybernetics theory looks at communica-
• Collaboration. Patients, families, health care practitioners, tion and control—how family members self-regulate at
and leaders collaborate in policy and program develop- differing levels at the same time. Communications theory
ment, implementation, and evaluation; in health care focuses on how family members interact with each other,
facility design; and in professional education as well as and change theory examines how changes occur within
in the delivery of care. individuals and families (Wright & Leahey, 2013). Wright
and Leahey (2013) noted the importance of understand-
Nursing of families challenges nurses to shift their ing the multiple family realities and perceptions to gener-
perspective from thinking of the client as an individual ate interventions to achieve family goals.
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In current practice settings, the individual is viewed reciprocity within relationships between family members,
as the primary focus of nursing concern and the fam- between the family and the nurse, and between illness
ily as a significant contextual influence on health, ill- and the family. This work typically requires advanced
ness, and recovery. Family nursing, however, focuses on practice nursing skills.
both individuals (foreground) and families (background).
Participation of family members in decisions related
Development of Family
to discharge planning is desirable, as they can provide
emotional support and instrumental assistance to the
individual upon his or her return home. Likewise, family
members can be a valuable resource to both the patient Nursing
and the health care team for decision making around
serious illness. Proactive communication empowers fam- Historically, nurses have encountered family members by
ily members of dying patients, helping them to share virtue of their shared presence in homes, communities,
in discussions and decisions, if they so wish (Lautrette, and hospitals. However, although the interest in the fam-
Ciroldi, Ksibi, & Azoulay, 2006). ily as a focus of nursing care extends back to the earliest
Although the individual is the focus of care, evi- traditions of modern nursing (Whall & Fawcett, 1991), it
dence shows that there should also be varying degrees is important to note that the family unit and its activities
of intent to care for family members by attending to (including childrearing) were considered a private mat-
the impact of the health situation on the family. Nurses ter. Public health nurses have a longstanding tradition
can offer assistance and reduce family stress, for example, of educating families to address the health needs of all
by providing education to parents of neonatal patients family members. The rise of scientific biomedicine and
during the painful procedures that their infants have to the organizational efficiencies of hospital care contrib-
go through (Johnston, Campbell-Yeo, Fernandes, Inglis, uted to a focus on the individual. The client was viewed
Streiner, & Zee, 2014). Nurses can also improve the health as the individual patient, with a particular pathology,
of family members who are caring for loved ones with requiring diagnosis and treatment. Families were viewed
dementia by teaching them personal coping strategies as less relevant, with little right to involvement in hospital
(Livingston et al., 2014). In addition, telephone counsel- care. In recent years, there has been renewed attention to
ling has been shown to reduce depressive symptoms for the psychosocial aspects of health and illness, including
caregivers of people with dementia (Lins et al., 2014). recognition of the influence of family. As health care ser-
Likewise, nurses can acknowledge families by including vices have been challenged to reconsider the importance
them in discharge planning discussions and recognizing of family, many changes in practice and policy have been
the impact on the demands of the family caregiver (their guided by nurses’ responsiveness to the needs, requests,
time, energy, and health) when the patient returns home and expectations of families.
(Davidson et al., 2007). As Friedemann (1995) argued,
“all nursing is family nursing and is practiced in all
clinical settings” (p. 34). She proposed that nurses cannot Family Care Traditions in Public Health,
contribute to the healing of persons without attention to Maternal–Child, Pediatric, and Mental
the contexts and relationships in which they live. Indeed,
nurses are often the eyes and ears of the health care Health Nursing
team and the voice for the family, thus creating a critical Throughout these developments, public health nurses,
connection between the family and the health care team. maternal–child nurses, and pediatric nurses main-
Families identify their need for someone to listen to tained an enduring interest in family care. Hospitals
them, to educate them and others about their loved one’s were challenged to provide structural support for family
health condition, to acknowledge their experience and involvement. In maternity settings, couples demanded
emotions, and to direct them to appropriate resources. the presence of fathers in the delivery room. Mothers
Therefore, nurses need to take action to assist families objected to postpartum separation from their newborns,
through the challenges associated with caring for the leading to “rooming in” practices. In pediatric settings,
patient, helping them develop resiliency, and facilitating parents desired round-the-clock access to their children
improved outcomes for the patient and the entire family. through flexible visiting policies. Although much of the
Nursing practice may also focus on the family research on attachment, transitions, and maternal-role
unit as the client of care. Attention is simultaneously attainment focused on mother–child relationships,
directed toward the individual and the family—with the the role of fathers has also been explored (Wolff, Pak,
family in the foreground in family therapy. The family Meeske, Worden, & Katz, 2011).
unit is assisted to make change in family relationships and Family nursing research has broadened its focus
processes around the difficulties they encounter (Wright, to include more theory development (Frye, 2015), best
Watson, & Bell, 1996). Heightened attention is given to practices or standards (Aldiss, Ellis, Cass, Pettigrew,
M13_KOZI2703_04_SE_C13.indd 226 30/01/17 4:41 PM

Rose, & Gibson, 2015), and recommendations regard- and preparation for their roles so they can confidently
ing a family-centred integrative approach to palliative provide ongoing physical and emotional care. Unfor-
care in the neonatal intensive care unit (NICU) and tunately, most family caregivers provide ongoing care
patient-centred care (DiGioia, Lorenz, Greenhouse, without support from any formal caregivers. Research
Bertoty, & Rocks, 2010; Hundon, Fortin, Haggerty, shows that nurses who have had education in family sys-
Lambert, & Poitras, 2011; Kenner, Press, & Ryan, 2015) tems nursing report a significantly more positive attitude
and the implementation of the Nurse-Family Partner- toward involving families in their care (Svavarsdottir
ship in Canada (Jack, Sheehan, Gonzalez, MacMillan, et al., 2015), thus supporting a way to progress.
Catherine, & Waddell, 2015).
Interestingly, the importance of family in mental
health nursing is a relatively recent phenomenon. When Canadian Contributions
families try to contact care providers for information and
emotional support, they are sometimes unsuccessful as to the Field of Family Nursing
nurses often are ethically constrained from discussion Canadian nurses have made significant contributions
of the confidential patient situation. Only recently has to the field of family nursing. The “Calgary Family
nursing research begun to understand the experience and Assessment Model” was first published in 1984, updated,
needs of families whose loved ones have a mental illness, and then enhanced with the addition of “The Calgary
by exploring the perceptions of parents and children Family Intervention Model” in subsequent editions of
(Montreuil, Butler, Stachura, & Pugnaire Gros, 2015). the landmark text Nurses and Families: A Guide to Family
Assessment and Intervention (Wright & Leahey, 2013). The
first International Family Nursing Conference was held
Family Nursing in Critical Care Settings in Calgary, Alberta, in 1989, and the conference con-
During the last 4 decades of the twentieth century, acute tinues to be conducted regularly. The Journal of Family
care hospitals introduced specialized critical care units. Nursing was first published in 1995 under the editorship
Nurses recognized the impact on family members of of Dr. Janice Bell, University of Calgary. Nursing educa-
implementing highly invasive and technological proce- tion programs increasingly offer family nursing in both
dures under tenuous life-and-death circumstances. Nurs- undergraduate and specialized graduate programs in
ing research reflected a desire to understand and assist Canadian universities. Recent research has examined
with emotional distress, uncertainty, and informational how Canadian nurses have integrated the Illness Beliefs
needs of family members under these extraordinary Model in clinical practice (Duhamel, Dupuis, Turcotte,
circumstances (Madden & Condon, 2007). Again, nurses Martinez, & Goudreau, 2015).
were challenged to humanize these environments by
finding ways to enable family access to patients and
information and to facilitate family involvement in
decision making (Hudson & Payne, 2011). Canadian Families:
A Demographic Snapshot
Family Expectations for Involvement
in Care Canada has a growing population of about 35.8 million
people (Statistics Canada, 2015). However, its growth is
Clinical practice guidelines (Registered Nurses Asso- not sustained from within. Indeed, Canada has a declin-
ciation of Ontario [RNAO], 2015) offer examples of ing fertility rate (1.5 children per woman compared with
family’s hopes and expectations for involvement in care. a replacement rate of 2.1 children) and a population
Family members want to be able to communicate with of seniors whose numbers surpassed those of the child
health care professionals about the ill person’s condition, population (under 14 years) in 2015 and should account
according to the patient’s wishes. They want access to for 20.1% of the population by 2024, while children
information about test results, diagnosis, treatment plans, under 14 years should account for only 16.3% (Statistics
and prognosis. Family members want to be able to trust Canada, 2015). Yet, of the G7 countries, the United
that the ill person will be given good care and treated States (15%) and Canada (16.1%) have the lowest pro-
compassionately. They may feel compelled to be vigilant portions of persons aged 65 years and older. The average
to protect the ill family member at a time of vulnerability. age of first marriages has been rising but seems to have
Family members want recognition that they are included stabilized (28.5 years for women, 30.6 years for men).
and valued. Emotional attachment to the ill person may Parents are older when giving birth to their first child
be a powerful motive for their involvement in providing and are having fewer children. Middle-class families are
care, but they also seek recognition of their own emo- under increasing financial pressure. Both parents work-
tional distress. Finally, family members want information ing is the norm.
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Canada’s population growth (+0.9%) is largely due moved within the past 5 years (Vanier Institute of the
to immigration (the highest among the G7 countries, Family [VIF], 2010). About 37% had moved to another
exceeding that of the United States (+0.7%), the United location within their municipality, whereas more than 3%
Kingdom (+0.2%), France (+0.2%), Germany (+0.1%), as had moved to another province. This is noteworthy since
well as Italy and Japan, whose populations have remained mobility occurred most often among those 15 to 44 years
stable (Statistics Canada, 2015). More than one in five old, in which group families tend to be young and vulner-
Canadians were born in another country, and about 43% able. Mobility can trigger family stress, as families join new
of Canada’s population has origins other than Aboriginal, communities, establish friendships, schools, employment,
French, or English, according to Statistics Canada (2015). or handle a long-distance relationship (e.g., with an older
If the current trends continue, the provinces could parent or a spouse who works away from home). Many
become increasingly different in terms of the age struc- young families also experience difficulty with regard to cop-
ture, ethnic diversity, and population share. In 2014, for ing with their jobs as they are unable to call on their usual
example, the proportion of people aged 65 years and older supports (e.g., parents, grandparents, friends) for childcare.
at the national level was 16%. However, on a provincial Also, with the current downturn in the Canadian economy,
basis, this proportion ranged between 11% in Alberta it is increasingly common for a parent in the Atlantic Prov-
and more than 18% in Nova Scotia and New Brunswick, inces to leave the family behind and move to the Western
a seven-percentage-point difference in 2011. In addition, provinces for employment, which challenges family stability.
19% of Canadians belonged to a visible minority, but that
proportion ranged between 1% in Newfoundland and
Labrador and 27% in British Columbia, a difference of 26 Family: Trends in Marriage, Divorce,
percentage points. (See Chapter 11.) Common-Law Relationships, and
Parenting
Cultural Diversity As with other social structures, the family (more than
9 million in Canada) is experiencing a number of signifi-
Canada is heavily influenced by diverse ethnic, religious,
cant changes. Although married couple families accounted
and cultural traditions. In 2011, 1.4 million Canadi-
for nearly 67% of families in 2011, their numbers are
ans (4% of the total Canadian population) reported
falling (down from 69% in 2006, 71% in 2001, and 80%
some Aboriginal ancestry (including Indian, Inuit, and
in 1986) (Statistics Canada, 2012). According to Statis-
Métis) (Statistics Canada, 2011). From 2006 to 2011,
tics Canada (2012), the number of common-law families
the First Nations population in Canada increased by
increased 13.9% between 2006 and 2011, which is more
23%; the Inuit population rose by 18%; and the Métis
than four times the gains observed for married-couple
population rose by 16%. The Aboriginal community is
families (3.1%). Lone-parent families increased by 8%
generally younger than their counterparts in the general
for a total of 16.3%, with higher growth for lone-parent
population, with close to half (46%) under the age of
families headed by males. For the first time in the history
25 years, compared with 30% of the non-Aboriginal
of Canadian census, common-law couple families were
population. Although some Aboriginal people live on
a higher proportion (16.7%) compared with lone-parent
designated reserves, many are integrated into the gen-
families. The number of same-sex couples rose by 42.4%
eral communities, and about half live in urban areas
between 2006 and 2011, with tripling of married same-
located in the Northern and Prairie communities west
sex couples, reflecting the legality of same-sex marriage.
of Ontario. Over a third (37%) of First Nations children,
Although almost 41% of marriages end in divorce
30% of Métis children, and 26% of Inuit children live in
(VIF, 2010), divorce rates are declining—reflecting lower
lone-parent families, nearly twice the rate of their non-
rates of marriage, increasing common-law partnerships,
Aboriginal peers (17%) (Statistics Canada, 2011).
and the drop that followed a peak subsequent to the 1986
Immigrants represent a large composition of the
amendments to the Divorce Act. The 2011 Census recorded
Canadian population. Between 2006 and 2011, over
a higher percentage of census families without children
1 million foreign-born people arrived in Canada repre-
(44.5%) compared with those with children (39.2%), a phe-
senting 20.6% of Canada’s total population (Statistics
nomenon first noted in 2006 (Statistics Canada, 2012). In
Canada, 2013). Before 1970, Canadian culture was pow-
2011, just over one-fifth of Canadians lived alone. This was
erfully shaped by European immigration; however, post-
a small percentage until the fifth decade or so, and 40.1%
1970 statistics reveal that the majority of immigrants
of persons over 80 years who were not institutionalized
now come from Asia.
lived alone (Statistics Canada, 2012).
In 2011, over 3.5 million step-couples with children
were counted and stratified as simple or complex families.
Mobility Of the step-families, 87.4% were simple step-families, com-
Canadian families are characterized by high mobility. In prising two parents and their children (Statistics Canada,
the 2006 census, over 40% of Canadian residents had 2012). In 2011, 10% of children 14 years and younger
M13_KOZI2703_04_SE_C13.indd 228 02/03/17 11:05 AM

Box 13.2 The Top 10 Trends for aside 13% of its disposable income, but by 2008, this
Canadian Families was down to only 3% (VIF, 2010). In 2011, personal debt
continued to climb; if household debt were spread evenly
Although these were written several years ago, current across all Canadian families, a family with two children
statistics attest to the fact that the top 10 trends for would owe approximately $176 461 (Certified General
Canadian families are still relevant:
Accountants of Canada [CGA], 2011).
• Fewer couples are getting legally married. The Canadian Income Survey (released July 2015)
• More couples are breaking up. reported the following using the low income measure
• Families are getting smaller. after tax (LIM-AT), an internationally used tool indicat-
• Children experience more transitions as parents ing that all persons in a household have low income if
change their marital status. their household income is less than half of the median
• Canadians are generally satisfied with life. income of all households:
• Family violence is underreported.
• According to the LIM-AT, 4.6 million people, or 13.5%
• Multiple-earner families are now the norm.
of the population, lived in low income in 2013, virtually
• Women still do most of the juggling involved in unchanged from 2012.
balancing work and home.
• Inequality is worsening. • In 2013, 16.5% of children aged 17 years and under
lived in low-income families. Among children living in
• The future will have more aging families.
two-parent families, 12.8% lived in low-income families.
Source: Sauvé, R. (2004). Profiling Canada’s families III. Ottawa, ON: The Vanier
For children living in lone-parent families headed by a
Institute of the Family. Retrieved from http://www.vifamily.ca. © 2007. woman, the incidence was 42.6%.
Reproduced with permission from The Vanier Institute of the Family.
• For seniors living in an economic family, the low-income
rate was 5.2%, while for seniors not in an economic
family, the rate was 27.1%.
lived in step-families. Almost 5% of this age group lived Nearly 10% of Canadians receive social assistance
with one or more grandparents, an increase from 2006. or welfare and have an income well below the poverty
These families are frequently intergenerational, including line. Reduced access to employment insurance and the
three generations (Statistics Canada, 2012). See Box 13.2 lack of affordable housing and dependable childcare
on the top trends for Canadian families. force many families to rely on social assistance at some
time (Morissette & Ostrovsky, 2007). Thus, almost 13%
of all Canadian households were living in poverty in
Family Income 2007 (VIF, 2010).
According to Statistics Canada (2015), In addition, as McIntyre et al. (2014) found, house-
holds dependent on social assistance are at increased
• In 2014, 69% of couple families with at least one child risk of experiencing food insecurity. Food insecurity
under 16 were dual-earner families, up from 36% also has been reported in households in which the main
in 1976. Among dual-earner families, almost three- source of income was employment or wages (work-
quarters had two parents working full time in 2014. ing households). Further, visible minority workers with
• In 2014, single-earner families made up 27% of all couple comparable education levels experienced higher rates
families with children, down from 59% in 1976. Families of food insecurity compared with European-origin
with two non-working parents accounted for 4% of couple workers.
families with children in 2014 (compared with about 6% According to Canadian Feed the Children (2014),
in 1976). Among the 27% of single-earner families, 16%
• One in ten Canadian children is growing up in poverty. In 2014,
had a stay-at-home mother and 2% had a stay-at-home
36.9% of food bank users were children under the age
father. Others (9%) had a parent that was either unem-
of 18 years (although they make up only 21% of the
ployed, attending school or permanently unable to work.
population).
• Between 1999 and 2012, the average wealth (or net
• One in four Aboriginal children in Canada is growing up in
worth) of Canadian families increased by 73% (from
poverty. In 2014, 13.6% of food bank users were Aborigi-
$319 800 to $554 100) in constant 2012 dollars.
nal persons (although they make up only 4% of the
• In 2012, families in the top income quintile held 47% of population).
the total wealth held by Canadian families, compared • The Aboriginal population carries a disproportionate burden of
with 45% in 1999. Families in the bottom income quin- nutrition-related illness, including nutritional deficiencies,
tile held 4% of the overall net worth in 2012, compared childhood obesity, and type 2 diabetes.
with 5% in 1999.
• Food insecurity for Aboriginal children (and adults) living on and
Canadian families are spending faster than they are off-reserve ranges from 21% to 83%, compared with 3% to
earning. In 1990, the typical household was able to put 9% for non-Aboriginal Canadians.
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Although nobody knows how many homeless peo- Box 13.3 Family Assessment Guide
ple live in Canada, it is estimated that from 150 000
to 300 000 are on the streets or in shelters (Human For each of the areas assessed, the nurse should consider
Resources and Skills Development Canada, 2010). The strengths, limitations, and opportunities.
March 2015 study by Employment and Social Devel-
Family Structure
opment Canada estimates that 2250 former soldiers
use shelters on a regular basis, about 2.7% of the total • Size and type: nuclear, extended, or other alternative
homeless population that uses temporary lodging. How- family
ever, since many homeless families do not go to shelters • Age and gender of each family member
or facilities, their numbers are not reflected in counts of
homeless persons, and they thus remain almost invisible. Family Roles and Functions
Instead, they live in unsafe, overcrowded housing, with
friends and family, or in cheap motels. These families • Family members working outside the home; type of
work and satisfaction with it
are often headed by lone-parent mothers struggling with
mental health issues, addiction problems, or abuse. Fami- • Household roles and responsibilities and how tasks are
distributed
lies who do access shelters are often forced to split up.
• Ways childrearing responsibilities are shared
• Major decision maker and methods of decision making
Families Providing Care • Family members’ satisfaction with roles, the way tasks
are divided, and the way decisions are made
More than 8 of 10 Canadians over the age of 85 years

have some form of disability, and more than 9 of 10 Physical Health Status
individuals with special needs or disabilities live with • Current physical health status of each member
their families in their own homes, their parents’ homes, • Perceptions of own health and other family members’
or their children’s homes. Families continue to provide health
much of the care required for family members who are • Preventive health practices (e.g., status of
aging or disabled. About 21% of women and 19% of immunizations, oral hygiene practices, regularity and
men provide care to seniors, but it is not known how frequency of visits to the dentist, regularity of visual
many families care for a child or family member with examinations)
a disability (VIF, 2010). Caregivers make a significant • Routine health care, when and why physician last seen
contribution to the health and well-being of the country;
indeed, they are the very foundation to the nation’s long- Interaction Patterns
term care system (Gibson & Houser, 2007).
In a recent report on cost of caregiving, Janet Fast • Ways of expressing affection, love, sorrow, anger, and
so on
(2015) argued that the number of people requiring care
will increase significantly in coming years, whereas fami- • Most significant family member in person’s life
lies’ capacity to meet those demands will decrease as a • Openness of communication with all family members
result of demographic and socioeconomic factors—fewer
children, more divorce and remarriage, more geographic Family Values
mobility, more adult children employed. In 2012, 28%
• Cultural and religious orientations; degree to which
of Canadians ages 15 years or older (8.1 million) were cultural practices are followed
caregivers. Caregiving can be demanding; most caregiv-
• Use of leisure time and whether leisure time is shared
ers (74%) spent under 10 hours per week on care, but with total family unit
for 10%, it occupied 30 or more hours, equivalent to a
• Family’s view of education, teachers, and the school
full-time job. system
Financial costs of caregiving include those related to
• Health values: how much emphasis is put on exercise,
care labour, employment restrictions, and out-of-pocket diet, preventive health care
expenses. Fast argued that there is an increasingly urgent
need to correct deficiencies in approaches. She called for
Coping Resources
a comprehensive caregiver policy strategy based on four
pillars: (1) recognizing caregivers and their rights, (2) ade- • Degree of emotional support offered to one another
quate, accessible, and affordable services for care receiv- • Availability of support persons and affiliations outside the
ers and caregivers, (3) work–care reconciliation measures, family (e.g., friends, church memberships)
and (4) measures to protect caregivers’ income security. • Methods of handling stressful situations and conflicting
Older adults often serve as caregivers for their part- goals of family members
ners, but women between the ages of 35 and 54 years are • Financial ability to meet current and future needs
most likely to provide unpaid care to seniors, and they do
M13_KOZI2703_04_SE_C13.indd 230 30/01/17 4:41 PM

so while maintaining other career and family responsi- Unfortunately, much of this family information is
bilities. Little is known about children who serve as care- lost because it is not documented or communicated.
givers, for example, to a lone parent with a debilitating More structured documentation about the family can
mental illness, out of fear of having the family separated be facilitated by a genogram inquiry (Wright & Leahey,
if authorities are informed. 2013). The genogram is a concise visual depiction of
Caregiving affords many personal rewards. How- the family structure and relevant situational informa-
ever, there are numerous physical, psychological, social, tion that can be sketched on nursing admission forms or
and financial risks assumed by family and friends provid- progress notes and used in numerous areas of nursing.
ing care (Gibson & Houser, 2007; VIF, 2010). Unfor- Mapping out a genogram can be brief (minutes) or
tunately, limited health care resources or government the focus of an entire family assessment interview. The
financial supports and lack of employment flexibility or nurse can introduce the genogram by explaining that it
respite alternatives isolate caregivers and can increase helps the health care team understand the family situ-
their distress and burnout (VIF, 2010). The current ation and provide more effective care, for example, by
health care system would not function without informal identifying others who might be involved in the care, have
caregivers. Nurses are, however, in a position to give access to information, or assist with discharge planning.
them the much-needed support. See Box 13.3 on the Figure 13.2 illustrates an example of a detailed
family assessment guide for nurses. genogram and common conventions for constructing
these diagrams. The situation involves a family in which
the father, Ron, is hospitalized following a heart attack.
Understanding Families He is a long-haul truck driver and divorced from Susan,

with whom he had two children (Scott and Evan). Ron
is now married to Elaine, a licensed practical nurse.
Nursing care of families begins with understanding the Together, they have a daughter, Katie. Elaine is the main
family at a particular point in time, that is, who is involved caregiver for her mother, the only living grandparent in
and how. It is not realistic to expect that the nurse will the family, who lives a 45-minute drive away. The family
“fix” all the past, present, or future problems confronting resides in a small city in which one of the main industries
the family. However, it is reasonable to expect the nurse is closing. Ron does most of his driving for this company.
to assist the family to navigate through a particular dif-
ficulty with a health problem or life transition. Illness
affects the family, and the family affects the illness (see
Figure 13.1). By exploring both segments of this recipro- 1987 1997 2000
cal loop in clinical conversation, the nurse can uncover
many areas of inquiry that inform the nurse and create 59 yr 65 yr 79 yr Gail
79
openings for addressing concerns of family members.
At a minimum, the nurse must acknowledge the Heart attack Heart attack Stroke Lives alone
presence of family members, inviting their questions and
concerns, explaining the value of family to patient health,
and welcoming their participation. More specifically, the
nurse can ask the patient about the extent to which family d.1989 m.1991
Susan Ron Elaine
members should be involved in care, what family mem- 45 39
bers understand of the health situation, and, if appropri-
ate, provide clear, honest information, answer questions, June/01 Heart Attack Licensed practical
and strive for consensus (Davidson et al., 2007). Long-haul truck driver nurse (full time)
Work stress Main caregiver
for mother
Scott Evan Katie

20 17 8
Living with mother Worries about Dad
Genogram Conventions
Family Health and Illness S 1999
Male Marital separation
D 2000
Female Divorce
Index person Death (Indicate year)
Abortion/Miscarriage
(Indicate year)
FIGURE 13.1 Reciprocal influence between family and health

or illness. FIGURE 13.2 Family genogram.
M13_KOZI2703_04_SE_C13.indd 231 25/02/17 2:36 PM

The nurse can introduce the genogram with basic

questions about individuals’ ages, interests, and occupa- Brothers—
tions. Age-appropriate questions can also be directed to not involved
young children about school, friends, and favourite games in mother’s
Mother— care
or toys. Beginning questions usually focus on the family Fear of job awaiting
cutbacks— nursing home
members currently residing together or who are involved work stress placement
in some way in the health care situation. However, inquiry Licensed
practical
should also explore other family relationships that seem nurse at
to be relevant to the current situation. For example, in hospital, shift
work
Figure 13.2, the genogram inquiry uncovered the 8-year- Ex-wife
(parenting
old daughter’s worries about her father’s health, Ron’s conflict) Ron Elaine
significant family history with heart disease, and Elaine’s
caregiving responsibilities for her aging mother. Community
nurse
The genogram inquiry may reveal recent losses in Katie
the family or significant family events that may contribute
Cardiologist
to concurrent stress or difficulties confronted by the fam-
ily. Asking questions about relationships with previous
marital partners who are involved in ongoing co-parenting School,
responsibilities may also be important. For example, the Golf Dance Grade 3
nurse could ask Ron how his ex-wife, Susan, believes that weekly lessons
Scott and Evan have been reacting to the news of his heart
attack. This discussion not only builds an understanding
Ecomap Conventions:
of Ron’s relationship with the two sons but also the nature
strong connections stressful relations
of his relationship with his ex-wife. It is important that the
tenuous connections stronger relations
genogram questions explore and focus on family concerns
and the impact of the health problem on family members
and their relationships. Conversations can begin with
FIGURE 13.3 Family ecomap.
more general questions (e.g., “Tell me about. . .” or “Help
me understand. . .”) and then become more specific (e.g.,
“You said that the kids have become quite quiet around • To understand the family’s support network: Are there any
you. . . wondering if they are afraid to talk about your other religious groups, self-help groups, or personal
heart attack. . . out of fear of causing you more harm”). relationships outside your family that either have been
As they explore the genogram information together, the supportive to you or have contributed to your stress?
nurse and the family members can become more engaged
and committed to working together. Initiating a genogram The ecomap can also depict the dynamic nature
inquiry can be an intervention that encourages the nurse of the relationships and stressors with extended fam-
and the family to “think family” and to consider the impact ily members, work colleagues, or friends. For example,
of the situation on all family members. Figure 13.3 helps highlight many external demands on
The context and external environment of the fam- Elaine. In addition to coping with her husband’s heart
ily can similarly be explored by sketching an ecomap attack, she does shift work and is a caregiver for her
(Figure 13.3). This diagram uses symbols to depict the mother. She is dealing with the transition of placing her
family’s connections to larger systems, including commu- mother in a nursing home, which is often difficult, with
nity agencies, health care providers, work, church, friends, little apparent support from her brothers.
and other meaningful activities in their lives (Kaakinen, Each circle on the ecomap represents an outside
Gedaly-Duff, Hanson, & Coehlo, 2011; Wright & Leahey, contact with either an individual or the entire family.
2013). The symbols are able to express relationships in Straight lines are drawn to indicate the intensity of help-
ways that may be inadequately portrayed in words (Ray ful relationships (for either party); dotted lines indicate
& Street, 2005). The genogram of family members shar- ambivalent relationships; and slashed (or jagged) lines
ing a household is sketched at the centre of the diagram. indicate difficult or stressful relationships. The ecomap
Ecomap questions could include the following examples: can heighten the nurse’s awareness of the possibility of
social isolation or of family overload with multiple over-
• To understand how connected the family is with other resources: lapping connections with health care professionals or
Are there any other clinics, health care professionals, or agencies. The number of identified contacts in the social
community agencies that are involved with your family network should not be assumed to indicate that support
regarding this health concern? is provided or received or that such contacts are easily
• To understand the family’s level of satisfaction: Which of these accessible. The ecomap inquiry provides an opportunity
contacts have been most or least helpful to you? to explore the nature and quality of these networks.
M13_KOZI2703_04_SE_C13.indd 232 27/02/17 1:21 PM

How Does Illness Affect the Family?

EVIDENCE-INFORMED
Exploring the impact of illness on the family increases PRACTICE
the nurse’s appreciation of the distress and suffering of
all family members, including the person who is experi-
encing the health problem (Wright & Leahey, 2005). The
What Are the Consequences for
long-term impact of illness demands will differ when Nurse–Daughters Who Are Caring
the family is confronted with the ill person’s recovery for Older Parents?
from an acute illness episode, compared with those who
face these responsibilities on an ongoing basis, as with a These authors have been examining the experiences of
registered nurses who were also daughters of older par-
chronic or debilitating illness (Hopkins & Brett, 2005).
ents. For this study, they interviewed 20 nurses who care
Instrumental functioning of the family (i.e., activities for their older relatives. Qualitative analysis revealed themes
of daily living [ADLs]) may be affected. If caring for a indicating situations where the boundaries between profes-
person who is ill or recovering at home, family members sional identity and work were blurred with personal identity
may need to assist with hygiene or mobilization, medi- and work. These nurses were often so caught up in their
cation administration, changes in meal preparation, or relatives’ health care needs, in addition to their professional
follow-up visits to doctors and clinics. work, that they developed what is described as compas-
sion fatigue. In fact, some of the participants noted that
Illness may also impact expressive functioning and
the continuous balancing between work and family could
communication within the family (Gjerberg, Førde, & and did result in the nurses experiencing adverse health
Bjørndal, 2011). Anxiety, depression, and uncertainty not themselves.
only can cause distress for the person who is ill but may
NURSING IMPLICATIONS: With an aging nursing pro-
also be an even greater difficulty for others in the family,
fession caring for older relatives, society needs to
including discussing their distress and worries. Com- re-examine its expectations of care from professional
munication patterns may shift as family members either family members, and the support available for families
address these concerns together or conceal these worries to ensure that all needs are met.
from each other. Family members often feel compelled
Source: Based on Ward-Griffin, C., St-Amant. O., & Brown, J. B. (2011). Compassion
to maintain an optimistic attitude regarding the future fatigue within double duty caregiving: Nurse-daughters caring for elderly parents. The
and family roles may shift dramatically. If one partner Online Journal of Issues in Nursing,16(1), 4. doi: 10.3912/OJIN.Vol16No01Man04
is unable to work and struggling with physical limita-

tions, the other partner may be pressed to take on new
responsibilities for childcare, household maintenance, or human immunodeficiency virus/acquired immunodefi-
employment. Every new diagnosis, change in treatment ciency syndrome (HIV/AIDS), nurses need to be sensi-
plan, or contact with a new health care setting potentially tive to the fact that making a disclosure to family is not
has an impact on family members, including height- only a difficult task but may require different approaches
ened vulnerability to illness in other members (Goodwin, according to gender, sexual orientation, and cultural
Wickramaratne, Nomura, & Weissman, 2007) (see the background (Przybyla, Golin, Widman, Grodensky, Earp,
Evidence-Informed Practice box on the consequences for & Suchindran, 2013). Examples of questions that may be
nurse–daughters who are caring for older parents). helpful for exploring the impact of illness on the family
Nurses need to encourage productive conversations are provided in Box 13.4.
that explore family understandings of the impact of ill-
ness. Such discussions can help family members listen to
the concerns of others and become mutually supportive. BOX 13.4 EXAMPLES OF QUESTIONS THAT
The nurse may help a family who is hesitant to EXPLORE THE IMPACT OF ILLNESS ON
raise sensitive matters by asking members to meet together, THE FAMILY
introducing topics, and helping them explore the issues. The nurse can ask these questions to help a family work
Alternatively, the nurse may meet privately with individual through the illness of a family member:
members with an understanding that some highly stig- • What do you think has been the most difficult change
matized behaviour and health conditions are disclosed at that each of you has had to deal with since the heart
considerable risk to those affected. For example, the nurse attack? How do your views compare with those of the
other members of your family?
may meet alone with a mother who has brought her child
to the pediatric emergency room, to initiate a discussion • Of all your family members, who do you think is worrying
the most about what this new diagnosis means?
of interpersonal partner violence. In this case, the nurse
• Of all the things that you or your family are confronting as
needs to first wait until the child’s health problem has you prepare for discharge, which ones do you think we
been addressed and then, when raising the possibility of could try to address today?
abuse, reassure the mother that immediate assistance is • What do you anticipate will cause the most difficulty for
available, if needed (Hawley & Hawley Barker, 2012). In each member of your family when you return home?
the case of sexually transmitted infections (STIs), such as
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How Does the Family with opportunities to help the family recognize their own
strengths and capability and explore other possible ways
Affect the Illness? of coping based on the family’s knowledge. These con-
versations help the nurse understand the family’s usual
ways of coping with difficulties. Exploration of family
Just as the illness has an influence on each family mem-
strengths in illness management is an often-neglected
ber, each family member also has an influence on the
domain of inquiry. Some examples of questions that
illness (Morrison & Meier, 2011). Family members cope
explore family influence on the illness are provided in
with and respond to the illness in many different ways—
Box 13.5.
each journey is unique and different from that of the
patient. However, the need for support, information,
valuing, and respect is the same. Therapeutic conversa-
tion in this domain helps uncover ways family members
have found to manage the demands of the illness in Nursing Care of Families
their daily lives. They may be overwhelmed by illness
demands that compound other concurrent life stressors. As stated earlier, nursing care of families is exercised
A new diagnosis may challenge family members to seek almost exclusively through relational practices. Even
new information and to figure out what this means for if there are only one or two family members directly
their lives. involved in the health care encounter, the nurse–family
Family members typically attempt to offer help and relationship is more complex than when working with
encouragement to the person who is ill or recovering. individual clients. The nurse needs to engage and under-
On occasion, family offers of support are seen by the stand each family member to elicit concerns and invite
person who is ill as intrusive or as a limitation to their questions. Family members and patients may hold simi-
independence. Conversations about these attempts to lar or different perspectives and may require different
influence illness can help family members understand supports. The nurse needs to not only appreciate these
their sense of helplessness and explore how they would multiple perspectives but also attempt to respond in ways
most prefer to be involved, to limit the caregiving bur- that account for these similarities or differences. Nurses
den, and to enable family members to show their caring can enhance their family nursing practice by using the
in a manner that is experienced as supportive. In some guidelines in Box 13.6.
instances, the illness may compound other life stressors.
Marital discord, difficulties with parenting of teenagers,
unemployment, and conflict within the extended family Engaging in a Collaborative
are examples of adverse circumstances that can interfere
with family coping and increase the complexity of family
Relational Stance
involvement during health care encounters. Relational practices are influenced by nurses’ beliefs
Conversely, conversations that explore family about the kinds of obligations we have toward family
responses to illness can reveal incredible capability and members, about our expectations of family members,
competency on the part of family members. Learning and about the skills and knowledge that nurses bring
about the family’s resourcefulness provides the nurse to family encounters. Ideas about whether nurses are
responsible to care for family members and what ought
to be done in terms of family care may not be clear.
Box 13.5 Examples of Questions That The nurse’s stance toward the family is influenced by
Explore the Impact of the Family on
Illness
These questions can help debrief families when someone Box 13.6 Family Nursing Practices
experiences an illness:
• What has been the most helpful thing that your Effective family nursing practices include the following:
family has done for you that has made a difference • Engaging in a collaborative relational stance
to this hospitalization?
• Asking reflective questions
• What has each of you learned about limiting stress
that will be most useful to you when you return • Enabling access to the patient
home? • Eliciting illness narratives
• How have each of your family members been most • Commending family and individual strengths
helpful to you as you have been preparing for
• Offering information
discharge?
• How would you like each of your family members to be • Creating and encouraging family support
involved in your recovery at home? • Suggesting respite from caregiving
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BOX 13.7 QUESTIONS INVITING NURSING of blaming and criticism helped family members speak
REFLECTION ON RELATIONAL STANCE with less reservation. Families appreciated the nurse as a
mirror for family strengths, whose positive orientation toward
A collaborative relational stance is important in the nurse– strengths, resources, and possibilities fostered family con-
family relationship. Use the questions that follow to evaluate fidence and capability. Collaboration entails working with
your own relational stance:
the family to co-evolve shared understandings of the
• Do my actions and comments acknowledge the difficulties they are encountering. Together, the family
strengths and abilities of this family?
and the nurse generate other possibilities for dealing with
• To what extent did I elicit the patient’s and family mem-
health concerns or illness. A collaborative relational
bers’ expectations, hopes, questions, and ideas?
stance is one that values the multiple ideas and perspec-
• How frequently are decisions about the patient’s health
care made mutually by the patient, the family, and tives that are inevitably encountered within the family
myself? and demonstrates respect for family strengths and capa-
• What can I learn from this family about their experiences bilities in addressing health concerns and living with ill-
in living with this health problem? ness. It is through the process of “shaping mutuality” that
• To what extent am I imposing my beliefs on the family? the nurse and the family caregiver learn to collaborate
and achieve their individual goals and desired outcomes,
Source: Leahey, M., & Harper-Jaques, S. Family-nurse relationships: Core both for the patient and for themselves (Camargo-Borges,
assumptions and clinical implications. Journal of Family Nursing, 2(2), 133–151. & Moscheta, 2014; Jeon, 2004).
Copyright © 1996 by SAGE. Reprinted by Permission of SAGE Publications.
Asking Reflective Questions

the habits, practices, concerns, and skills the nurse A series of studies have consistently shown that families
brings to the situation (Browning & Warren, 2006; find nurses to be particularly helpful when they ask
Sturdivant & Warren, 2009). In family nursing, rela- good questions (Marshall & Harper-Jaques, 2008; Wand,
tional stance refers to the thoughtful and purposeful 2010). The best questions enable them to think differently
choices that nurses make in clinical practice about about themselves, about other family members, and
the ways that they will engage and involve families about health and illness—both in the present and
and respond to their concerns (Tapp, 2000; Walker & future. Wright and Leahey (2005) described reflective
Dewar, 2001). Families feel engaged when information questions as interventional because they not only
is shared and they are included in decision making per provide information to the nurse but also facilitate changes in
the patient’s wishes, when there is someone to contact the family as new information emerges in conversations.
when needed, and when services are responsive to Family members come to understand each other, their
their needs (Repper & Breeze, 2007; Walker & Dewar, difficulties, and possible solutions differently as they
2001). Nurses can evaluate their relational practice by listen to each other’s responses to reflective questions.
asking themselves some questions, such as those sum- Table 13.1 summarizes examples of reflective questions,
marized in Box 13.7. including difference questions, behavioural effect
It is often assumed that having a good nursing rela- questions, and hypothetical/future-oriented
tionship with the patient and family will increase the questions (Wright & Leahey, 2013). In addition, the
effectiveness of their work together. Robinson’s (1996) three most common errors in family nursing are also
research challenged nurses to reconsider relational prac- included along with strategies for avoiding such mistakes
tices—to see that they not only create a context or (Wright & Leahey, 2013).
climate in which “interventions” can be more effective
but that these relational practices in themselves are
interventional. This research described examples of Enabling Access
relational practices that were noticed by family mem-
bers in this study of women and families experiencing
to the Hospitalized Patient
chronic illnesses. Within inpatient practice settings, an issue commonly
They described the nurse as a curious listener, who encountered by families is that of visiting hours (Sarode,
found a balance between listening and asking good ques- Sage, Phong, & Reeves, 2015). Hospital policies regard-
tions that focused conversation and brought out in the ing visiting hours may impose constraints for family
open significant differences in family perspectives. They members who want to be present at the patient’s bedside.
viewed the nurse as a compassionate stranger, someone who Reasons for limiting family access may include concerns
was deeply interested in the family’s situation and yet had for patient rest and privacy, infection control, limited
some objectivity and could offer a new point of view that space at the bedside, patient instability, and the pos-
was impartial to various family members. Families valued sible impact of viewing procedures on family members.
the nurse as a nonjudgmental collaborator, whose avoidance Nurses may not be comfortable when family members
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TABLE 13.1 Types of Reflective Questions
Types of Question Examples
Difference Question
Explores differences among people, Who do you think will be most affected by this new diagnosis of heart
relationships, time, ideas, or beliefs disease as you return home?
What impact has this experience with a heart attack had on your
relationship as a couple?
Behavioural Effect Question
Explores the effect of one family member’s When your daughter Katie is worried about her dad’s health, what do
behaviour on another you tell her?
How does Ron show his stress when his work is demanding?
What impact does this have on you, Elaine?
What impact does it have on Katie?
Hypothetical/Future-Oriented Question
Explores family options and alternative actions or What do you predict will be the most difficult change for you as you try
implications for the future to implement lifestyle changes?
How do you anticipate your family’s daily routine to be different when
you are discharged home?
Most Common Errors How to Avoid
Failing to create a context for change (being • Show interest.

curious about the problem)—the foundation • Obtain a clear understanding of the most pressing concern.
of the therapeutic relationship
• Validate each family member’s experience.
• Acknowledge the suffering and the sufferer.
Taking sides • Maintain curiosity.
• Identify all the perspectives (identifying does not equate with
condoning).
• Remember that all members experience some suffering during a family
illness/problem.
• Give equal time to each concern and each member.
• Treat all information as a new discovery.
• Avoid having private conversations with one family member reporting
on another.
Giving too much advice • Give advice, opinions, recommendations only after a thorough
assessment.
• Offer advice without believing that the nurse’s ideas are the best or
better.
• Focus more on asking questions than giving statements during initial
conversations.
Source: Wright, L. M. & Leahey, M. (2013). Nurses and families: A guide to family assessment and intervention (6th ed.). F.A. Davis Company, Philadelphia, PA with permission; and
Wright, L. M. & Leahey, M. (2005). The three most common errors in family nursing: How to avoid or sidestep. Journal of Family Nursing, 11(2). Copyright © 2005 SAGE. Reprinted by
Permission of SAGE Publications.
observe their performance of bedside care or technical be made by health care providers (Davidson, 2009).
procedures. Nurses may believe that the impact of an Access to the patient often means access to informa-
emotionally distraught family member at the bedside can tion. F
amily members who are present at the bedside
upset the patient. Sometimes, the patient may request may have more opportunities to consult directly with
limitations to family visiting. the health care team. When family members are able to
Family members may want to be present to provide access the patient, they also have more opportunity to
emotional support to the person who is ill or to protect understand their loved one’s condition, which, in turn,
him or her from harm through mistakes that could can help them gain confidence as they see the patient
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Table 13.2 Examples of Questions to Elicit Medical and Illness Narratives
Medical Narrative Illness Narrative
Could you describe the onset of the chest pain? What does it mean to you when the chest pains come and
are very unpredictable?
Have you had any acute health problems or chronic Of all of the health problems that you have encountered in
illnesses in the past? the past, what has been the most difficult thing you have
had to deal with?
Does your extended family have any previous history of What have you learned from your parents’ experiences with
heart disease? heart disease that might be helpful during your own
recovery?
Have you had any cardiac diagnostic tests done in Based on the diagnostic tests that you have had done,
the past? what are your predictions about your health in the
future?
Which of the following cardiac risk factors would apply to you? Tell me how it has been for you and your family as you have
(e.g., smoking, sedentary lifestyle, high-fat diet) tried to incorporate the lifestyle changes that have been
recommended.
progress in strength and recovery or assist them to process, and concurrent or past illness problems for the
prepare for difficulties and loss. Nurses have a respon- person or other family members. In contrast, illness
sibility to facilitate that understanding. Families want narratives seek understanding of the person’s or the
different kinds of information in different situations, family’s experience of illness in the ordinary acts of
and it is important to determine the kind of informa- everyday living; the influence of illness on relationships
tion needed. with family, friends, and workmates; the ill person’s
Nurses interpret hospital policy and unit guidelines ability to gain influence over the impact of illness in
and often have discretion to be flexible with visiting their lives; and the stories told of encounters with the
rules when warranted in particular situations or to health care system. Both medical and illness narratives
collectively generate a unit culture that is more family are important and useful, and nurses must be able to
friendly. Many nurses argue that visiting hours require conduct both forms of inquiry (Anderson & Kirkpatrick,
balancing the visitors’ needs for information and access 2015). Table 13.2 offers examples of questions that
to a loved one with the nurse’s need to safely manage the illustrate the differences between medical and illness
care of a critically ill individual. Studies of the effects narratives.
of visiting on mental status and various physiologi- Eliciting illness narratives with families is an impor-
cal systems have shown no physiological rationale for tant relational practice. These stories help the nurse
restricting visitors (Chakma & Ocampo, 2011). Many understand family strengths and difficulties and also
pediatric settings and, increasingly, adult intensive care help patients and their families come to terms with
unit (ICU) or emergency settings show positive effects their own experiences. In the telling of these stories,
on the family when they have open, unrestricted visiting people reach a new understanding of their experiences
policies, even during resuscitation (Kenner et al., 2015). with illness. Family members are better able to appreci-
However, these situations require adequate preparation ate what is happening and to realize that their experi-
of the family, availability of support personnel to help ences are both similar and different. Family members
the family through a crisis situation, and family debrief- may describe the telling of illness stories as therapeutic
ing and support following a crisis (Kenner et al., 2015). in itself (Browning, 2009). However, there are many
constraints against having illness conversations. Fam-
ily members may want to maintain privacy or may not
Eliciting Illness Narratives want to burden friends or other family members while
they expect to tell health care professionals their medi-
Nurses access the beliefs and meanings that people hold cal story.
about their day-to-day experience of illness through ill- When nurses elicit illness stories, they are drawn
ness narratives, rather than medical narratives (Morris, into the richly contextualized lives of the people they
1998; Schwind, Fredericks, Metersky, & Porzuczek, encounter. It becomes much more difficult to objectify
2015). Medical narratives provide clinicians with or depersonalize people and easier to recognize the
information relevant to the nature and course of physi- strengths, resourcefulness, and capabilities of the family
cal symptoms, diagnosis and treatment of a disease members.
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Commending Family and Individual family members to accept, with comments such as the
following:
Strengths
“You have all really pulled together in wonderful ways
Nurses may adopt the stance that patients and families
to understand your son’s illness. Unfortunately, as
have strengths and capabilities, that they have solved
there is no cure for his illness, he will need increasing
problems before and are resourceful and only temporar-
amounts of care . . . care that is often painful.”
ily in need of assistance from health care professionals.
This stance heightens the nurse’s ability to recognize and Commendations offered at the end of a conversa-
elicit examples of the family’s resourcefulness through- tion can highlight change or support family choices that
out their work together. Examples of strength and capa- have emerged within the discussion through comments
bility appear in the illness narratives as persons and such as the following:
families tell of ways they have been able to manage
“It is quite remarkable how many decisions you have
or live with a health problem or illness. When nurses
made today, given that when we started our discussion
acknowledge strengths directly to the family, the practice
today, each of you said that you were in no position to
of offering commendations (Limacher & Wright, 2006)
make any decisions.”
emerges. This practice can help families recognize their
own strengths and realize that these can be transferred
to other situations and are valued by other health care
professionals. Offering Information
Commendations are statements of praise that Families indicate that obtaining information about the
identify individual and family strengths, and support the health situation greatly assists them to make decisions,
development of the nurse–patient–family relationship to cope more effectively, and to be able to support their
to engage the family to meet their needs and identify ill family member appropriately (Davidson et al., 2007;
resources for problem solving (Limacher & Wright, Momen & Barclay, 2011). Nurses play an important
2006; Moules, 2009). When health problems arise, fami- role in providing information during acute episodes of
lies may be overwhelmed by difficulties and feel unable illness or for health promotion, recovery, and health
to cope with the uncertainty or transitions they are maintenance. Nurses are positioned in the middle of
facing. Commendations can help change the view that health promotion messages in the public domain and the
families have of themselves or their situations and sup- biotechnical jargon in acute care and can help families
port their confidence in each other. Commendations interpret this information. Also, nurses can offer infor-
support the idea that the patient and the family are mation to help people access appropriate services effec-
active participants who are in charge of their health or tively. They can provide handouts of resources, assist
life situation and can offer hope for the future (Moules, clients to navigate bureaucratic systems, make advance
2009). This practice can encourage families to continue contact to services, and make follow-up phone calls to
seeking further options to discover their own solutions families. These actions foster a sense of partnership with
to problems (Wright & Leahey, 2013). Commendations families and facilitate service access.
can also enhance connection in the family–nurse rela- Family members other than the ill individual may
tionship as the nurse conveys respect and appreciation play an important role in garnering information about
for the family’s contributions and efforts within difficult diagnosis, treatment, and health maintenance. The ill
situations. person may be less able to seek out or comprehend new
Commendations should echo the family’s own lan- information because of illness, effects of medications,
guage and fit with their values and perceptions of their or invasive diagnostics and treatment. By informing
experiences. When the nurse does not know the fam- and educating family members, the nurse helps them
ily well, commendations can be offered as “beginning understand the illness events, anticipate likely events on
impressions” of what they have been doing well. Com- a trajectory of illness, and prepare for their caregiving
mendations can be introduced by comments such as the roles (Momen & Barclay, 2011).
following: Nurses often make assumptions about the kind of
information that would be most helpful to particular
“What I’ve noticed about your family [or about what
persons or families. However, it is important to discuss
you’ve told me] is that . . .”
with the family the kind of information they would like
“I’m really impressed by the way that . . .” to get. Nurses often believe that more information will
“I appreciate how you have been able to . . .” result in decreased anxiety, but it is not always so. Nurses
“I’m wondering if your talent in this situation is the can be very helpful to families by assisting them to locate
way that you . . .” other sources of information, such as availability of self-
help or support groups, public service groups, websites,
It may be helpful to offer a commendation prior to or community resource centres. The challenge is to offer
offering an opinion or idea that might be difficult for resources (information and support) that address family
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questions or needs in a timely fashion (as needed) and in concerns, come to appreciate the perspective of other
suitable ways (e.g., plain language). members, and discuss how each person would prefer to
both receive and offer assistance.
Creating and Encouraging Family Support

When nurses are thinking in a family context, they are
Suggesting Respite from Caregiving
more likely to be aware that all family members may Families differ in their desire to be directly involved
be in need of various degrees of support. The health in caregiving. For example, Benner, Hooper-Kyriakidis,
care literature often conceptualizes family support as and Stannard (1999) suggested that family members of
a form of social support—the provision of emotional, patients who are chronically ill and hospitalized may
instrumental, informational, and appraisal assistance wish to participate in familiar caregiving rituals (such
that helps to buffer stress. It is not unidirectional, as grooming, assisting with meals, comfort measures) to
but rather reciprocal and mutual as individuals maintain connection. Others may be exhausted from
attempt to be supportive of each other. Therefore, in caregiving at home and welcome respite from these
health care, the focus remains not solely on the patient demands. It is important to encourage family participa-
but, instead, on identified caregiver(s) and other family tion in caregiving to the extent that they desire, but this
members as well. should be facilitated following careful exploration of the
Social support is not simply “nice to have”; it actu- preferences of both the patient and the family (McIntosh
ally plays a critical role in psychological health (Deci, & Runciman, 2008).
La Guardia, Moller, Scheiner, & Ryan, 2006; Koestner, Ward-Griffin (1999) explored transitions in caregiv-
Powers, Carbonneau, Milyavskaya, & Chua, 2012). In ing between community nurses and family members
addition, giving support has been found to be a stronger caring for an older person at home. Although initially,
predictor of psychological health than the act of receiving family members were grateful to be of assistance, they
support (Deci et al., 2006). Further, the perceived quality reported a feeling of being overwhelmed, which ulti-
of social relationships and the extent to which they are mately led to caregiver burden (Parker, Teel, Leenerts,
experienced as supportive is most important. Nurses can & Macan, 2011). Another study by Leenerts and Teel
assist family members to listen to each other’s concerns, (2006) explored communication skills used by nurses to
feelings, and stories and make meaning of illness and create partnerships with the older spouses of persons
health care encounters, thus increasing the possibility for with dementia who are their caregivers. Conversations
them to be supportive of each other. Family members that resulted in partnerships depended on one theme
may seek guidance about how they can be supportive of only: relational conversation—that is, conversation that
the ill person. These needs typically arise at times when included listening with intent, affirming emotions, creat-
family members are also experiencing distress, concern, ing relational images, and planning enactment.
and need for emotional support. Nurses can help fam- Financial constraints may make it difficult for fami-
ily members discuss their preferences about the kind of lies to secure respite from caregiving. Research shows
assistance or support they desire from each other (Tapp, that caregivers who are poor, married, have a poor
2000). For example, following an acute episode of illness, health status, provide care for a long time, care for
the patient may want to regain a sense of independence patients with poor performance status, and pay high
but family members may have difficulty gauging how medical expenses are more likely to lose their family
much assistance the patient desires. As another example, savings (Li, Mak, & Loke, 2013). Household income
following diagnosis of diabetes, family members fre- may be reduced as a result of the person’s inability to
quently attempt to be helpful through watchful monitor- work, or family members may be forfeiting income to
ing of medications, activity, or diet while the person who be available to the family member who is ill. Finances
is ill may find these reminders unhelpful or intrusive. At may limit options to compensate a replacement care-
the same time, it can be hurtful to family members when giver, and it may be difficult for family members to
their well-intended efforts are rebuffed. allow themselves to take respite from caregiving without
The person who is ill may be self-absorbed with guilt (Golla, Mammeas, Galushko, Pfaff, & Voltz, 2015;
the experience of illness and recovery and may be less Wright & Leahey, 2013). Also, the person who is ill may
aware of impacts on other family members. Illness con- be reluctant to accept help from an alternative caregiver.
versations may be constrained by a desire to maintain a Possible constraints should be explored with the family,
positive attitude. Family members may be reluctant to perhaps by discussing the implications should the care-
discuss their own needs or frustrations, especially if their giver get rundown or ill without a break, or measures
distress is motivated by worries about the future or the that would give the caregiver comfort if respite care
prognosis. These difficulties can contribute to significant were provided.
family conflict. Using reflective questions, the nurse can Many possible options are available for respite
assist family members to explore their perceptions and care. Regularly obtaining a few hours away from home
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may be sufficient for some, whereas others may prefer opportunities for fostering ongoing development in clini-
an extended vacation. Respite programs may be avail- cal skills that enable nursing care of families to be pro-
able either to provide care in the home or for temporary vided in a respectful and healing manner.
inpatient placement. Unfortunately, for many families,
respite care must be provided by other family members
or friends. BOX 13.8 EVALUATING THE NURSING CARE
OF FAMILIES
Gaining feedback from the patient and family about their
Evaluating Nursing
experience of the family–nurse relationship is important for
professional development. These questions can assist in
Care of Families
getting started:
• Of all the things that we have talked about today,
which of these ideas, if any, seemed most useful to
Relational practices are inherent in nurses’ efforts to you? In what way is it useful?
evaluate their clinical practice with families (Dewar & • What else could we have talked about that would be
Nolan, 2013). Every encounter with patients and fami- more helpful?
lies provides opportunities for the nurse to invite them • Which family member do you think has benefited most
to express their viewpoint. The nurse can reflect on from our conversation? How?
the extent to which information was communicated to • If I were to encounter another family in a similar
situation tomorrow, what do you think I must discuss
families, how families were involved in decision mak- with them?
ing, and the ways that patient and family expectations,
• What advice would you give to me about working
hopes, questions, and ideas were discussed (Leahey & with other families who might be facing a similar
Harper-Jaques, 1996) and met. The nurse can also solicit situation?
feedback from the patient and family about their expe- • Is there anything in our work together that supported
rience of the family–nurse relationship (see Box 13.8). your confidence in dealing with this difficulty?
Their comments and suggestions may provide useful
Case Study 13
At the morning change-of-shift report on the medical unit of
a large city hospital where you work, you are warned about
2. How would you engage this family to foster a more pro-
ductive and collaborative relationship?
John’s “demanding family.” The family has recently immigrated
to Canada looking for a safer country to call home. They speak 3. How would you attempt to address their concerns?
English as a second language. The father, although a teacher in 4. What is the relationship between the health problem and
his home country, has been working as a dishwasher or cleaner the family members?
on nightshift when he can find a job. John (his Canadian name)
5. How might the family’s cultural background be affect-
is a 1-year-old boy who has been hospitalized for the past week
ing the parenting practices? How would you engage the
for diagnostic tests that have attempted to locate the cause for
family in a discussion about this matter?
his progressive neurological deficits. Test results have been incon-
clusive. The mother has not left John’s side since his admission.
Each morning, when the father arrives, he interrogates the nurse,
with limited English, about John’s progress overnight and the plan
of action for the day. The nurses are concerned
about what they describe as the father’s “overly
strict” parenting practices with John, and the
wife’s overly subservient attitude toward her
husband. The father approaches you as you
begin your shift.
1. How might the family’s cultural background be affecting

their response to this health situation?
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Key Term s
behavioural effect difference questions family unit as the client medical narratives p. 237
questions p. 235 p. 235 of care p. 226 mutual p. 239
census family p. 224 ecomap p. 232 genogram p. 231 reciprocal p. 239
collaborative relational family p. 224 hypothetical/future- reflective questions
stance p. 235 family nursing p. 224 oriented questions p. 235
commendations family support p. 235 relational stance p. 235
p. 238 p. 239 illness narratives p. 237 respite care p. 239
C hapter Highli g hts

• Definitions of “family” should include shifting social to employment, health care services, and recreational and
norms in family structure and each family’s mode of religious communities.
describing itself. • Reflective questions invite family members to think differ-
• Nursing care of families is based on relational practices ently about themselves, health and illness concerns, and
that involve family members in care, respond to their options for addressing concerns.
concerns, provide them with information, and/or offer
• Illness narratives help nurses more fully understand
emotional support.
the reciprocal influences between health and the fam-
• Family expectations of health care providers may include ily and can assist families to make sense of the illness
a desire for access to information about diagnosis and experience.
treatment, ability to trust that their ill family member will
receive good care and be treated compassionately, recog- • Commendations acknowledge and convey respect for
nition for their own involvement in care, and preparation family capabilities and strengths.
for their roles at home. • Families vary in their desire to be directly involved in
• The genogram inquiry helps the nurse demonstrate a caregiving activities and may need encouragement to take
concern for all family members, to document relevant a respite from prolonged caregiving.
information about those involved in the health situ- • Nurses can evaluate nursing care of families by reflecting
ation, to appreciate developmental transitions in the on their efforts to invite family questions and concerns,
family, and to begin to understand family relationships. by involving family members in decision making, and by
• The ecomap inquiry helps the nurse understand sources asking the family directly about their experience of the
of family support or stress by tracing external connections family–nurse relationship.
N CLE X- ST YLE PRACTI CE QUI Z

1. Chris, a 42-year-old father, is terminally ill. He continues 2. Skyla is an Aboriginal woman with rapidly advancing
to want to drive his children to school, but his wife, Susan, cancer. She has the choice of following the usual course
fears that his illness makes him an unsafe driver. Susan of treatment, known to have mixed outcomes, or try-
asks the nurse to reinforce her view. Which response by ing an experimental treatment with little or no clear
the nurse best reflects a family nursing approach? outcome data. The client asks the nurse to help her plan
a. “You have raised an important issue. However, this is for a discussion of the dilemma with her family. Which
a family matter and not really any of my business.” response by the nurse best indicates the use of a differ-
ence question?
b. “You both have very legitimate concerns. Can we
talk about some ways for you, Chris, to maintain a. “Who do you think will be most affected by these
independence despite your illness and for you, Susan, treatment choices?”
to ensure that everyone is safe?” b. “Are you nervous about your family’s reaction?”
c. “Chris, your wife is only looking out for your best c. “Your decision is very personal—no one but you can
interests. I know it is a painful reality, but you are too decide.”
ill to be driving.” d. “What effect do you think your cultural beliefs will
d. “Susan, I think driving is only one of many issues that have on your decision?”
you and Chris are going to have to address around your
husband’s illness. I’d like to refer you for counselling.”
M13_KOZI2703_04_SE_C13.indd 241 30/01/17 4:41 PM

3. Eight-year-old Darren was diagnosed with kidney 6. Ashley Jackson recently lost her job when the candy
disease 2 years ago. He lives with his parents and factory where she had been a line worker for 6 years
5-year-old sister in a small rural community 4 hours closed. Her oldest son, Tremaine, aged 4 years, has
away from the closest tertiary health centre. Since his asthma and needs weekly visits to the community health
diagnosis, Darren and his mother have travelled to the clinic to get established on a new treatment regime. The
city eight times—three times for admission. At first, the family has missed the last three appointments because
entire family came to the hospital, but now his father of the cost of transportation, but Ashley denies any
and sister stay home for work and school. Darren has financial difficulty when asked directly. What informa-
been hospitalized this admission for 3 weeks. The nurse tion would an ecomap inquiry regarding Ashley and her
notices that Darren’s mother is becoming exhausted; family provide for the nurse?
but when invited to take breaks, she politely, but firmly, a. Family financial information
refuses. What best explains the mother’s reaction as a
family caregiver? b. Developmental transitions in the family
a. Darren’s mother fears that Darren will not receive c. An understanding of family relationships
good care or be treated compassionately. d. Sources of family stress and supports
b. She has become overly possessive of Darren since his
hospitalization. 7. Grandparents Hester and Randy Bishop have had cus-
tody of their grandchildren (ages 10, 12, and 14 years)
c. She would actually be relieved if the nurse “ordered” for 13 months. The mother, who has been getting treat-
her to take a break. ment for a drug addiction, comes to visit her 12-year-
d. She wants to ensure that hospital staff consider her a old daughter, Sarah, who has been hospitalized for
“good” mother. minor surgery. Which response by the nurse best reflects
a family nursing perspective to the mother?
4. Tracy, an 8-year-old girl with cystic fibrosis, is hospital- a. “I can see that you care about your daughter, but as
ized with a respiratory infection. Even though she is you do not have custody, I’ll have to ask you to leave.”
very ill, the nurse notices that Tracy tries to help her
mother, who has been at her bedside night and day, by b. “I can see that you have made good progress with
doing simple tasks. What best explains Tracy’s demon- your addiction, so I think it is important that you
stration of social support? visit your daughter. If your parents do not want to
meet with you, then I will stay with your daughter
a. Tracy’s psychological development will be compro- during the visit.”
mised if she continues to take on caregiving respon-
sibilities at such a young age. c. “I can see that it is very important to you that your
daughter and family see that you care about Sarah
b. The nurse knows that she will have to explain to and are making a real effort to address your addic-
Tracy that although her gestures are very thoughtful, tion. However, this may not be an easy visit for your
she should call the nurse when she thinks her mother family. What challenges do you think your daughter
needs help as Tracy is too ill. and parents might have around accepting your visit?”
c. Relationships are reciprocal, and even though Tracy d. “I’ll have to ask your daughter and, if she agrees to
is young and ill, both she and her mother gain see you, then you are welcome to visit.”
strength when they each give and receive support.
d. Tracy is a born helper, and she should be encour- 8. The community health nurse is doing a hospital dis-
aged to help out on the unit, whenever possible. charge follow-up visit with 74-year-old Mrs. Pineau.
She recently suffered a cerebrovascular accident that
5. The nurse expresses her concerns about a client’s wife has caused some cognitive impairment with short-term
who has been at her husband’s bedside round the clock memory loss. She can still carry out many activities of
over the past 2 months to other team members. Misha, daily living (e.g., shopping, cooking, and going to the
the husband, has a terminal illness and is not expected to bank) with minimal assistance. In discussion with Mrs.
live more than a few weeks. He is a 36-year-old father of Pineau, the nurse learns that she has one son, who
three young children who immigrated to Canada 4 years rarely visits and does not appear to be very supportive.
ago with his family and parents. He had high hopes of Mrs. Pineau mentions that she is going to give her life
setting up his own engineering business but found him- savings to her son so that he can buy a house. Which
self driving a taxi. Misha has been the sole breadwinner immediate action by the nurse best reflects a family
for the family. The nurse notes that the family is in need nursing approach?
of additional supports. Which approach by the nurse a. Calling for a thorough assessment of Mrs. Pineau’s
best reflects family-centred nursing? mental competence
a. Demonstrating sympathy and making the hospital b. Telling Mrs. Pineau that her intentions may not be
environment as comfortable as possible for his wife a good idea and that she should call her lawyer to
b. Working with Misha’s wife to connect her with sup- discuss the matter
port services for the family situation c. Inviting Mrs. Pineau to discuss her intentions more
c. Calling regular family meetings and ensuring that fully and how she thinks family members, including
together, they plan and carry out a family plan of care her son, might view the decision
d. Introducing Misha’s wife to another family on the unit d. Calling individual family members to tell them of
with a family member with a similar terminal illness Mrs. Pineau’s intentions
M13_KOZI2703_04_SE_C13.indd 242 30/01/17 4:41 PM

9. Mabel, 70 years old, was diagnosed with Alzheimer’s 10. Eric is a 14-year-old boy who was diagnosed with cystic
dementia 2 years ago. She and her husband, Harold, fibrosis during infancy. His parents appear to be cop-
were adamant that they would stay in their home, even ing well, but they state that there are times when they
though their two children lived a 5-hour drive away and feel very alone when dealing with the chronic aspects
could visit only once a month. Mabel has been cared for of Eric’s condition. Which response by the nurse best
by her husband with the help of home care services reflects a family nursing approach?
(personal care workers under the direction of commu- a. “You seem lonely and depressed; talking to a coun-
nity health nurses). Mabel’s memory loss has now pro- sellor may relieve some of your concerns.”
gressed to the point that her husband is exhausted with
the caregiving responsibilities. Yet he fiercely denies that b. “You appear to be coping well. Although things may
the care is a burden. Which statement by the community seem difficult now, they will improve.”
health nurse best demonstrates a reflective response? c. “Would you like me to arrange for you to talk with
a. “I know that you love your wife very much, but her another family experiencing cystic fibrosis?”
care is wearing you out.” d. “You should join the Cystic Fibrosis Association. It
b. “Maybe it is time for your children to move closer so always needs volunteers, and it can help you meet
that they could help you care for your wife?” people.”
c. “I think your wife would be best cared for in a nurs-
ing home.”
d. “If she were well, what do you think your wife would
be telling your children?”
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Chapter 14
Community Health
Nursing
Updated by
Susan Duncan, RN, PhD
Thompson Rivers University
Tanya Sanders, RN, BScN, MSN

Thompson Rivers University
W
LEARNING OUTCOMES
After studying this chapter, you will be able to orking as a community
1. Describe the significance of the community health nursing role in home care nurse, you
the Canadian health care system. receive a call from the
2. Describe the philosophy and principles of primary health care as hospital discharge coordinator that a
the core of community health nursing practice. client with complex wounds is being
3. Identify the knowledge required for community health nursing discharged home. The client requires
practice. pain management and follow-up for
4. Describe the relevance of the following: ongoing laboratory work. Upon fur-
• The Canadian Public Health Association’s roles and activities of ther enquiry, you discover the client is
the public/community health nurse elderly, is frail, has had previous falls,
• The Canadian Association for Schools of Nursing entry-to- lives with an aging partner who has
practice public health nursing competencies for undergraduate dementia, and has not yet accessed
nursing education any services for home health care or
5. Explain essential aspects of collaborative practice in health care: support. It is the start of an assess-
definitions, objectives, benefits, and the nurse’s role. ment and engagement with this client,
6. Define the role of a community health nurse and identify the his or her family, and the community
various roles and specialty areas. to ensure that the client has the sup-
port, equipment, medication, and ser-
vices needed to become well again
and to manage his or her own care.
The above scenario illustrates
how community health nurses have
the opportunity to influence the
health of individuals, families, and c
M14_KOZI2703_04_SE_C14.indd 246 17/03/17 11:10 AM

Chapter 14 Community Health Nursing 247
c populations in a variety of community settings. In this chapter, we will explore the context of com-
munity health nursing practice in Canadian health care, roles in community health, and competencies
required for community health nursing.
What Is Community health nursing and one of its most important distin-
guishing features (Canadian Public Health Association
Health Nursing? [CPHA], 2010; Falk-Rafael & Betker, 2012). CHN theo-
rists explain that nurses are well positioned to pro-
mote health because they are with people in their most
Community health nurses (CHNs) support the
immediate environments. They see and understand the
health and well-being of individuals, families, groups,
conditions of living that lead to illness and those that
communities, populations, and systems (Community
are required to promote health (Falk-Rafael, 2005). The
Health Nurses of Canada [CHNC], 2012). CHNs work
scenario at the beginning of the chapter illustrates how
wherever people are in their communities—homes,
the community home care nurse develops an in-depth
schools, hospitals, clinics, recreational settings, and work-
understanding of the client and family in the home situ-
places. Because their main focus is on promoting health
ation and, on the basis of that understanding, is able to
and preventing illness, CHNs adopt a variety of theoreti-
see how illness can be prevented and how the optimal
cal perspectives to inform their practice. These perspec-
health of the family unit can be promoted. This proxim-
tives vary according to the specialty area of practice, for
ity to peoples’ lives positions nurses to understand how
instance, home health care, public health, community
some members are more vulnerable to being subjected
mental health, occupational health, and so on. Within
to poor health resulting from inequities in how they
the various specialty roles in community health nurs-
experience living conditions and access to the basic
ing, there are unifying features, including a focus on
requirements for healthy living. Several foundational
the determinants of health, the opportunity to prevent
perspectives and guiding documents inform community
illness and promote optimal health, concern for social
health nursing practice with vulnerable populations and
justice, and the emphasis on capacity building based on
the nurses’ roles in advocating for health.
human strengths (CHNC, 2012).
Figure 14.1 depicts the unique elements in the role of
Understanding the connection between individual,
the CHN in Canada and the perspectives that inform it.
family, and community health is essential in community
Secure resources to CHNs promote, protect

support health by View health as a
& preserve the health of
coordinating care, and individuals, families, resource & focus on
planning nursing groups, communities & capacities and
services, programs, and populations... strengths
policies
Build partnerships
Wherever people live,
based on principles Work with a high
work, learn, worship &
of primary health level of autonomy
play...
care
Building on the
Have a unique foundational education
understanding of the requirements of a BSN,
...in a continuous versus CHNs combine
influence of the episodic process specialized nursing, and
environmental public health science
context on health with experiential
knowledge
FIGURE 14.1 Unique characteristics of community health nursing.

Source: Adapted with permission from CCHN Standards of Practice PowerPoint (Slide 14) © Community Health Nurses of Canada.
Retrieved from www. https://www.chnc.ca/en/membership/documents. Further reproduction prohibited.
M14_KOZI2703_04_SE_C14.indd 247 25/02/17 2:44 PM

As health systems evolve, CHNs provide leadership BOX 14.1 FIVE PRINCIPLES OF PRIMARY
for the development of programs to provide essential HEALTH CARE
care where and when people need it. CHNs work across
health care settings, including institutions, homes, and The following five principles of primary health care are
clinics to facilitate the best access to essential services. endorsed by the Canadian Nurses Association:
Nurses provide leadership to develop new health pro- 1. Accessibility: A continuing and organized supply of
grams as the system changes and to meet emergent essential health services is available to all people, with
no unreasonable geographical or financial barriers.
needs of populations. According to the Canadian Insti-
2. Public Participation: Individuals and communities have
tutes for Health Information (CIHI), between 2009 and
the right and responsibility to be active partners in making
2013, the number of regulated nurses continued to decisions about their health care and the health of their
rise, with a small increase in the proportion of those in communities.
community-based settings. Fifteen percent of registered 3. Health Promotion: This is the process of enabling people
nurses (RNs) in Canada report community health as to increase control over and to improve their health.
their place of work, and an additional 11% of RNs in 4. Appropriate Technology: This includes methods of care,
Canada report “other” as their place of work, includ- service delivery, procedures, and equipment that are
ing some settings such as occupational health (CIHI, socially acceptable and affordable.
2014). The numbers of CHNs working across the health 5. Intersectoral Cooperation: Commitment from all sec-
tors (government, community, and health care profes-
care system is expected to increase steadily in the com-
sionals) is essential for meaningful action on health
ing years to promote health and provide care to peo- determinants.
ple where they are in their communities. CHNs must
Source: From Canadian Nurses Association. (2005). Primary health care: A summary
develop and expand their knowledge and skill in the of the issues. © Canadian Nurses Association. Reprinted with permission. Further
competencies required to practise in diverse community reproduction prohibited.
settings and to lead system change (National Expert
Commission, 2012).
Organization [WHO], 2008; National Experts Commis-
sion [NEC], 2012). The precursor of much of Canada’s
focus on health promotion and illness prevention was the
Community Health 1978 International Conference on Primary Health Care.
This meeting of the World Health Assembly resulted
Nursing in the Context in a report known as the Declaration of Alma-Ata (so
of Canadian Health Care named for the geographical location in which the con-
ference was held). In this report, the term primary health
care was coined by the WHO and the United Nations
The Canadian health care system is evolving. Expanding International Children’s Emergency Fund (UNICEF).
technologies, changing demographics, shorter hospital Subsequently, five principles central to the care delivery
stays, recent public health emergencies, and opportuni- philosophy were outlined (see Box 14.1). These prin-
ties to promote health and prevent illness are just some ciples are still commonly referred to today.
of the factors driving these changes. One of the most The Canadian Nurses Association (CNA) continues
striking changes has been the shift of health care delivery to endorse the philosophy and principles of primary
from institutions to the community and home environ- health care as the most effective way to achieve optimal
ments. Health care, once delivered predominantly in health care and health equity for the population (CNA,
hospital settings, is now routinely provided in the home 2015). Specifically, the CNA has recommended that
and other community-based environments. Although governments commit to a strong, publicly funded health
acute care institutions will undoubtedly remain a vital care system that permits universal accessibility to essen-
component of the health care system, their prominence tial health services, allows for public participation in
may be lessened in the future. health decisions, and emphasizes health promotion and
There is agreement that care must continue to shift the adoption of a community health approach.
from a strict illness focus to one that includes the promo- Primary health care (PHC) is defined as
tion of health, a strong focus on the social determinants
of health (see Chapter 7); this systemic shift is occurring. Essential health care based on practical, scientifically
Several reports over the past decades have affirmed the sound, and socially acceptable methods and technology
need for the principles of primary health care (PHC) made universally accessible to individuals and families
to guide changes to achieve health equity on a global in the community through their full participation and
scale and to shift health care delivery systems. The at a cost that the community and country can afford to
trend toward PHC is most influential in determining maintain at every stage of their development in the spirit
the future of Canada’s health care system, and CHNs of self-reliance and self-determinations. (WHO &
have a key role to play in leading the way (World Health UNICEF, 1978, para. 7)
M14_KOZI2703_04_SE_C14.indd 248 02/03/17 1:40 PM

PHC, as a guiding philosophy for health care, has CPHA Campaign 2008, which identified the following
its roots in social justice (CNA, 2012; Reutter & Ogilvie, three priority public health issues that warrant national
2011). Deep concern for the health of the world’s popu- political attention: (a) reinforced national leadership on
lation, specifically short life expectancies and high mor- public health, (b) enhanced public health capacity, and
tality rates among children, led to the formation of the (c) increased investment in public health (CPHA, 2008).
global health strategy of primary health care. All members As highly educated, competent, and trusted profes-
of the WHO were encouraged to take actions toward the sionals, nurses have a responsibility to influence change
attainment of “health for all by the year 2000” through by attending to the history, current status, and future
ensuring adequate food supply, safe water, adequate sani- projections of health care. By taking action individually
tation, maternal and child health care, immunization, and collectively, the nursing profession has the power
prevention and control of endemic diseases, provision of to bring greater attention to the social determinants
essential drugs, health education, and treatment of com- of health and to ensure more effective delivery of care
mon diseases and injuries. Despite strong efforts, there under the PHC philosophy.
is little argument that health disparities continue to exist The distinction between PHC and primary care
worldwide. “Moving towards health for all requires that (PC) is an important one. PHC differs from PC in that in
health systems respond to the challenges of a changing PC, the emphasis is on the delivery of health services to
world and growing expectations for better performance” individuals and families at the first point of care. PC, by
(WHO, 2008). These continued systemic changes con- definition, is a component of PHC, most often when the
stitute the agenda of the renewal of PHC, made by the health care professional focuses on health care or health
WHO in response to the continued need for health care promotion and prevention with clients at the point of
mobilization toward the principles of PHC. entry to the system. To illustrate the difference, consider
The Declaration of Alma-Ata (WHO & UNICEF, the scenario of the home care nurse working with the
1978) emphasized health, or well-being, as a funda- senior and his partner at the point of discharge from
mental right and a worldwide social goal. It was an hospital. The home care nurse is providing PC at the
attempt to address inequality in the health status of point of entry to home care services, which includes a
persons in all countries and to target governments that comprehensive family assessment, the provision of essen-
needed to be responsible for policies that would promote tial nursing care, and promotion of health to the extent
economic, social, and health development, which were possible. Within the philosophy and according to the
considered basic to the achievement of “health for all.” principles of PHC, the home care nurse will ensure that
PHC extends beyond traditional health care services. It the client has access to a range of services, and the nurse
involves issues of the environment, climate, agriculture, is involved in planning programs, such as fall prevention
housing, and other social, economic, and political issues, programs, and advocates for essential services for seniors
such as poverty, transportation, unemployment, and eco- in the community.
nomic development. A major feature of PHC is that
consumers, governments at all levels, and public institu-
tions are involved in the planning and delivery of health
care. As a result, the roles of physicians and nurses Community Health
must change. For PHC to be realized, systems must be
organized in such a way that they span geographical Nursing Practice
boundaries, bridge service sectors, and create seamless
linkages within and across professions serving the pub- In Canada, health care delivery is a provincial and ter-
lic. Additionally, PHC requires health care providers, ritorial responsibility, and the manner in which health
including nurses, to develop specialized skills in working regions finance, organize, and deliver community health
with individuals, families, and communities that enable nursing services differs across the country. Therefore,
providers to collaborate with, rather than merely provide some variation in practice exists across Canada. Each
care to, clients. province and territory, and the health regions within
The implementation of PHC requires strong politi- these, employs nurses with varying scopes of practice in
cal will to make essential changes and to safeguard the delivery of health education, health promotion, and
Canada’s universal health system and principles of the PC in the community. These nurses include registered
Canada Health Act. In the seminal report on health nurses (RNs), registered psychiatric nurses (RPNs), reg-
system change in Canada, Building on Values: The Future of istered practical nurses (RPNs), licensed practical nurses
Health Care in Canada, Roy Romanow stressed “the need (LPNs), nurse care aides (NCAs), nurse practitioners
to change the scopes and patterns of practice of health (NPs), and advanced practice nurses (APNs), including
care providers to reflect changes in how health care ser- clinical nurse specialists (CNSs). As a result, it is impor-
vices are delivered, particularly through new approaches tant that the practice of community health nurses be
to primary health care” (Romanow, 2002, p. xxvii). This distinguished and their practice competencies include
focus on population health and PHC was echoed by the collaborative practice and teamwork (CASN, 2014).
M14_KOZI2703_04_SE_C14.indd 249 02/03/17 1:41 PM

Community Health Nursing Roles among the professions, depending on the needs of the
client. Some of the professions with which CHNs rou-
CHNs practise in a variety of settings and roles, includ- tinely collaborate include occupational therapy, physi-
ing schools (school health nursing), workplaces (occupa- cal therapy, medicine, pharmacy, nutrition, education,
tional health nursing), homes (home care nursing), clinics and social work.
(public health nursing), churches (parish nursing), and
• Health Promoter: Health promotion is certainly within
correctional facilities (forensic nursing). Nurses have cli-
the scope of every nurse. However, for many CHNs,
ents through these as well as countless other community
health promotion constitutes the majority of their
agencies (e.g., homeless shelters, mental health shelters,
practice. For some, health promotion occurs at the
drug and alcohol rehabilitation centres, and harm reduc-
population level through such activities as policy
tion programs).
development or social marketing, immunization, or
The following roles are shared by all CHNs regard-
disaster planning; for others, it occurs at the individ-
less of the setting or focus of their practice:
ual or small-group level through such activities as pre-
• Advocate: Advocacy involves supporting the client’s natal classes. CHNs function highly independently in
choices in health care and includes discussion about the community, often visiting clients in their homes or
client rights and the provision of assistance in access- workplaces. Because these nurses interact with clients
ing community resources. The role of advocate can in their territory, their approach often differs from
be particularly challenging when family members’ or that in a hospital setting. For example, entry into a
other caregivers’ views differ from those of the client. client’s home is granted, not assumed; therefore, the
In the event of conflict, it is the nurse’s responsibil- development of trust and rapport are crucial. As well,
ity to ensure that the client’s rights and desires are unlike in hospital settings, the family and client set
upheld. CHNs also advocate in terms of public policy. their own priorities and schedules. Engaging with
• Practitioner: The role of practitioner is one common clients in their own environment fosters rapport and
to every nursing specialty. In community health, this trust. As a result, behaviours are more natural, cul-
role may or may not include the provision of direct tural beliefs and practices are more visible, and multi-
client care. The CHN may provide direct care, such generational interactions are more readily displayed.
as sexual health services, intravenous therapy, medi- Home care nurses and public health nurses (PHNs)
cation administration, or complex dressing changes. are able to complete more in-depth individual or
However, much of the CHN’s time can also be spent community assessments and deliver care that meets
teaching the client or family and friends to provide the client’s needs (whether the client is an individual,
required care. In home care, additional nursing care, a family, or a community).
such as bathing, feeding, and maintaining a clean and
safe environment, may be provided by care aides or Public Health Nursing PHNs’ practice includes
practical nurses. activities such as immunizations and well-baby clin-
ics, postnatal visiting programs, and population health-
• Educator: In the role of educator, a CHN focuses on
promotion programs. Some PHNs spend much of their
illness care, prevention of health problems, and the
time with individual clients, whereas others are involved
promotion of optimal wellness. The context of health
predominantly with population level interventions, such
education will vary, depending largely on the practice
as community health assessment, social marketing, media
setting and client population with which the CHN
advocacy, policy planning, program development, and
works. Teaching can take the form of group presenta-
disaster planning. A role within public health nursing is
tions (as seen in public health or occupational health)
school health nursing, as discussed below.
or individual client teaching (as seen in home care and
community mental health nursing). The role of edu- School Health Nursing School health services are
cator is critical to community health nursing; inform- provided at the individual, family, and community lev-
ing clients enables them to become active participants els in an effort to ensure an optimal level of health
in their own health care. As such, it is imperative that within the school community. A school health nurse
every CHN have knowledge of teaching and learn- works within the school and surrounding community by
ing principles and be skilled in the use of strategies using primarily health-promotion and illness-prevention
that facilitate learning (see Chapter 26 for additional strategies. There is a renewed emphasis and vision for
information). public health nursing in schools based on the compre-
• Interprofessional Care Coordinator: Ultimately, it is often hensive school health model (CSHM) (Pan-Canadian
the CHN who is responsible for the assessment of Consortium of School Health, 2009; Community Health
actual and potential health problems, the coordina- Nurses Initiatives Group, 2013). As a part of an inter-
tion of care plans, and the evaluation of client out- professional team, the PHN working within the CSHM
comes. When multiple professions are involved in the is responsible for the assessment, planning, implementa-
delivery of care, the role of case manager can shift tion, and evaluation of school health programs. Within
M14_KOZI2703_04_SE_C14.indd 250 30/01/17 4:58 PM

workers and worker groups” (COHNA, 2015). Within

this role, nurses may provide health examinations; assess
work environments; develop and deliver health educa-
tion, health promotion, and prevention programs; be
involved in monitoring illness and injury trends; and
Social Teaching
and Physical be involved in policy and program planning (COHNA,
and Learning
Environment 2015). The context of practice is dynamic, and the work
of an occupational health nurse is collaborative with
workers, employers, physicians, human resource mem-
bers, and specialized physical and occupational thera-
pists (COHNA, 2015).
FORENSIC NURSING Forensic nurses specialize in the
care of both victims and perpetrators of violence. These
Policy Partnerships nurses form an important link between the medical
and Services
and legal systems in Canada through direct care, legal
consultation, and evidence collection. Forensic nurses
deliver comprehensive, equitable treatment to victims
of crime (e.g., sexual assault nurse examiners or nurse
coroners) and to perpetrators of crime (e.g., nurses in
custody environments). It is their focus on the health of
FIGURE14.2 Comprehensive school health model. those affected by the trauma of violence and crime that
Source: Pan-Canadian Joint Consortium for School Health Annual Report, September 30,
2016, page 5. Retrieved from http://www.jcsh-cces.ca/index.php/partnerships/about-
distinguishes their practice (Forensic Nurses’ Society of
cross-sector-collaboration. Canada, 2015).
HOME CARE NURSING Home care nursing is the deliv-
ery of health care services in the client’s home environ-
this context, a school health nurse provides direct care ment, often with the effect of delaying or alleviating the
to students, provides leadership in the development and need for long-term care or acute care alternatives (see
implementation of health policy and services, promotes Figure 14.3 and the Evidence-Informed Practice box).
a healthy school environment, and builds partnerships These services are delivered by a variety of agencies
among the school, family, community, and health care and focus on health promotion (e.g., diabetic nutrition
system (see Figure 14.2). counselling), acute health care (e.g., intravenous line man-
agement), chronic health care (e.g., medication manage-
PARISH NURSING Parish nursing was first established ment), or palliative care.
in Canada in 1992. Since then, the specialty has become
more common as faith communities seek to sustain and COMMUNITY MENTAL HEALTH NURSING Community
improve the health of their members. “A parish nurse mental health nurses work with a variety of populations
is a registered nurse with specialized knowledge, who to provide assessment, care, medication management,
is called to ministry and affirmed by a faith community and referrals in community-based settings. They adopt a
to promote health, healing, and wholeness” through perspective on the determinants of health and advocate
health advocacy, health counselling, health education,
and resource referral (Canadian Association for Parish
Nursing Ministry, 2011). Although a parish nurse is,
by definition, a holistic practitioner, the focus is on the
spiritual component of health promotion, not necessarily
hands-on care. Initially, parish nurses were volunteers,
but now many are employees paid by the congregation
or an affiliated institution, such as a health system or
community agency.
Tetra Images/Alamy Stock Photo
OCCUPATIONAL HEALTH NURSING Organizations

have an obligation to address the health and safety of
their employees. As a result, the need for health services
in the workplace is greater than ever before. According
to the Canadian Occupational Health Nurses Associa-
tion (COHNA), “the primary role of the occupational
health nurse is to coordinate the delivery of comprehen- FIGURE 14.3 A home care nurse provides direct client care in
sive, equitable, quality occupational health services for the home.
M14_KOZI2703_04_SE_C14.indd 251 02/03/17 1:43 PM

individuals, alternative approaches to health care deliv-

EVIDENCE-INFORMED ery become integral. Some of these include community
PRACTICE initiatives and coalitions, population health-promotion
programs, and outreach programs:
Unique Aspects of Community Health • Community initiatives and coalitions rely on community-
Nursing in Home Care based interest groups or individual members of the
community to establish health priorities, set measur-
Home care is becoming the most common setting and role able goals, and determine actions required to attain
for nursing, and it is vital that nursing knowledge is expanded
to support nursing practice. Nurse researchers are conduct-
these goals. Nurses are major participants and con-
ing research into the unique features of community health tributors in these coalitions and often assume lead-
nursing in home care. This study examined how nurses’ roles ership roles. However, the nurse and community
in the home are different from those in institutional settings. members assume a shared responsibility for the direc-
Canadian nurse researchers examined how the language tion, coordination, and implementation of health care
used by nurses in discussing illness and care intersected initiatives. These initiatives may focus on a single or
with the home environment and how the context of the home multifaceted problem and can be health promoting,
determined the unique aspects of how nurses related to their
clients. The researchers employed an ethnographic method
illness and injury preventive, or restorative in nature.
in studying triads of how master’s-prepared clinical nurse Examples include the establishment of affordable
specialists interacted with a patient and family caregiver in housing programs, gang violence prevention and
the home. Key findings point to the unique aspects of the youth mental health promotion, older adult assess-
role of the home care nurse, including how nurses are guests ment programs, and immunization programs for vul-
in the home, adjust their relationships and language to fit the nerable street-involved populations.
home environment, and avoid highly technical medical terms
and explanations of health and illness. • Population health-promotion programs focus on the health
needs of larger groups. Nurses employ research, epide-
NURSING IMPLICATIONS: The study includes implica-
miology, and community assessment data in the devel-
tions for best practices in home care nursing and, in
particular, how home care nurses must choose differ-
opment and delivery of population-based initiatives.
ent ways of relating with clients and families and adapt These include, but are not limited to, immunization,
their approaches based on the clients’ home environ- social marketing, program planning or evaluation,
ment, needs, and goals. It is important that nursing policy development, and media advocacy.
education programs prepare students with competen- • Outreach programs that use lay health workers are a
cies to support this understanding and collaborative
practice with clients in the home. The researchers point
method of linking underserved or high-risk popula-
to the need for additional research and knowledge tions with the formal health care system. They can
development to support home care nursing. minimize or reduce barriers to health care, increase
access to services, and thus improve the health status
Source: Based on Giesbrecht, M. D., Crooks, V. A., & Stajduhar, K. I. (2014). Exam-
ining the language–place–healthcare intersection in the context of Canadian homec- of the community. They involve partnerships among
are nursing. Nursing Inquiry, 21(1), 79–90. doi: 10.1111/nin.12010 nurses, community members, and lay health workers
who assist their neighbours through outreach net-
works. Nurses often provide training, consultation,
and support to these individuals, who then assume
for housing and other programs that support people with responsibility for contact with marginalized individu-
mental health challenges in their homes and supportive als and groups in their community. Examples include
living residences. These nurses also provide intake and home visiting programs for young isolated families,
counselling for youths and others who experience com- provision of Direct Observed Therapy for Tuberculo-
mon health challenges, such as anxiety, substance use sis programs, and health education and social support
issues, or psychiatric illnesses. Community mental health programs for immigrants.
nursing is an evolving field.
Approaches in Community Health Nursing

The Community Health
A community may be defined as a group of people who
live, learn, work, and/or play in an environment at a Nurse as a Collaborator
given time. They function in a social system, such as an
organization or region, based on shared characteristics Collaborative partnership is defined as “the pursuit of
and interests. person-centred goals through a dynamic process that
As greater emphasis is placed on the general health requires the active participation and agreement of all
of the community and population, in contrast to the partners. The relationship is one of partnership and the
traditional system that focused on care of ill and injured way of working together is collaborative, hence the term
M14_KOZI2703_04_SE_C14.indd 252 21/02/17 11:15 AM

collaborative partnership” leading to interprofessional Collaborative Partnerships

cooperation (Gottlieb & Feeley, 2006, p. 8).
CHNs routinely collaborate with clients, peers, In the collaborative partnership model of health care,
health care professionals, and other care providers. They the client shares responsibility for their health, and the
frequently collaborate about client care but can also be nurse acknowledges that the client has knowledge and
involved in collaboration on bioethical issues, legisla- capabilities that can be used to understand and manage
tion, and health-related research with other professional the illness in a meaningful way. The relationship between
organizations. Box 14.2 outlines selected aspects of the the nurse and the client is reciprocal and mutual, and
nurse’s role as a collaborator. goals and plans of care are jointly determined. Within
this context, the role of the nurse is one of facilitator. The
nurse encourages the client to share their perceptions and
BOX 14.2 THE COMMUNITY HEALTH NURSE expertise. Joint decisions are made in an effort to develop
AS A COLLABORATOR the client’s autonomy and self-efficacy. In the end, the
The community health nurse’s role as a collaborator covers health problem may or may not be resolved, but more
many different aspects: importantly, the client’s capacity to manage current and
future problems is enhanced (Gottlieb & Feeley, 2006).
WITH CLIENTS
• Acknowledges, supports, and encourages clients’ active
involvement in health care decisions Continuity of Care
• Encourages a sense of client autonomy and an equal
position with other members of the health care team A major responsibility of the CHN is to ensure continu-
• Helps clients set goals and objectives for health care ity of care. Continuity of care is a vital component of
that are mutually agreed upon quality care and patient safety. It involves the coordina-
• Provides client consultation in a collaborative fashion tion of health care services by health care providers for
clients moving from one health care setting to another
WITH PEERS and of their relationships with care providers and pro-
• Shares personal expertise with other nurses and elicits
fessionals. There are three interrelated elements of con-
the expertise of others to ensure quality client care tinuity of care: (a) informational continuity wherein
• Develops a sense of trust and mutual respect with peers patients receive accurate and consistent health infor-
that recognizes their unique contributions mation, (b) management continuity, in which services
are linked and accessible, and (c) relational continuity
WITH OTHER HEALTH CARE PROFESSIONALS between clients and their families and those who pro-
• Recognizes the contribution that individual members
vide care (Haggerty et al., 2003). Continuity ensures
of the interdisciplinary team can make by virtue of their uninterrupted health care services as the client moves
expertise and view of the situation from one level of care to another, for example, from an
• Listens to each individual’s views acute care hospital to the home, or from the home to a
• Shares health care responsibilities in exploring options, long-term care facility. This link is of increasing impor-
setting goals, and making decisions with clients and tance as changes in the health care system, nursing roles,
families interprofessional relationships, and client populations
• Participates in collaborative interdisciplinary research to continue. It is important that assessment focus equally
increase knowledge of a practice problem or situation on the client’s strengths and needs as well as on his or
her home, family, and community environments. Since
WITH PROFESSIONAL NURSING ORGANIZATIONS all these factors play a part in the optimal care of the
• Seeks out opportunities to collaborate with and within client, the nurse must build on strengths while attending
professional organizations to needs of the individual and his or her family. To pro-
• Serves on committees in local, provincial or territorial, vide continuity of care, nurses need to do the following:
and national nursing organizations or specialty groups
• Supports professional organizations in political action
• Initiate discharge planning for all clients when they
to create solutions for professional and health care are admitted to any health care setting or program
concerns • Involve the client and family or support persons in all
phases (assessing, planning, implementing, and evalu-
WITH POLICY MAKERS ating care) of the planning process
• Offers expert opinions on legislative or policy initiatives • Collaborate and communicate with other health care
related to health care professionals, as needed, to ensure the highest quality
• Collaborates with other health care providers and of care possible
consumers on health care legislation or policy to best
serve the needs of the public • Ensure accessibility to required services to facilitate
seamless care
M14_KOZI2703_04_SE_C14.indd 253 21/02/17 11:15 AM

Discharge planning is frequently viewed as syn- the following: The information is reliable and up to date;
onymous with continuity of care. Traditional discharge the referral is practical and timely; the referral is indi-
planning has referred to discharge from the hospital vidualized to the client; and the referral is coordinated
to the patient’s home. However, discharges occur from and mutually agreed upon by health care practitioners,
many other settings. Nurses are employed in liaison or caregivers, and, of course, the client.
discharge planning roles focused on ensuring continuity Referrals need to present as much information as
of care between episodic and continuous experiences of possible about the client and his or her care. Most insti-
health and illness. Discharge planning can be viewed as tutions and agencies have well-established protocols and
the process of preparing a client to transition between detailed referral forms for this purpose. Beyond this,
care environments in the same facility. For example, a nurses are often called on to examine client and family
client with a cerebrovascular accident may move from a needs at a larger systems level to assist in the delibera-
medical unit to a community-based rehabilitation unit, or tions regarding the provision of health care services in
a client with multiple traumas may move from an inten- a community to ensure that the full spectrum of client
sive care unit to a medical or surgical unit and then to needs can be addressed and met in the spirit of PHC.
home care. The term discharge planning can also refer to Education in public health policy and strategies to influ-
the movement of a client from one care environment ence and effect change is essential.
to another entirely. For example, an older client may
transition to long-term care when he or she is no longer
able to live at home. The focus of discharge planning
is always at the individual client and family level, but each
Developing Programs and Resources
agency generally has its own policies and procedures to at a Community Level
guide the process. Many agencies have discharge planners, Although assessment and intervention at the individual
a health or social services professional who coordinates and family levels are major components of the scope of
the transition and acts as a link between the discharging community health nursing, there is also community- and
and the receiving facilities. Often, a nurse assumes the population-level focus in the health-promotion work of
responsibility of providing continuity of care. CHNs.
Discharge planning needs to begin when a client is These community-level assessments and interven-
admitted to an agency, especially in hospitals, where the tions are based on the principles of PHC and health
lengths of stays are considerably shortened and care is promotion. Community health assessment involves
often continued through public health (as with postnatal many areas, including community members, physical
care) or home care services. Effective discharge planning environments, socioeconomic environments, health and
involves (a) ongoing assessment to obtain comprehen- social services, culture and religion, communication,
sive information about the client’s continuing needs, transportation, government and politics, law and safety,
(b) statements of nursing care, and (c) plans to ensure and education and healthy childhood development. The
that the client’s and caregivers’ needs are met. In some community health-promotion process begins with this
situations, discharge planning necessitates health care holistic assessment; moves through analysis, planning,
team conferences and family conferences. At a health intervention, and evaluation; and ends with assessment
care team conference, health care professionals focus again (see Figure 14.4 for more details). This model
on ways to individualize care for the client. At a family of care illustrates the complexity of community health
conference, both health care professionals and the fam- nursing. With firm grounding in PHC, health promo-
ily discuss family issues related to the client. Both types tion, health education, and the determinants of health,
of conferences give the client, the family, and the health community health nurses are especially qualified to work
care professionals the opportunity to mutually plan care in partnership to effect positive health changes within
and set goals. the community.
Communicating across the System of Care

Community Health Nursing
Regardless of the setting from and to which clients are
moving, the referral process is a systematic problem- Competencies
solving approach that ensures that appropriate and
timely information is communicated to assist the client The Community Health Nurses of Canada (CHNC),
in accessing resources that meet his or her health care a national association of CHNs and community health
needs. During the referral, pertinent information about nursing interest groups, promotes community health
the client’s health, care needs, and social environment nursing and the health of communities. As such, CHNC
is communicated between the discharging and the care- has defined the scope of CHNs and established standards
providing agencies. An effective referral involves all of of practice for them as well. These standards—(a) health
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Assessment
• Focus on purpose of assessment
• Assess what determines the health of
the community
Physical Environments Socioeconomic
Environments Analysis
Evaluation
• Identify community strengths
• Gather evidence
$ and needs
$$
• Monitor results for
• Formulate community diagnoses
progress and changes
Health and
Social Services
Education
and Healthy Child
Development
People
Law and Safety
Culture and
Religion
Biological Endowment
Government and Communication
Politics
Interventions Planning
Implement primary, secondary, Address health-promotion
and tertiary prevention: challenges:
Transportation
• Health promotion • Reduce inequities
• Accessibility • Increase prevention
• Intersectoral collaboration • Enhance coping
• Public participation
• Appropriate technology
• Public policy
• Supportive environments
Figure 14.4 Community health-promotion model.

Source: Stamler, L. L., & Yiu, L. (2012). Community health nursing: A Canadian perspective (Figure 13.1, p. 216). Toronto, ON: Pearson Canada Inc. Reprinted with permission from the illus-
trator, Camillia Matuk.
promotion, (b) prevention and health protection, knowledge from the social sciences” and “focuses on pro-
(c) health maintenance, restoration, and palliation, moting, protecting, and preserving the health of popula-
(d) professional relationships, (e) capacity building, (f) tions” (CHNC, 2008, p. 8). PHNs practise in a variety
access and equity, and (g) professional responsibility and of settings, including, but not limited to, “community
accountability—form the basis of CHN and PHN prac- health centres, schools, street clinics, youth centres, and
tices in Canada (CHNC, 2011). nursing outposts” (p. 8). However, it is their focus on the
The CNA has also acknowledged the specialized health promotion of populations that distinguishes their
knowledge and skill required for working with com- practice. In contrast to HHNs, who work mainly with
munities and now offers a certification examination in individuals and families, the focus of PHNs’ practice is at
community health nursing (CNA, 2011). A renewed the larger population level. PHNs do recognize that the
emphasis has been placed on PHC in Canadian nursing health of a population is inextricably linked to that of its
in the most recent CNA Strategic Plan (CNA, 2015). constituent members, and as a result, PHNs may work
It is under this broad designation of CHNs that with individuals and families to realize the ultimate goal
home health nurses (HHNs) and PHNs practise. A of population health.
home health nurse (HHN) “is a community health
nurse who combines knowledge from primary health
care (including determinants of health), nursing science, Public Health Nursing Competencies
and theory and knowledge of the social sciences” to
focus on “prevention, health restoration, maintenance,
for Undergraduate Nursing Education
or palliation” (CHNC, 2008, p. 8). Home health nurses In 2014, a public health nursing task force of the CASN
provide care in the client’s home, school, or workplace. defined a set of competencies for all students graduat-
In contrast, a public health nurse (PHN) “is a ing from a baccalaureate nursing program in Canada.
community health nurse who combines knowledge from Although these competencies are specific to the prac-
public health science, primary health care (including tice of public health nursing, the competencies are also
determinants of health), nursing science, and theory and relevant to nursing practice with populations wherever
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Table 14.1 Canadian Association of Schools of Nursing (2014) Entry-to-Practice Public Health Nursing Competencies for
Undergraduate Nursing Education
Domain Competency
Domain 1: Public Health Sciences in Applies essential knowledge from public health sciences and nursing sciences in nurs-
Nursing Practice ing practice including, but not limited to, primary health care, determinants of health,
population health ethics, population health status
Domain 2: Population and Community Assesses and analyses population and community health using relevant data, research,
Health Assessment and Analysis nursing knowledge, and considering the local and global context
Domain 3: Population Health Planning, Participates in the planning, implementation, and evaluation of one or more of the fol-
Implementation and Evaluation lowing: population health promotion, injury and disease prevention, and health protec-
tion programs and services within the community.
Domain 4: Partnerships, Collaboration Engages with partners to collaborate and advocate with the community to create and
and Advocacy implement strategies that improve the health of populations
Domain 5: Communication in Public Applies communication strategies to effectively work with clients, health professionals,
Health Nursing communities and other sectors (application of health literacy, social media and strate-
gies to influence decision makers and health policies)
Source: Based on CASN (2014) Entry to Practice Public Health Nursing Competencies for Undergraduate Nursing Education.
nurses practise. The task force identified that “it is impera- community health nursing include, but are not limited
tive that all new nurses enter the workforce with a sound to, the following:
preparation of public health” (CASN, 2014, p. 4), through
• Technology
the acquisition of competencies displayed in Table 14.1.
• Focus on Aboriginal peoples’ health
• The role of public health in addressing the ecological
Home Health Nursing Competencies determinants of health
“Home health nursing encompasses disease prevention, • Education, research, and knowledge development for
rehabilitation, restoration of health, health protection, community health nursing practice
and health promotion with the goal of managing existing
problems and preventing potential problems” (CHNC,
2010, p. 7). The Home Health Nursing Competencies (CHNC, Technology and Community
2010) were developed to describe the nursing standards
in this specialty area of practice. Table 14.2 identifies
Health Nursing
these elements, foundations, and areas of responsibility. Technology in nursing is increasing, with expanded use,
development, and evaluation. CHNs use technology to
access client information and specialist care, and for con-
sultations, surveillance, and communication. CHNs also
Focus on Trends in develop technology for practice and are the translators
and supports for the use of technology with clients. PHNs
Community Health Nursing are leading the development and use of electronic records
for documentation, notification, and tracking for immu-
Community health nursing is an evolving and nization records and reportable communicable diseases
dynamic field of practice. Major trends in developing in a national system (Canada Health Infoway, 2015).
Table 14.2 Home Health Nursing Competencies
Quality and Professional

Elements of Home Health Nursing Foundations of Home Health Nursing Responsibility
- Assessment monitoring and clinical decision - Health promotion - Quality care
making - Illness prevention and health protection - Professional responsibility
- Care planning and care coordination
- Maintenance, restoration, and palliation
- Teaching and evaluation
- Communication
- Relationships
- Access and equity building capacity
Source: Adapted from Community Health Nurses of Canada. (2010). Home health nursing competencies. Toronto, ON: Author.
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Home care nurses across the country use cameras and completed with Aboriginal people, as “First Nations, Inuit
electronic communication systems to access wound care and Métis peoples possess the knowledge, determination
specialists. Taking photos when visiting clients and send- and resilience rooted in their varied traditions and cultures
ing them to the nurse specialist for expert recommenda- to meet those challenges, particularly if they are aided by
tions speeds up and increases access to specialist care in culturally-appropriate care” (NCCAH, 2013, p. 7).
all neighbourhoods and communities, particularly rural CHNs have the ability to contribute to the health
and remote sites. In rural and remote communities, the of Aboriginal communities by delivering and improving
use of telehealth and telemedicine is expanding. The primary care and utilizing a primary health care philoso-
role of the nurse is crucial in the implementation, client phy in Aboriginal communities, taking a role in leading
connection, assessment, documentation, and use of this community development initiatives, and utilizing world-
technology. Telehealth projects use communication and views that recognize health in a holistic way seeing health
information technology to provide health information beyond a biomedical focus (Exner-Pirot & Butler, 2015).
and health care services to people in rural, remote, or Community health nurses are uniquely positioned to build
underserved areas, or clients with mobility challenges. relationships with, develop a deeper understanding of,
Video conferences or video clinics enable health care and provide nursing services to Aboriginal communities.
workers to provide remote assessment, treatment, and These services can include public health nursing, home
monitoring for clients with a variety of health care needs. health care, population health initiatives, and specialized
These video conferences are similar to any outpatient and expanded scope of services in rural communities.
clinic visit, except that the client and health care special-
ist are kilometres apart. With every changing technology
at their disposal, it is critical that nurses learn to use tech- Ecological Determinants of Health
nology in a manner that can enhance the quality of care
while making every attempt to ensure that the essence of
and Climate Change
nursing, the relationship between the nurse and the cli- The WHO’s position on the social determinants of
ent, is not disrupted. health and, most recently, an expanded view on the
Social media and their use in community health ecosystem and the effect of climate changes on human
nursing is increasing. Social media can be utilized to dis- health emphasize the critical importance of the ecologi-
tribute information, to track health and social events, and cal determinants of health (CPHA, 2015). Recognition
to receive information back from the public (Newbold, of the dynamic relationship between humans and the
2015). Although there are potential benefits to the use planet, and of the effects of this relationship on the
of social media, nurses need to continue to question the health of both, is leading to calls for action in this area
effectiveness of the methods used in social media and be of health determinants. Nurses are contributing to this
continually conscious of access to social media channels vision of health and how it can be achieved.
and health inequalities (Newbold, 2015). Newbold (2015)
has provided best practice guidelines for the use of social
media in public health to guide the utilization of social Education, Research, and Knowledge
media in client care. Development for Community Health
Nursing Practice
Community health nursing is evolving within the dynamic
Aboriginal Peoples’ Health context of the twenty-first century, with many forces influ-
In Canada, disparities in health between Aboriginal and encing the roles that nurses are playing now and will play
non-Aboriginal Canadians continue to exist (National in the future. CHNs are educated at the baccalaureate
Collaborating Centre for Aboriginal Health [NCCAH], level for entry to practice to acquire theoretical perspec-
2013). Aboriginal peoples, as referred to in this statement tives and the competencies identified in this chapter. The
by the NCCAH, are the “original inhabitants of Canada largest group of health care providers worldwide, CHNs
and their descendants, including First Nations, Inuit, and have opportunities to promote the health of all people as
Métis peoples, as defined in Section 35(2) of the Canadian well as global health. It may be surprising to know that
Constitution Act, 1982” (NCCAH, 2013). Understanding community health nursing is the earliest form of nursing
the root causes of these disparities, including coloniza- practice, bringing essential services to people in their com-
tion and the social determinants of health, is critical to munities long before the development of hospitals and
the delivery of community health nursing care, health institutional care. The breadth of preparation required to
policy, working with Aboriginal communities, and ulti- prepare nurses for public health nursing was the impetus
mately reducing and eliminating the disparities. Although for nursing education to be situated in universities in the
the solution to the issue of disparities is complex and will early twentieth century (Duncan, 2015, in press).
take time to achieve, there is an increasing understand- Theoretical perspectives, which are defined as a
ing that the best path forward needs to be guided by and mindset for practice (Gottlieb, 2013) and are particularly
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relevant for community health nursing, are drawn from increasingly relevant to the Canadian nursing research
public health and from nursing sciences; these perspec- agenda. These areas mentioned above are being taken
tives include ethics of social justice, health equity, pri- up by nurse researchers to develop the body of knowl-
mary health care, strength-based nursing, critical caring, edge required for community health nursing practice. It
and relational inquiry (CNA, 2005; CNA, 2015; Doane is essential to expand and develop nursing education for
& Varcoe, 2015; Falk-Rafael & Betker, 2012; Gottlieb, community health nursing practice and for researchers
2013; Reutter & Kushner, 2010). In Canada, practice to continue to develop the knowledge essential for this
questions and theoretical concepts to guide practice are evolving practice in the twenty-first century.
Case Study 14
Mrs. Smith is a 21-year-old new mother who recently gave birth
to her first child in hospital. Her labour and delivery were without
2. What factors within the home environment might affect
Mrs. Smith’s care?
complications, but she is apprehensive about breast-feeding,
bathing, and caring for her infant once home. Today is Mrs. 3. What financial and health benefits might be derived from
Smith’s postpartum day 2, and she is being discharged. She has caring for a client at home rather than in a hospital or
been referred to the public health postpartum other institution?
home-visiting program; she will be assigned
a nurse to visit her in her home for follow-up Visit MyNursingLab for answers and explanations.
physical assessment of mother and baby as
well as for health teaching.
1. How will the nurse’s role differ when delivering care in

the client’s home instead of the hospital?
Ke y Terms
community health continuity of care interprofessional public health nurse
assessment p. 254 p. 253 cooperation p. 253 (PHN) p. 255
community health home health nurse primary health care
nurses (CHNs) p. 247 (HHN) p. 255 (PHC) p. 248
Ch apt er Highlights
• Health care costs, access to health care, and the quality • Community health nursing is client driven and involves a
of health care are major areas of concern in the current broad range of services designed to promote health, pre-
health care system. vent illness, restore health, and protect the public.
• The CNA’s position paper and the Alma-Ata Declaration • Public health nursing and home health nursing, which
have set forth recommendations for health care reform that are subsets of community health nursing, are becoming
focus on accessibility of health care services, health promo- increasingly prominent specialties in health care delivery.
tion and disease prevention, public participation, the use of • CHNs practise in a variety of settings and provide a vari-
appropriate technology, and intersectoral cooperation. ety of services: community health centre nursing, parish
• Clients support an increased emphasis on health care nursing, school health nursing, occupational health nurs-
measures that promote wellness and do so at the indi- ing, home care nursing, and forensic nursing.
vidual, family, group, and community levels. • Various approaches are emerging to address community
• Community health nursing provides health-related ser- health nursing: community initiatives, community coali-
vices in places where people spend their time—in homes, tions, and outreach programs using lay health workers.
in shelters, in long-term care residences, at work, in • Community health nursing directs nursing care toward
schools, in seniors’ centres, and so on. a specific population or group. It is not confined to one
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practice setting; it extends beyond institutional boundaries • It is predicted that nurses will emerge as community
to involve a network of nursing services: nursing wellness health care leaders. Because primary health care is
centres, ambulatory care, long-term care, home health, directed toward the community and the client, nurses’
and hospice care. roles will change to those of facilitator, consultant, and
• To practise in community health systems, nurses will need resource, rather than those of expert provider and team
to learn new knowledge and competencies, such as deter- leader.
minants of a healthy community, primary and secondary • A major responsibility of the nurse is to ensure conti-
preventive strategies, health-promotion strategies, collab- nuity of care as clients move from one level of care to
orative and interdisciplinary teamwork, information man- another.
agement, and so on. Education in public health policy and • Continuity of care extends beyond the individual and
strategies to influence and effect change are also essential. includes a series of actions both within and outside an
• Intrasectoral and intersectoral cooperation are essential individual agency, which involve (a) discharge planning
components of community health nursing. Key elements of that begins when clients are admitted to an agency,
cooperation include effective communication skills, mutual (b) collaboration with the client and support persons, and
respect and trust, and a good decision-making process. (c) interdisciplinary cooperation.

1. On the basis of a community-needs assessment, a public c. Social justice and equity

health nurse develops a program to prevent childhood d. Appropriate use of technology and community
obesity. Which strategy is most appropriate for success- organization
ful implementation?
a. Providing information to the teacher for classroom use 5. Planning for discharge from an institutional setting, such
as a hospital, can include a referral to a home care nurse.
b. Involving parents, teachers, and children in program What best describes the expectations of the referral?
development
a. The home care nurse will deliver all care himself or
c. Asking the school administration to remove all vend- herself.
ing machines
b. The discharge assessment of service needs will be
d. Initiating an exercise program during recess for chil- followed exactly.
dren who are obese
c. The home care nurse will coordinate the health care
service needs of the client.
2. What is a characteristic of public health nursing
practice that is different from the practice of a home d. The discharge plan is developed solely by the dis-
health nurse? charge planner and the client.
a. Illness and injury prevention 6. An older adult client is being discharged from the
b. The health of populations home care services program. Which of the following
c. Work in school health, occupational health, and strategies is most appropriate to ensure a successful
home care transition?
d. Work with marginalized groups a. Making one last home visit to review client teaching
b. Calling the client’s family physician to advise him or
3. What is the best description of the concept of primary her of the change
health care? c. Scheduling a case conference with the client, his or
a. Medical care provided at the initial point of contact her family, and relevant health care professionals
within the health care system d. Providing the client with a list of applicable commu-
b. Synonymous with community-based nursing nity resources
c. More relevant for developing countries than for
industrialized nations 7. A nurse has reached the home-visiting period with a
first-time mother. Which of the following is most impor-
d. A philosophy of care delivery that can be applied in
tant for the nurse to assess?
any sector
a. The new mother has been given the answers to all of
4. A community health nurse is involved in political action her questions about breast-feeding.
to reduce homelessness through increased availability b. Mother and baby are no longer experiencing diffi-
of affordable housing. Which of the following primary culty with breast-feeding.
health care principles would the nurse most likely fulfill? c. The mother feels confident that she can access the
a. Accessibility, health promotion, and public necessary resources to deal with current and future
participation difficulties with breast-feeding.
b. Illness and injury prevention; political action d. Baby is gaining weight appropriately.
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8. Which of the following best exemplifies the three com- b. Interprofessional team model
petencies basic to collaboration in the care of a client by c. Brokerage or service management model
a home care nurse?
d. Partnership model
a. Questioning the appropriateness of a prescription
from the client’s attending physician 10. A graduate nurse is working in a Sexual Health Clinic
b. Involving physical therapy and occupational therapy that offers counselling, birth control, and testing services
in the client’s plan of care for sexually transmitted infections on a university cam-
c. Informing the client’s family of changes made to the pus. The nurse learns that male students are reluctant
client’s plan of care to attend the clinic. What would be the best approach
for the nurse to take?
d. Calling a case planning meeting for the client, the
family, and the involved health care professionals a. Distribute posters and flyers around campus to
advertise the clinic’s services
9. A client is receiving services from an occupational b. Hold teaching sessions in the student residence about
health nurse for an injury sustained at work. The the importance of safe sex
nurse recognizes that the client has knowledge and
c. Explore ways to make the clinic more welcoming to
capabilities that can be used to understand and man-
male students
age the client’s injury and recovery. Which of the
following best describes the model the nurse has d. Organize a sexual health fair to be held during
employed? orientation week at the start of each school year
a. Self-managed care model
R e f ere nc e s
Canada Health Infoway. (2015). Panorama safegaurding the health of from http://www.chnac.ca/images/downloads/standards/
Canadians. Retrived from https://www.infoway-inforoute.ca/ chn_standards_of_practice_mar08_english.pdf.
en/component/edocman/resources/videos/2272-panorama- Community Health Nurses of Canada. (2010). Home health nursing
safeguarding-the-health-of-canadians?Itemid=101. competencies version 1.0. Toronto, ON: Author. Retrieved from http://
Canadian Association for Parish Nursing Ministry. (2011). The chnc.ca/documents/HomeHealthNursingCompetenciesVersion1.
Canadian Association for Parish Nursing Ministry. Retrieved from 0March2010.pdf.
http://www.capnm.ca. Community Health Nurses of Canada. (2011). Canadian community
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Entry-to-practice public health nursing competencies for undergraduate nursing Toronto, ON: Author. Available at http://cna-aiic.ca
education. Ottawa ON: Author. Community Health Nurses’ Initiatives Group. (2013). Healthy schools,
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Canadian Nurses Association. (2005). Primary health care: A summary with individuals and families in changing health and health care contexts.
of the issues. Ottawa, ON: Author. Philadelphia, PA: Wolters Kluwer.
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Chapter 15
Rural and Remote
Health Care
Updated by
Lois E. Berry, RN, PhD
Associate Dean, College of Nursing, University of Saskatchewan
C
LEARNING OUTCOMES
After studying this chapter, you will be able to anada was originally a
1. Describe the issues related to establishing universal definitions of predominantly rural (a

rural and remote communities. word to describe places
2. Describe the geographical characteristics of rural and remote such as the countryside, towns,
communities and associated health care issues. and small cities outside urban cen-
3. Describe the predominant occupational trends in rural and remote tres), agrarian-based nation, and it
communities and the associated health care issues. remained so until societal changes
4. Summarize the health concerns of individuals, families, and following World Wars I and II resulted
communities within rural and remote contexts, including a specific in the growth of industry in urban cen-
focus on Aboriginal people living in rural areas. tres. This growth led to the migration
5. Identify existing and emerging health care delivery issues within of rural residents to find employment
rural and remote contexts. in these industrial centres. In 1901,
6. Analyze the broad scope of rural and remote nursing practice. 37% of the population lived in urban
7. Examine topics of concern to nurses in rural and remote practice. centres, compared with over 80%
in 2011 (Statistics Canada, 2012).
Urban populations surpassed rural
ones in the period between 1921
and 1931; before that time, agri-
culture and natural resources were
dominant industries. The number of
farms has steadily declined. Between
1991 and 2011, the total number
of farms in Canada decreased by
26.5% (Beaulieu, 2015). Less than
10% of Canadians live on farms, a
decrease from two-thirds of the pop-
ulation prior to World War I (Bollman
& Reimer, 2009). c
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Chapter 15 Rural and Remote Health Care 263
c Approximately 19% of Canadians continue to live in rural and remote regions (those areas located
far from urban and even rural centres); that is, 6 million Canadians live in rural and remote areas of
Canada. Rural communities in Canada have long been confronted by demographic, ecological, eco-
nomic, and social challenges related to geographical isolation (a state of complete physical separa-
tion from other regions), including boom–bust cycles; a reliance on non-renewable natural resources;
chronic high unemployment; lower income levels; the vulnerability of single-industry communities;
aging populations; lack of social, cultural, and recreational facilities; lack of access to postsecond-
ary education; and so on (Pong, 2007; Williams & Kulig, 2012). Correspondingly, nursing practice is
affected by the diversity found within this huge geographical region of Canada. Health care delivery
is further complicated by incomplete and sometimes conflicting data on the health status of residents
in these regions.
Definition of Rural obtain health care. Health geographers in Canada have

traditionally looked at two issues in particular: (1) using
geographical techniques to map disease and epidemics
One obstacle identified by researchers is the lack of and (2) looking at the geography of access to health care
consensus regarding the definition of the term rural services (Luginaah, 2009).
(DesMeules, Pong, Read Guernsey, Wang, Luo, & Dressler,
2012; MacLeod, Martin–Meisner, Banks, Morton, Vogt,
& Bentham, 2008). Du Plessis, Beshiri, Bollman, and
Clemenson (2002) indicated that the proportion of the
population considered rural varies from 22% to 38%,
Elements of a Rural Health
depending on which definition is used in defining rural-
ity. Statistics Canada defines rural and small town Canada as
Framework
labour market areas that are outside of the commuting The Canada Health Act (1984) provides for the “right
areas of larger urban centres with core populations of to health care for all.” The five federally defined prin-
10 000 or more (Beshiri & He, 2009). This definition was ciples of this act are universality, accessibility, portability,
used by the largest national research project to date on nurs- comprehensiveness, and public administration. Rural
ing in rural Canada, The Nature of Nursing Practice in Rural and and remote communities are confronted by challenges in
Remote Canada (MacLeod et al., 2004) and by the follow-up gaining access to equitable health care, that is, com-
studies (Kulig, Kilpatrick, Moffit, & Zimmer, 2013). parable health care as is provided elsewhere. Issues of
There is no commonly accepted definition for the accessibility to services and provision of comprehensive
term remote, but researchers use such terms geographical services are particular issues in rural areas. In addition,
and social isolation, limited services, limited or poor quality road the fact that administration of health services is left up to
access, limited and expensive air access, high cost of living, and the provinces and territories results in differing priorities
small, widely dispersed population to describe remote areas being given to rural health services by different regions
(Berry, Butler, & Wright, 2014). (Williams & Kulig, 2012).
A framework to guide the assessment, planning,
implementation, and evaluation of rural health care
Rural Health: Place, for individuals, families, and communities must include
mechanisms for assessing the unique aspects of rural life
Space, and Time in general, and the specific attributes of the community
being studied. In particular, such a framework helps us
Health geography examines the relationship between understand and provide the optimal care possible to rural
health and “place.” Evidence has shown that place can residents in relation to research, policy, and practice. The
affect health both directly and indirectly (Rainham, Public Health Association of Canada Population Health
McDowell, Krewski, & Sawada, 2010). Examples of Framework has served as the basis for development of a
how geography can affect rural health include environ- Rural Health Framework to guide evidence-based devel-
mental factors that affect residents of a certain area, opment, implementation, and evaluation of rural health
the type of employment associated with a particular policy and programming. This framework addresses
geographical area, or the distances required to travel to the social determinants of health and links them with
M15_KOZI2703_04_SE_C15.indd 263 06/02/17 3:33 PM

current evidence regarding rural best practices in health and an additional 12% lived in other rural areas. The
and health care delivery (White, 2013). majority of non-status Indians (75%) and Métis people
(71%) live in urban areas. Inuit people (56%) live primar-
ily in rural areas in northern Canada (Aboriginal Affairs
and Northern Development Canada, 2013). Aboriginal
Geography and Regional Diversity people make up the majority of Canada’s northern
Regional variations in Canada’s rural population exist. population in several regions. In Nunavut, 86.3% of
Between 2006 and 2011, the rural population decreased the total population is Aboriginal, and in the Northwest
in both actual numbers and as a percentage of the popu- Territories, 51.9% of the population belongs to this
lation in Newfoundland, Nova Scotia, New Brunswick, group (Statistics Canada, 2013). The Aboriginal popula-
Quebec, Ontario, and the Northwest Territories, includ- tion is growing at a significantly faster rate compared
ing Nunavut. In Manitoba, Saskatchewan, Alberta, with the rest of the Canadian population. As a result,
British Columbia, and Yukon Territory, the actual pop- the Aboriginal population is much younger than the
ulation numbers increased, but because of a greater rest of the population, with 46% under age 25 years,
increase in the urban population in each of these prov- compared with 29% for the rest of Canada’s population
inces, the percentage of the provincial population living (Aboriginal Affairs and Northern Development Canada,
rurally actually decreased (Statistics Canada, 2011a). 2013).
Enormous diversity exists among the rural com- These regional variations, combined with the
munities in Canada. Some rural communities remain increasing concentration of population in major urban
relatively self-contained with limited impact from, and regions, contribute to issues for the delivery of health
relationship to, urban areas. However, with the advent of care to rural residents. Particular geographical factors
improved transportation and the decline in farm income influence access to health care services. For example,
and income from other commodities, increasing num- distance and lack of resources affect emergency care
bers of rural and small town residents commute to work for persons involved in farming and resource industry
in urban centres on a daily basis or to remote mining and accidents. Various governments have indicated a need to
resource jobs on a weekly or biweekly basis (Ali, Olfert, & work with rural communities to develop successful solu-
Partridge, 2007). The variations in geographical, politi- tions to the challenges they face. Thus, nurses working
cal, social, and economic makeup of rural communities in rural areas need to participate in policy and program
add to the complexity of health care issues and delivery development initiatives of various governmental depart-
systems across the country. ments, recognizing how these actions affect health and
With all of the challenges of other rural and remote health care delivery within their communities. In addi-
regions, and the added challenge of northern latitude tion, the Aboriginal population is the fastest-growing
and an inhospitable climate impacting travel and activ- population in Canada, with many being youths and chil-
ity for a portion of the year, Canada’s north has its own dren living in underserviced northern, rural, and remote
unique trials with respect to health care services (Berry communities. Nurses working in northern, rural, and
et al., 2014). As with the definition of rural and remote, the remote communities with large Aboriginal populations
north is challenging to define. It is difficult to specifically need to participate in policy and program initiatives that
locate where the north begins, as this is relative. Areas in aim to address their unique needs.
Ontario considered north, such as Sioux Lookout, are at
the same degree of latitude as Kelowna, which is in the
southern part of British Columbia.
However, all of Canada’s northern areas share com-
Demography
mon issues. Great distances, difficult terrain, and sparse Even though Canada is the second-largest country in the
population result in widely separated communities. With world in size of landmass, it has a relatively small popu-
relatively few roads through a large geographical area, lation, the majority of which is concentrated close to the
travel is often dependent on weather. For example, win- Canada–United States border. According to Statistics
ter roads on ice and snow can be built only when the Canada (2011b), Canada’s population in 2011 was more
weather is cold enough to permit travel across the frozen than 34.4 million, an increase of 5.7% since the 2006
expanses of northern lakes and rivers. This, in turn, census. In 2011, 6.3 million people lived in rural areas, a
affects the type of goods transported into northern com- number that has remained relatively constant since 1991
munities. These factors are not as important in areas of (Statistics Canada, 2012).
Canada with an integrated highway system. The ethnic composition of rural areas differs from
Canada’s Aboriginal population, that is, those that of urban areas. For example, the vast majority
who can trace their origins to First Nations, Inuit, or (95.9%) of Canada’s immigrants live in urban areas
Métis, has traditionally lived in rural Canada. This, how- (Statistics Canada, 2008a). However, immigration settle-
ever, is changing. The 2011 census showed that 45% of ment patterns are changing, with the growth in the
Registered Indian (First Nations) people lived on reserves, economies of some provinces, such as Saskatchewan
M15_KOZI2703_04_SE_C15.indd 264 06/02/17 3:33 PM

and Manitoba, reversing traditional patterns of popula- Box 15.1 Major Occupations
tion decline (Beshiri & He, 2009). Smaller centres are in Rural Regions
increasingly developing strategies to recruit and retain
immigrants to fill jobs in their growing manufacturing Rural communities support many different occupations.
and processing industries (Beshiri & He, 2009). The following are a few of the major ones:
Economic conditions vary by region and the degree Agriculture Mining
of reliance on single industries, such as agriculture and Logging Fishing
natural resources. Population growth rates in rural and Oil and potash extraction Tourism
small town areas vary, depending on the nature of the Merchants Service sector
community. When communities are dependent on pro-
duction of commodities that are growing in value, they
grow rapidly, with resulting challenges of housing, ser-
vice availability, and infrastructure such as servicing rural Canada. They noted: “The landscape may still
of building lots and provision of sewer and water ser- be agricultural. The rural people-scape is decidedly
vices. Such was the case in the rural areas of Alberta, non-agricultural” (p. 135). Less than 10% of Canadians
Saskatchewan, and Manitoba during the oil and potash live on farms, a decrease from two-thirds of the popu-
booms, which slowed in 2014–2015. This illustrates the lation prior to World War II. Only in Manitoba and
“boom and bust cycle,” which accompanies dependence Saskatchewan is agriculture a major employment sector
on an economy based on natural resources. in rural areas. Economists predict that economic growth
Populations are growing in rural and small town in rural communities will be dependent on the growth of
areas within commuting distance of large urban centres. manufacturing in the future.
Populations are also growing in areas around lakes and moun- Although traditionally rural and small town families
tains—preferred areas for many retiring “baby boomers.” had lower per capita incomes compared with urban
Over time, a significant reduction in the number and families, currently, the rural incidence of low income is
growth in size of family farms has been associated with similar to that of those living in urban areas (Bollman
a decrease in rural population. Despite overall recent & Reimer, 2009). Rural employment has matched that
improvements in the farming economy, the countrywide in urban areas since 2001, after lagging throughout
trend has been toward older farm operators retiring but the previous decade. The biggest employment increases
fewer of their children carrying on the family farming occurred in northern Manitoba, followed by Athabasca,
business. The consequent decrease in population has a Alberta, driven by the development of the oil sands.
significant economic and sociocultural impact on the Rural areas that are reliant on such commodities as
residents and communities in rural areas. agriculture, forestry, or mineral extraction for their eco-
Most rural areas in Canada have a high depen- nomic welfare are subject to “boom and bust” economic
dency ratio, meaning that there is a larger proportion changes, which result in lack of predictable income.
of the population in age groups not generally earning This lack of security can act as a major source of stress
income, including youths (0–19 years) and seniors (older in rural areas (Brannen, Johnson Emberly, & McGrath,
than 60 years), in relation to those who are employable 2009).
(20–50 years). This makes those not earning income
dependent on those who do (Government of Canada,
2011). Factors that contribute to the aging of the rural
population in many areas include out-migration of
the rural youth for education and employment, and
Health of Rural Residents
in-migration of retirees (Pong, 2007).
Health Issues
Although there is a perception that rural residents are
healthier than their urban counterparts, statistics demon-
Occupations strate that, for the majority, this is not the case (DesMeules
Although the term rural is often equated with agriculture, et al., 2012). The rates of smoking and obesity are higher
other major industries in rural regions include mining, among rural residents compared with their urban coun-
fishing, logging and forestry, and resource extraction, terparts. Rural residents are generally poorer, have lower
such as for oil and potash. In addition, rural communi- educational attainment, and have a higher overall mortal-
ties have a variety of merchants, service dealers, and ity rate compared with urban residents (DesMeules et al.,
support services (see Box 15.1). The concentration of 2012). Other health influences, such as healthy eating
unskilled occupations is sizeably higher in predominantly habits and physical activity, show lower practice levels in
rural regions (Bollman & Reimer, 2009). rural communities. Smith, Humphreys, and Wilson (2008)
Bollman and Reimer (2009) described a signifi- reported lower life expectancy for men in rural Canada
cant shift from farming to nonfarming activities in than for urban men. (See Box 15.2.)
M15_KOZI2703_04_SE_C15.indd 265 06/02/17 3:33 PM

Box 15.2 Health Concerns for Rural noted that less than 1% of stroke patients were benefit-
Residents ting from such services. This study advocated establish-
ing a national Telestroke program, thus eliminating any
Rural residents face a number of health concerns: barriers with respect to cross-provincial consultation as
• Respiratory problems well as promoting the timely use of existing available
• Circulatory diseases Telestroke services (Canadian Stroke Network, 2011).
• Chemical contaminants
Chemical Contaminants Chemical contaminants
• Cancer
can cause a variety of health issues, depending on the
• Water safety
agent, source, amount, and route of absorption. Skin
• Zoonoses
disorders, such as dermatitis, are a common problem for
• Agricultural injuries those working with chemicals without the use of per-
• Primary industry injuries sonal protective equipment, such as gloves and coveralls.
• Injuries to children A Canadian study found that farmers exposed to chemi-
• Motor vehicle collisions cals, such as pesticides, gasoline and diesel emissions,
• Mental health issues petroleum by-products, and solvents, have a twofold
• Suicide higher risk of prostate cancer compared with unexposed
• Problematic substance use farmers (Parent, Desy, & Siemiatycki, 2009). Arbuckle,
Bruce, Ritter, and Hall (2006) recommended that people
who handle pesticides be counselled (along with their
It is important to look at the unique characteristics families) on hygienic practices (e.g., removing footwear
of individual rural communities before applying findings and washing soiled hands before entering the home) to
about rural health in a generalized way. Aspects of the reduce exposure to herbicides.
specific community, including individual income, educa- Cancer Rural residents are at greater risk of dying
tion, employment, unique cultural factors, and migra- from some cancers compared with urban residents.
tion patterns, all impact the health of local residents However, gaps in survival are believed to be related to
(Lavergne & Gephart, 2012). differences in diagnosis and treatment rather than to an
Respiratory Problems Respiratory disease is a increased risk of getting cancer. Rural patients with can-
common health problem among agrarian rural dwellers, cer access screening, radiation, surgery, and clinical trials
and rates of respiratory diseases are significantly higher less frequently compared with their urban counterparts
across the board in rural communities compared with (Canadian Partnership against Cancer, 2014).
urban centres (DesMeules et al., 2012). However, resi- The incidence of cancers varies widely between the
dents in rural areas, of whom 30% or more commute rural and urban areas of Canada. Cervical, prostate,
regularly to large urban centres, have a lower risk of lip, and eye cancers and melanoma are more common
dying from respiratory diseases compared with residents in rural areas, whereas the incidence of breast, lung,
living in urban areas (DesMeules et al., 2012). Exposure stomach, and lymphatic cancers is higher in urban areas
to grain dust, wood smoke, agricultural chemicals used (Smith et al., 2008). The incidence of thyroid cancer
in crop production, and noxious gases emitted from silos is 25% lower in Canadian towns or rural areas com-
or oil and gas wells have all been implicated as having pared with cities (Guay, Johnson-Obaseki, McDonald,
immediate or long-term adverse effects on the health of Connell, & Corsten, 2014). Pong (2007) found that cer-
this population. Inhalation of toxic substances can result vical cancer rates were significantly higher for women
in systemic problems, such as headaches, blurred vision, in rural areas compared with those in urban areas, in
or possibly convulsions. the 20- to 44-year age group, and the rate of having
a Papanicolaou (Pap) test, a screening test for cervical
Circulatory Problems Rural residents have higher
cancer, was lower. However, according to DesMeules
than average rates of high blood pressure, heart disease, et al. (2006), in general, no significant differences exist
and cerebrovascular accidents (strokes) (DesMeules et al., between rural and urban residents in terms of cause-
2012). Mortality rates due to circulatory diseases are specific cancers.
higher in areas more distant from urban centres (Pong,
DesMeules, & Lagace, 2009). Although current treat- Water Safety Water safety is a dual concern: first,
ments of strokes have resulted in a high degree of success, irrigation ditches, dugouts, and the northern lakes and
it is highly time sensitive. Ideally, treatment should be rivers are common sites of drowning; second, contami-
adminstered within 1 hour of arrival at the health care nated wells and creeks that supply drinking water for
facility. A number of Canadian provinces have established rural residents pose health risks.
Telestroke programs, in which physicans can be consulted Canadian rural society faces enormous challenges
and assessments done via high-technology modern com- in terms of potable drinking water. Sanitation systems
munication methods in a timely manner; a 2011 study are either deteriorating or have never met rigorous
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health standards. In May 2000, in Walkerton, Ontario, loss of sales impacted 90 000 Canadian beef producers
Escherichia coli bacterial contamination of the water sys- and exporters, resulting in a loss of $6.3 billion (Pletsch,
tem caused seven deaths and made 2300 other resi- Amaratunga, Corneil, Crowe, & Krewski, 2012).
dents ill. Vicente and Christoffersen (2006) examined the Another zoonosis seen in rural and northern areas
sequence of events in Walkerton that culminated in the is rabies, which is often transmitted from bats, foxes,
contaminated water supply and the resultant illness and raccoons, and skunks. Pets, especially dogs, in rural
revealed an interaction among all levels in a complex areas are at risk for contracting the infection from rabid
community system, including “physical factors, unsafe animals and transmitting the disease through their saliva
practices of individual workers, inadequate oversight to household members. Rabies, left untreated, is fatal.
and enforcement by local government and a provincial Teaching the importance of immunization of pets and
regulatory agency and budget reductions imposed by the careful monitoring of their interactions with humans,
provincial government” (p. 93). especially children, is important.
In many remote and northern communities, resi- Hantavirus, which is prevalent in arid rural areas,
dents obtain their drinking water from sources that are has recently become a serious health concern. This
not treated to remove bacteria and parasites. In 2011, pathogen is spread through the droppings of deer mice
more than 80 rural Canadian First Nations communities and produces hantavirus pulmonary syndrome. As of
were under “boil water” advisories, and 21 communi- January 2014, 100 cases and 27 deaths from hantavirus
ties were at high risk for ground water contamination infection were reported in Canada. Death occurs as a
(Council of Canadians, 2011). Inadequate sewage dis- result of pulmonary and renal failures, as well as internal
posal and contamination from livestock have resulted hemorrhage (Public Health Agency of Canada, 2015).
in outbreaks of infection that are extremely harmful
Agricultural Injuries Between 1990 and 2008,
to infants, children, older adults, and persons who are
1975 people died in agricultural accidents in Canada.
immunocompromised. A study comparing water safety
Of these fatalities, 70% were related to machinery; 46%
management in two Canadian provinces found consid-
resulted from rollovers, runovers, and entanglements
erable variability in their systems to assess and manage
involving farm vehicles (Canadian Agricultural Injury
risks to water quality. Risk assessment systems that are
Reporting, 2012). A comparison of all farms reporting
formalized, continuous, and applied throughout the sys-
injuries, according to farm type, has shown that livestock
tem have not been adopted widely (Dunn, Harris, Cook,
operations result in a higher proportion of injuries com-
& Prystajecky, 2014). The development of water and
pared with crop operations.
sewage treatment plants, the education of communities
The majority of farm injuries (51.95%) are muscu-
with respect to their maintenance, and the creation and
loskeletal (fractures, dislocations, sprains or strains, and
enforcement of stringent regulatory standards for water
back injuries). Reported injury cases are more frequent
quality at a national level are crucial requirements for
among men than among women. When farm injuries
ensuring the health of the residents of rural and north-
occur, income is jeopardized because operators of small
ern areas (Eggertson, 2008; Hrudey, 2008).
family farms are not usually covered by workers’ compen-
sation (Maltais, 2007). Farm injury prevention programs
Zoonoses Other risks for the residents of rural and
should stress gender implications (e.g., women avoiding
remote communities include zoonoses (LeJeune &
performance of tasks with machinery designed for men,
Kersting, 2010). These are diseases that are communi-
who generally have larger bodies) by using education,
cated from animals to humans, and vice versa. Nearly
regulation, or engineering approaches (Dimich-Ward,
60% of infectious diseases in humans originate in animals.
Guernsey, Pickett, Rennie, Hartling, & Brison, 2007).
Recent global epidemics of infectious diseases caused
by H1N1 influenza virus, West Nile virus, Ebola virus, Primary Industry Injuries The most danger-
human immunodeficiency virus (HIV), and the virus ous industries to work in, as reported for the period
that causes severe acute respiratory syndrome (SARS) 1996–2005, were mining, quarrying, and oil wells (49.9
originated in animals (National Collaborating Centre for fatalities per 100 000 workers); followed by logging and
Environmental Health, 2011). forestry (42.9 fatalities per 100 000 workers); fishing and
Bovine spongiform encephalopathy (BSE) is a pro- trapping (35.6 fatalities per 100 000 workers); agriculture
gressive, fatal disease of the nervous system in cattle. (28.1 fatalities per 100 000 workers); and construction
Although the exact cause of BSE is unknown, it is asso- (20.6 fatalities per 100 000 workers) (Sharpe & Hardt,
ciated with the accumulation of BSE prions, which are 2006). From 1996 to 2005, primary industry occupations
abnormal proteins, in the brain. No treatment or vaccine had the highest fatality rate at 19.5 per 100 000 work-
is currently available to cure the disease (Agriculture and ers. Occupational health and safety programs should
Food, Alberta, 2007; Canadian Food Inspection Agency, ensure that appropriate safety equipment is available,
2005). In May 2003, one Alberta cow tested positive properly maintained, and used correctly. Such programs
for BSE, and 40 countries immediately stopped their have done much to reduce the incidence of occupational
importation of Canadian beef. It is estimated that this injuries and fatalities in these industries.
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Injuries to Children Agricultural injuries and roads that are not divided into two lanes (Transport
fatalities are an important health issue for preschool chil- Canada, 2011). Of rural drivers who are fatally injured,
dren. Of the agricultural fatalities occurring in Canada most have an average blood alcohol level that is twice the
between 1990 and 2008, 14% involved children (Canadian legal limit. However, rural deaths resulting from drinking
Agricultural Injury Reporting, 2012). Brison, Pickett, Berg, and driving are decreasing. This decrease can be attrib-
Linneman, Zentner, and Marlenga (2006) analyzed fatal uted to a combination of factors: better engineering of
injuries in children aged 1 to 6 years and found three major vehicles and roads, advances in medical care, increased
causes of death: (a) being run over as a bystander, (b) being public awareness campaigns, and education regarding
run over as an extra rider, and (c) drowning. Statistics show drinking and driving.
a decrease in agriculture-related injuries and fatalities once
children reach school age until they are 10 years of age Mental Health Issues Mental health issues are
or older. At that age, many farm children begin to help those that affect an individual’s mood, behaviour, think-
with work. The North American Guidelines for Children’s ing, and perceptions. The problem may be the result of
Agricultural Tasks provide information and guidance to an organic process, such as Alzheimer’s disease, or be of
parents and employers regarding the hazards and adult a functional nature, such as depression.
responsibilities assumed by children assigned to agricultural Recent studies show that members of rural com-
tasks (Marshfield Clinic Research Foundation, 2015). munities in Canada experience fewer mental health
issues compared with urban residents and are more
Motor Vehicle Collisions (MVCs) The most com- likely to have social support, express a sense of belong-
monly considered motor vehicles are cars, trucks, and ing, and have lower stress levels (Brannen, Dyck, Hardy,
motorcycles. However, farm vehicles, such as tractors, & Mushquash, 2012). Several factors differentiate rural
all-terrain vehicles (ATVs), dirt bikes, and snowmobiles, mental health issues and care from urban ones and may
are also included in this category, even though they are influence whether or not residents seek care:
primarily used for off-road activities. MVC fatality rates
are three times higher in rural areas than in urban cen- • The lack of locally available resources
tres (Janke, Dobbs, McKay, Linsdell, & Babenko, 2013). • Unique variables precipitating a mental health event or
Conditions thought to affect the mortality rate of rural crisis, such as drought conditions during which farmers
and northern regions include the following: are unable to produce crops
• Road conditions: narrow gravel roads, rock cuts, winter • The lack of anonymity in rural communities
ice and snow • The stigma still associated with mental health problems
• High traffic speeds • Concern regarding confidentiality
• Wildlife or livestock on the roads
Problematic Substance Use Problematic substance
• Lower rates of seat belt and child restraint use
use refers to the inappropriate use of prescription drugs
• The practice of riding in the back of open pick-up trucks and nonprescription drugs (including alcohol) and the
• Limited emergency medical personnel use of illicit drugs. Commonly misused substances
• Greater distances to emergency medical services include tobacco, alcohol, opioids, and a wide range of
illicit drugs, such as cannabis and hallucinogens. In addi-
In addition to the majority of collisions involving more tion, the inhalation of various aerosol products, glues,
than one vehicle, single-vehicle rollovers are common. and gasoline is a growing problem among Canadian
These may be the result of high speed and loose gravel youth, especially in the more remote regions.
on country roads. ATV rollovers occur in the process of Alcohol continues to be the primary drug leading
carrying out farm or ranch work. Numerous injuries are to health-related problems (Centre for Addiction and
incurred when ATV, dirt bike, and snowmobile riders Mental Health, 2002). Problematic alcohol use causes
encounter barbed-wire fences, especially while travelling chronic disease, permanent disabilities, and fatalities
at high speeds. In northern areas, snowmobile mishaps that result from sensory and motor impairment. This, in
are the leading cause of injury and death. turn, leads to a variety of traumatic injuries and deaths
A concerning factor related to the increased mortal- as a result of falls, drowning, and MVCs. In some cases,
ity in MVCs in rural areas is the distance that must be children born to women who consume alcohol during
travelled to get either the necessary resources to the per- pregnancy are born with fetal alcohol spectrum disorder
son in need or the injured individual to the appropriate (FASD), a condition that produces facial deformities,
level of care. In trauma care, the first hour following a growth deficiencies, and central nervous complications
traumatic event is commonly referred to as the “golden that result in learning disabilities, inability to socialize
hour,” since the care delivered to the victim during this successfully, and behavioural difficulties. Pacey (2009)
initial phase strongly influences patient outcome. indicated that a larger proportion of the research in
Two-thirds of fatal collisions and 30% of injury FASD has been done in Aboriginal communities com-
crashes in Canada occur in rural areas, typically on pared with non-Aboriginal communities, leaving the
M15_KOZI2703_04_SE_C15.indd 268 06/02/17 3:33 PM

impression that Aboriginal communities have a dis- First Nations on reserve populations have higher
proportionate incidence of FASD. However, the actual rates of smoking, obesity, and diabetes; less leisure time
extent of FASD in Aboriginal and non-Aboriginal com- activity; and lower consumption of fruits and vegetables.
munities is not actually known, nor has the prevalence in All of these are risk factors for cancer (Elias et al., 2011).
rural and urban Aboriginal communities been explored Diabetes is a major health issue—the prevalence being
(Pacey, 2009). two times higher among the Métis population com-
pared with the general population, and 3.5 times higher
Suicide In recent years, the incidence of suicide among
among First Nations people compared with the general
rural youth has increased, with the highest rate occur-
population (Tjepkema, Wilkins, Senécal, Guimond, &
ring among the Canadian Aboriginal population. Smith
Penney, 2009). Diabetes is a metabolic disease, in which
et al. (2008) reported higher suicide rates for males
high blood glucose levels are caused by defects in insulin
in rural and remote populations, whereas suicide rates
secretion or action or in both.
for females were similar in both rural or remote and
The most common causes of death among First
urban populations. However, as noted previously, this is
Nations people aged 1 to 44 years were reported to
highly dependent on the existing conditions in a specific
be poisoning and injury. Children under 10 years died
community.
predominantly from unintentional injuries. In a study
Factors that contribute to a high incidence of suicide
of unintentional injuries in children and adolescents in
are depression; problematic substance use; changing
Newfoundland and Labrador, Alaghehbandan, Sikdar,
family, community, and economic dynamics; cultural
MacDonald, Collins, and Rossignol (2010) found the
changes that emphasize the valuing of increased per-
mortality rate for unintentional injury to be eight times
sonal freedom and heterogeneity; declining religious
higher among Aboriginal children compared with chil-
affiliations; and Western society’s tendency to view sui-
dren in the general population.
cide as a terminal means of problem solving. Although
Suicide rates in the Aboriginal population are dra-
these factors are also influential in urban settings, a
matically higher than in the general population, with the
factor that has a major influence in the case of rural
First Nation suicide rate twice that of the general popu-
communities is that they tend to be more isolated from
lation, and the Inuit suicide rate over 10 times that of
formalized health and social services.
others (Kirmayer, Brass, Holton, Paul, Simpson, & Tait,
2007). Suicide and self-injury were the leading cause
of death for youths and adults up to 44 years. Suicide
Special Concerns in Rural accounted for 22% of deaths in youths and 16% in early
adulthood. Social disruption, lack of hope for the future,
and Remote Aboriginal problematic substance use, and family violence have all
been suggested as underlying or related factors for sui-
Communities cide. Efforts to combat these problems include commu-
nity mobilization and awareness campaigns (Kirmayer
The problems that exist in rural communities in gen- et al., 2007).
eral are magnified in rural Aboriginal communities. Kirmayer et al. (2007) suggested that even though
Aboriginal Canadians have been found to have sig- showing direct causal links quantitatively can be chal-
nificantly greater health challenges compared with the lenging, obvious and convincing evidence shows that a
general population. Lower income and lower educa- long history of cultural oppression and marginalization
tional levels among Aboriginal people account for some, has played a role in the high levels of mental health
but not all, of these challenges (Garner, Carriére, & problems found in many Aboriginal communities. On
Sanmartin, 2010). Infant mortality rates among First the positive side, evidence also shows that fortifying an
Nations people, both on and off reserve, are reported to ethnocultural sense of identity, community unity, and
be two times that of the general population (Smylie, Fell, political empowerment can help improve mental health
& Ohlsson, 2010). These rates, coupled with significantly in Aboriginal communities. Mental health promotion
higher accident and injury rates in all age groups, con- that emphasizes youth and community empowerment
tribute to lowered life expectancy. Lack of clean water through individual and community-based initiatives, as
and sewage systems, inadequate housing, and a high well as larger political and cultural processes, is likely
unemployment rate are contributing factors. Despite to have broad effects on improving mental health and
the fact that the 2007 federal budget speech stated general well-being in these communities.
unequivocally that “all Canadians deserve clean drink- Tradition and healing are central to current efforts
ing water,” in February 2008 there were 93 First Nations by Aboriginal peoples to confront historical injus-
communities in Canada living under “boil water” or “do tices and suffering brought on by colonialism, when
not consume” orders. People in one of those communi- European settlers arrived in Canada and took over
ties were still living under such an order issued in 1995 control of the land and its resources. Aboriginal peoples
(Eggertson, 2008). in Canada are involved in healing using their own
M15_KOZI2703_04_SE_C15.indd 269 06/02/17 3:33 PM

traditions, repairing the ruptures and discontinuity in

the sharing of traditional knowledge and values, and Health Care Delivery
asserting their collective identity and power (Kirmayer
et al., 2007). Health Care Delivery Issues
Residential schools were established by the Canadian
Many factors contribute to making the delivery of appro-
government in the late nineteenth century and were in
priate and cost-effective health services to rural, remote,
operation until the 1990s to provide education to First
and northern populations a challenge (see Box 15.3).
Nations children (Llewellyn, 2002). They were admin-
Accessibility to equitable health care services is at the
istered by Christian churches, including the Methodist
heart of health care delivery issues. A major factor is
(now part of United Church of Canada), Presbyterian,
the need to deliver a variety of health care services to a
Anglican, and several Roman Catholic denominations.
population that is sparsely distributed over a large geo-
The policies by which the schools were run came from
graphical area with a limited number of health care pro-
the Canadian government; however, day-to-day manage-
fessionals. Current and impending shortages of health
ment was in the hands of the religious organizations.
care professionals will only exacerbate an already chal-
Government used these schools to implement its policy
lenging health human resources problem (Kulig et al.,
of assimilation. These schools created and enforced situ-
2013). In addition, the current practice of educating
ations of shame, humiliation, and physical, mental, emo-
health care professionals in urban settings with lim-
tional, and spiritual disconnectedness that led to feelings
ited clinical exposure to rural settings results in health
of helplessness and powerlessness (Chansonneuve, 2005).
care professionals being less inclined to practise in rural
The removal of children from their families; the destruc-
settings on completion of their programs (Blankenau,
tion of First Nations languages, culture, and spiritual-
2010).
ity; and the physical and emotional abuse the children
The work of DesMeules et al. (2006) was a beginning
endured are at the core of many of the health and social
step in addressing the challenge of adequate and useful
challenges that face the First Nations communities even
statistical data to affect health care policy and practice in
today.
rural, remote, and isolated communities across Canada.
On June 11, 2008, then Prime Minister Stephen
Smaller independent studies have added to our under-
Harper officially apologized to the Aboriginal peoples on
standing of rural health issues in specific areas, including
behalf of the people of Canada for the abuses inflicted
the health issues of rural and remote black women in
on them in residential schools. Also, in June 2008, the
Nova Scotia (Etowa, Wiens, Thomas Bernard, & Clow,
Indian Residential Schools Truth and Reconciliation
2007) and determinants of women’s health in southwest
Commission began its national-level work to under-
Ontario (Leipert & George, 2008). However, a compre-
stand how the Aboriginal peoples were affected by the
hensive review of the literature of rural–urban health
residential school experience (Truth and Reconciliation
differences notes that although rurality plays a major role
Commission, 2011). In June 2015, the Truth and
in the nature of services and level of access available,
Reconciliation Commission released its findings, outlin-
rurality itself does not lead to health disparities. “Much
ing 93 recommendations, or calls to action, to address
the wrongs done to the Canadian Aboriginal peoples by
the residential school process. These recommendations
called for establishing measurable goals and timelines to Box 15.3 Nursing and Health Care
reduce the gaps between Aboriginal and non-Aboriginal Delivery Issues
communities in areas such as infant mortality, maternal
Nursing in rural and remote areas can be affected by a
health, suicide, mental health, addictions, life expec- number of delivery issues:
tancy, birth rates, infant and child health issues, chronic
• Data gaps and inadequate information about the health
diseases, illness and injury incidence, and the availability status of rural residents
of health services. In addition, the Commission called • Distance
for increased numbers of Aboriginal health professionals
• Sparse population
working in health care and for all medical and nursing
• Limited infrastructure, including transportation and
schools in Canada to mandate courses on Aboriginal communication
health issues, including a course on the history and
• Limited health care resources and access to technology
legacy of residential schools (Truth and Reconciliation
• Educational preparation for generalist–specialist
Commission of Canada, 2015). practice
Health care providers working in rural, remote, and
• Recruitment and retention of professionals
isolated communities must be knowledgeable about the
• Ethical issues (lack of anonymity, confidentiality,
history of the Aboriginal peoples of Canada and the resources)
impact it has had on their culture, spirituality, health,
• Changing demographics and care requirements of the
and well-being. Health care workers must also be able to community
provide culturally safe care.
M15_KOZI2703_04_SE_C15.indd 270 06/02/17 3:33 PM

of the variation between rural and urban health status • Nurses’ personal and professional roles are inseparable
[can] be explained by socioeconomic factors affecting the in small communities.
use of health services” (Smith et al., 2008, p. 59). • Many rural nurses work alone, indicating a need for
RURAL, REMOTE, AND NORTHERN NURSING PRACTICE at-a-distance, face-to-face, and technological supports.
Nurses practise in multiple settings in rural, remote, and • Understanding of nurses and their partnerships with
northern sites; they provide acute and extended care, their communities could aid recruitment and retention.
community health services, home care, occupational • Support for new ways of interprofessional practice is
health services, and mental health services, and, in many essential.
provinces and territories, they are taking on expanded
practice roles, in which nursing goes beyond the tra- • Particular attention must be paid to and support given
ditional nursing roles. Often, these nurses, especially to nurses in Aboriginal communities to provide cultur-
in remote communities, work alone (MacLeod et al., ally competent, appropriate care.
2008). • Retirement and migration need to be addressed by pro-
Health care providers in rural, remote, and northern viding relevant continuing education.
areas must possess a broad, generalized knowledge base • The distinctiveness of rural and remote nursing prac-
to meet the diverse health care needs of the residents. tice cannot be captured until unique personal iden-
Kulig et al. (2013) indicated that rural nursing practice is tifiers are created along with relevant urban rural
characterized by experiences such as professional isola- indicators.
tion, independent decision making, heavy responsibil-
ity, the need for a wide ranging skill set, knowledge of Nurses working in rural and remote areas face occu-
patients as community members, and being the nurse at pational risks that differ from those in metropolitan
work and in the community. areas. An Australian study comparing the risks faced
Rural nurses in Canada, the United States, and by rural nurses with those of their urban counterparts
Australia share many common characteristics. Rural found that rural nurses lifted and transferred patients
nurses are often described as highly visible members of more often compared with their urban colleagues. Rural
the community, resourceful, flexible, autonomous, self- nurses reported facing less risk of bloodborne patho-
reliant, and effective team members (MacLeod et al., gens and excessive noise but more risk of temperature
2008). Above all else, rural nurses are described as gen- extremes compared with metropolitan nurses (Timmins,
eralists and specialist–generalists. The need to maintain Hogan, Duong, & Miller, 2008). Rural nurses are
general practice skills covering all ages and all the condi- exposed to weather extremes more frequently compared
tions that clients or patients can present with is a major with their urban counterparts. The impact of extreme
challenge for rural nurses. weather challenges is rarely identified in the literature
as a concern in the provision of home, community,
and emergency care, and even more rarely reflected
Nursing Practice Issues in health policy (Skinner, Yantzi, & Rosenberg, 2009).
Distance and geography also pose significant challenges
In the past, the majority of research regarding rural and and potential risks (Skinner et al., 2009).
remote nursing has come from Australia and the United A Canadian study published in 2010 found that
States. During the past few years, there has been an explo- rates of workplace injury for rural health care work-
sion of Canadian research focusing on rural nursing ers, particularly musculoskeletal injury, were remarkably
practice (e.g., Jackman, Myrick, & Yonge, 2010; Martin high. This study found that risk factors for poor work
Meisner et al., 2008; Montour, Baumann, Blythe, & disability prevention outcomes were different for rural
Hunsberger, 2009; Penz, Stewart, D’Arcy, & Morgan, 2008; health care workers as a result of older age, lower edu-
Thomlinson, McDonagh, Crooks, & Lees, 2004), nurses cational levels, heavy workloads (long hours, extensive
(e.g., Andrews, Stewart, Morgan, & D’Arcy, 2012; Kulig, on-call demands, complex patient needs), low staff sup-
Stewart, Penz, Forbes, Morgan, & Emerson, 2009; Stewart port, exposure to violence, lack of replacement staff, and
et al., 2010), nurse practitioners (Way, Jones, Baskerville, inadequate safety features in buildings (Franche, Murray,
& Busing, 2001), and nursing education and professional Ostry, Ratner, Wagner, & Harder, 2010).
development (Kosteniuk, D’Arcy, Stewart, & Smith, 2006). Despite these risks, rural nursing practice provides
(See the Evidence-Informed Practice box.) Issues that were many rewards, including the following:
identified in the MacLeod et al. (2004) pan-Canadian
study of rural nursing practice and rural nurses remain • Greater autonomy because there are fewer nurses and
relevant even today. They include the following: other health care professionals
• Managers and policymakers need to better understand • Greater knowledge of the client’s or patient’s home and
the realities of rural and remote practice to develop family conditions
a “rural lens” that could be used as part of a pan- • Closer interface and collaborative practice with other
Canadian rural and remote nursing strategy. health care professionals
M15_KOZI2703_04_SE_C15.indd 271 02/03/17 1:33 PM

emphasis placed on the setting itself. The recruitment

EVIDENCE-INFORMED and retention of nurses for practise in rural, remote, and
PRACTICE northern regions of Canada have been persistent prob-
lems, and these continue to grow in importance (Kulig
“And Then You’ll See Her in the et al., 2013; MacLeod et al., 2008). Nursing leaders and
educators have a role in the education and psychological
Grocery Store”: The Working preparation of nurses to work in these diverse settings.
Relationships of Public Health It is essential that more nursing students be educated
Nurses and High Priority Families to practise in rural and remote acute care and com-
munity settings. Programs based at Lakehead University
in Northern Canadian Communities in Thunder Bay, Ontario; the University of Northern
Moules, MacLeod, Hanlon, and Thirsk (2010) explored the British Columbia in Prince George, British Columbia;
nature of working relationships between health care pro- the University of the North in The Pas/Thompson,
fessionals and high-needs families in small rural, northern Manitoba; and the University of Saskatchewan are
communities. The researchers interviewed 32 public health delivering baccalaureate nursing programs in smaller
nurses, 25 families, and three lay home visitors from 14 com- rural centres in an attempt to address rural and remote
munities across northern British Columbia to determine the
unique experiences and challenges faced. The study found
health care needs. The University of Saskatchewan
that the relationships established were multifaceted and that program uses remote mobile telementoring in the nurs-
the nature of small communities increased the complexity of ing laboratory to teach assessment and psychomotor
the health care professional–client relationship. The multiple nursing skills to students in two small northern nursing
roles played by nurses in small communities and the nego- communities. University faculty members teach and
tiation of relationship boundaries were major issues. The supervise students remotely, with local nurses providing
nurses described the issues that arose from knowing clients onsite support.
in multiple contexts and being known to them. They spoke
of the pressure to bend the rules because of the complexity
The University of Northern British Columbia offers
of these relationships. Confidentiality, anonymity, role confu- a 1-year certificate program in rural and northern nurs-
sion, and proximity all posed challenges. The study provided ing to experienced registered nurses with an undergradu-
insights into the day-to-day issues that arise when working ate degree in nursing. As well, a graduate program with
with vulnerable, marginalized families in small community a focus on rural and northern nursing is offered through
settings and the challenges faced by nurses when living and a blended-mode (face-to-face and online) delivery at
working in small communities. Laurentian University in Northern Ontario. Laurentian
NURSING IMPLICATIONS: Nurses working in small University also offers a unique interdisciplinary pro-
communities must be aware of the unique demands gram at the doctoral level in rural and northern health,
that this work situation creates. Relationships may not focusing on health services and health policy. Aboriginal
begin or end at the clinic door or in the home visit. nursing–specific programs are offered by 8 of the 91
They simply change. Nurses working in rural communi-
ties must have a clear understanding of their profes-
Canadian Association of Schools of Nursing member
sional role, an ability to negotiate shifting boundaries, schools (Gregory, 2007).
and supports to assist them in this complex work. TELEHEALTH AND RURAL AND REMOTE PRACTICE
Source: Moules, N., MacLeod, M., Hanlon, N., & Thirsk, L. (2010). “And then you’ll Telehealth (the sharing of nursing information by using
see her in the grocery store”: The working relationships of public health nurses and
high priority families in northern Canadian communities. Journal of Pediatric Nursing,
electronic means, such as a telephone or the Internet, to
25, 327–334. answer consumers’ questions), telemedicine (the use
of technology to transmit electronic medical data about
clients to persons at distant locations), and blended-mode
learning (a combination of face-to-face, videoconfer-
• Greater opportunity to affect health care planning and encing, Internet, paper-based, and web casting) have
policy at the local level because of the recognized role mushroomed with technological advances and increased
as a resource on health care and the prominence in the access to high-speed Internet connections and videocon-
community ferencing capacity. In remote Labrador, Rosie the Robot
moves throughout the health centre, allowing patients
EDUCATION FOR RURAL AND REMOTE PRACTICE As to talk with physicians 350 km away. Physicians per-
early as 1975, a course in rural hospital nursing was form visual assessments and have access to all diagnostic
offered at the Foothills Hospital School of Nursing in data while they interact with each patient (Canadian
Calgary (Reimer & Mills, 1988). Across the country, Broadcasting Corporation, 2010).
some undergraduate nursing programs are beginning Gibson, Kakepetum-Shultz, Coulson, and
to include theory and clinical practice specific to rural O’Donnell (2009) explored the use of telehealth in men-
nursing in their curricula. Other programs continue to tal health services in Northern Ontario. Telemental
use rural placements as practicum sites, with a lesser health, using primarily videoconferencing, was used in
M15_KOZI2703_04_SE_C15.indd 272 21/02/17 11:23 AM

mental health services provided to the First Nations 2013), vision problems (Kassam, Amin, Sogbean, &
people. Telehealth was seen as useful by clients in pro- Damji, 2012), kidney failure (Sicotte, Moqadem,
viding greater access to and better continuity of service. Vasilevsky, Desrochers, & St-Gelais, 2011), rehabilita-
Community members reported a degree of comfort tion and therapy, including stroke follow-up (Taylor,
with the process, indicating that having the counsellor Stone, & Huijbregts, 2012), smoking cessation (Carlson,
at a distance actually facilitated disclosure. Privacy and Lounsberry, Maciejewski, Wright, Collacutt, & Taenzer,
security were concerns for some community members, 2012; Pignatiello, Teshima, Boydell, Minden, Volpe, &
who indicated that they felt that the staff in the rest Braunberger, 2011), and long-term adult and pediatric
of the health centre might overhear their interactions. psychotherapy (Rudnick & Copen, 2013).
Others noted concerns about the therapist not being in Technological approaches are not only seen in ser-
the community, both from the perspective of developing vice delivery. Russell and Perris (2003) reported on a
an understanding of the context of people’s lives and 6-month telementoring staff development initiative in
also in relation to the lack of contribution to community a Canadian community nursing agency. The online dis-
capacity building if the therapist is not part of the fabric cussions focused on collaborative learning and profes-
of the community. A study in Northern Ontario found sional development that showed improved asynchronous
that telehealth programs for mental health removed the communication and problem-solving skills as a result of
individual financial burden of travel to larger centres; online discussions and fostered “communal opportunis-
allowed them to remain in the community with fam- tic learning and professional development” (Russel and
ily, friends, and familiar health care providers to sup- Perris, 2003, p. 227).
port them; and was a more efficient and effective use Technology has the potential to support service pro-
of patient and health provider time (Sevean, Dampier, vision, accessing health information for clients, nursing
Spadoni, Strickland, & Pilatzke, 2008). education, and staff development in rural and remote
A review of recent studies found that telehealth strat- settings. Given the distances required for travel, technol-
egies were used in Canada for active treatment, includ- ogy is an important aspect of rural and remote health
ing emergency trauma (Zakrison, Ball, & Kirkpatrick, care now and in the future.
Case Study 15
Mr. Donaldson, a 45-year-old farmer living in rural Saskatche-
wan, presented to the emergency department with cellulitis in his
2. How might the patient’s regime vary from that in an
urban setting?
right leg, secondary to a puncture wound from the tine of a pitch-
fork. He runs a family grain-and-cattle operation about 50 km 3. How might Mr. Donaldson’s occupation influence his
from town and the nearest hospital. He is given the choice of recovery?
being admitted to hospital or returning to hos- 4. What health care delivery issues common to rural and
pital every 8 hours for a 1-hour antibiotic treat- remote residents affect Mr. Donaldson’s treatment?
ment and for a daily dressing change. He is
told he must limit his activity and keep his leg Visit MyNursingLab for answers and explanations.
elevated as much as possible.
1. What issues should the nurse discuss with Mr. Donaldson

to assist him in choosing his treatment options?
Key Terms
Aboriginal dependency ratio p. 265 expanded practice p. 271 rural p. 262
population p. 264 equitable health isolation p. 263 telehealth p. 272
colonialism p. 269 care p. 263 remote p. 263 telemedicine p. 272
M15_KOZI2703_04_SE_C15.indd 273 06/02/17 3:33 PM


• Consensus on clear, comprehensive definitions for rural and • Numerous factors contribute to high mortality rates from
remote areas is required to allow for data collection on health motor vehicle collisions.
care information of residents in these regions of the country. • Social and economic factors contribute to increased mor-
• Rural communities are diverse. Issues vary, depending on tality and morbidity within the Aboriginal population in
rurality, demography, and economic base. Canada.
• Great diversity in the geography of Canada contributes • Challenges to health care delivery are sparse population,
to particular regional issues. distance, and difficulties in recruiting and retaining health
• Rural and remote residents have higher rates of obesity care professionals.
and smoking, lower life expectancy among males, and • Knowledge about the impact of residential schools on
higher rates of injuries and death than urban residents. the culture, spirituality, health, and well-being of the
• Common health concerns include respiratory illnesses, Aboriginal peoples must be considered in the delivery of
chemical exposures, circulatory diseases, and zoonoses. culturally safe health care.
• Water safety concerns include the contamination of • A major challenge for rural nurses is to attain and main-
drinking water supplies and drowning in ditches, tain practice skills for providing care for all ages and
dugouts, rivers, and lakes. health conditions.
• Injuries and deaths within rural and remote primary • Nurses in rural areas face issues of confidentiality, ano-
industries are a significant factor in the health care of nymity, proximity, and boundary definition in working
rural populations. with clients from their home communities.
• Children are at particular risk for injury or death because • Key characteristics of rural and remote practice are lack of
of the lack of designated safe play areas for young children. anonymity, greater autonomy, and broad generalist practice.

1. Which term best describes a significant challenge 4. Which community best exemplifies one defined as being
confronting delivery of rural health care in Canada? remote? (Select all that apply.)
a. Universality a. A community on the West Coast of British
b. Portability Columbia with water access (float plane or boat) only
and a population of approximately 1000 people
c. Public administration
b. Prairie town with a population of about 20 000
d. Equitability
people
2. A nurse lives and works in a rural community. While c. Residential township where most of the population
grocery shopping, the nurse is approached by a neigh- commutes to work to a larger community
bour who asks, “How’s old Bob doing? I hear he has d. Northern Canadian community with a sparse popu-
cancer and is in hospital.” What is the nurse’s best lation, where travel is often weather dependent and
response? on ice roads
a. “I suggest you call Bob’s wife and ask her how he’s 5. A nurse is working in a rural First Nations community
doing.” in Northern Ontario. Lately, there have been a number
b. “I know you are concerned about Bob, but I can’t of serious motor vehicle collisions, including one that
share that information with you.” killed four local teenagers. Problematic substance use
c. “Call the hospital, and ask for the nurse on duty.” was part of the causes of the accidents. What should be
the nurse’s next step?
d. “Bob’s doing okay, but that’s all I can tell you.”
a. Approach the local high school about doing a lecture
on the dangers of alcohol and substance use
3. What is the primary reason for the decline in rural
populations compared with urban populations in the b. Approach the local high school and invite students to
past century? participate in a “stop drinking and driving” contest
a. Few new immigrants choose to live in rural areas. you have designed
b. Rural Aboriginal populations are not increasing. c. Meet with a group of local teenagers and commu-
nity elders and work with them to develop a video
c. Urban residents have a higher birth rate than rural game on stopping drinking and driving
residents.
d. Meet with the high school principal to tell him or
d. An increase in farming technology means there is her about the dangers of substance use, drinking,
less rural opportunity. and fatal accidents
M15_KOZI2703_04_SE_C15.indd 274 06/02/17 3:33 PM

6. A nurse working in a rural and remote community in c. A higher rate of physical activity
Saskatchewan is aware that farm injuries are a major d. A higher incidence of obesity
health issue. Preschool children are at particularly high risk
of fatal injuries. The wife of a local farmer approaches the
nurse requesting help to organize a safe play area for pre- 9. Why is providing health care to inhabitants of rural
school children. What should be the nurse’s next step? and remote communities experiencing motor vehicle
collisions particularly challenging?
a. Arrange to meet with the farmers at a local fall fair
to talk with them about the hazards of farming a. Many new immigrants live in rural communities.
b. Post signs in the community about farm hazards b. The primary industries are fishing, farming, mining,
c. Talk to the town mayor, the school principal, and and forestry.
other civic leaders, as well as parents, and tell them c. The population is sparsely distributed over a wide
they must recognize farm hazards for children geographical area.
d. Invite parents, teachers, the school principal, the d. The nurse must be flexible and friendly with local
mayor, and other civic leaders to a meeting to talk inhabitants.
about safe play areas for preschool children
7. After suffering a detached retina, Mr. Boucher, 78 years 10. Children in northern Aboriginal communities are at
old and a retired farmer, must adapt to his blindness while increased risk for type 2 diabetes. The nurse in the com-
continuing to live in the rural area with his wife. What is munity wants to raise awareness about this health risk.
the most important factor that the nurse should consider What should be the nurse’s next step?
to help them rearrange the inside of their house?
a. Talk with the teenagers in the community because
a. The distance separating the couple from their neigh- they may have younger siblings
bours
b. The family’s beliefs b. Meet with the school principal and launch a poster
contest featuring student-drawn pictures of healthy
c. The availability of resources foods
d. Mrs. Boucher’s level of literacy
c. Ask the children to draw pictures of their healthy
8. What has research shown about the health practices community and post these on the walls
of individuals living in Canadian rural communities in
d. Ask the children to draw and post pictures of healthy
comparison with those in urban communities?
foods that come from their community
a. A lower incidence of smoking
b. Better eating habits
R efere nc es
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Rossignol, A. (2010). Unintentional injuries in children and Practice, 4(9), 33–43.
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Chapter 16
Complementary
and Alternative
Updated by
Health Modalities
A
LEARNING OUTCOMES
After studying this chapter, you will be able to s our Canadian popula-
1. Describe the terms complementary medicine, alternative medicine, tion becomes increas-
and integrative medicine. ingly older and more
2. Explain the basic concepts of complementary and alternative ethnically diverse, there are more
health modalities: holism, humanism, balance, spirituality, energy, Canadians (~71%) using complemen-
and healing environments. tary and alternative health modalities
3. Describe the key principles and clinical applications used in (CAHM), either for personal or cul-
complementary and alternative health modalities: systematized tural beliefs. In response to this trend,
health care practices, biological-based treatment, nutritional Health Canada (2012) has been rais-
therapy, manual healing methods, mind–body therapies, and
spiritual therapy. ing awareness among Canadians
about natural health products (NHPs)
4. Describe the role of Health Canada in complementary and
alternative medicine. and regulating the safety and efficacy
of these products. Nurses entering
5. Explain why natural health products should be used with care.
practice are expected to collaborate
6. Discuss the role of the nurse in supporting clients in the uses with members of the health care team
of, and safety precautions regarding, complementary health
modalities. to develop plans of care that will
support their clients in using alter-
native medical therapies (Canadian
Nurses Association [CNA], 1999;
College of Nurses of Ontario, 2014).
Nurses must understand the differ-
ent interventions that complement
Western medicine and their potential
risks and benefits to provide safe
and effective nursing care.
The terms complementary medi-
cine and alternative medicine are used c
M16_KOZI2703_04_SE_C16.indd 279 17/03/17 11:17 AM

c to describe as many as 1800 therapies that have been practised around the world for centuries. Many of
these modalities originated from ancient medical systems of Egyptians, Chinese, Asian Indians, Greeks,
and Aboriginal peoples. Complementary medicine is used together with conventional or Western
medicine. For example, the scent of essential oils from flowers or herbs used in aromatherapy can help
promote relaxation and well-being. Alternative medicine is used in place of conventional medicine. An
example of an alternative therapy is the use of acupuncture for back pain relief instead of surgery, as
recommended by the health care provider. Integrative medicine combines treatments from Western
medicine and complementary and alternative medicine (CAM) to achieve maximum safety and effective-
ness of care (National Institutes of Health, 2015).
Basic Concepts ability to appreciate and create. Spiritual aspects involve

moral values, a meaningful purpose in life, and a feeling
of connectedness to others and to a divine source. Envi-
Several concepts are common to most alternative health ronmental aspects include physical, biological, economic,
practices. These are holism, humanism, balance, spiritu- social, and political conditions. Being in balance is a
ality, energy, and healing environments. learned skill and must be practised regularly to engage
in the process of healthful living.
Holism
Holism refers to the interplay of mental, emotional, Spirituality
spiritual, relational, and environmental components; and
Spiritual healing techniques and spirituality-based health
individuals are central to their own healing. Holistic
care systems are among the most ancient healing prac-
health care considers all the components of health,
tices. Spirituality includes the drive to become all that
from birth to death. The nurse provides holistic health
we can be, and it is bound to intuition, creativity, and
care by drawing on biomedical and caring-healing mod-
motivation. It is the dimension that involves relationship
els and technology. Nurses help their clients assert their
with the self, with others, and with a higher power. Spiri-
right to choose their own healing journey and the quality
tuality gives people meaning and purpose in their lives.
of their life and death experiences (Fontaine, 2014).
It involves finding significant meaning in the entirety of
life, including illness and death (see Chapter 46).
Humanism
The humanist views the mind and body as indivis- Energy
ible and believes that people have the power to solve
Most cultures view energy as the force that integrates
their own problems, that people are responsible for the
and connects body, mind, and spirit. Chinese Taoist
patterns of their lives, and that well-being is a combina-
scholars believed that energy was the basic building
tion of personal satisfaction and contributions to the
material of the universe. Albert Einstein and other physi-
larger community. Nurses have historically used their
cists proved that matter and energy are the same and
hands, heart, and head in natural and traditional healing
that energy is not only the raw material of the cosmos
interactions.
but also the glue that holds it together. People are beings
of energy, living in a universe composed of energy.
Grounding and centring are common terms used in
Balance various healing practices. Grounding relates to a person’s
The concept of balance consists of mental, physical, connection with the ground and, in a broader sense, to
emotional, spiritual, and environmental components. that person’s whole contact with reality. Being grounded
Balance is attained when each component reaches a suggests stability, security, independence, the presence
state of equilibrium. Physical aspects include optimal of a solid foundation, and the ability to live in the pres-
functioning of all body systems. Emotional aspects include ent rather than escape into dreams. Centring refers to the
the ability to feel and express the entire range of human process of focusing the mind on the centre of energy,
emotions. Mental aspects include feelings of self-worth, allowing the person to operate intuitively, with aware-
a positive identity, a sense of accomplishment, and the ness, and to channel energy throughout the body. People
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Chapter 16 Complementary and Alternative Health Modalities 281
Box 16.1 Self-Healing Methods Systematized Health Care Practices

for Nurses
A number of health care practices have been system-
• Check your posture. Sit up or stand straight. Imagine atized throughout the centuries and throughout the
that a cord is attached to the top of your head, pulling world. These typically include an entire set of values,
it gently toward the sky. This image helps readjust your attitudes, and beliefs that generate a philosophy of life,
posture. not simply a group of remedies.
• Boost your energy. Take your shoes off; sit on the floor
with your legs stretched out in front of you and your Ayurveda The Indian system of medicine, Ayurveda,
palms facing down and resting on the floor at your sides. is at least 2500 years old. Ayurveda views illness as
Point your toes as hard as you can and hold for 5 sec- a state of imbalance among the body’s systems. The
onds, then dorsiflex your feet as hard as you can, and individual aims to minimize stress by achieving an opti-
hold for 5 seconds. Repeat 10 times.
mal balance of emotional health, physical health, spiri-
• Check your breathing. Sit comfortably and close your
eyes. Note your breathing without trying to change it.
tual health, mental health, and environmental health.
Breathe in, and breathe out. Feel your breath flowing in Specific lifestyle interventions are a major preventive
and out of your heart. Do this for 5 to 10 minutes. and therapeutic approach in Ayurveda. Each person is
prescribed an individualized diet and exercise program
depending on dosha (body) type and the nature of the
underlying dosha imbalance. Herbal preparations are
are centred when they are fully connected to the part of added to the diet for preventive or regenerative purposes
their bodies where all their energies meet. as well as for the treatment of specific disorders. Yoga,
breathing exercises, and meditative techniques are also
prescribed by the practitioner.
Healing Environments Traditional Chinese Medicine Traditional Chi-
Nursing has always focused on creating healing environ- nese medicine (TCM) has been practised in China for
ments for clients. Nurses create these environments by more than 3000 years. TCM sees the body as a delicate
providing compassionate and holistic care through the balance of yin and yang: two opposing but inseparable
use of their hands, hearts, and minds. Nurses must also forces. Yin represents the cold, slow, or passive prin-
create healing environments for themselves. Working ciple, whereas yang represents the hot, excited, or active
with people can be draining work. Nurses need to learn principle. Health is achieved by maintaining the body
how to restore their energy and replenish themselves to in a balanced state, and disease is caused by an inter-
avoid burnout. (See Box 16.1.) nal imbalance of yin and yang. This imbalance leads
to blockage in the flow of qi (pronounced chee), or vital
energy, and of blood along pathways known as meridians.
TCM views a person’s mind, body, spirit, and emo-
Complementary tions as inseparable. The heart is not just a blood pump;
and Alternative Health it also influences a person’s capacity for joy, a sense of
purpose in life, and connectedness with others. Kidneys
Modalities filter fluids, but they also manage the capacity for fear,
will and motivation, and faith in life. Lungs breathe in
air and breathe out waste products, but they also regulate
Ethnocentrism, the assumption that one’s own cultural or
the capacity to grieve, as well as a person’s acknowledg-
ethnic group is superior to others, has often prevented
ment of the self and of others. The liver cleanses the
Western health care practitioners from learning new
body, and it also influences feelings of anger, vision, and
ways to promote health and prevent chronic illness.
creativity. The stomach has a part in the digestion of
With consumers demanding a broader range of health
food and influences the ability to be thoughtful, kind,
options, health care providers must be open and learn
and nurturing as well. These are just a few of the mind–
about various complementary health modalities being
body connections that TCM practitioners recognize.
practised in other cultures and countries for disease
TCM practitioners use a variety of ancient and
prevention and treatment. The World Health Organiza-
modern therapeutic methods, including acupuncture,
tion (WHO) endorses traditional healing practices that
acupressure, herbal medicine, massage, heat therapy,
have been used in various cultures in many communities
qigong, Tai Chi, and nutritional lifestyle counselling.
for thousands of years (WHO, 2015). To strengthen the
role of traditional medicine while keeping populations Traditional Aboriginal Healing Spirituality and
healthy, the WHO developed WHO Traditional Medicine medicine are inseparable in Aboriginal healing. Medi-
Strategy 2014–2023 to address the challenges and develop cine women and men see themselves as channels through
proactive policies and action plans for practitioners to which the Great Power helps others achieve well-being in
prioritize health services (WHO, 2013). mind, body, and spirit. The only healer is the One, who
M16_KOZI2703_04_SE_C16.indd 281 06/02/17 3:32 PM

created all things. Medicine people consider that they Biologically Based Treatments
have certain knowledge to put things together to help the
sick person heal and that knowledge has to be dispensed Botanical (plant) healings are used by 80% of the world’s
in a certain way, often through ritual or ceremony. Heal- population. These include herbs, aromatherapy, home-
ers use medicine objects to assist them in ceremony opathy, and naturopathy. Herbal medicine refers to
treatments, such as the sweat lodge, singing, the pipe the use of herbs to treat disease and supplement other
ceremony, the sun dance, and the vision quest. Other treatments. Herbal therapy is used to prevent disease
treatments include smudging, drumming and chanting, or promote health through the routine use of herbs.
healing lodges, healing touch, acupressure, and herbs.
Herbal Medicine Herbs have been used by humans
Health is viewed as a balance or harmony of mind
since antiquity for the prevention and treatment of ill-
and body. The goal is to be in harmony with all things
ness. Herbs or botanicals are plants that are valued for
and with oneself. If the mind is negative, the body will
their medicinal properties, flavour, scent, and so on.
be drained, making it more vulnerable. When people
Herbs contain dozens of bioactive compounds. It is not
open up to the universe, learn what is good for them, and
clear which of these compounds underlie an herb’s medi-
find ways to be happier, they can begin to work toward a
cal use. More than 10 000 herbs have been identified as
longer and healthier life (see the section “Aboriginal
useful for medicinal purposes. Over 30% of all prescrip-
Views of Wellness” in Chapter 7).
tion drugs sold in North America are derived from plants.
Homeopathy Homeopathy is a self-healing system, Health Canada (2012) plays a key role in ensur-
assisted by small doses of remedies or medicines, which is ing that Canadians have access to high-quality, safe,
useful in treating a variety of acute and chronic disorders. and effective natural health products (NHPs) while
It is based on the premises of the law of similar, which claims respecting culturally oriented health care practices.
that a natural substance that produces a given symptom in Under the 2004 Natural Health Products Regulations,
a healthy person cures it in a sick person. If taken in large NHPs include vitamins and minerals, herbal remedies,
amounts, these natural compounds will produce symptoms homeopathic medicines, traditional medicines, probiot-
of disease. In the doses used by homeopaths, however, ics, and other products such as amino acids and essen-
these remedies stimulate a person’s self-healing capacity. tial fatty acids. Many natural products have sufficient
Natural healing compounds are prepared through efficacy data but do not have long-term data to warrant
a process of serial dilution and are taken orally. The their safe use (Greenlee et al., 2014). Most herbs are con-
compound is first dissolved in a water–alcohol mixture, sumed without untoward reactions when they are taken
called the mother tincture. One drop of the tincture is in small amounts. It is when the product is consumed in
then mixed with 10 drops of the water–alcohol mixture, excessive amounts that problems may arise.
and this process is repeated hundreds or thousands of There is a proliferation of lay literature on herbal
times, depending on the potency of the compound being remedies and the wide availability of such products in
prepared. The more the substance is diluted, the more health food stores. More people are now relying on herbal
potent it becomes as a remedy. It is not currently under- and other less conventional therapies for a wide variety of
stood how homeopathic remedies work. problems. Nurses must be aware of their clients’ use of
herbs and be knowledgeable and evidence-informed by
Naturopathy Naturopathic medicine “blends reviewing resources such as Health Canada’s Canadian
modern scientific knowledge with traditional and natural Adverse Reaction Newsletter and MedEffect Canada
forms of medicine. It is based on the healing power of (Health Canada, 2014), or visiting Natural Standard
nature and it supports and stimulates the body’s ability (https://naturalmedicines.therapeuticresearch.com). See
to heal itself ” (Canadian Association of Naturopathic Table 16.1 for some of the more commonly used herbs.
Doctors, 2015, para.1). Based on the individual clients’
physiological, structural, psychological, social, spiritual, Aromatherapy Aromatherapy is the therapeutic
environmental, and lifestyle factors, the treatment goal use of plant essential oils, in which the odour, or fra-
is the restoration of health and normal body func- grance, plays an important part. The essential oils that
tion, rather than the application of a particular therapy. are used in aromatherapy are plant oils extracted from
This may involve botanical medicine, homeopathy, clini- flowers, roots, bark, leaves, wood resins, and lemon
cal nutrition, hydrotherapy, naturopathic manipulation, or orange rinds. The oils are massaged into the skin,
TCM and acupuncture, and prevention and lifestyle inhaled, placed in baths, used as compresses, or mixed
counselling. Clients are given the responsibility for their into ointments. The chemicals in the essential oils are
own health and well-being, and traditional pharmaceu- absorbed into the body, resulting in physiological or psy-
ticals and surgical interventions are rarely used. In Can- chological benefit. Different oils calm, stimulate, improve
ada, naturopathic practitioners are primary health care sleep, change eating habits, or boost the immune system.
providers trained at an accredited school of naturopathic Nurses should be aware of the potential complica-
medical in a 4-year, full-time program; they are required tions from using certain oils and should caution clients
to pass licensing board examinations to practise. about their use and storage. Essential oils, other than
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TABLE 16.1 Uses, Cautions, and Contraindications for Popular Herbal Preparations*
Herb Traditional Uses Selected Warnings

Feverfew Prevents migraine headaches, arthritis; May increase the anticoagulant effects of aspirin and anticoagulant
stimulates digestion medications
Garlic Reduces high blood pressure and cho- May increase the anticoagulant effects of aspirin and anticoagulant
lesterol; antibiotic/antifungal; anticlotting medications
Ginger For digestion; relieves motion sickness, May increase the anticoagulant effects of aspirin and anticoagulant
dizziness, and nausea medications
Ginkgo May improve memory function, relieve May increase the anticoagulant effects of aspirin and anticoagulant
stress, treat dizziness medications
Echinacea May boost the immune system, May reduce the effectiveness of immunosuppressants; has not been
enhance wound healing found effective in treating colds in children ages 2 to 11 years
Ginseng Stimulates mental activity; enhances May interact with caffeine and cause irritability; may decrease the
immune system and appetite effectiveness of glaucoma medications
Milk thistle Enhances flow in gallbladder, liver, Reduces the effectiveness of oral contraceptives
spleen, and stomach
St. John’s wort Acts as antidepressant, anti- May potentiate antidepressant medications, causing severe
inflammatory; is antiviral agitation, nausea, confusion, and possible cardiac problems
Saw palmetto Treats prostate hypertrophy; May give false low prostate-specific antigen (PSA) levels, thereby
anti-inflammatory delaying diagnosis of prostate cancer
Valerian Sedative, tranquilizer; lowers blood May increase the sedative effects of antianxiety medication
pressure; helps menstrual cramps
*Some preparations may vary in efficacy and toxicity, depending on the age of the client. Use extra caution with young children and older adults.
lavender and tea tree oil, are quite potent and can irritate DIETARY THERAPY Dietary therapy, or nutritional
the skin. They should be diluted with a carrier oil before therapy, consists of the consumption of specific types of
being used on the skin. Carrier oils, such as sunflower diets (see Chapter 40) or supplements—including vita-
oil, grapeseed oil, and soy oil, contain vitamins, proteins, mins, minerals, amino acids, herbs and other botanicals,
and minerals that provide added nutrients to the body. and miscellaneous substances, such as enzymes and fish
Essential oils should not be ingested because even mod- oils—to prevent or treat illness. The therapy focuses on
est amounts can be fatal. Pregnant women and people eating more fresh vegetables, fruits, and whole grains. A
with epilepsy should consult a knowledgeable health care variety of diets are offered for treating cancer, cardio-
practitioner or qualified aromatherapist before using vascular disease, and food allergies. In many cases, diet
essential oils. Some oils can trigger bronchial spasms, therapy mirrors traditional dietary and medical advice:
so people with respiratory conditions should consult reducing excessive use of sugar and salt, reducing excess
their primary health care provider before using oils. fat, increasing the intake of fruit and vegetables, and
Table 16.2 describes oils that may be used at home. stressing the need for a well-balanced diet.
TABLE 16.2 Oils That May Be Useful to Have at Home
Oil Use
Chamomile Soothes muscle aches, sprains, swollen joints; acts as gastrointestinal (GI) antispasmodic; can be rubbed
on abdomen for colic, indigestion, gas; decreases anxiety, stress-related headaches; decreases insom-
nia; can be used in children
Eucalyptus Feels cool to skin and warm to muscles; decreases fever; relieves pain; anti-inflammatory; antiseptic,
antiviral, and expectorant to respiratory system in steam inhalation; boosts immune system
Ginger Helps ward off colds; calms upset stomach, decreases nausea; soothes sprains and muscle spasms
Jasmine Is uplifting and stimulating, antidepressant; can be used to massage abdomen and lower back to treat
menstrual cramps
Lavender Is calming, sedative for insomnia; can be used to massage around temples for headache; can be inhaled
to speed recovery from colds, flu; can be used to massage chest to decrease congestion; heals burns
Tea Tree Works as an antifungal agent for athlete’s foot; soothes insect bites, stings, cuts, wounds; can be used
in baths for yeast infection; is used as drops on handkerchief for relief from coughs, congestion
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Not all nutritional supplements are harmless. Three

major concerns regarding the use of nutritional supple-
ments by clients are (a) efficacy, (b) consistency, and
(c) safety (Health Canada, 2012; WHO, 2015). Some
supplements cause adverse effects, such as diarrhea or
high blood pressure, and some others become dangerous
when taken in combination with certain medications.
Another safety concern with supplements is that they
may be contaminated with dangerous substances, such

as mould, bacteria, pesticides, and metals (Rolfes, Pinna,
& Whitney, 2012). Nurses must assess clients for use of
dietary supplements and include teaching about the
supplements, their known benefits, and risks of supple-
ments in the care planning.
FIGURE 16.1 Massage over the shoulder and back.
Manual Healing Methods

Some manual healing methods come from ancient times,
and some were developed in the latter half of the twenti- EXAMPLES OF THE USES OF MASSAGE
eth century. These healing practices include chiropractic; Following are a few of the many examples illustrating the uses
massage; acupuncture, acupressure, and reflexology; and of massage in children, adults, and older adults.
hand-mediated biofield therapies.
CHILDREN
CHIROPRACTIC THERAPY Chiropractic therapy Infant massage is gaining in popularity in Canada. Infant mas-
focuses on the relationship between the body’s struc- sage stimulates weight gain in premature infants, reduces
ture—mainly the spine—and its functioning. Chiro- complications in infants born to mothers addicted to cocaine,
practors believe that displacements of the spine can and helps mothers soothe their babies. It improves parent–
infant bonding; eases painful procedures, such as immuniza-
result in a variety of symptoms that can be treated
tions; reduces pain from teething and constipation; reduces
by spinal manipulation or adjustment. Three primary colic; induces sleep; and makes parents feel they are doing
goals guide chiropractic intervention. The first goal is to something good for their baby.
reduce or eliminate pain. The second goal is to correct
ADULTS
the spinal dysfunction thereby restoring biomechanical
balance to re-establish shock absorption, leverage, and • Massage is usually contraindicated until after the first
trimester of pregnancy because of the danger of mis-
range of motion. In addition, muscles and ligaments are carriage during that time. During the second and third
strengthened by spinal rehabilitative exercises to increase trimesters, massage can ease pain and provide comfort
resistance to further injury. The third goal is preventive to the pregnant woman. Pregnancy massage is usually
maintenance to ensure the problem does not recur. done with the client in the side-lying position, with plenty
of pillows or cushions for support. The massage usually
Chiropractors work with many facets of clients’ is done to the neck, arms and hands, back, pelvis, legs,
lifestyles. Exercise programs are designed; rehabilitation and feet. Since not all massage therapists are trained
measures are planned; correct posture and lifting tech- in pregnancy massage, consumers must ask about the
niques are explained; and activities of daily living are experience and credentials of a particular therapist.
assessed and improved. • Massage has become popular among athletes. Prior to
an athletic event, massage loosens, warms, and readies
MASSAGE Healing through touch, or massage, goes the athlete’s muscle for intensive use, especially when
combined with stretching. Besides helping prevent injury,
back to early civilization. Touch is an important part of
it can improve performance and endurance. Post-event
healing. One possible explanation is that touch stimulates massage relieves pain, prevents stiffness, and returns
the production of certain chemicals in the immune sys- the muscles to their normal state more rapidly. The use
tem that promote healing. of massage in sports health care is increasing rapidly in
both training and competition. Recreational athletes have
Therapeutic Massage Physically, massage relaxes also discovered the benefits of sports massage as a
muscles and releases the buildup of lactic acid that regular part of their workouts.
accumulates during exercise (see Figure 16.1). It can
OLDER ADULTS
also improve blood and lymph circulation, stretch joints,
Older adults who had received a massage therapy tend to
and relieve pain and congestion. On the emotional level,
have higher physical and social functioning and general health
massage can relieve anxiety and provide a sense of and emotional well-being, and less bodily pain and change in
relaxation and well-being (Fontaine, 2014). Spiritually, health than those who had not (Munk & Zanjani, 2011).
it provides a sense of harmony and balance. Individuals
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ACUPUNCTURE, ACUPRESSURE, AND REFLEXOLOGY

Acupuncture and acupressure are techniques of
applying pressure or stimulation to specific points on
the body, known as acupuncture points, to relieve pain, cure
certain illnesses, and promote wellness. Acupuncture
uses needles (see Figure 16.2), whereas acupressure uses
finger pressure. Reflexology is a form of acupressure
most commonly performed on feet, but hands or ears
may also be manipulated. See Figure 16.3 for foot reflex
areas.
Acupuncture, acupressure, and reflexology are treat-
ments rooted in the traditional Eastern philosophy that
Yuri/Getty Images
qi flows through the body along the meridians. This

leads to the formation of tiny whirlpools close to the
skin’s surface at the acupuncture points, which function
FIGURE 16.2 Acupuncture involves the insertion of thin, sterile
somewhat like gates to moderate the flow of qi.
needles. When the flow of energy becomes blocked or con-
gested, people experience discomfort or pain on the
physical level, may feel frustrated or irritable on the
receiving a massage may enter a meditative state, which emotional level, and may experience a sense of vulner-
relaxes their minds and expands their awareness. A ability or lack of purpose in life on the spiritual level.
variety of massage strokes or movements can be used The goal of care in wellness acupuncture is to recognize
singly or in combination, depending on the outcome and manage the disruption before illness or disease
desired. These include effleurage (stroking), friction, pres- occurs. Practitioners bring balance to the body’s ener-
sure, petrissage (kneading, or large, quick pinches of the gies, and this promotes optimal health and well-being,
skin, subcutaneous tissue, and muscle), and Tui Na (an and facilitates people’s own healing capacity. A systemic
oriental massage using a series of pressing, tapping, and review including 17 randomized clinical trials with 1806
kneading with palms, fingertips, knuckles, or implements participants found that acupuncture was not better at
that help remove blockages along the meridians of the treating irritable bowel syndrome than sham (“pretend”)
body and stimulate the flow of qi and blood to promote acupuncture, but was superior to certain medication
healing). (See the Lifespan Considerations box.) treatments (Manheimer et al., 2012).
Sinus Brain Sinus

Side of neck
Eyes/ears
7th cervical
Throat/neck/thyroid
Lungs
Shoulder
Liver Heart
Diaphragm/solar plexus
Gallbladder
Stomach
Kidneys
Spine
Descending colon
Ascending colon
Small intestine
Ileocecal valve
Bladder
and appendix
Sacrum/coccyx
Sigmoid colon
Sciatic
Right Sole Left Sole
FIGURE 16.3 Foot reflex areas.
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Qigong and Tai Chi A number of therapies focus on systems. These therapies work best in combination with
movement, body awareness, and breathing, and their other healing modalities and are considered adjunct
purpose is to maintain health as well as to correct specific treatments to conventional medical therapies.
problems. Qigong (pronounced chee goong) is a Chinese Bioelectromagnetic therapy is among the most com-
discipline consisting of breathing and mental exercises mon and controversial energy therapies (Synovitz &
combined with body movements. Tai Chi (pronounced Larson, 2013). Contraindications for magnetic therapy
teye chee) arose out of qigong and is a discipline that include pregnancy and presence of implanted devices,
combines physical fitness, meditation, and self-defence. such as pacemakers, defibrillators, aneurysm clips in the
Both disciplines consist of soft, slow, continuous circu- brain, cochlear implants, and others. It should not be
lar movements. The slowness of movements requires used by people on anticoagulants, those with an actively
attentive control that quiets the mind and develops the bleeding or open wound, or those with a freshly torn
person’s powers of awareness and concentration. The muscle.
continuous circular nature of the movements develops
strength, balance, and endurance.
Almost anyone, young or old, can participate in
movement-oriented therapies anywhere, outdoors or
Mind–Body Interventions
indoors. These movement-oriented therapies can be The following mind–body interventions guide the indi-
learned by the young and by seniors. These Eastern viduals to focus on realigning or creating balance in
practices can be done alone, in pairs, or in large groups. mental processes to bring about healing.
Yoga Yoga has been practised for thousands of years
in India. It is an approach to living a balanced life that
Energy Therapies includes mental and physical exercises aimed at produc-
The three most prominent therapies that use the hands ing spiritual enlightenment. Yoga has many different
to alter the biofield, or energy field, are (a) therapeutic schools. Each school stresses a different technique, but all
touch (TT), (b) healing touch, and (c) reiki. The goals have as their goal the mastery of self. Yoga can be a series
are to accelerate the person’s own healing process and of gentle stretching exercises, breathing techniques, hot
to facilitate healing at all levels of body, mind, emotions, yoga, or antigravity yoga. The Western approach to yoga
and spirit. These treatments are designed neither to tends to be more fitness oriented, with the goal of man-
diagnose physical conditions nor to replace conventional aging stress, learning to relax, and increasing vitality and
surgery, medicine, or drugs in treating organic or patho- well-being. Systematic reviews have found that yoga can
logical disease. improve cardiovascular fitness and reduce blood pres-
sure, blood glucose, and body weight (Okonta, 2012) and
Therapeutic Touch Noncontact therapeutic reduce pain (Southerst et al., 2014). (See the Evidence-
touch (TT) is a process by which practitioners believe Informed Practice box.)
they can transmit energy to a person who is ill or injured
to potentiate the healing process. Hypnosis Hypnosis is a trance state, or an altered
state of consciousness, in which an individual’s concen-
Healing Touch Contact healing touch is a group tration is focused and distraction is minimized. People
of noninvasive energy-based techniques that incorporate in trances are aware of what is going on around them
TT. Healing touch can be helpful in promoting relax- but choose not to focus on it. They can return to nor-
ation, reducing pain, and managing stress. mal awareness whenever they choose. Hypnosis is not
Reiki Reiki (pronounced ray-key), a Japanese word for a surrender of control; it is only an advanced form
“universal life force,” is a healing technique that chan- of relaxation. It can be used to help people gain self-
nels life energy to someone through the hands. It is a control, improve self-esteem, and become more autono-
stress-reduction and relaxation technique that taps into mous. Hypnosis can be used with a variety of clients
the client’s own life-force energy to improve health and with different medical problems, usually in conjunction
enhance quality of life. with other forms of medical, surgical, psychiatric, or
psychological treatment. It can be used with clients with
Bioelectromagnetic Therapy Bioelectromag- nonmedical problems as well for the management of
netic therapy is an emerging science that studies how such problems as performance anxiety or for changing
living organisms interact with electromagnetic fields. bad habits, such as smoking. Depending on the complex-
It works on the principle that every animal, plant, and ity and seriousness of the complaint, treatment typically
mineral has an electromagnetic field that enables organic runs from 2 to 10 sessions.
beings and inorganic objects, such as crystals, to com-
municate and interact as part of a single, unified energy Meditation Meditation is a technique used to relax
system. Magnetic fields are able to penetrate the body the body and calm the mind. It produces a state of deep
and affect the functioning of cells, tissues, organs, and peace and rest combined with mental alertness, and it
M16_KOZI2703_04_SE_C16.indd 286 06/02/17 3:32 PM

BOX 16.2 GUIDELINES FOR MEDITATION AND

EVIDENCE-INFORMED PRACTICE PROGRESSIVE RELAXATION
Practise this process daily for 10- to 20-minute periods:
What Is the Evidence for Using
1. Create a special time and place for meditation. Ideally,
Complementary and Alternative choose the early morning or evening, and wait at least
Health Modalities? two hours after eating so that complete energy is devoted
to meditation, rather than to digestive demands. A quiet,
Up to 80% of breast cancer survivors in North America use comfortable place, devoid of distractions, is essential.
complementary and alternative therapies during and beyond 2. Sit either cross-legged on the floor or upright in a straight-
their cancer treatment to manage side effects and improve backed chair, keeping the spine straight and the body
their quality of life. The purpose of this systematic review of relaxed. Avoid the side-lying position; this increases the
randomized clinical trials is to determine safe and effective tendency to fall asleep.
therapies and guidelines for clinicians and patients when 3. Support your palms on the thighs, and close your eyes.
using complementary and alternative health modalities. Of
4. Follow deep-breathing or progressive relaxation
the 4900 articles published between 1990 and 2013, 203
exercises.
were reviewed. The findings showed strong evidence that
meditation, yoga, and guided imagery are associated with • Tense and tighten your right fist. Focus on the feeling
improvement in those with anxiety and depression. Others of tension as you do so.
such as music therapy and massage are recommended for • Allow the muscles in your right fist to relax. Contrast
routine use to improve quality of life in those with common the difference in feeling from tension to relaxation.
conditions, such as anxiety, mood disorders, depression, • Repeat the preceding two steps for the left fist.
stress, fatigue, and pain. Some other interventions were • Now tense and relax both your left and right fists.
found to have weaker evidence (n = 32) of benefit, no
• Focus on and relish the feeling of relaxation.
benefit (n = 7), or did not have sufficient evidence to form
specific recommendations (n = 138). The study concluded • Now tighten the muscles in both fists and both arms.
that specific integrative therapies can be recommended as Feel the tension, fully relax the muscles, and again
evidence-based supportive care options during breast can- focus on the sensation of relaxation.
cer treatment. • Progressively tighten and relax each muscle group
in the body: toes, ankles, knees, buttocks and groin,
NURSING IMPLICATIONS: Further research is needed stomach and lower back muscles, chest and upper
for high-quality trials to investigate the long-term back muscles, shoulders, forehead, jaw muscles.
effects and underlying benefits of these CAHM
• Couple deep breathing with progressive relaxation.
therapies. Nurses must be knowledgeable about the While relaxing your muscles, inhale deeply, send the
evidence-based supportive care options of CAHM breath to the fist (or other muscle group), and exhale.
and adhere to their practice guidelines when assisting
5. If using a mantra, repeat the word or phrase either aloud
their clients to make decisions regarding the safe use
or silently while exhaling. When distracting thoughts
of CAHM.
appear, allow them to drift into and out of your mind
Source: Based on Greenlee, H., Balneaves, L. G., Carlson, L. E., Cohen, M., Deng, without giving them undue attention; then refocus on
G., Hershman, D., Mumber, M., Perlmutter, J., Seely, D., Sen, A., Zick, S. M., & your breathing or your mantra.
Tripathy, D. (2014). Clinical practice guidelines on the use of integrative therapies as
supportive care in patients treated for breast cancer. Journal of the National Cancer
Institute Monographs, (50), 346–58. doi: 10.1093/jncimonographs/lgu041
are improved with the practice of meditation. Skill in

meditation is enhanced when the person first masters the
skills of breathing, progressive relaxation, and imagery.
See Box 16.2 for some of the guidelines for meditation
involves both relaxation and focused attention. Anyone
and progressive relaxation.
can meditate to feel calm, cope with stress, and, for
those with spiritual inclinations, feel as one with a higher GUIDED IMAGERY Imagery is a two-way communica-
power or the universe. Meditation can be practised indi- tion between the conscious and unconscious mind and
vidually or in groups and is easy to learn. involves the whole body and all of its senses. Imagery
If practised regularly, such as 20 minutes twice a enables people to open their minds to mental ideas of
day, meditation produces widespread positive effects on positive creative images that can foster self-healing and
physical and psychological functioning. The autonomic bring about desired achievements. Worry is the most
nervous system responds with a decrease in heart rate, common form of imagery that affects our health. In our
lower blood pressure, decreased respiratory rate and imagination, we react to current stressors and antici-
oxygen consumption, and a lower arousal threshold. pated dangers. Our bodies become aroused and tense,
People who meditate say that they have clearer minds and we activate the fight-or-flight mechanism. Guided
and sharper thoughts. Meditation’s residual effects— imagery is a state of focused attention, much like hyp-
improved stress-coping abilities—are a protection against nosis, that encourages changes in attitudes, behaviour,
daily stress and anxiety. All other self-healing methods and physiological reactions. Guided imagery can help
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Table 16.3 Types of Imagery
Type Description Example

Cellular Imagine events at cellular level Imagine natural killer cells surrounding and attacking
cancer cells
End state Imagine self in the situation wanted See self as strong and healthy
Energetic Imagine free-flowing energy Feel self by pulling up energy from the earth through the
soles of the feet
Feeling state Move from a feeling state of tension to one Imagine self at a beach or floating gently on water
of peace
Physiological Imagine events at the bodily level Imagine all blood vessels relaxed and widened in order
to lower blood pressure
Psychological Change perception of self Imagine a dialogue with a person with whom you are in
conflict in an effort to find a new solution to the problem
Spiritual Make contact with God, or the Divine Imagine being held in the hands of God, where you are
perfectly safe
people learn how to stop troublesome thoughts and focus Spiritual Therapy
on images that help them relax and decrease the negative
impact of stressors. Health care sciences have begun to demonstrate that
In guided imagery, the images may be created by the spirituality, faith, and religious commitment may play a
therapist based on the needs and desires of the client. role in promoting health and reducing illness. For more
Clients can also create the images as a way to understand information about spirituality, see Chapter 46.
the meaning of symptoms or to access inner resources.
Faith Faith refers to our beliefs and expectations about
Imagery stimulates changes in many body functions, such
life, ourselves, and others. In a religious context, faith
as heart rate, blood pressure, respiratory patterns, brain-
refers to a belief in a Supreme Being who listens and
wave rhythms and patterns, electrical characteristics of
responds to people and who cares about their well-being.
the skin, local blood flow and temperature, gastrointes-
In a spiritual context, faith is thought of as the power to
tinal motility and secretions, sexual arousal, and levels
accept the nature of life as it is and live in the present
of various hormones and neurotransmitters. Table 16.3
moment. It is a sense of letting go of the need to control
describes several types of imagery.
while trusting and waiting for the moment when answers
Biofeedback Biofeedback is a method by which come.
a person can learn to control certain physiological
Prayer Prayer is an active process of communica-
responses of the body. The technique uses electronic
equipment to provide clients with visible or audible evi- tion with God, a saint, or any kind of higher power that
dence that they are controlling their body in the desired answers prayer. Prayer can be conducted individually
manner. For example, a sensor attached from a person or in groups and may even be conducted at a distance
to a computer screen shows a wave pattern changing as by individuals unknown to the person for whom the
the person concentrates on such processes as increasing prayers of healing are made. The universality of prayer
blood flow in the hands, decreasing sweat gland activity, is evidenced in the fact that all cultures have some form
lowering blood pressure, and controlling incontinence. of prayer. Prayer has been, and continues to be, used in
times of difficulty and illness, even in the most secular
Pilates Pilates is a method of physical movement societies.
and exercise designed to stretch, strengthen, and balance Prayer can also be described according to form. Col-
the body, in particular the core or centre, including the loquial prayer is an informal talk with God, as if talking to
abdominal region. It is based on the principles of yoga, a good friend. Intercessory prayer is asking God for things for
Zen meditation, and ancient Greek and Roman physi- yourself or others. The focus is on what God can provide.
cal regimens. Exercises, coupled with focused breathing Intercessory prayer for others may be called distant prayer,
patterns, are done on the floor or with simple types of if the person being prayed for is in a remote place from
equipment. Benefits include increased lung capacity, the person who is praying. This form of prayer is of inter-
improved flexibility and joint health, muscular coordi- est to researchers. In one example, participants with can-
nation, increased bone density, and better posture and cer whom the research team randomly allocated to the
balance. Pilates can help rehabilitate back, knee, hip, experimental group to receive remote intercessory prayer
shoulder, and stress injuries, and relieve muscle aches. showed small but significant improvements in spiritual
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well-being (Olver & Dutney, 2012). Ritual prayer is the use used and anxiety levels are reduced. People also recall
of formal prayers or rituals, such as prayers from a prayer more information when they associate information
book or the Jewish siddur, or the Catholic practice of say- with a joke. Use of humour in instruction, however,
ing the rosary. Meditative prayer, also known as contemplative needs to be carefully planned so that it will contribute
prayer, is similar to meditation and is a process of focusing to learning.
the mind on an aspect of God for a period. Prayer is a • Coping with painful feelings. People may use humour to
self-care strategy that provides comfort, increases hope, blunt the immediate effect of situations that are too
and promotes healing and psychological well-being. painful, such as the effect of a threatening diagnosis or
treatment. Humour diminishes anxiety and fear and
reduces tension, thus enabling the person to confront
Miscellaneous Therapies and deal with the situation (Old, 2012).
These include music therapy, humour and laughter,
detoxifying therapies, animal-assisted therapy, and hor- Humour has physiological benefits that involve alternat-
ticultural therapy. ing states of stimulation and relaxation. Humour stimu-
lates the production of catecholamines and hormones. It
MUSIC THERAPY Music therapy can be used for a releases endorphins, thereby increasing pain tolerance.
variety of reasons in practice settings (e.g., perioperative Laughter, for example, helps relieve tension. It stimulates
holding areas, cardiac care units, birthing rooms, coun- increases in respiratory rate, heart rate, muscular ten-
selling rooms, rehabilitation and physical therapy units, sion, and oxygen exchange. A state of relaxation follows
and sleep induction units). Quiet, soothing music with- laughter, during which heart rate, blood pressure, respi-
out words is often used to induce relaxation. Music has ration, and muscle tension decrease.
been shown to reduce both pain intensity and distress in Many health care settings are providing humour as a
clients who have undergone abdominal surgery (Vaajoki, caring skill and have recognized that “laughter is the best
Pietilä, Kankkunen, & Vehviläinen-Julkunen, 2012). medicine.” The nurse needs to use humour effectively
and cautiously by considering the feelings of others and
HUMOUR AND LAUGHTER Humour involves the abil-
cultural variations in what people consider humorous.
ity to discover, express, or appreciate the comical or
“Humour rooms,” which are supplied with games, funny
absurdly incongruous, to be amused by our own imper-
audiotapes and videotapes, humorous books, collections
fections or the whimsical aspects of life, and to see the
of cartoons, and so on, are being created for clients and
funny side of an otherwise serious situation. Humour in
staff.
nursing can be a universal language among clients of
all ages and cultures. Elaboration on these functions of ANIMAL-ASSISTED THERAPY Animal-assisted
humour in nursing situations follows: therapy is the use of specifically selected animals as a
• Establishing relationships. Humour decreases the social treatment modality in health and human service settings.
distance between persons and helps put people at ease. It has been shown to be a successful intervention for peo-
When tension is decreased, people can focus on the ple with a variety of physical or psychological conditions.
message and on other people rather than on their own Throwing an object for a dog to retrieve or brushing
feelings. The use of humour helps the nurse establish the animal increases upper extremity range of motion.
rapport with clients, an important factor in achieving Reaching for the object the dog has retrieved improves
success in nursing interventions. coordination. Ambulating with a dog improves mobil-
ity. Giving simple commands to the animal increases
• Relieving tension and anxiety. The effective use of humour
verbal expression. Attending to the animal and the situa-
relieves the tension of emotionally charged events.
tion increases attention and concentration. Therapeutic
The personal nature of humour, for example, helps
horseback riding, or hippotherapy, uses the rhythmic move-
clients deal with the impersonal nature of wearing a
ment of the horse to increase sensory processing and
hospital gown and a numbered identity (ID) band and
improve posture, balance, and mobility in people with
with answering embarrassing questions and undergo-
movement dysfunctions.
ing uncomfortable tests. People can also use humour
Long-term health care facilities may have animals
prophylactically to decrease stress.
such as fish, birds, hamsters, gerbils, guinea pigs, rab-
• Releasing anger and aggression. Humour helps individuals bits, cats, and dogs. Some staff members report that pets
act out impulses or feelings in a safe and nonthreaten- can be so perceptive that they gravitate to people who
ing manner. It dissipates feelings of anger and aggres- are the most isolated or depressed. The contributions
sion by focusing on the comic elements of a situation. pet animals make to the emotional well-being of people
• Facilitating learning. Many lectures and presentations include unconditional love and opportunities for affec-
begin with a joke or cartoon. Humour not only tion; achievement of trust, responsibility, and empathy
reduces the presenter’s anxiety but also gains the audi- toward others; hope and motivation; and a source of
ence’s attention. People learn more when humour is reassurance.
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Assessment Interview
Complementary and Alternative Health Modalities

Nurses can use these questions to ask their clients about their use of CAHM:
• Tell me about your use of teas, herbs, vitamins, or other • What alternative therapies have you used (acupuncture,
natural products to improve your health. touch therapies, magnets, hypnosis, etc.)?
• What traditional or folk remedies are used in your family? • Have you discussed your use of CAHM with your health
• Do you meditate, pray, or use relaxation techniques, care provider?
music, or yoga for healing purposes?
Detoxifying Therapies Many cultures and religions products. The nurse must remain open minded, review
have rituals of purification. Detoxification is a practice the literature for current evidence of therapeutic value,
to clear the physical impurities and toxins from the body and advocate for the client in the use of the most ben-
to achieve better health. The use of water as a healing eficial approaches to their health care. The nurse asks
treatment is known as hydrotherapy. The use of hot and the obvious questions: Is there any supportive evidence?
cold moisture in the form of solid, liquid, or gas makes Does it sound too good to be true? Do the claims for the
use of the body’s response to heat and cold. Hydrother- product seem exaggerated or unrealistic for the purpose
apy is used to decrease pain, fever, swelling, and cramps; of selling a product? Remember that the only way to
induce sleep; and improve physical and mental tone. It know if a drug is working or is harmful is through large,
must be used with great care in the very young or old, preferably placebo-controlled, double-blind studies. See
who have poor heat regulation, and also in people expe- the Assessment Interview box for more questions.
riencing any prolonged illness or fatigue. Colonics, or colon The Internet can be a valuable source of accurate,
therapy, is the procedure for cleansing the fat accumu- reliable information. However, it also has a wealth of
lated on the inner wall of the colon by filling it with water misinformation that may not be obvious to distinguish
or herbal solutions and then draining it. Colon cleansing is hype from evidence-based science (see Chapter 25). In
a controversial method of detoxification. Contraindica- today’s health care environment, health care consumers
tions include people in a weakened state and those having are more knowledgeable than ever and are demanding a
ulcerative colitis, diverticulitis, Crohn’s disease, severe broader range of health options. Additionally, the Cana-
hemorrhoids, or tumours of the large intestine or rectum. dian population is getting more culturally diverse and
older. The CNA (2014) expects nurses to demonstrate
Horticultural Therapy Horticultural therapy,
“safe, competent, and ethical care” (p. 27) and “critical
also called gardening or a healing garden, is an adjunct ther-
inquiry in relation to new knowledge and technolo-
apy to occupational and physical therapy. People may
gies that change, enhance or support nursing practice”
view nature, visit a healing garden or a wander garden, or
(p. 28). It requires nurses to inquire about clients’ healing
actually participate in gardening. When it is a communal
practices and help them make informed choices to use
activity, gardening decreases social isolation by fostering
any CAHM (see Assessment Interview box). In relation
interactions with others. Horticultural therapy stimulates
to CAHM, nurses must develop the following healing
the five senses, provides leisure activities, improves motor
attitudes and behaviours:
function, provides a sense of achievement, and improves
self-esteem (Annerstedt & Währborg, 2011). Nurses must 1. Have a strong fundamental, evidence-based knowledge
also be aware, however, that clients who are prone to of the human body and various CAHM
infection should not come into contact with garden 2. Demonstrate practice competencies in teaching clients
soil, perform activities that can cause skin punctures or related to the safe and appropriate use of complemen-
scratches, or come close to stagnant water that can con- tary medicine
tain insects or infectious organisms.
3. Be nonjudgmental and respectful regarding clients’
choices to use any of the CAHM within his or her own
cultural context
Nursing Role in 4. Act as an advocate and facilitator by providing accu-
Complementary and rate information on CAHM modalities, NHPs, and
the risks and benefits as opposed to conventional
Alternative Health Modalities health care practices to help clients make informed
decisions
Every year, billions of dollars are spent on unproven, 5. Encourage clients to discuss their use of CAHM with
fraudulently marketed, and potentially dangerous health their health care provider
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Case Study 16
Tim Le is a 68-year-old accountant who has been diagnosed
with gastric cancer. He lost a great deal of weight before the
2. Which alternative therapies might be most useful for this
client and are in keeping with the principle of “do no
diagnosis and during chemotherapy and radiotherapy. He is now
harm”?
admitted to the hospital with pain and weakness, which are pre-
venting him from working or performing many activities of daily 3. How should the nurse respond to finding the bags in the
living. His wife, Susan, stays with him most of the day. His elderly client’s drawer? What options should be considered, and
parents visit often and bring him homemade what are the likely results of each?
food and drink. They do not speak English. 4. How might the nurse’s own belief system influence his
In the process of placing bathing items on or her interactions with the client and family regarding
Tim’s bedside stand, the nurse notices several CAHM?
plastic bags of a tea-like product in the drawer.
1. What aspects of this case suggest that it would be

appropriate for the nurse to discuss the use of alternative
therapies with the client or his family?
Key T erms
acupressure p. 285 complementary homeopathy p. 282 pilates p. 288
acupuncture p. 285 medicine p. 280 horticultural therapy prayer p. 288
alternative medicine detoxification p. 290 p. 290 qigong p. 286
p. 280 dietary therapy humanist p. 280 reflexology p. 285
animal-assisted p. 283 humour p. 289 reiki p. 286
therapy p. 289 energy p. 280 hypnosis p. 286 spirituality
aromatherapy p. 282 faith p. 288 integrative medicine p. 280
guided imagery p. 287 p. 280 Tai Chi p. 286
Ayurveda p. 281
healing touch p. 286 massage p. 284 therapeutic touch
balance p. 280
herbal medicine meditation p. 286 (TT) p. 286
bioelectromagnetic
p. 282 music therapy p. 289 traditional Chinese
therapy p. 286
herbal therapy p. 282 natural health products medicine (TCM)
biofeedback p. 288
holism p. 280 (NHPs) p. 282 p. 281
chiropractic therapy
holistic health care naturopathic Tui Na p. 285
p. 284
p. 280 medicine p. 282 yoga p. 286
Ch apt er Highli ghts

• Complementary health modalities are practised by a health care practices, biologically based therapies,
majority of Canadians. Therefore, nurses need to be manipulative and body-based methods, energy therapy,
aware of the different types of therapies and their poten- mind–body interventions, and spiritual therapy.
tial benefits and harms. • Total medical systems include Ayurveda, traditional
• The concepts common to most alternative practices Chinese medicine, traditional Aboriginal medicine,
include holism, humanism, balance, spirituality, energy, homeopathy, and naturopathy.
and healing environments. • Biologically based treatments include herbal medicine,
• Ancient health care practices typically include an aromatherapy, and dietary therapy.
entire set of values, attitudes, and beliefs that generate • Manipulative and body-based treatments include chiro-
a philosophy of life, not simply a group of remedies. practic therapy; massage therapy; acupuncture, acupres-
Harmony or balance in energy is the emphasis. sure, and reflexology; and qigong and Tai Chi.
• Complementary and alternative health modalities are • Energy therapies include therapeutic touch, healing
generally classified into these categories: systematized touch, reiki, and bioelectromagnetic therapies.
M16_KOZI2703_04_SE_C16.indd 291 06/02/17 3:32 PM

• Mind–body interventions include yoga, hypnosis, medita- • Other CAHM approaches include faith and prayer, music
tion, progressive relaxation, guided imagery, biofeedback, therapy, humour and laughter, bioelectromagnetic ther-
pilates, prayer, music therapy, humour, animal-assisted apy, detoxifying therapies, animal-assisted therapy, and
therapy, and horticultural therapy. They all focus on horticultural therapy.
realigning or creating balance in mental and physical pro- • Nurses act as the entry point for clients to access various
cesses to bring about healing. health care services. Nurses can advocate and facilitate
• Although many botanical and nutritional supplements their clients’ use of natural health products and comple-
can be helpful in certain conditions, their effectiveness mentary and alternative health modalities within their
and safety are not all well studied. cultural context as an integral part of care.
NCLE X- ST YLE PRACTI CE QUI Z

1. A nurse is teaching a prenatal class to a group of women c. Placing aquariums in day rooms of nursing homes
about pain relief measures during labour. A young d. Ensuring that physicians’ orders are carried out
woman states, “I prefer not to use any medication during
labour; aromatherapy oils have a calming effect on me.”
5. A mother who uses integrative medicine asks the nurse
What is the nurse’s most appropriate response?
whether doing massage on her 5-week-old baby might
a. “Aromatherapy oils may work for mild pain but will help to ease the baby’s colic. What would be the best
not reduce labour pain.” response by the nurse?
b. “Keep your options open at this point, since aroma- a. “No, your baby is too young to have massages.”
therapy may not be sufficient to manage labour pain.”
b. “It’s best to check with your physician to see if this is
c. “Aromatherapy oils are a good choice to use with appropriate.”
medication for labour pain.”
c. “There is research to support that massage increases
d. “You need to determine if aromatherapy oils are safe parent–infant bonding.”
to use during pregnancy.”
d. “Tell me more about infant massage.”
2. A client is taking warfarin (Coumadin) and digoxin
(Lanoxin). The client has been on these medications for 6. A father is wondering whether complementary thera-
years and is conscientious about taking the medications pies would help his 8-year-old daughter cope better
exactly as prescribed. The nurse reviews the client’s with her ongoing medical procedures and cancer treat-
laboratory results and finds that the international nor- ments. The father asks the nurse for some suggestions
malized ratio (INR) is 4 seconds and the digoxin level for complementary therapies that he could participate
is 1.2 nanomoles per litre (nmol/L). What would be the in. The nurse suggests that the father meet with the
best assessment question for the nurse to ask the client? clinical nurse specialist (CNS) to discuss one of the
following complementary therapies. Which comple-
a. “Have you changed your diet in the past month mentary therapy is likely to be the most useful in this
particularly in regard to dark green leafy situation?
vegetables?”
a. Therapeutic touch
b. “Did you miss a dose of your medication over the
past couple of days?” b. Guided imagery
c. “Tell me about your use of herbs, dietary therapy, or c. Acupressure
other natural products you may be using.” d. Meditation
d. “How has your health has been over the past month?”
7. A hospitalized client is due for surgery tomorrow. The
3. Which of the following is the best explanation of nurse learns that he had not told his physician that he
spirituality? was taking natural health products (NHPs) in addition
a. Something that gives people purpose and meaning in to his other prescribed medication. What should the
their lives nurse do?
b. A formalized religious dogma a. Encourage the client to continue taking the NHPs as
they are harmless
c. A nondenominational community service
b. Tell the client to stop taking the NHPs
d. People being responsible for their life patterns immediately
4. In what ways do nurses create healing environments? c. Report all medications and NHPs the client is taking
to the attending physician
a. Using technology to prevent hospital-acquired
infections d. Offer some additional herbal medicine to the client
before the surgery
b. Empowering clients to make healthy decisions for
themselves
M16_KOZI2703_04_SE_C16.indd 292 06/02/17 3:32 PM

8. A nurse is caring for a client who has colon cancer, b. Advise against using ginseng, as it is not recom-
has undergone chemotherapy, and has an unknown mended for pregnant and nursing mothers.
prognosis. The client has experienced much pain, and c. Endorse the use of ginseng, as it is a well-known and
is depressed and anxious. The client asks the nurse for popular Chinese medicine.
advice regarding the use of therapeutic touch to ease
his pain. Which is the most appropriate nursing action? d. Advise the mother on other ways to reduce stretch
marks, such as aiming for gradual weight gain during
a. The nurse cannot endorse the use of any comple- pregnancy.
mentary and alternative health modalities.
b. The nurse first ensures that the client understands 10. Which would be the most appropriate form of mind–
what therapeutic touch is. body intervention for older clients who are at risk for
c. The nurse encourages the client to consider music falls?
therapy to relieve his pain. a. Music therapy
d. The nurse encourages the client to pray so that he b. Tai Chi
will be protected from harm. c. Diet therapy
9. A woman who is eight weeks pregnant has told the d. Guided imagery
nurse that she wants to take ginseng to avoid stretch
marks. Which is the most appropriate nursing action?
a. Advise the mother not to take ginseng, as it may be
toxic if taken in very large quantities.
R eferen c es
Annerstedt, M., & Währborg, P. (2011). Nature-assisted therapy: National Institutes of Health. (2015). National Centre for Complementary
Systematic review of controlled and observational studies. and Integrative Health. Retrieved from https://nccih.nih.gov/health/
Scandinavian Journal of Public Health, 39, 371–388. integrative-health.
Canadian Association of Naturopathic Doctors. (2015). What is Okonta, N. (2012). Does yoga therapy reduce blood pressure in
naturopathic medicine? Retrieved from http://www.cand.ca/index patients with hypertension? An integrative review. Holistic Nursing
.php?36. Practice, 26, 137–141.
Canadian Nurses Association. (1999). Complementary therapies— Old, N. (2012). Survival of the funniest—Using therapeutic humour
Finding the right balance. Nursing Now: Issues and Trends in Canadian in nursing. Kai Tiaki Nursing New Zealand, 18(8), 17–19.
Nursing, 6. Olver, I., & Dutney, A. (2012). A randomized, blinded study of
Canadian Nurses Association. (2014). Framework for the practice of the impact of intercessory prayer on spiritual well-being in
registered nurses in Canada (Revision #2 for consultation). Ottawa, patients with cancer. Alternative Therapies in Health & Medicine,
ON: Author. 18(5), 18–27.
College of Nurses of Ontario. (2014). Competencies for entry-level regis- Rolfes, S. R., Pinna, K., & Whitney, E. (2012). Understanding normal
tered nurses practice (Revised 2014). Retrieved from https://www.cno and clinical nutrition (9th ed.). Belmont, CA: Wadsworth Cengage
.org/Global/docs/reg/41037_EntryToPracitic_final.pdf. Learning.
Fontaine, K. L. (2014). Complementary & alternative therapies for nursing Southerst, D., Nordin, M. C., Côté, P., Shearer, H. M.,
practice (4th ed.). Upper Saddle River, NJ: Prentice Hall. Varatharajan, S., Yu, H., . . . Taylor-Vaisey, A. L. (2014).
Greenlee, H., Balneaves, L. G., Carlson, L. E., Cohen, M., Deng, Is exercise effective for the management of neck pain and
G., Hershman, D., . . . Tripathy, D. (2014). Clinical practice associated disorders or whiplash-associated disorders? A
guidelines on the use of integrative therapies as supportive care systematic review by the Ontario Protocol for Traffic Injury
in patients treated for breast cancer. Journal of the National Cancer Management (OPTIMa) Collaboration. Spine Journal. pii,
Institute Monogram, 50, 346–358. S1529-9430(14)00210-1.
Health Canada. (2012). Drug and health products: About natural health Synovitz, L. B., & Larson, K. L. (2013). Complementary and alternative
product regulation in Canada. Retrieved from http://www.hc-sc.gc.ca/ medicine for health professionals: A holistic approach to consumer health.
dhp-mps/prodnatur/about-apropos/cons-eng.php. Burlington, MA: Jones & Bartlett.
Health Canada. (2014). Drugs and health products: Advisories, warnings Vaajoki, A., Pietilä, A., Kankkunen, P., & Vehviläinen- Julkunen,
and recalls. Retrieved from http://www.hc-sc.gc.ca/dhp-mps/ K. (2012). Effects of listening to music on pain intensity and pain
medeff/advisories-avis/index-eng.php. distress after surgery: An intervention. Journal of Clinical Nursing,
Manheimer, E., Cheng, K., Wieland, L. S., Min, L. S., Shen, X., 21(5/6), 708–717.
Berman, B. M., & Lao, L. (2012). Acupuncture for treatment of World Health Organization. (2013). WHO traditional medicine
irritable bowel syndrome. Cochrane Database of Systematic Reviews, 5, strategy: 2014–2023. Retrieved from http://www.who.int/
CD005111. medicines/publications/traditional/trm_strategy14_23/en/.
Munk, N., & Zanjani, F. (2011). Relationship between massage World Health Organization. (2015). Essential medicines and health
therapy usage and health outcomes in older adults. Journal of products. Retrieved from http://www.who.int/medicines/areas/
Bodywork and Movement Therapies, 15, 177–185. traditional/en/.
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UNIT 3
17
Lifespan and
Chapter Developmental
Stages
Concepts of Growth
and Development
Updated by
W
LEARNING OUTCOMES
After studying this chapter, you will be able to e live through various
1. Differentiate between the terms growth and development. stages of growth and
development, from the
2. Describe the factors that influence human growth and
development. moment of conception through to
the end of life. Understanding normal
3. Describe the essential principles and stages of human growth and
task development. growth and development provides
a framework for age-specific health
4. Describe the characteristics and implications of Freud’s five stages
of psychosexual development. assessment and health promotion
throughout a person’s lifespan. The
5. Describe Erikson’s eight stages of psychosocial development.
terms growth and development are
6. Describe Havighurst’s developmental tasks theory.
often used interchangeably, but they
7. Compare Peck’s and Gould’s stages of adult development. have different meanings. Growth
8. Explain Piaget’s theory of cognitive development. is physical change and increase in
9. Compare Kohlberg’s and Gilligan’s theories of moral development. size. Indicators of growth include
height, weight, bone size, and denti-
10. Compare Fowler’s and Westerhoff’s stages of spiritual
development. tion. Growth rates vary during differ-
ent stages; for example, growth rate
is rapid during the prenatal, neona-
tal, infancy, and adolescent stages.
Development is an increase in the
complexity of function and skill pro-
gression. It is the capacity and skill of
a person to adapt to the environment.
Development is the behavioural aspect
of growth; for example, a person devel-
ops the ability to walk, to talk, and
to run. Developmental milestones
are the developmental sequences and c
M17_KOZI2703_04_SE_C17.indd 294 17/03/17 11:19 AM

Chapter 17 Concepts of Growth and Development 295
c patterns that are predictable in a child’s growth. These milestones may vary from one culture to another;
they are the benchmarks for determining when to expect developmental tasks to take place.
Growth and development are independent but interrelated processes. For example, an infant’s
muscles, bones, and nervous system must grow to a certain point before the infant can sit up or
walk. Growth generally takes place during the first 20 years of life; development continues after that.
Principles of growth and development are shown in Box 17.1.
BOX 17.1 PRINCIPLES OF GROWTH AND DEVELOPMENT

All humans follow the same pattern of growth and develop-
ment. The process is independent, interactive, and gov- Cephalocaudal growth occurs
erned by the following general principles: from the head down.
• The sequence of each stage is predictable, although the
time of onset, the length of the stage, and the effects of
each stage vary from person to person.
• Each developmental stage has its own characteristics.
Growth and development occur as follows:
• In a cephalocaudal direction, that is, starting at the

head and moving to the trunk, legs, and feet. This
pattern is particularly obvious at birth, when the head
of the infant is disproportionately large.
Proximodistal growth
• In a proximodistal direction, that is, from the centre occurs from the centre
of the body outward (see Figure 17.1). For example, of the body out.
infants can roll over before they can grasp an object
with the thumb and the second finger. FIGURE 17.1 Cephalocaudal and proximodistal growth.
• In continuous, orderly, sequential processes influenced
by maturational, environmental, and genetic factors.
• Development proceeds from simple to complex or total body; a 5-year-old child can respond more specifi-
from single acts to integrated acts. To accomplish the cally with laughter or fear.
integrated act of drinking and swallowing a liquid from • Certain stages of growth and development are more c ritical
a cup, for example, the child must first learn a series than others. For example, the first 10 to 12 weeks after
of single acts: eye–hand coordination, grasping, hand– conception are critical. The incidence of congenital anoma-
mouth coordination, controlled tipping of the cup, and lies as a result of exposure to certain viruses, chemicals, or
then mouth, lip, and tongue movements to drink and drugs is greater during this stage than in others.
swallow. • The pace of growth and development is uneven. It is
• Development becomes increasingly differentiated. Differ- known that growth is greater during infancy than during
entiated development begins with a generalized response childhood. Asynchronous development is demonstrated
and progresses to a skilled specific response. For exam- by rapid growth of the head during infancy and of the
ple, an infant’s initial response to a stimulus involves the extremities at puberty.
Factors Influencing Growth Temperament

and Development Temperament (i.e., the way individuals respond to
their external and internal environments) sets the stage
for the interactive dynamics of growth and develop-
Many factors can influence growth and development. ment. Temperament may persist throughout the lifespan,
Knowledge of these factors helps the nurse provide although caution must be taken not to label or categorize
anticipatory guidance to promote optimal growth and infants and children.
development of an individual.
Genetic Family
The genetic inheritance of an individual is established Family provides support and safety for the child. Families
at conception. It remains unchanged throughout life are involved in their children’s physical and psycho-
and determines such characteristics as gender, physical logical well-being and development. Children are social-
characteristics (e.g., eye colour, potential height), and, to ized through family dynamics. The parents set expected
some extent, temperament. behaviours and model appropriate behaviour.
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296 UNIT THREE Lifespan and Developmental Stages
Nutrition Culture
Adequate nutrition is an essential component of growth Cultural customs, nutritional practices, and childrearing
and development. For example, poorly nourished chil- practices may all influence growth and development in
dren are more likely to have infections compared with infants and children.
well-nourished children. In addition, poorly nourished
children may not attain their full height potential.
Stages of Growth
Environment and Development
A few environmental factors that can influence growth
The rate of a person’s growth and development is highly
and development are the child’s living conditions (e.g.,
individual. However, the sequence of growth and develop-
homelessness), socioeconomic status (e.g., poverty versus
ment is predictable. Stages of growth usually correspond
financial stability), climate, and community (e.g., one
to certain developmental changes (see Table 17.1).
that provides developmental support versus one that
exposes the child to hazards).
Growth and Development

Health Theories
Illness or injury can affect growth and development.
Hospitalization is stressful for a child and can affect Growth and development are commonly thought of
his or her behaviours. Prolonged or chronic illness may as having eight major components: (a) biophysical,
affect normal developmental processes. (b) psychosocial, (c) cognitive, (d) behavioural, (e) social,
TABLE 17.1 Stages of Growth and Development
Stage Age Significant Characteristics Nursing Implications

Neonatal Birth to 28 days Behaviour is largely reflexive and develops Assist parents to anticipate, identify, and
to more purposeful behaviour. meet unmet needs.
Infancy 1 month to Physical growth is rapid. Control the infant’s environment so that phys-
1 year ical and psychological needs are met.
Toddlerhood 1 to 3 years Motor development permits increased Safety and risk-taking strategies must be
physical autonomy. Psychosocial skills balanced to permit growth.
increase.
Preschool 4 to 6 years The preschooler’s world is expanding. Provide opportunities for play and social
New experiences and the preschool- activity.
er’s social role are tried during play.
Physical growth is slower.
School age 6 to 12 years This stage includes the preadolescent Allow time and energy for the school-age
period (10 to 12 years). The peer child to pursue hobbies and school activi-
group increasingly influences behav- ties. Recognize and support the child’s
iour. Physical, cognitive, and social achievements.
development increases, and commu-
nication skills improve.
Adolescence 13 to 19 years The self-concept changes with biologi- Assist adolescents to develop coping behav-
cal development. Values are tested. iours. Help adolescents develop strategies
Physical growth accelerates. Stress for resolving conflicts.
increases, especially in the face of
conflicts.
Young adulthood 20 to 39 years A personal lifestyle develops. The person Accept the adult’s chosen lifestyle and assist
usually establishes a relationship with with necessary adjustments relating to
a significant other and a commitment health. Recognize the person’s commit-
to something. ments. Support change, as necessary, for
health.
Middle 40 to 64 years Lifestyle changes because of other Assist clients to plan for anticipated changes
adulthood changes; for example, children leave in life, to recognize the risk factors related
home, occupational goals change. to health, and to focus on strengths rather
than weaknesses.
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Stage Age Significant Characteristics Nursing Implications

Older adulthood
Young-old 65 to 74 years Adaptation to retirement and changing Assist clients to keep physically and socially
physical abilities is often necessary. active and to maintain peer group
Chronic illness may develop. interactions.
Middle-old 75 to 84 years Adaptation to decline in speed of move- Assist clients to cope with loss (e.g., hear-
ment, reaction time, and sensory abili- ing, sensory abilities, eyesight, death of
ties, and increasing dependence on a loved one). Provide necessary safety
others may be necessary. measures.
Old-old 85 and over Physical problems may increase. Assist clients with self-care, as required, and
with maintaining as much autonomy and
independence as possible.
(f) ecological, (g) moral, and (h) spiritual. The follow- or adaptive mechanisms, are the result of conflicts
ing describes some of the major theories relating to the between the id’s impulses and the anxiety created by the
various stages and aspects of growth and development, conflicts arising from social and environmental restric-
particularly with regard to infant and child development. tions. The superego contains the conscience and the
ego ideal. The conscience consists of society’s “do not’s,”
usually as a result of parental and cultural expectations.
Biophysical Theory The ego ideal comprises the standards of perfection
toward which the individual strives. Freud proposed that
Biophysical development theories describe the devel-
the underlying motivation to human development is an
opment and physical changes of the body compared
energy form or life instinct, which he called libido.
against established norms. Arnold Gesell’s (1880–1961)
According to Freud’s theory of psychosexual devel-
theory states that development is directed by genetics. He
opment, the personality develops in five overlapping
asserts that child development is a maturational process
stages from birth to adulthood. The libido changes its
and refinement of abilities and skills based on an inborn
location of emphasis within the body from one stage to
timetable. For example, children achieve maturational
another. Therefore, a particular body area has special
milestones, such as rolling over, sitting, and walking, at
significance to a client at a particular stage. The first
specific times.
three stages (oral, anal, and phallic) are called pregenital
stages. The next stage is the latency stage. The culminating
stage is the genital stage. Table 17.2 indicates the charac-
Psychosocial Theories teristics for each stage.
Psychosocial development refers to the development of If the individual does not achieve a satisfactory resolu-
personality. Personality is a complex concept. It can be tion at each stage, the personality becomes fixated at that
considered as the outward (interpersonal) expression of stage. Fixation is immobilization or the inability of the
the inner (intrapersonal) self. It encompasses a person’s personality to proceed to the next stage because of anxiety.
temperament, feelings, character traits, independence, For example, nurses can assist an infant’s development by
self-esteem, self-concept, behaviour, ability to interact making feeding a pleasurable experience and by making
with others, and ability to adapt to life changes. toilet training a positive experience, thereby enhancing the
child’s feeling of self-control. If, however, the toilet training
SIGMUND FREUD (1856–1939) Sigmund Freud (1946)
has been a negative experience, the resulting conflict or
introduced the following concepts about development:
stress could delay or prolong progression through a stage
the unconscious mind; defence mechanisms; and the id,
or cause a person to regress to a previous stage. Ideally,
the ego, and the superego. The unconscious mind
an individual progresses through each stage with balance
is the part of a person’s mental life that the person is
among the id, the ego, and the superego.
unaware of. This concept of the unconscious is one of
Freud’s major contributions to the field of psychiatry. ERIK ERIKSON (1902–1994) Erik H. Erikson (1963,
The id resides in the unconscious and operates on seek- 1964) expanded Freud’s theory of development to
ing immediate pleasure and gratification. The ego is the include the entire lifespan, believing that people continue
realistic part of the person and balances the gratifica- to develop throughout life. He described eight stages of
tion demands of the id and the limitations of social and development. In contrast to Freud, Erikson believed the
physical circumstances. The methods the ego uses to ego to be the conscious core of the personality.
fulfill the needs of the id in a socially acceptable manner Erikson envisioned life as a sequence of develop-
are called defence mechanisms. Defence mechanisms, mental stages or levels of achievement. Each stage
M17_KOZI2703_04_SE_C17.indd 297 21/02/17 11:42 AM

TABLE 17.2 Freud’s Five Stages of Development
Stage Age Characteristics Task to Be Attained

Oral Birth–1½ years Pleasure is accomplished by exploring the Weaning
mouth and by sucking.
Anal 1½–3 years Pleasure is accomplished by exploring the Bowel and bladder control
organs of elimination. Toilet training
Phallic 4–6 years Pleasure is accomplished by exploring the Resolution of the Oedipus or Electra
genitals. complex
The child is attracted to the parent of the
opposite sex.
Latency 6 years–puberty Pleasure is directed by focusing on rela- Engagement in activities, such as sports,
tionships with same-sex peers and the schoolwork, and socialization with
parent of the same sex. same-sex peers
Genital Puberty and after Pleasure is directed in the development of Engagement in activities to promote
sexual relationships. independence
Source: Freud, A. (1946). The ego and the mechanisms of defense. New York, NY: International Universities Press.
signals a task that must be achieved. The resolution Otherwise, feelings of confusion, indecision, or antisocial
of the task may be complete, partial, or unsuccessful. behaviour will occur.
The greater the task achievement, the healthier is the From age 18 to 25 years, the young adult’s central
personality of the person; failure to achieve a task influ- task is intimacy versus isolation. The individual is exploring
ences the person’s ability to achieve the next task. These relationships with other individuals while also exploring
developmental tasks can be viewed as a series of crises, educational and work experiences. A negative resolution
and successful resolution of these crises is supportive to would be the avoidance of career or relationship.
the person’s ego. Failure to resolve the crises is damaging Adulthood is generativity versus stagnation. The adult
to the ego. After attaining one developmental stage, the age 25–65 years is creative and develops other interests.
person may fall back and need to approach it again. From age 65 years to death, the individual’s central task
According to Erikson (1963), all eight developmental is integrity versus despair. The individual accepts their life
stages reflect both positive and negative aspects of the and ultimate death (see Figure 17.3).
critical life periods. The resolution of the conflicts at When using Erikson’s developmental framework,
each stage enables the person to function effectively in nurses should be aware of indicators of positive and
society. Each stage has its developmental task, and the negative resolutions of each stage and note that the envi-
individual must find a balance between, for example, ronment is highly influential in development. Nurses can
trust versus mistrust (stage 1) or integrity versus despair enhance a client’s development by being aware of the
(stage 8). person’s developmental stage and by helping the person
Stage one is trust versus mistrust and spans birth to develop coping skills relative to stressors experienced at
18 months of age. The infant learns to trust the primary that level and by providing the individual with appro-
caregiver to meet his or her needs for food, shelter, and priate opportunities and encouragement. For example,
personal care (see Figure 17.2). In early childhood, age
18 months to 3 years, the development task is autonomy
versus shame and doubt. The child begins to identify with
the development of control of bodily functions.
Initiative versus guilt is the developmental task of late
childhood. The child is between the ages of 3 and
5 years. At this stage, the child becomes assertive and
is aware of his or her own behaviour. If this task is not
successfully achieved, the child will have decreased self-
confidence, and a feeling of fear will result.
From age 6 to 12 years, the developmental task is

industry versus inferiority. Successful attainment indicates
the child’s ability to create. A negative response is with-
drawal and a sense of hopelessness.
The developmental task for adolescents, ages 12 to
20 years, is identity versus role confusion. Identity is achieved FIGURE 17.2 Trust is established when the infant’s basic
when one can realize one’s own abilities or sense of self. needs are met.
M17_KOZI2703_04_SE_C17.indd 298 02/03/17 11:26 AM

EVIDENCE-INFORMED PRACTICE
Do Parenting Behaviours Affect

Children’s Sleep and Behavioural
Problems?
This longitudinal study examined a cohort of children and
their families in Quebec, between 1998 and 2007, at 5, 17,
and 29 months of age. Participants included parents from
2120 families who completed the self-administered ques-
tionnaire on Parental Cognitions and Conduct Towards the
Infant Scale (PACOTIS). Data from over these three time peri-
ods revealed that parents with children with waking periods
of more than 20 minutes were associated with lower sense
of parenting impact and higher overprotectiveness and coer-
cive behaviours. Children with extended night waking hours
showed more behavioural problems such as aggression or
hyperactivity compared with those with no or shorter wake
periods.
NURSING IMPLICATIONS: Many parents tend to worry
more about their children’s sleep problems than
about their expected developmental milestones such
as motor, social, and language skills. Furthermore,
children with chronic sleep problems could impact on
relationships between parents and their children, and

their psychological development. Nurses could assist
parents to manage their children’s night sleep routine
and to reduce the effects of potential parenting cogni-
tions such as overprotective or coercive behaviours
toward their children.
FIGURE 17.3 Assistive devices help maintain independence Source: Adapted from: Zaidman-Zait, A., & Hall, W. A. (2015). Children’s night waking
and self-esteem, which also help the older adult’s ego integrity among toddlers: Relationships with mothers’ and fathers’ parenting, approaches and
to adapt and cope with the reality of aging. children’s behavioural difficulties. Journal of Advanced Nursing, 71(7), 1639–1649.
doi: 10.1111/Jan.12636
when a toddler has long waking hours at night, the nurse Havighurst’s developmental tasks provide a frame-
can assist the parents to develop strategies to promote work to evaluate a person’s general accomplishments.
healthy sleep routine for their children. (See Evidence- However, the broad categories limit its usefulness as
Informed Practice box.) a tool in assessing specific accomplishments, particu-
Erikson emphasized that people must change and larly those of infancy and childhood. In a multicultural
adapt their behaviour to maintain control over their lives. society, the definition of success of tasks may vary with
No stage in personality development can be bypassed, values and belief systems (e.g., not all individuals may
but people can become fixated at one stage or regress to wish to marry or have children), making these tasks less
a previous stage. For example, a middle-aged woman who relevant for some.
has never satisfactorily accomplished the task of resolving
identity versus role confusion might regress to an earlier ROBERT PECK (1919–2002) Robert Peck believed that
stage when stressed by an illness she cannot cope with. physical capabilities and functions decrease with old age
but that mental and social capacities tend to increase in
ROBERT HAVIGHURST (1900–1991) Robert Havighurst
the latter part of life (Peck, 1968). He proposed three
believed that learning is basic to life and that people con- developmental tasks during old age, in contrast to Erik-
tinue to learn throughout life. He described growth and son’s stage of maturity (integrity versus despair):
development as occurring during six stages, with tasks to
be learned in each (see Table 17.3). A developmental 1. Ego differentiation versus work-role preoccupation. An adult’s
task is “a task which arises at or about a certain period identity and feelings of worth are highly dependent
in the life of an individual, successful achievement of on that person’s work role. On retirement, people may
which leads to his happiness and to success with later experience feelings of worthlessness unless they derive
tasks, while failure leads to unhappiness in the individ- their sense of identity from a number of roles so that
ual, disapproval by society, and difficulty with later tasks” one such role can replace the work role or occupation
(Havighurst, 1972, p. 2). as a source of self-esteem. For example, a man who
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TABLE 17.3 Havighurst’s Age Periods and Developmental Tasks
Infancy and Early Childhood 8. D

eveloping intellectual skills and concepts necessary for
civic competence
1. Learning to walk
9. Desiring and achieving socially responsible behaviour
2. Learning to take solid foods
10. A
cquiring a set of values and an ethical system as a
3. Learning to talk guide to behaviour
4. Learning to control the elimination of body wastes
Early Adulthood
5. Learning sexual differences and sexual modesty
1. Selecting a mate
6. Achieving psychological stability
2. Learning to live with a partner
7. Forming simple concepts of social and physical reality
3. Starting a family
8. L
earning to relate emotionally to parents, siblings, and
other people 4. Rearing children
9. L
earning to distinguish right from wrong and developing 5. Managing a home
a conscience 6. Getting started in an occupation
Middle Childhood 7. Taking on civic responsibility
1. Learning physical skills necessary for ordinary games 8. Finding a congenial social group
2. Building wholesome attitudes toward oneself as a grow- Middle Age
ing organism
1. Achieving adult civic and social responsibility
3. Learning to get along with age-mates
2. E
stablishing and maintaining an economic standard of
4. Learning an appropriate masculine or feminine social role living
5. Developing fundamental skills in reading, writing, and 3. A
ssisting teenage children to become responsible and
arithmetic happy adults
6. Developing concepts necessary for everyday living 4. Developing adult leisure-time activities
7. Developing conscience, morality, and a scale of values 5. Relating oneself to one’s spouse as a person
8. Achieving personal independence 6. A
ccepting and adjusting to the physiological changes of
9. Developing attitudes toward social groups and institutions middle age
Adolescence 7. Adjusting to aging parents
1. Achieving new and more mature relations with age- Later Maturity
mates of both genders 1. Adjusting to decreasing physical strength and health
2. Achieving a masculine or feminine social role 2. Adjusting to retirement and reduced income
3. Accepting one’s physique and using the body effectively 3. Adjusting to death of spouse
4. Achieving emotional independence from parents and 4. Establishing an explicit affiliation with one’s age group
other adults
5. Meeting social and civic obligations
5. Achieving assurance of economic independence
6. Establishing satisfactory physical living arrangements
6. Selecting and preparing for an occupation
Source: Havinghurst, Robert J. (1930). Developmental Tasks (Ist ed.). Reprinted and
7. Preparing for marriage and family life electronically reproduced by permission of Pearson Education, Inc., Upper Saddle
River, New Jersey.
ROGER GOULD Roger Gould (1972) believed that

likes to garden or golf can obtain ego rewards from
transformation is a central theme during adulthood. He
those activities, replacing rewards formerly obtained
described seven stages of adult development:
from his occupation.
2. Body transcendence versus body preoccupation. This task calls 1. Stage 1 (ages 16–18). Individuals consider themselves
for the individual to adjust to decreasing physical part of the family, rather than individuals, and want
capacities and, at the same time, maintain feelings of to separate from their parents.
well-being. Preoccupation with declining body func- 2. Stage 2 (ages 18–22). Although the individuals have
tions reduces happiness and satisfaction with life. established autonomy, they feel it is in jeopardy; they
3. Ego transcendence versus ego preoccupation. Ego transcen- feel they could be pulled back into their families.
dence is the acceptance, without fear, of death as inevi- 3. Stage 3 (ages 22–28). Individuals feel established as
table. This acceptance includes being actively involved adults and autonomous from their families. They see
in our own future beyond death. Ego preoccupation, in themselves as well defined but still feel the need to
contrast, results in holding onto life and a preoccupa- prove themselves to their parents. They see this as the
tion with self-gratification. time for growing and building for the future.
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4. Stage 4 (ages 28–34). Marriages and careers are well in negativism. The spouse is seen as a valuable compan-
established. Individuals question what life is all about ion (Gould, 1972).
and want to be accepted as they are, no longer finding
The concept map provides an overview of growth
it necessary to prove themselves.
and development theories and theorists (see Figure 17.4).
5. Stage 5 (ages 34–43). Through self-reflection, individ-
uals question values and life itself. They see time as
finite, with little time left to shape the lives of adoles- Temperament Theories
cent children.
STELLA CHESS (1914–2007) AND ALEXANDER THOMAS
6. Stage 6 (ages 43–50). Personalities are seen as set. (1914–2003) Stella Chess and Alexander Thomas iden-
Time is accepted as finite. Individuals are interested tified nine temperamental qualities seen in children’s
in social activities with friends and spouse, and desire behaviour (see Table 17.4). The “goodness of fit” between
both sympathy and affection from spouse. children’s temperamental qualities and the demands of
7. Stage 7 (ages 50–60). This is a period of transforma- their environment contributes to positive interaction and
tion, with a realization of mortality and a concern for positive growth and development (De Pauw & Mervielde,
health. There is an increase in warmth and a decrease 2010). Goodness of fit refers to whether parents’
FIGURE 17.4 CONCEPT MAP Overview of Growth and Development Theories and Theorists
Growth and Development
Theory Theory Theory Theory Theory
Biophysical Cognitive Behaviourism Social Learning Ecological

Development
Gesell Piaget Skinner Vygotsky Bandura Bronfenbrenner
Development Stimulus–response Views the child as

is a maturational behaviour; rewards interacting with
process that reinforce positive the environment
occurs on a set behaviour at different levels
“timetable” or systems:
• Microsystem
• Mesosystem
• Exosystem
Five major phases: Social construction Individual learns • Macrosystem
• Sensorimotor of learning: child through imitation • Chronosystem
• Preconceptual is guided by adults and practice;
• Intuitive within social, self-regulation
• Concrete operations historical, and and self-efficacy
• Formal operations cultural contexts are important
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TABLE 17.4 Characteristics of Temperament (stimuli) must occur before intellectual abilities can
develop. Piaget’s cognitive developmental process is
Characteristic Examples of Behaviour Style divided into five major phases: (a) the sensorimo-
Activity level Active, restless, always on the move tor phase, (b) the preconceptual phase, (c) the intuitive
versus quiet, inactive thought phase, (d) the concrete operations phase, and (e)
Sensitivity Apparently oblivious to stimuli versus the formal operations phase. See Table 17.5. A person
reacts to minimal stimuli develops through each of these phases, and each phase
Intensity Minimal reaction to stimuli versus strong has its own unique characteristics.
and intense reaction In each phase, the person uses three primary abili-
Adaptability Responds smoothly to unexpected events
ties: (a) assimilation, (b) accommodation, and (c) adap-
versus resists change tation. Assimilation is the process through which
humans encounter and react to new situations by using
Distractibility Focuses on tasks versus easily distracted
by minimal stimuli the mechanisms they already possess. In this way, people
acquire knowledge and skills as well as insights into the
Approach/ Jumps right into activities versus hesitant
Withdrawal to engage, slow to warm up world around them. Accommodation is a process of
change whereby cognitive processes mature sufficiently
Mood Cheerful, happy versus serious, sombre
to allow the person to solve problems that were unsolv-
Persistence Sticks to tasks versus easily gives up able before. This adjustment is possible chiefly because
Regularity Demonstrates patterns of behaviour new knowledge has been assimilated. Adaptation, or
versus random activity coping behaviour, is the ability to handle the demands
made by the environment.
Nurses can employ Piaget’s theory of cognitive
expectations of their child’s behaviour are consistent with
development when developing teaching strategies. For
the child’s temperament type. When parents understand
example, a nurse can expect a toddler to be egocen-
a child’s temperament characteristics, they are better able
tric and literal; therefore, explanations to the toddler
to shape the environment to meet the child’s needs.
should focus on the needs of the toddler, rather than on
the needs of others. When teaching adults, nurses may
become aware that some adults are more comfortable
Attachment Theory with concrete thought and are slower to acquire and
JOHN BOWLBY (1907–1990) British psychologist and apply new information than are other adults.
physician John Bowlby’s attachment theory shares a com-
mon belief with Freud’s psychoanalytic theories that early
childhood experiences have a strong influence on the Behaviourist Theory
child’s development and later behaviour. He hypothesized
B. F. SKINNER (1904–1990) Behaviourist theory states
that humans have an essential need for attachment—or
that learning takes place when an individual’s reaction to
lasting, strong emotional bonds—to others and that the
a stimulus is either positively or negatively reinforced. The
infant–caregiver relationship is the first such attachment.
more rapid, consistent, and positive the reinforcement is,
Attachment served as a protective or survival mecha-
the more likely it is that a behaviour will be learned and
nism for the infant. For example, the infant experiences
retained. Skinner believed that organisms learn as they
separation anxiety when the attachment figure is absent
respond to or operate in their environment. He main-
(Bowlby, 1999).
tained that rewarded or reinforced behaviour will be
repeated; behaviour that is punished will be suppressed.
Cognitive Theory
JEAN PIAGET (1896–1980) Cognitive development Social Learning Theory
refers to the manner in which people learn to think,
Social learning theory is based on the principle that
reason, and use language. It involves a person’s intelli-
individuals learn by observing and thinking about the
gence, perceptual ability, and ability to process informa-
behaviour of the self and others; it can be seen as span-
tion. Cognitive development represents a progression of
ning both behaviourist and cognitive learning theories.
mental abilities from illogical thinking to logical thinking,
from simple problem solving to complex problem solving, ALBERT BANDURA (B. 1925) Albert Bandura believes
and from understanding concrete ideas to understanding that learning occurs through imitation and practice;
abstract concepts. that it requires more awareness, self-motivation, and
According to Piaget (1966), the most widely known self-regulation of the individual; and that the individual
cognitive theorist, cognitive development is an orderly, actively interacts with the environment to learn new
sequential process in which a variety of new experiences skills and behaviours.
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TABLE 17.5 Piaget’s Phases of Cognitive Development
Phases and Stages Age Significant Behaviour

Sensorimotor phase Birth–2 years
Stage 1: Use of reflexes Birth–1 month The use of reflexes.
Stage 2: Primary circular 1–4 months Sucking habits are developed, such as thumb sucking and the protrusion of the
reaction tongue when the infant is hungry. The infant acknowledges objects visually,
grasps at objects, and is attracted by sounds.
Stage 3: Secondary circular 4–8 months The infant begins to discover and rediscover the external environment.
reaction
Stage 4: Coordination of 8–12 months First actual intellectual behaviour patterns emerge. The infant begins to distin-
secondary schemata guish the ends and the means. The infant is utilizing cognitive development
to attain a goal.
Stage 5: Tertiary circular 12–18 months The child discovers new ways of solving problems by utilizing experimentation.
reaction
Stage 6: Inventions of new 18–24 months Possess mental images of the environment and utilizes cognitive skills to solve
means problems. The child’s play time is an imitation of what has been seen lead-
ing to pretend play.
Preconceptual phase 2–4 years Uses an egocentric approach to accommodate the demands of an environ-
ment. Everything is significant and relates to “me.” Explores the environ-
ment. Language development is rapid. Associates words with objects.
Intuitive thought phase 4–7 years Egocentric thinking diminishes. Thinks of one idea at a time. Includes others in
the environment. Words express thoughts.
Concrete operations 7–11 years Solves concrete problems. Begins to understand relationships such as size.
phase Understands right and left. Cognizant of viewpoints.
Formal operations phase 11–15 years Uses rational thinking. Reasoning is deductive and futuristic.
Source: Piaget, J. (1966). The origins of intelligence. New York, NY: W. W. Norton and Company, Inc.; and Piaget, J. and Inhelder, B. (1969). The psychology of the child. New York, NY:
Basic Books.
LEV VYGOTSKY (1896–1934) Lev Vygotsky explored contact (e.g., parent’s job, local school board). (d) The
the concept of cognitive development within social, his- macrosystem includes attitudes and beliefs of the child’s
torical, and cultural contexts. His view was that adults culture. (e) The chronosystem involves the period in which
guide children to learn and that development depends the child is growing up as it influences views of health
on the use of language, play, and extensive social interac- and illness.
tion. His ideas have been used in the treatment of chil-
dren with learning disorders, autism, mental challenges,
and other disabilities. His work also supports the benefit Theories of Moral Development
of adult social learning opportunities via group interac-
tion and observation. Moral development involves learning what ought to be
and what ought not to be done. It is more than imprinting
parents’ rules and virtues or values on children. The term
Ecological Systems Theory moral means “relating to right and wrong.” The terms
morality, moral behaviour, and moral development need to be
URIE BRONFENBRENNER (1917–2005) Urie Bronfen-
distinguished. Morality refers to the requirements neces-
brenner viewed the child as interacting with the environ-
sary for people to live together in society; moral behav-
ment at different levels, or systems. He believed each child
iour is the way a person perceives those requirements and
brings a unique set of genes—and specific attributes, such
responds to them; moral development is the pattern of
as age, gender, health, and other characteristics—to his or
change in moral behaviour with age (see Chapter 5).
her interactions with the environment.
There are five levels, or systems, in the ecological LAWRENCE KOHLBERG (1927–1987) Lawrence Kohlberg’s
systems theory. (a) The microsystem includes close relation- (1984) theory specifically addressed moral development in
ships the child has on a daily basis (e.g., home, school, children and adults. Kohlberg focused on the reasons an
friends). (b) The mesosystem level includes relationships of individual makes a decision. He viewed moral development
microsystems with one another. For example, two com- as progressing through three levels and six stages. These
mon microsystems for children are home and school. levels and stages are not always linked to a certain develop-
(c) The exosystem includes those settings that may influence mental stage because some people progress to a higher level
the child but with which the child does not have daily of moral development than others do.
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At Kohlberg’s first level, called the premoral or pre- Caring relationships bring with them responsibility.
conventional level, children are responsive to cultural rules The definition of responsibility includes self-sacrifice,
and labels of good and bad, right and wrong. However, where “good” is considered to be “caring for others.”
children interpret these in terms of the physical conse- The individual now approaches relationships with
quences of their actions, that is, punishment or reward. a focus of not hurting others. This approach causes
At the second level, the conventional level, the individual the individual to be more responsive and submissive
is concerned about maintaining the expectations of the to others’ needs, excluding any thoughts of meeting
family, group, or nation and sees this as right. The his or her own. A transition occurs when the individ-
emphasis at this level is on conformity and loyalty to his ual recognizes that this approach can cause difficul-
or her own expectations as well as those of society. Level ties with relationships because of the lack of balance
three is called the postconventional, autonomous, or principled between caring for the self and caring for others.
level. At this level, people make an effort to define valid • Stage 3, caring for the self and others. A person sees the
values and principles without regard to outside authority need for a balance between caring for others and car-
or to the expectations of others. (See Table 17.6.) ing for the self. The concept of responsibility now
CAROL GILLIGAN (B. 1936) Carol Gilligan (1982) includes responsibility for the self and for other people.
believes that moral development involves the concepts of Care remains the focus by which decisions are made.
caring and responsibility. She views moral development However, the person recognizes the interconnections
as proceeding through three levels and two transitions, between the self and others and realizes that if his or
with each level representing a more complex under- her own needs are not met, other people may also suffer.
standing of the relationship of the self and others and Gilligan believes women often see morality in the
each transition resulting in a crucial re-evaluation of the integrity of relationships and caring, so the moral prob-
conflict between selfishness and responsibility. lems they encounter are different from those of men.
• Stage 1, caring for the self. In this stage, the person is con- Men tend to consider what is right to be what is just,
cerned only with caring for the self. The individual whereas for women, what is right is taking responsibility
feels isolated, alone, and unconnected to others and for others as a self-chosen decision (Gilligan, 1982). The
has no concern or conflict with the needs of others ethical principle of justice, or fairness, is based on the
because the self is most important. The focus of this idea of equality and equal treatment.
stage is survival. The end of this stage occurs when
the individual begins to view this approach as selfish.
At this time, the person also begins to see a need for Theories of Spiritual Development
relationships and connections with other people. The spiritual component of growth and development
• Stage 2, caring for others. The individual recognizes the refers to individuals’ understanding of their relationship
selfishness of earlier behaviour and begins to under- with the universe and their perceptions about the direc-
stand the need for caring relationships with others. tion and meaning of life.
TABLE 17.6 Kohlberg’s Stages of Moral Development
Level Stage
I. Preconventional 1. Punishment and Obedience
Actions are judged in terms of physical consequences.
Egocentric Focus 2. Individual Instrumental Purpose and Exchange
A person begins to understand An individual engages in actions that are right to meet his or her needs. The individual
the rules of right and wrong. separates his or her own interests from the interests of authorities.
II. Conventional 3. Mutual Interpersonal Expectations, Relationships, and Conformity
A person is concerned about An individual is in relationships with other people. The individual is paying attention to
other people and their feelings. the feelings of others. The individual puts oneself in the other person’s shoes.
Social Perspective 4. Social System and Conscience Maintenance
A person is doing his or her duty An individual fulfills the duties assigned by authority figures thus fulfilling obligations
to society. set forth by society’s laws.
III. Postconventional 5. Prior Rights and Social Contract
The person upholds the basic An individual has an obligation to obey the law. There is a commitment to family and
rights, values, and legal work obligations. The individual has a responsibility to consider the moral and
contracts of the society. legal point of view in ascertaining what will provide the g
reatest good for people.
Universal Focus 6. Universal Ethical Principle
An individual follows what is right in accordance with ethical principles.
Source: Kohlberg, L. (1981). Essays on moral development, Vol. 1: The philosophy of moral development. San Francisco, CA: Harper & Row.
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JAMES FOWLER (B. 1940) James Fowler describes

faith as a force that gives meaning to a person’s life. Faith Applying Growth and
is a form of knowing, a way of being in relation to “an
ultimate environment”; it is a relational phenomenon
Development Concepts
and is “an active ‘mode-of-being-in-relation’ to another
or others in which we invest commitment, belief, love,
to Nursing Practice
risk and hope” (Fowler & Keen, 1985, p. 18).
Different theories explain one or more aspects of an
Fowler believes that the development of faith is an
individual’s growth and development. The nurse may
interactive process between the person and the environ-
find it necessary to apply several theories for an ade-
ment. In each of Fowler’s stages, new patterns of thought,
quate understanding of the growth and development
values, and beliefs are added to those already held by the
of a client. Developmental theories can be useful in
individual; therefore, the stages must follow in sequence.
guiding assessment, explaining behaviour, and provid-
JOHN WESTERHOFF (B. 1933) Westerhoff (2012) ing a direction for nursing interventions. An under-
described faith as a way of being and behaving that standing of a child’s intellectual ability helps a nurse
evolves from an experienced faith guided by parents and anticipate and explain certain reactions, responses, and
others during a person’s infancy and childhood to an needs. Nurses can then encourage client behaviour
owned faith that is internalized in adulthood and serves that is appropriate for that particular developmental
as a directive for personal action. For the client who is stage. In adult care, knowledge about the physical,
ill, faith—whether in a higher authority (e.g., God, Allah, cognitive, and psychological aspects of the aging pro-
Jehovah), in the client’s own self, in the health care team, cess is a fundamental aspect of administering sensitive
or in a combination of all—provides strength and trust. nursing care.
Case Study 17
Finnegan, an inquisitive, energetic 2-year-old, is diagnosed with
amblyopia (lazy eye) and far-sightedness in his stronger eye.
2. What strategies could you suggest Finnegan’s parents
use to increase his cooperation with treatment?
Untreated, this condition will lead to blindness in the affected
eye. Treatment includes wearing an eye patch over his stronger 3. Specifically describe strategies based on Piaget’s theory
eye for 2 hours a day and wearing glasses with a corrective of cognitive development and the theory of social
lens at all times when he is awake. Finnegan’s learning.
mother says he resists actively when she or his
father places the patch and that it is “almost Visit MyNursingLab for answers and explanations.
impossible” to get him to leave his glasses on.
1. According to Erikson, at what stage of development is

Finnegan?
KEY TERM S
accommodation defence mechanism ego p. 297 moral behaviour
p. 302 p. 297 faith p. 305 p. 303
adaptation p. 302 development p. 294 fixation p. 297 moral development
adaptive developmental goodness of fit p. 303
mechanisms p. 297 milestones p. 294 p. 301 morality p. 303
assimilation p. 302 developmental stages growth p. 294 personality p. 297
attachment p. 302 p. 297 id p. 297 superego p. 297
cognitive developmental task libido p. 297 temperament p. 295
development p. 302 p. 299 moral p. 303 unconscious mind p. 297
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• Growth is physical change and an increase in size. The • Cognitive development refers to the manner in which
pattern of physiological growth is similar for all people. people learn to think, reason, and use language. The
• Development is an increase in the complexity of function most widely known cognitive theorist is Piaget.
and skill progression. It is the capacity and skill of the • Behaviourist learning theory emphasizes stimulus
individual to adapt to the environment. response and either positive or negative reinforcement as
• The rate of a person’s growth and development is highly the basis for learning and behaviour change.
individual, but the sequence of growth and development • Social learning theory states that learning can occur by
is predictable. observation. Role modelling and learning from watching
• Heredity and environment are the primary factors influ- role models are a part of social learning theory.
encing growth and development. • Ecologic systems theory sees the child as interacting
• Components of growth and development are generally with the environment at different levels, or systems.
categorized as biophysical, psychosocial, cognitive, behav- Bronfenbrenner described five levels or systems of
ioural, social, ecological, moral, and spiritual. interaction.
• Temperament, the way in which individuals respond to • Moral development, a complex process not fully under-
their external and internal environments, influences the stood, involves learning what ought to be and what ought
interactive dynamics of growth and development. not to be done. Kohlberg’s theory focuses on the reasons
an individual makes a decision. Gilligan’s theory included
• Gesell’s biophysical development theory stated that devel- the concepts of caring and responsibility.
opment is directed by genetics.
• The spiritual component of growth and development
• Psychosocial development refers to the development of refers to individuals’ understanding of their relationship
personality. Psychosocial theorists include Havighurst, with the universe and their perceptions about the direc-
Freud, Erikson, Peck, and Gould. tion and meaning of life. Fowler and Westerhoff are two
• Attachment theory states that humans have a need for theorists who describe stages of spiritual development or
strong emotional bonds to others. faith.
• Havighurst believed that learning is basic to life and that • The nurse uses developmental theories in guiding assess-
people continue to learn throughout life. His theory describes ment, explaining behaviour, and providing a direction for
six age periods, with developmental tasks for each period. interventions to promote the client’s health.

1. A parent drops into a child health clinic looking for guid- 3. A 12-year-old girl is crying by her locker at school. Her
ance on how to manage an issue with her son. The parent friends are gathered around, trying to “give her some
states, “My 5-year-old son plays with his penis all the time. protection.” The school nurse is called by the physical
What should I say to my son the next time I see him doing education teacher to come and help out. Based on the
this?” What is the nurse’s best response to this question? norms of growth and development, which situation is
a. “Just ignore the behaviour because talking about it the nurse most likely to encounter?
will only embarrass your son.” a. She has begun her menstrual cycle, was unprepared,
b. “Tell your son, ‘That’s not what nice boys do. Please and is embarrassed and frightened.
take your hands out of your pants.’” b. Students are putting peer pressure on the girl.
c. “Say, ‘I know that feels good to you, but do that in c. She got a failing grade on a math test and is upset
the privacy of your room.’” about it.
d. “Ask him if it’s itchy or sore ‘down there’ because I d. Her friends have been trying to protect her from
suspect he has a urinary tract infection.” bullies in the school.
2. Which is one example of how to integrate Piaget’s 4. The parents of a 5-month-old infant and a 3-year-old
theory to nursing practice? child ask the nurse about the sequence and timing of
a. Giving a thorough explanation of why taking medi- developmental milestones. Which of the following is the
cation is important to a 3-year-old most appropriate response?
b. Providing a choice of two methods of medicine a. “This infant should reach the milestones at the same
administration, by glass or spoon, to a 5-year-old times as your older child did.”
c. Assimilating family members into the care plan to b. “The infant may reach the milestones in a different
promote positive outcomes order from that of your older child.”
d. Providing a structured daily routine for a hospital- c. “The sequence of milestones should follow the same
ized adolescent pattern.”
M17_KOZI2703_04_SE_C17.indd 306 21/02/17 11:42 AM

d. “There are no predictable patterns. Try to enjoy the for the family.” Using Havighurst’s developmental tasks,
uniqueness of each child.” what would be the nurse’s best response?
a. “This is somewhat unusual. Are there problems that
5. A university student is urged by a group of students to we need to discuss?”
cheat on an examination. He declines and reports the b. “Although this is normal development, this transition
situation to university officials as he believes the behav- can be difficult for families.”
iour is unethical. Which of Kohlberg’s stages of moral
development does this exemplify? c. “Become involved in her life, and insist that she set
aside time for the family.”
a. Conventional
d. “This is normal development. You need to let her
b. Societal focus grow up.”
c. Postconventional
d. Universal 9. A 5-year-old boy arrives for the pre-admission workup
for a surgical procedure. When the nurse brings in the
6. A 14-year-old is scheduled to have stem cell transplan- intravenous (IV) control pump the child states, “I am
tation to treat acute leukemia. The adolescent will be afraid that it will bite me because I have been bad.”
hospitalized for about two weeks. What nursing inter- Using knowledge of the theories by Piaget, Erikson,
vention will be most helpful during the hospital stay? and Fowler, which of the following is the best nursing
a. Having peers visit frequently during the day intervention?
b. Instructing parents to room-in with her a. Reassuring the child by providing opportunities
for touching and exploring the machine, as well as
c. Encouraging her to go to the recreation room explaining how it works
d. Encouraging her to arrange for her teachers to pro- b. Understanding that his imagination is out of control
vide her with homework and telling him that his fears are unfounded and that
he should act like a “big boy”
7. A 70-year-old man who recently retired after 40 years c. Recognizing that he is too young to understand and
of work as an independent contractor is scheduled for that he needs to be quickly distracted
a physical examination. Using Erikson’s stages of social
development, which of the following comments should d. Acknowledging his need for fantasy by reassuring
cause concern in the nurse? him that if he is a “good boy” the bad machine will
not bite him.
a. “My wife and I are planning to drive to Halifax in
June to visit our grandkids.”
10. What are the nursing considerations associated with the
b. “Every day, when I wake up, it’s hard to find a rea- care of people in middle adulthood?
son to get out of bed.”
a. Clients’ stage of development encourages them to be
c. “I often take ibuprofen for the pain in my knees.” self-centred and actively changing.
d. “People still call me for advice on building projects. I b. Individuals will be focused on their increasing age
may never get to retire!” and physical limits.
c. Personal lifestyle changes result from physical
8. An 11-year-old child is scheduled for an annual physical changes in the self and others.
examination. The accompanying parent expresses con-
cern because the child “seems all wrapped up with soc- d. The peer group is vitally important to the accom-
cer teammates and other peers, leaving very little time plishment of developmental tasks.
REFERENCES
Bowlby, J. (1999). Attachment and loss. Vol. 1. Attachment (2nd ed.). New Gilligan, C. (1982). In a different voice: Psychological theory and women’s
York, NY: Basic Books. development. Cambridge, MA: Harvard University Press.
De Pauw, S. W., & Mervielde, I. (2010). Temperament, personality, Gould, R. L. (1972). The phases of adult life: A study in develop-
and developmental psychopathology: A review based on the con- mental psychology. American Journal of Psychiatry, 129, 33–43.
ceptual dimensions underlying childhood traits. Child Psychiatry and Havighurst, R. J. (1972). Developmental tasks and education (3rd ed.).
Human Development, 41, 313–329. New York, NY: Longman Publishers.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: Kohlberg, L. (1984). Essays on moral development: Vol. 2. The psychology
Norton. of moral development. San Francisco, CA: Harper & Row.
Erikson, E. H. (1964). Insight and responsibility: Lectures on the ethical Peck, R. (1968). Psychological developments in the second half
implications of psychoanalytic insight. New York, NY: Norton. of life. In B. L. Neugarten (Ed.), Middle age and aging (pp. 88–92).
Fowler, J., & Keen, S. (1985). Life maps: Conversations in the journey of Chicago, IL: University of Chicago Press.
faith. Waco, TX: Word Books. Piaget, J. (1966). The origins of intelligence in children. New York, NY: Norton.
Freud, A. (1946). The ego and the mechanisms of defense. New York, NY: Westerhoff, J. (2012). Will our children have faith? (3rd ed.). New York,
International Universities Press. NY: Morehouse Publishing.
M17_KOZI2703_04_SE_C17.indd 307 21/02/17 11:42 AM

Chapter 18
Development from
Conception through
Updated by
Adolescence
Tracie Risling, RN, PhD
College of Nursing, University of Saskatchewan
K
LEARNING OUTCOMES
After studying this chapter, you will be able to nowledge of growth and
1. Identify the characteristics and tasks at different stages of development is essen-

development, from infancy through adolescence. tial for nurses to provide
2. Describe expected physical development from infancy through clients with anticipated guidance for
adolescence. optimal developmental milestones. On
3. Trace psychosocial development according to Erikson, from infancy the basis of the concepts of growth,
through adolescence. as discussed in Chapter 17, this chap-
4. Explain cognitive development according to Piaget, from infancy ter will emphasize health assessment,
through adolescence. including health-promotion and health-
5. Describe the influence of relationships on mental health, from protection activities to meet physical,
infancy through adolescence. psychosocial, cognitive, moral, and
6. Describe spiritual development according to Fowler and moral spiritual developmental needs from
development according to Kohlberg throughout childhood and infancy through adolescence.
adolescence.
7. Discuss assessment activities and expected characteristics from
birth through late childhood.
8. List essential nursing activities to promote and protect the health
of infants, toddlers, preschoolers, school-age children, and
adolescents.
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Chapter 18 Development from Conception through Adolescence 309
Conception and Prenatal BOX 18.1 MATERNAL FACTORS THAT

CONTRIBUTE TO A HIGHER RISK OF LOW-
Development BIRTH-WEIGHT BABIES
The following factors can contribute to mothers having low-
Conception and prenatal, or intrauterine, development birth-weight babies:
lasts approximately 9 calendar months (10 lunar months) • Underweight before pregnancy
or 38 to 40 weeks, depending on the method of calcula- • Less than 9 kg weight gain during pregnancy
tion. A lunar month of pregnancy comprises 28 days.
• Inadequate prenatal care
Pregnancy is divided into three periods called trimes-
• Age 17 years or younger, or 49 years or older
ters, each of which lasts about 3 months. The two
• History of hypertension
phases of intrauterine life are the embryonic phase in the
first trimester and the fetal phase in the second and third • Low socioeconomic level
trimesters. • Exposure to toxic substances or chemicals
The fertilized ovum develops into an organism with • Smoking cigarettes during pregnancy
most of the human features in the embryonic phase. The • Use of addictive drugs or alcohol during pregnancy
embryo is implanted in the endometrium of the uterus. • Complications during pregnancy, poor health status,
The placenta is a flat, disc-shaped organ that is highly exposure to infections
vascular. It normally forms in the upper segment of the • High stress levels, including physical or emotional abuse
endometrium of the uterus. Its functions are to exchange • Previous low-birth-weight infants or multiple miscarriages
nutrients and gases between the embryo or fetus and the • Having given birth less than 6 months or 10 or more
mother to sustain fetal growth in utero. years ago
Within the first 3 weeks of life, tissues differentiate
into three layers—the ectoderm (outer layer), the mesoderm Source: Adapted from Murray, R. B., Zentner, J. P., & Yakimo, R. (2009). Health
promotion strategies through the life span (8th ed.) (p. 233). Upper Saddle River, NJ:
(middle layer), and the endoderm or entoderm (inner layer). Prentice Hall. Reprinted with permission.
The ectoderm and endoderm are formed in the second
week; the mesoderm forms in the third week. These lay-
ers form all of the body’s complex organs and systems
as a series of outpouchings, inpouchings, foldings, and through the placenta to meet its basic survival needs.
tubular formations. Organs are developed between 8 The health of the mother is essential for optimal fetal
and 12 weeks during this embryonic phase. The fetal phase is growth and development.
characterized by a period of rapid growth in the size of OXYGEN To meet the fetal demands for oxygen, the
the fetus. Both genetic and environmental factors affect pregnant woman’s normal blood flow gradually increases
its growth (Murray, Zentner, & Yakimo, 2009). by about one-third, peaking at about 8 months; tidal vol-
At the end of the second trimester, the fetus resembles ume increases by about 40%, with associated increased
a small baby. Because very little fat is present beneath the respiration; and cardiac output increases significantly.
skin of the fetus, skin appears wrinkled, red, and transpar- Fetal circulation travels from the placenta through two
ent. The underlying blood vessels are visible. A protective umbilical arteries, which carry deoxygenated blood away
covering, called vernix caseosa, begins to develop over from the fetus. By 20 weeks, the fetal heartbeat is audible
the fetus’s skin. This is a white, cheese-like substance that through a fetoscope, or as early as the tenth week if a
adheres to skin and may become 3 mm thick by birth. Doppler stethoscope with ultrasound is used.
Lanugo—fine, downy hair—covers the body. At about
5 months, the mother begins to feel fetal movement, and NUTRITION AND FLUIDS The fetus obtains nourish-
the fetal heartbeat is audible. ment from the placental circulation and by swallow-
At the end of the third trimester, the fetus is approxi- ing amniotic fluid. Nutritional needs are met when the
mately 50 cm long and weighs 3.2 to 3.8 kg (Public Health mother eats a well-balanced diet containing sufficient
Agency of Canada, 2012). Lanugo has disappeared, and calories to meet both her needs and those of the fetus.
skin has a normal colour and appears less wrinkled. More Adequate folic acid, which is one of the B vitamins,
subcutaneous fat makes the fetus look more rotund. The is important to prevent neural tube defects (e.g., spina
fetus gains most of its weight during the last 2 months in bifida) in the fetus.
utero. Box 18.1 lists maternal factors that can lead to a REST AND ACTIVITY The fetus sleeps most of the time
higher risk of a low-birth-weight baby (<2.5 kg). but develops a pattern of sleep and wakefulness that can
persist after birth. Fetal activity begins about the fifth
lunar month of pregnancy.
Health Promotion ELIMINATION Throughout pregnancy, fetal feces are
During the intrauterine stage of fetal development, the formed from swallowed amniotic fluid, but normally no
embryo, or fetus, relies on the maternal blood flow stool is passed until after birth. Inadequate oxygenation
M18_KOZI2703_04_SE_C18.indd 309 27/02/17 11:45 AM

of the fetus during the third trimester can result in relax-

ation of the anal sphincter and passage of feces into
the amniotic fluid. Urine normally is excreted into the
amniotic fluid when the kidneys mature (16 to 20 weeks).
TEMPERATURE MAINTENANCE Although amniotic
fluid provides a constant temperature for the fetus, sig-
nificant increases in temperature caused by maternal
fever or the use of hot whirlpool baths or saunas can

alter the temperature of the amniotic fluid and that of
the fetus and may result in birth defects. In the last weeks
of gestation, the fetus develops subcutaneous fatty tissue
stores that will help maintain body temperature at birth.
SAFETY The embryo is particularly vulnerable to dam-
age or harm from a teratogen—anything that adversely FIGURE 18.1 Measuring an infant head to heel, from the top
affects normal cellular development in the embryo or of the head to the base of the heels.
fetus. Expectant mothers must avoid radiography (x-ray),
chemicals, and medications that are known teratogens.
Exposure to environmental tobacco smoke has been of their birth weight because of normal biological fluid
associated with preterm labour, spontaneous abortion, loss and regain that weight in about 1 week. After sev-
low-birth-weight infants, sudden infant death syndrome, eral days of age, newborns gain weight at the rate of
and learning disorders (Pogodina, Brunner Huber, 150 g to 210 g weekly for 6 months. By 5 months of
Racine, & Platanova, 2009). Maternal, neonatal, and age, infants usually have doubled their birth weight, and
infant mortality rates are significantly increased with by 12 months, tripled their birth weight. Rapid weight
maternal use of drugs or alcohol and exposure to other gain in the first year of life, especially in the first 5 to
chemicals (Wigle et al., 2008). Fetal alcohol spec- 6 months, is related to obesity in children and adults
trum disorder (FASD), a result of alcohol use by (Goodell, Wakefield, & Ferris, 2009). Exclusive breast-
the pregnant woman, is defined as impaired mitochon- feeding in the first 4 to 6 months may be helpful in pre-
drial development in the fetus, leading to microcephaly, venting excessive weight gain.
intellectual disability (previously known as mental retar-
dation), learning disorders, and other central nervous LENGTH The average length of a Canadian newborn
system defects (Rasmussen, Andrew, Zwaigenbaum, & is about 50 to 52 cm. Female babies, on average, are
Tough, 2008). All women of childbearing age should smaller than male babies. Two lengths measured are (a)
abstain from alcohol and drug use when trying to the crown-to-rump length (the sitting length) and (b) the
become pregnant and throughout the pregnancy. Those recumbent head-to-heel length (from the top of the head
who engage in unprotected sex, especially those with to the base of the heels). See Figure 18.1. Normally, the
multiple sex partners, are at significant risk for sexually crown-to-rump length is approximately the same as the
transmitted infections (STIs). head circumference. By 6 months, infants gain another
13.75 cm of length. By 12 months, they add another
7.5 cm. The rate of increase in length is largely influ-
enced by the baby’s size at birth and by nutrition.
Neonates and Infants Growth charts are useful health assessment tools
for children. While there are many factors that can con-
(Birth to 1 Year) tribute to differences in birth weight and length, includ-
ing ethnicity, the Canadian Paediatric Society (CPS)
(Marchand, 2010) saw little purpose in devising a special
Physical Development growth curve for each ethnic group. The CPS adapted
The neonate’s basic task is survival, which requires the World Health Organization’s growth charts (see the
breathing, sleeping, sucking, eating, swallowing, digest- Weblinks section online) for all Canadian children, from
ing, and eliminating. Newborns and infants undergo birth to age 19 years. Rather than focusing on race and
significant physiological changes in weight, length, head ethnicity, the CPS emphasized the importance of assess-
growth, vision, and motor development. Because many ing growth patterns over time to detect deviations and to
of the infant’s activities and pleasures are mouth centred, address the problem early. Consider how using growth
this stage in development is often referred to as the oral charts is a reflection of the primary health care prin-
stage (see Chapter 17, the section on Freud). ciples of appropriate technology and health promotion.
WEIGHT At birth, most babies weigh about 3.2 to HEAD AND CHEST CIRCUMFERENCE Assessment of
3.8 kg. Just after birth, most newborns lose 5% to 10% head circumference is of particular importance in infants
M18_KOZI2703_04_SE_C18.indd 310 27/02/17 11:45 AM

Sagittal
suture
Coronal
suture
Posterior
fontanelle Anterior
fontanelle

Lambdoid suture
FIGURE 18.2 An infant’s head circumference is measured FIGURE 18.3 The bones of the skull, showing the fontanelles
around the skull, above the eyebrows. and the suture lines.
and children to determine the growth rate of the skull HEARING Newborns with normal hearing will react with
and the brain. An infant’s head should be measured at a startle to a loud noise, a reaction called the Moro reflex.
every checkup until the child is 2 years old (Figure 18.2). Within a few days, they are able to distinguish different
Normal head circumference (normocephaly) is often sounds and may distinguish between the mother’s voice
related to chest circumference. At birth, the average and that of another woman. Between 3 and 6 months, the
head circumference is 33 cm to 35 cm and generally var- infant will look for sounds, stop an activity to listen, and
ies only by 1 cm or 2 cm. The chest circumference is usu- respond with distress or pleasure to angry or happy voices.
ally less than the head circumference by about 2.5 cm. As
SPEECH Between 6 and 9 months, individual words
the infant grows, the chest circumference becomes larger
begin to take on meaning, and the infant may look at
than the head circumference. At about 9 or 10 months,
named objects or people. The 9- to 12-month-old infant
both circumferences are about the same, and after 1 year
understands many words (e.g., “no,” “hot,” “dog”), uses
of age, the chest circumference is larger.
gestures (e.g., waves “bye-bye”), may articulate one or two
HEAD MOULDING Moulding of the heads in newborn words with a specific reference (e.g., “mama,” “dada”),
babies can occur during vaginal deliveries. Moulding and may respond to simple commands.
of the head is made possible by fontanelles (unossified
SMELL AND TASTE The senses of smell and taste are
membranous gaps) in the bone structure of the skull
and by overriding of the sutures (junction lines of the functional shortly after birth. Newborns can recognize
skull bones). Within a week, a newborn’s head usually the smell of breast milk and respond to this smell by
regains its symmetry. The larger anterior fontanelle (4 to turning toward the mother.
6 cm in diameter and diamond shaped) can increase in TOUCH The sense of touch is well developed at birth.
size for several months after birth. After 6 months, the Skin-to-skin touching (also known as “kangaroo care”)
size gradually decreases until closure occurs between 9 is important for an infant’s development. The newborn
and 18 months. The posterior fontanelle, between the responds positively to warmth, love, and comfort when
parietal bones and the occipital bone, closes from 4 to touched, held, and cuddled and is also sensitive to tem-
8 weeks after birth (Figure 18.3). perature extremes and pain.
VISION Newborns can follow large moving objects and REFLEXES The reflexes of the newborn are involuntary
blink in response to bright light and sound. A newborn’s nervous system responses to stimuli. They are neither
pupils respond slowly, and the eyes cannot focus on learned nor consciously carried out. Reflexes normally
close objects. By 1 month, infants can focus their gaze present at birth are the rooting, sucking, Moro, pal-
on objects 18 to 25 cm from the face and follow mov- mar grasp, plantar, tonic neck, stepping, and Babinski
ing objects. At 4 months, the infant recognizes parents’ reflexes. See Box 18.2 for a description of these reflexes.
smiles, although social smiles may appear as early as Infant reflexes disappear during the first year of life. In
2 months. The 4-month-old has almost complete colour addition, the abilities to yawn, stretch, sneeze, burp, and
vision and follows objects through a 180-degree arc. A hiccup are all present at birth.
5-month-old infant reaches for objects. Between 6 and
10 months, the infant’s gaze can fix on an object and MOTOR DEVELOPMENT Motor development increases
follow its movements in all directions. By 12 months, the with the infants’ abilities to move and to control the
infant will have depth perception and recognize drop- body. Initially, body movement is uncoordinated. At
offs, such as steps or the edge of the bed. 1 month, infants lift their head momentarily when prone,
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BOX 18.2 INFANT REFLEXES

From the moment of birth, newborns display the following
reflexes of the involuntary nervous system:
• Sucking reflex: A feeding reflex occurs when the infant’s
lips are touched; it lasts throughout infancy.
• Rooting reflex: A feeding reflex is elicited by touching the
baby’s cheek, causing the baby’s head to turn to the
side that was touched; it usually disappears after
4 months.
• Moro reflex: This reflex is often assessed to estimate the
maturity of the central nervous system. A loud noise or
a sudden change in position elicits this startle reflex. The
infant reacts by extending both arms and legs outward
with the fingers spread, then suddenly retracting the
limbs. The infant may cry at the same time. This reflex
disappears after 4 months.
• Palmar grasp reflex: This reflex occurs when a small
object is placed against the palm of the hand, causing
D. Hurst/Alamy Stock Photo

the fingers to curl around it. This reflex disappears after
3 months.
• Plantar reflex: When an object is placed just beneath
the toes, they curl around it. This reflex disappears
after 8 months.
• Tonic neck reflex (TNR), or fencing reflex: When a baby
lying on its back turns its head to the right side, for
example, the left side of the body shows a flexing of the FIGURE 18.4 An infant sits without support at 6 months of age.
left arm and the left leg. This postural reflex disappears
after 4 months.
• Stepping reflex (walking or dancing reflex): This reflex can Newborns are helpless to care for themselves; they
be elicited by holding the baby upright so that the feet cry to elicit care from their caregivers (Crittenden, 2008).
touch a flat surface. The legs then move up and down as
Infants react socially to caregivers by paying attention
if the baby were walking. This reflex usually disappears at
about 2 months. to the face or voice and by cuddling when held. See
• Babinski reflex: A newborn baby has a positive Babinski
Table 18.1 for examples of motor and social development.
reflex if the big toe rises and the other toes fan out when Mothering behaviour, such as consistent care, handling,
the sole of the foot is stroked. After age 1 year, the infant stroking, talking to the child, and cuddling, is essential
exhibits a negative Babinski reflex—that is, the toes curl for healthy psychosocial development. By 8 months, most
downward. A positive Babinski reflex after age 1 year infants tend to become attached to their parents and may
indicates brain damage.
show displeasure when left with strangers.
turn their head, and have a head lag when pulled to a

Cognitive Development
sitting position. After 6 months, they can sit without Piaget (1966) viewed cognitive development as a result of
support (Figure 18.4). At 9 months, they can sit, reach, interaction between an individual and the environment.
grasp a rattle, and transfer it from hand to hand. At The initial period of cognitive development is the senso-
12 months, they can turn the pages of a book, put rimotor phase (see Table 17.5). This phase has six stages,
objects into a container, and walk and dress themselves three of which take place during the first year. From 4 to
with some assistance. 8 months, infants begin to have perceptual recognition.
By 6 months, they attend to new stimuli, and familiar
objects are looked at for a short time. By 12 months,
Psychosocial Development infants have a concept of both space and time. They
experiment to reach a goal, such as a toy on a chair.
According to Erikson (1963), the central crisis at this stage
is trust versus mistrust. Fulfillment of needs is required for
the infant to develop a basic sense of trust. Parents can
enhance this sense of trust by (a) responding consistently
Moral Development
to an infant’s needs, (b) providing a predictable environ- Infants associate right and wrong with pleasure and
ment in which routines are established, and (c) being pain. What gives them pleasure is right, since they are
sensitive to the infant’s needs and meeting these needs too young to reason otherwise. Positive responses from
skillfully and promptly. the parents, such as smiles, caresses, and voice tones of
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TABLE 18.1 Examples of Motor and Social Development in Infancy
Age Motor Development Social Development

Newborn Turns head from side to side when in a prone posi- Displays displeasure by crying and satisfaction by soft
tion; grasps by reflex when object is placed in vocalizations; attends to adult face and voice by eye
palm of hand contact and quieting
4 months Rolls over; sits with support, holds head steady Babbles, laughs, and exhibits increased response to
when sitting verbal play
6 months Lifts chest and shoulders off table when prone, bear- Starts to imitate sounds; vocalizes one-syllable sounds:
ing weight on hands; manipulates small objects “ma ma,” “da da”
9 months Creeps and crawls; uses pincer grasp with thumb and Complies with simple verbal commands; displays fear of
forefinger being left alone (e.g., going to bed); waves “bye-bye”
12 months Walks with help; uses spoon to feed self Clings to caregiver in unfamiliar situations; demonstrates
emotions, such as anger and affection
approval, in these early months teach that certain behav- the anxiety of the caregiver may be associated with colic.
iours are “good.” Pain or harsh voices are associated Although nursing mothers may be tempted to change
with “bad” behaviour. In later months and years, chil- their dietary intake to reduce the colic symptoms, ongo-
dren can tell easily and quickly by changes in parental ing research has found that in most cases, nutritional
facial expressions and voice tones whether their behav- alterations in the mother do not lessen colic symptoms
iour is approved or disapproved. in the infant (Critch, 2014).
The nurse can help relieve colic by assessing the
infant during feeding and suggesting possible measures,
Health Risks such as cuddling the infant and finding the position that
provides the infant with the most comfort (e.g., carrying
A number of health problems of neonates and infants the baby in a front pack, placing the infant in a swing-
require interventions from health care providers. Safety ing or vibrating chair, playing soft music, dimming the
concerns are of particular importance. light, giving the baby a warm bath) (Canadian Paediatric
Society, 2011). Providing respite care or support to par-
FAILURE-TO-THRIVE SYNDROME Failure to thrive
ents is also essential.
(FTT) is a condition in which an infant falls below the
fifth percentile for weight and height or whose growth CHILD ABUSE Abuse can take various forms, including
declines across two percentiles on a standard growth physical abuse and neglect, sexual abuse, and emotional
chart over time (Emond, Drewett, Blair, & Emmett, abuse and neglect. Child abuse may be associated with
2007). Weight is altered initially, followed by length and parental mental illness, substance abuse, or exposure to
head circumference. violence and abuse. Deliberate whiplash shaking can lead
FTT may have organic causes (e.g., causes associated to shaken baby syndrome (SBS), a constellation of
with physiological or genetic disorders, such as cardiac severe injuries, such as cerebral damage, neurological
disease) or inorganic causes, which usually involve the defects, blindness, and intellectual disability, in infants.
parent–child relationship. Infants deprived of mother- These injuries often occur without external evidence of
ing, especially from months 3 to 15, will not learn to head injury. Nurses should suspect SBS in infants less
form significant relationships or to trust others. These than 1 year old who have apnea (a pause in or stoppage
infants show delayed physical and emotional develop- of breathing), seizures, lethargy or drowsiness, brady-
ment without any physical cause. They are often mal- cardia (a slow heart rate), or respiratory difficulty; who
nourished; they fail to gain weight or grow normally. are in a coma; or who die. Subdural and retinal hemor-
rhages with the absence of external signs of trauma are
INFANT COLIC Colic is acute abdominal pain caused
hallmarks of the syndrome (Altimier, 2008). Parents need
by periodic contractions of the intestines during the
to be aware of the dangers of shaking an infant and ask
first 3 months of life. The peak colicky period usually
for assistance if they feel they could harm their baby
is between 3 and 8 weeks. Infants who cry up to 10 to
(Canadian Paediatric Society, 2009).
12 hours a day are described as being colicky. A crying
or fussy period lasting 1 to 2 hours a day is not uncom- SUDDEN INFANT DEATH SYNDROME The sudden and
mon but is a concern and is stressful for the parents unexpected death of an infant may be a case of sudden
or caregivers. Although the direct cause is not known, infant death syndrome (SIDS). Postmortem exami-
temperament, swallowing air, feeding too rapidly, hav- nation usually fails to reveal the cause. The highest inci-
ing allergies, taking in excessive amounts of carbohy- dence of SIDS occurs in the second and fourth months
drates, or experiencing emotional distress and feeling of life, and boys are more susceptible than girls. SIDS is
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Health Assessment and Promotion

APGAR SCORING Apgar scores are usually assessed
in neonates 60 seconds after birth and repeated 5 and
10 minutes later. These scores provide a numeric indi-
cator of the baby’s physiological capacities to adapt to
extrauterine life. Each of the five signs is assigned a
maximum score of 2, with a total achievable score of
10. A score less than 7 suggests that the baby is having
difficulty, and a score less than 4 indicates that the baby’s
condition is critical. Those with very low scores require
special resuscitative measures and care. See Table 18.2.
DEVELOPMENTAL SCREENING TESTS The develop-

ment of infants can be assessed by observing the infant’s
behaviour and by using standardized tests, such as the
Denver Developmental Screening Test (DDST-II).
The DDST-II is used to screen children from birth to age 6
years. Four main areas are screened: personal–social, fine
motor–adaptive, language, and gross motor skills.
ONGOING NURSING ASSESSMENTS The nurse assesses

the infant, noting the variations that occur with develop-
mental age and activity. The nurse listens to the parents
for possible problems or areas of concern and reviews
FIGURE 18.5 Place an infant on his or her back for sleeping. with the parents the expected behaviours or character-
Note the infant’s tonic neck reflex. istics for the particular age group, reinforcing certain
behaviours, responses, and activities of the infant as nor-
less common among babies of parents who do not smoke, mal and expected, given individual differences among
when infants do not share the same bed with adults, and infants. The nurse assesses maternal bonding and infant
when infants sleep on the back. Sleeping on the back is attachment and provides anticipatory parental support
preferred as infants may roll onto their stomach from the and guidance, as needed.
side-lying position, blocking their breathing. Infants are The first month of life is critical for physical adjust-
at risk for asphyxia when sharing the bed with adults who ments to extrauterine life and for the psychosocial adjust-
cannot be easily aroused because of extreme fatigue or ment of the parents or caregivers. From 1 to 12 months,
impairment by alcohol or drug use. Nurses must assess infants exhibit rapid change, with advances in growth
the cultural practice for sleeping arrangements in the and psychosocial development. For a summary of health
home, discuss the dangers of bed-sharing practices with and wellness promotion, see the Health-Promotion
the parents, and suggest alternatives for a safe sleeping Guidelines for Neonates and Infants box. (See the sec-
environment for infants (Canadian Paediatric Society, tion titled “Promoting Safety across the Lifespan” in
2010, 2016). (See Figure 18.5.) Chapter 32.)
TABLE 18.2 Apgar Scoring System to Assess the Newborn
Score
Sign 0 1 2
1. Heart rate Absent Slow (fewer than 100 beats per Above 100 beats per minute
minute)
2. Respirations Absent Slow, irregular Regular rate, crying
3. Muscle tone Flaccid Some flexion of extremities Active movements
4. Reflex irritability None Grimace Cries
5. Colour Body pale or cyanotic Body pink; in babies with dark skin Body completely pink; pink mucous
(e.g., blacks, some East Indian, membranes in babies with dark skin
Hispanic), check mucous
membranes, extremities
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Health-Promotion Guidelines for Neonates and Infants

The following are important to the health of neonates and infants:
HEALTH EXAMINATIONS • Toys with no small parts or sharp edges
• At birth, screening for hearing, congenital hypothyroidism, • Elimination of toxins in the environment (e.g., tobacco,
and phenylketonuria (PKU). chemicals, radon, lead, mercury)
• Physical examination at birth, 2 weeks, and at 2, 4, 6, 9, • Use of smoke and carbon monoxide (CO) detectors in
and 12 months home
PROTECTIVE MEASURES NUTRITION
• Routine immunizations: 5-in-1 DTaP-IPV and Hib vaccines • Exclusive breast-feeding to 6 months
protect against diphtheria, tetanus, pertussis, polio, • Proper breast-feeding and bottle-feeding techniques
Haemophilus influenzae, type B (Hib) vaccine, hepatitis B
vaccine (HepB), varicella vaccine, pneumococcal conju- • Formula preparation
gate vaccine, and meningococcal C conjugate vaccine; • Feeding schedule
influenza vaccine and other vaccines, as recommended. • Introduction of solid foods
Schedules may vary across provinces and territories.
• Need for iron supplements at 4 to 6 months; iron-fortified
See Chapter 34: Routine Immunization Schedules for
formulas to infants who are not breastfed or for infants
Infants and Children.
receiving formula as well as breast milk; by age 6 months,
• Fluoride supplements, if inadequate water fluoridation (less iron-rich foods
than 0.7 parts per million [ppm])
• Continued breast-feeding to age 12 months
• Screening for congenital hypothyroidism, PKU, and other
metabolic and congenital disorders, according to jurisdic- ELIMINATION
tions • Characteristics and frequency of stool and urine elimina-
• Prompt attention for illnesses or fever tion
• Appropriate skin hygiene and clothing • Diarrhea and dehydration signs
• Assessment of caregiver–infant relationship quality REST AND SLEEP
INFANT SAFETY • Established routine for sleep and rest patterns
• Supervision at all times SENSORY STIMULATION
• Car seat, crib, playpen, bath, sleeping arrangement, and • Touch: holding, cuddling, rocking
home environment safety measures, as recommended by
Health Canada • Vision: colourful, moving toys
• Feeding measures (e.g., avoid propping the bottle during • Hearing: soothing voice tones, music, singing
feeding) • Play: toys appropriate for development
Toddlers (1 to 3 Years) between 1 and 2 years and about 1 to 2 kg between 2 and

3 years. The 3-year-old weighs about 13.6 kg.
Toddlers develop from having no voluntary control to HEIGHT Height is measured while the toddler is standing.
learning to walk, speak, and control their bladder and Length is measured while the toddler is in a recumbent
bowels and acquiring all kinds of information about position. The measurements differ slightly, so nurses
their environment. must specify which measurement is used. Between 1 and
2 years, the average growth in height is 10 to 12 cm, and
between 2 and 3 years, it slows to 6 to 8 cm.
Physical Development HEAD CIRCUMFERENCE The head circumference of the
toddler increases by about 2.5 cm, on average, during
Two-year-old toddlers are usually chubby, with relatively this period. By 24 months, the head is 80% of the aver-
short legs and large heads. Their face appears small age adult size and the brain is 70% of its adult size.
relative to the skull. As the toddler grows, the face seems
to grow relative to the skull and appears better propor- SENSORY ABILITIES Visual acuity is fairly well estab-
tioned. Toddlers have a pronounced lumbar lordosis lished at age 1 year. Estimates of visual acuity for tod-
and a protruding abdomen. The abdominal muscles dlers are 20/70 at 18 months and 20/40 at age 2 years.
grow and become stronger gradually and the abdomen Accommodation to near and far objects is fairly well
becomes flatter. developed by 18 months and continues to mature with
age. At age 3 years, the toddler can look away from a toy
WEIGHT Two-year-olds can be expected to weigh approxi- before reaching out and picking it up. This ability requires
mately four times their birth weight, gaining about 2 kg the integration of visual and neuromuscular mechanisms.
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The senses of hearing, taste, smell, and touch BOX 18.3 FOSTERING THE TODDLER’S
become increasingly developed and associated with one PSYCHOSOCIAL DEVELOPMENT
another. Hearing in the 3-year-old is at adult levels. The
taste buds of the toddler are sensitive to the natural fla- Parents and caregivers can do many things to stimulate a
vours of food, and the 3-year-old prefers familiar odours toddler’s psychosocial development:
and tastes. A distressed toddler is often soothed by tactile • Provide toys suitable for the toddler, including some toys
challenging enough to motivate but not so difficult that
sensations.
the toddler will fail. (Failure will intensify feelings of self-
MOTOR ABILITIES Fine muscle coordination and gross doubt and shame.)
motor skills improve during toddlerhood. At the age of • Make positive suggestions rather than giving commands.
18 months, toddlers can pick up small beads and place Avoid an emotional climate of negativism, blame, and
punishment.
them in a receptacle. They can also hold a spoon and
• Give the toddler two or three options, all of which
a cup and can walk upstairs with assistance. They will
are safe.
probably crawl down the stairs.
• When the toddler has a temper tantrum, make sure he
At age 2 years, toddlers can hold a spoon and put it or she is safe, and then leave.
into their mouths correctly. They are able to run; their
• Help the toddler develop inner control by setting and
gait is steady; they can balance on one foot, and ride a enforcing consistent, reasonable limits.
tricycle. By age 3 years, most children are toilet trained, • Praise the toddler’s accomplishments; give spontaneous
although they still may have the occasional accident feedback for positive behaviour.
when playing or during the night.
Psychosocial Development and security are able to deal with periodic failures later in
life without damage to their self-esteem. (See Chapter 12.)
According to Freud (1923), the ages of 2 and 3 years repre-
Young children can experience acute separation
sent the anal phase, when the rectum and the anus are areas
anxiety—the fear and frustration that come with paren-
of the body that are of particular interest to the toddler
tal absences—peaking around 8 to 9 months. At this age,
(see Table 17.2). Erikson sees the period from 18 months to
abandonment is their greatest fear. The child may also
3 years as the time when the central developmental task is
have difficulty accepting a babysitter or strongly resist
autonomy versus shame and doubt (see Table 12.1).
being left by the parents at a daycare centre or when
Toddlers begin to develop their sense of autonomy by
separated from their parents or admitted to hospital.
asserting themselves with the frequent use of the word
“no.” They are often frustrated by restraints on their
behaviour and may have temper tantrums and “act
out” to elicit a response from their caregivers (see the
Evidence-Informed Practice box on what causes temper
tantrums). Toddlers learn to gain control over their emo-
tions with guidance from their caregivers. Parents need
to be patient and understand the importance of this
What Causes Temper Tantrums?
developmental milestone. They need to give the child The purpose of the study was to determine how emo-
some measure of control and, at the same time, be con- tional reactivity and emotional competence of the children
sistent in setting limits so that the child learns the results contribute to temper tantrums, and 127 families with 3- to
of misbehaviour. The nurse can also assist the parents 5-year-old children in British Columbia took part in the study.
Results showed that children who were more emotionally
and caregivers in promoting the toddler’s development
competent were less likely to display anger and distress. But
by suggesting the activities summarized in Box 18.3. more importantly, emotionally competent children, although
Self-concept is made up of body image, feelings they may be just as emotionally reactive as other children,
about the self, adaptive and defensive mechanisms, reac- were less likely to display the full-blown temper tantrum.
tions from others, and our own perceptions of these reac-
NURSING IMPLICATIONS: A child’s level of emotional
tions, attitudes, values, and many of life’s experiences competence, not the tendency to be emotionally reac-
(Burns, Dunn, Brady, Starr, & Blosser, 2008). Children tive, was the key to understanding why some reactive
learn to develop a sense of self through their immediate children have tantrums and others do not. Nurses need
social environment, in which their parents play a sig- to understand that two children with similar thresholds
nificant role. If the children’s social interactions with their for emotional reactivity may display widely different fre-
parents are negative (e.g., constant disapproval regarding quencies of temper tantrums and that maturity (i.e., age)
and verbal ability had little effect on temper tantrums.
eating, toilet training, or other behaviour), they may begin
to see themselves as bad. Parents need to give toddlers Source: Based on Giesbrecht, G., Miller, M., & Müller, U. (2010). The anger-distress
model of temper tantrums: Associations with emotional reactivity and emotional
positive input so that they can develop a positive and competence. Infant and Child Development, 19, 478–497.
healthy self-concept. Children with a strong self-concept
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Toddlers need room for exploration and interac-

tion with other children and adults. At the same time,
they need to know that they are loved, safe, and secure.
They assert their independence by saying “no.” Toddlers
acquire receptive and expressive language skills quickly.
They can understand words and follow directions long
before they can actually speak them.
Regression, or reverting to an earlier development
stage, can take the form of bedwetting or using baby
talk. Nurses can help parents to understand that this
behaviour is normal and indicates that the toddler is try-
ing to establish his or her position in the family.

According to Piaget (1966), the toddler completes the
fifth and sixth stages of the sensorimotor phase and starts
the preconceptual phase at about age 2 years. In the fifth
stage, the toddler solves problems by a trial-and-error
process. By stage 6, toddlers can solve problems men-
tally. During Piaget’s preconceptual phase, toddlers have FIGURE 18.6 Keep medicines and other poisonous material
some symbolic thought; for example, a chair may rep- locked away.
resent a place of safety, and a blanket may symbolize
comfort. Concepts develop in late toddlerhood when
the child learns words to represent classes of objects drowning, burns, poisoning, and falls. Researchers have
or thoughts. An example of a concrete concept is table, found that more than 90% of unintentional injuries
representing a number of articles of furniture that may could be prevented (CPS, 2012). Parents or other care-
look different but match the characteristics of a table givers need to take measures to prevent accidents (see
(see Table 17.5). Figure 18.6).
VISION PROBLEMS Early screening to detect amblyopia
and strabismus can correct common problems in tod-
Moral Development dlers. Amblyopia (“lazy eye”) is reduced visual acuity
According to Kohlberg (1977), the first level of moral in one eye without obvious defect or change in the eye;
development is preconventional, when children respond to the brain favours the images from the stronger eye over
punishment and reward. During the second year, chil- those from the affected eye. Strabismus (“cross eye”) is
dren begin to know that some activities elicit affection unequally aligned eyes, which distorts vision so that the
and approval and recognize that certain rituals create child’s brain suppresses vision in one eye.
feelings of security. Children also sense what attitudes DENTAL CARIES Dental caries are common and often a
their parents hold about moral matters. result of the excessive ingestion of sweets or a prolonged
exposure of teeth to carbohydrates, such as through the
use of the bottle during naps and at bedtime. Good den-
Spiritual Development tal hygiene can prevent dental caries and hence promote
Fowler believed the toddler may be aware of some reli- proper speech development and nutrition.
gious practices, but they are primarily involved in acquir- RESPIRATORY TRACT AND EAR INFECTIONS Respiratory
ing knowledge and learning emotional reactions (Fowler, and middle ear infections are common during toddler-
1981; Thompson & Randal, 1999). For example, a tod- hood and contribute significantly to visits to health care
dler may repeat short prayers at bedtime, conforming to providers. The incidence increases with exposure to other
a ritual for praise and affection. children and the use of a bottle during naps or at bedtime
or if bottles are propped for feedings.
Health Risks
ACCIDENTS Accidental injury is the leading cause
of death and morbidity among all Canadian children
(Oliver & Kohen, 2012). Toddlers are curious explorers Growth and development in the toddler and preschool
and like to feel and taste everything. The most com- years provide the basis for a child’s future health and
mon causes of fatal injuries are automobile accidents, well-being. It is essential that nurses provide anticipatory
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Health-Promotion Guidelines for Toddlers

The following are important to the health of toddlers:
HEALTH EXAMINATIONS • Outdoor safety measures (e.g., close supervision near
• At 15 and 18 months and later, as recommended by the water, use of car seat)
health care provider • Appropriate toys with lift locks on toy boxes
• Supervise tooth brushing and start regular dental visits at • Elimination of toxins in environment (e.g., pesticides, her-
age 3 years or earlier bicides, mercury, lead, arsenic in playground materials)
• Hearing tests by 18 months or earlier • Use of smoke and carbon monoxide detectors in home
PROTECTIVE MEASURES NUTRITION
• Routine immunizations: continuing 5-in-1 DTaP-IPV and • Importance of nutritious meals and snacks
Hib series, measles-mumps-rubella vaccine (MMR), pneu- • Teaching of simple mealtime manners
mococcal conjugate vaccine, influenza vaccine, varicella
vaccine, flu vaccine, and other vaccines, as recom- • Dental care
mended by jurisdiction ELIMINATION
• Screenings for tuberculosis (TB) and lead poisoning, as • Toilet training techniques
recommended
• Fluoride supplements, if inadequate water fluoridation (less REST AND SLEEP
than 0.7 ppm) • Dealing with sleep disturbances
TODDLER SAFETY PLAY
• Importance of supervision and teaching child to obey • Provision of adequate space and a variety of activities
instructions • Encouraging regular, vigorous physical activity
• Home environment safety measures (e.g., lock medicine • Toys that allow “acting out” behaviours and provide motor
cabinet) and sensory stimulation safely
guidance and accurate assessments to promote health WEIGHT Weight gain in preschool children is generally
and detect problems for early interventions. slow. By age 5 years, they gain about 3 kg to 5 kg and
Promoting health and wellness includes such areas reach between 18 kg and 20 kg.
as accident prevention, toilet training, and good den-
tal hygiene. See the Health-Promotion Guidelines for HEIGHT Preschool children grow about 5 cm to 6.25 cm
Toddlers box. each year. By age 5 years, they double their birth length
and measure 102 cm.
VISION Preschool children are generally hyperopic
Preschoolers (4 to 5 Years) (farsighted), that is, unable to focus on near objects. As

the eye grows in length, it becomes emmetropic (it
refracts light normally). If the eyes become too long,
During the preschool period, physical growth slows, but the child becomes myopic (nearsighted), that is, unable
control of the body and coordination increase greatly. to focus on objects that are far away. In severe cases of
Preschoolers’ worlds expand as they meet relatives, hyperopia or myopia, glasses may be prescribed. Visual
friends, and neighbours. acuity generally improves by the end of the preschool
years. Normal vision for the 5-year-old is approximately
20/30. The Snellen “E” chart can be used to assess the
Physical Development preschooler’s vision. (See the section titled “Eyes and
Vision” in Chapter 28.)
By age 4 or 5 years, preschool children appear taller and
thinner than toddlers because they tend to grow more in HEARING AND TASTE The hearing of the preschool
height than in weight. The preschooler’s brain reaches child has reached optimal levels, and the ability to lis-
almost adult size by age 5 years. The extremities grow ten (attending to and comprehending what is said) has
more quickly than the body trunk, making the child’s matured since the toddler stage. Preschoolers show their
body appear somewhat out of proportion. The pre- taste preferences by asking for something “yummy,”
schooler appears slender with erect posture as the pelvis and they may refuse to eat a few particular foods.
becomes straighter and the abdominal muscles become Parents should not “nag” the child to eat certain foods.
stronger. The child will eat what is needed if there is a pleasant
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environment and a variety of healthful foods that are the family. Associations with neighbours, family guests,
pleasing to eat. and babysitters reinforce social relationships.
In their speech, 4-year-old children are often dog-
MOTOR ABILITIES By age 5 years, children can wash
matic; they tend to believe that what they know is right.
hands and face and brush teeth by themselves. They are
They can speak and understand 1500 or more words.
self-conscious about exposing their bodies and go to the
They love making up their own words and mixing fact
bathroom without telling others. Typically, preschool
and fiction. Exaggeration is common. Their language
children run with increasing skill each year. They can
skills are well developed by age 5 years. They use words
jump three steps and can balance on their toes and dress
purposefully, ask questions to acquire information, speak
themselves without assistance.
as a means of social interaction, and are capable of hav-
ing long conversations.
Preschoolers become increasingly aware of them-
Psychosocial Development selves, and they play with their bodies largely out of curi-
Erikson (1963) writes that the major developmental crisis osity. By age 5 years, they know the correct names for the
of the preschooler is initiative versus guilt (see Table 12.1). different body parts and can draw the various features of
Preschoolers begin to solve problems in accordance with a person. Preschoolers can also describe their feelings, as
their consciences as their personalities and self-concepts sad, happy, angry, and so on. The preschooler begins to
develop. Parents can enhance the self-concept of the learn how to control his or her feelings and behaviour
preschooler by providing opportunities for new achieve- and uses the same types of coping mechanisms in response
ments where the child can learn, repeat, and master. For to stress as the toddler does, although protest behaviour
example, a child is given a two-wheel bike with safety (kicking, screaming) is less likely to occur.
wheels and quickly learns coordination, balance, use Preschoolers need to feel that they are loved and
of the brakes, and bicycle safety. Mastery of these tasks are an important part of the family. The child who has
provides children with a sense of accomplishment and to compete with siblings for parental attention will often
prepares them for new challenges.
The self-concept of the preschooler is also based
on gender identification. Preschoolers often imitate sex-
ual stereotypes and usually begin by identifying with
the parent of the same sex. They may mimic the par-
ent’s behaviour, attitudes, and appearance (Figure 18.7).
Preschoolers will be curious about their own bodies and
sexual functions as well as those of others, and they will
often ask questions about them.
Freud (1923) theorized that the preschooler is in the
phallic stage of development (see Table 17.2). The focus
during this stage is on the genital area. In the Electra
complex or the Oedipus complex, the child focuses on
feelings of love chiefly for the parent of the opposite sex,
and the parent of the same sex may receive some hostile
feelings. The child begins to develop sexual interests and
becomes interested in clothes and hair styles.
Four adaptive mechanisms are learned: identifi-
cation, introjection, imagination, and repression.
Identification occurs when the child perceives self
as being similar to another person and behaves like
that person. For example, a boy may internalize the
attitudes and gender-based behaviours of his father.
Introjection is the assimilation of the attributes of oth-
ers. When preschoolers observe their parents, they assim-
ilate many of their values and attitudes. Imagination,
or make-believe, is an important part of preschool-

ers’ lives and is culturally and socially dependent. For
example, some children may fantasize that a footstool is
a robot warrior and some may imagine it as a beautiful
swan. Repression is removing experiences, thoughts,
and impulses from awareness. Preschoolers learn to play FIGURE 18.7 Preschoolers often identify with the parent of the
with their peers, and socialize and participate more in same sex and like to mimic behaviour.
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display jealousy or sibling rivalry. Parents and caregivers protecting, befriending, showing affection, and giving
should be aware that preschoolers need time to adjust to encouragement to others. Children who perceive their
a new baby and may need additional attention or special parents as strict may become resentful or overly obedi-
activities to help them cope with this adjustment period. ent. Preschoolers usually control their behaviour because
Guidance and discipline are important parts of they want love and approval from their parents. It is also
the parental role. As children seek independence from important for parents to answer preschoolers’ “why”
adults, they often test limits by refusing to cooperate and questions and discuss values with them (see Table 17.6).
by ignoring parental requests. Such power struggles can
be controlled by encouraging children to be responsible
for their own behaviour and setting reasonable expecta- Spiritual Development
tions and consistent limits. According to Fowler (1981), children from ages 4 to
6 years are at the intuitive–projective stage of spiritual devel-
opment. At this stage, faith is primarily taught by parents
Cognitive Development and teachers through picture books or simple explana-
According to Piaget (1966), preschoolers gain intuitive tions of spiritual matters. Preschoolers’ imaginations can
thought and form concepts by learning through trial and envision concepts such as angels and the devil. Children
error (see Table 17.5). At this stage, children are still imitate religious behaviour, for example, by bowing their
egocentric, but egocentrism gradually subsides as they heads in prayer, although they do not understand the
encounter wider experiences. Preschoolers learn through meaning of the behaviour.
trial and error, observation, imitation, and practice in
play and make-believe. Preschoolers can become con-
cerned about death as something inevitable, and they also Health Risks
associate death with others rather than themselves. Death Respiratory tract problems and communicable diseases,
may still be confused with sleep and “going away” for such as fifth disease (a viral disease that causes a distinc-
prolonged periods. Reading and mathematical skills (e.g., tive rash on the face, arms, and body), meningitis, and
recognizing and naming letters and numbers, counting, head lice, are common as the preschooler interacts with
and “reading” age-appropriate books) begin to develop at other children. Accidents and dental caries continue to
this age. Young children like fairy tales and books about be problems. Congenital abnormalities, such as cardiac
animals and other children and should be read to often. disorders and hernias, are often corrected by this age.
Moral Development Health Assessment and Promotion

Moral behaviour to a preschooler may mean taking turns During assessment, the preschooler can often participate
at play or sharing. Preschoolers enjoy sharing, helping, in answering questions with assistance from parents or
Health-Promotion Guidelines for Preschoolers

The following are important to the health of preschoolers:
HEALTH EXAMINATIONS NUTRITION
• Every 1 to 2 years • Importance of nutritious meals and snacks
PROTECTIVE MEASURES ELIMINATION
• Routine immunizations: DTaP-IPV, IPV series, MMR, and • Teaching of proper hygiene (e.g., washing hands after
other immunizations, as recommended using bathroom)
• Tuberculin skin test, as recommended REST AND SLEEP
• Vision and hearing screening • Ways to deal with sleep disturbances (e.g., nightmares,
• Regular dental screenings and fluoride treatment sleepwalking)
PRESCHOOLER SAFETY PLAY

• Education about simple safety rules (e.g., crossing the • Encouraging regular, vigorous physical activity
street, use of car seat, avoiding strangers) • Provision of times for group play activities
• Teaching of ways to play safely (e.g., bicycle and play- • Teaching of simple games that require cooperation and
ground safety, use of helmets) interaction
• Education to prevent poisoning, exposure to toxic materials • Provision of toys and dress-ups for role playing
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caregivers. They are fairly independent but still need of the eye changes during growth, the farsightedness of
supervision and guidance. (See the Health-Promotion the preschool years gradually changes to 20/20 vision
Guidelines for Preschoolers box.) Promoting health and during the school-age years; 20/20 vision is usually well
wellness includes preventing accidents and ensuring established between ages 9 and 11 years.
dental health, good nutrition, cognitive stimulation, and
HEARING AND TOUCH Auditory perception is fully
sufficient sleep.
developed in school-age children. They are able to iden-
tify fine differences in voices, both in sound and in pitch.
They have a well-developed sense of touch for heat and
School-Age Children cold on all body surfaces; they are also able to identify
an unseen object, such as a pencil or a book, simply by
(6 to 12 Years) touch. This ability is called stereognosis.
PREPUBERTAL CHANGES Little change takes place in
The school-age period starts at about age 6 years, when the reproductive and endocrine systems until the pre-
the deciduous teeth are shed, and ends with the preado- puberty period. At about ages 9 to 13 years, endocrine
lescent (prepuberty) period at about age 12 years with functions slowly increase, which can result in increased
the onset of puberty. Puberty is the age at which the perspiration and more active sebaceous glands. Girls
reproductive organs become functional and secondary may have sticky vaginal discharge prior to puberty. In
sex characteristics develop. The average age of onset of the case of early-onset menses, a health care practitioner
puberty is 10 years for girls and 12 years for boys. Skills should be consulted.
learned and willingness to try new tasks during this stage
MOTOR ABILITIES Between ages 6 and 10 years, chil-
are particularly important for later life.
dren perfect their muscular skills and coordination. By
age 9 years, most are becoming skilled in games of inter-
est or school sports, such as football or baseball. Most
Physical Development have sufficient fine motor control for such activities as
The school-age child gains weight rapidly and thus building models, sewing, or playing musical instruments.
appears less thin than previously. Individual differences
resulting from the effects of both genetic and environ-
mental factors become obvious at this time. Psychosocial Development
WEIGHT At age 6 years, boys tend to weigh about 21 kg, The central task of school-age children is industry versus
about 1 kg more compared with girls. The weight gain inferiority (Erikson, 1963). At this time, children begin to
from ages 6 to 12 years averages about 3.2 kg per year, create and develop a sense of competence and perse-
but the major weight gains occur from ages 10 to 12 for verance. They are motivated by activities that provide
boys and from ages 9 to 12 for girls. By age 12 years, a sense of self-worth. They concentrate on mastering
boys and girls weigh 40 kg to 42 kg on average; girls are skills that will help them function in the adult world.
usually heavier. Overweight and obesity are unlikely at Children who are successful and receive recognition for
this age if the child has demonstrated a pattern of good their efforts feel competent and confident. Children who
nutrition and regular physical activities in the infant, tod- feel unaccepted by their peers, or who receive negative
dler, and preschool years. feedback and little recognition, may feel inferior and
worthless (see Table 12.1).
HEIGHT At age 6 years, both boys and girls are about Freud (1923) described a latency stage in school-age
the same height, 115 cm. They are about 150 cm by age children. Their focus is on physical and intellectual activ-
12 years. Before puberty, children of both sexes have a ities, whereas sexual tendencies seem to be repressed (see
growth spurt—girls between ages 10 and 12 years and Table 17.2). However, curiosity about sexual matters is
boys between ages 12 and 14 years. Thus, girls may well present, and children are aware of the messages related
be taller than boys at age 12 years, but boys are usually to sex in popular media, films, and on the Internet;
stronger. parents need to set limits, answer questions, and provide
The extremities tend to grow more quickly com- guidance to help their children understand and cope
pared with the trunk; thus, school-age children’s bodies with information and feelings. Although the focus of
appear somewhat ill-proportioned. By age 6 years, the interest for this age group has moved to school, peers,
thoracic curvature starts to develop, and lordosis disap- and other activities, the home remains the crucial place
pears. Full adult posture is not assumed until after the for the child’s development of high self-esteem.
complete development of the skeletal musculature dur-
ing the adolescent period.
VISION Perceptions of depth and distance in 6- to
8-year-olds are accurate. By age 6 years, the eye muscles The ages 7 to 11 years mark Piaget’s (1966) concrete
are well developed and coordinated. Because the shape operations phase (see Table 17.5). The behaviours of these
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children change from egocentric interactions to coopera- level has two stages: stage 3 is the interpersonal concordance
tive interactions. They also develop an increased under- (“good boy” or “nice girl”) stage, and stage 4 is the law
standing of concepts that are associated with specific and order orientation. The child shifts from the concrete
objects, for example, associating “conservation” with interests of individuals to the interests of groups. They
“wildlife.” Logical reasoning develops from intuitive rea- are motivated to live up to what significant others think
soning (e.g., adding and subtracting to obtain an answer of them (see Table 17.6).
to a problem). Children also learn about cause-and-effect
relationships (e.g., knowing that a stone will not float
because it is heavier than water). Spiritual Development
By age 6 years, children learn the concept of time
and can read both digital and numerical clocks. The According to Fowler (1981), the school-age child is at
schedule in school helps them learn the time periods. stage 2 in spiritual development, the mythical–literal stage.
By age 7 or 8 years, children usually know the value of Children learn to distinguish fantasy from fact. Spiritual
money. facts are those beliefs that are accepted by a religious
Reading skills are usually well developed. What a group, whereas fantasy is thoughts and images formed
child reads is largely influenced by the family. By age in the child’s mind. School-age children may ask many
9 years, most children are self-motivated. They may questions about God and religion in these years. Parents
compete with themselves; they like discussion and and religious leaders still influence the child more than
debate and like to plan ahead. By age 12 years, they peers do in spiritual matters (see Chapter 46).
are motivated by inner drive rather than by competition
with peers.
Health Risks
Communicable diseases, dental caries, accidents, and
Moral Development failure to achieve a healthy weight are health risks
In Kohlberg’s (1977) stage 1 of the preconventional level for school-agers. The most common nutrition-related
(punishment and obedience), school-age children act problem among children is obesity, which contributes
to avoid being punished. Some, however, are at stage 2 to breathing difficulties, increased risk of fractures,
(instrumental–relativist orientation): they do things to benefit increased incidence of hypertension, and type 2 dia-
themselves, but ensuring a fair share or a chance for betes in childhood and increases the risk for diabetes,
everyone is important. Between ages 10 and 13 years, hypertension, and cardiovascular disease in adulthood
most children progress to the conventional level. This (DeCorby, Graham, & Dobbins, 2012).
Health-Promotion Guidelines for School-Age Children

The following are important to the health of school-age children:
HEALTH EXAMINATIONS • Taking responsibility for own safety (e.g., participating in
• Annual physical examination or as recommended bicycle and water safety courses)
NUTRITION
PROTECTIVE MEASURES
• Importance of eating a balanced diet and not skipping meals
• Immunizations as recommended; human papillomavirus
(HPV) vaccination given only to females age 9 to 26 years • Minimizing consumption of foods contributing to obesity
at a three-dose schedule (0, 2, and 6 months)
ELIMINATION
• Tuberculin skin test, as recommended
• Using positive approaches for elimination problems (e.g.,
• Periodic vision, speech, and hearing screenings enuresis)
• Regular dental screenings and fluoride treatment
PLAY AND SOCIAL INTERACTIONS
• Provision of accurate information about sexual health
(e.g., reproduction, acquired immunodeficiency syndrome • Provision of opportunities for a variety of organized group
[AIDS], chlamydiasis) activities
• Using the right gear for the sport: helmets, pads, face and • Acceptance of realistic expectations of child’s abilities
mouth guards • Being a role model for acceptance of other persons who
may be different
SCHOOL-AGE CHILD SAFETY • Provision of a home environment that limits television
• Use of proper sports equipment (e.g., helmets, pads) and viewing and playing video games and encourages
booster seat in car, as applicable completion of homework
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Health Assessment and Promotion Physical growth is largely influenced by heredity,

nutrition, medical care, illness, physical and emotional
Comprehensive assessment relies on the nurse’s ability environments, family size, race, and culture. Growth is
to respond to questions from the child and parents or noted first in the musculoskeletal system, which follows
other caregivers; provide feedback, encouragement, and a sequential pattern: the head, hands, and feet are the
support; and build on the child’s strengths. first to grow to adult status, followed by the extremi-
Promoting health and wellness includes dental exam- ties. Because the extremities grow before the trunk, the
inations and hygiene, immunization, safety measures to adolescent looks “leggy.” After the trunk grows to full
prevent accidents, physical fitness, supporting auton- size, the shoulders, chest, and hips grow. Skull and facial
omy, self-esteem, and infection control. (See the Health- bones also change proportions—the forehead becomes
Promotion Guidelines for School-Age Children box.) more prominent, and the jawbones develop.
GLANDULAR CHANGES The eccrine and apocrine
Adolescence
glands increase their secretions and become fully func-
tional during puberty. The eccrine glands, found over
(12 to 18 Years) most of the body, produce sweat. The apocrine glands
develop in the axillae, the anal and genital areas, and
the external auditory canals and around the umbilicus
Adolescence is the period during which the person and areolae of the breasts. Apocrine sweat is released
becomes physically and psychologically mature and onto the skin in response to emotional stimuli only.
acquires a personal identity. At the end of this period, Sebaceous glands also become active under the influ-
the teen is ready to enter adulthood and assume respon- ence of androgens in both males and females. The seba-
sibilities. The length of adolescence is culturally deter- ceous glands, which secrete sebum, become most active on
mined to some extent and may extend to ages 18 or 20 the face, neck, shoulder, upper back, chest, and genitals.
years in North America.
Puberty is the first stage of adolescence, in which SEXUAL CHARACTERISTICS Primary sexual char-
the sexual organs begin to grow and mature. Menarche acteristics relate to the organs necessary for repro-
(onset of menstruation) occurs in girls and ejaculation duction, such as the testes, penis, vagina, and uterus.
(expulsion of semen) in boys. For girls, puberty normally Secondary sexual characteristics differentiate the
starts between ages 10 and 14 years and for boys between male from the female but are not directly related to
ages 12 and 16 years. The adolescent period is often reproduction. Examples are pubic hair growth, breast
subdivided into three stages: early adolescence (ages 12 development, and voice changes.
to 13), middle adolescence (14 to 16 years), and late ado- Both primary and secondary sex characteristics
lescence (from 17 to 18 or 20 years). Late adolescence is develop during puberty. The first noticeable sign that
a more stable stage, when adolescents are involved with puberty has begun in males is the appearance of pubic
planning their future and economic independence. hair. The first ejaculation is considered the milestone
of male puberty, which commonly occurs at about age
14 years. Fertility follows several months later. Sexual
Physical Development maturity is achieved by age 18 years. Often, the first
noticeable sign of puberty in females is the appearance
During puberty, growth is accelerated through an ado-
of the breast bud, although the appearance of hair along
lescent growth spurt. In males, it begins between ages 12
the labia may precede this. The milestone of female
and 16 years; in females, it begins between ages 10 and
puberty is menarche, which occurs about 2 years after
14 years. Because the growth spurt begins earlier in girls,
the breast bud appears. At first, menstrual periods are
many girls surpass boys in height at this time. Boys will
scanty and irregular and may occur without ovulation.
catch up and often surpass the girls by the end of this
Ovulation is usually established 1 to 2 years after men-
period.
arche. Female internal reproductive organs reach adult
PHYSICAL GROWTH Physical growth continues through- size at about ages 18 to 20 years.
out adolescence. Growth is fastest for boys at about age
14 years, and the maximum height is often reached
at about age 18 or 19 years. Some males add another
1 cm or 2 cm to their height in their 20s. From ages 10 to
Psychosocial Development
18 years, the average Canadian male doubles his weight, According to Erikson (1963), the psychosocial task of the
gaining about 32 kg, and grows about 41 cm. The fast- adolescent is the establishment of identity. The danger of
est rate of growth in girls occurs at about age 12 years; this stage is role confusion (see Table 12.1). The inability
they reach their maximum height at about ages 15 to 16 to settle on a career path commonly disturbs the ado-
years. From ages 10 to 18 years, the average Canadian lescent. Less commonly, questions about sexual identity
female gains about 25 kg and grows about 24 cm. arise. Adolescents help one another through this identity
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crisis by forming cliques and a separate youth culture, At about age 15 years, the need for independence, com-
often excluding all those who are “different” in cultural bined with the need for family support, sometimes creates
background and lifestyles. Hair styling, skin care, and conflict within the adolescent and between the adolescent
clothes become very important. In-groupers of an ado- and the family. The young person may appear hostile or
lescent clique can be excessively clannish and cruel in depressed at times during this crisis. Adolescents prefer
excluding out-groupers; this intolerance is a temporary to be with their peers and may seek advice from adults
defence against identity confusion. other than parents. Parents sometimes are bewildered by
The adolescent has unlimited imagination and ambi- this stage, and instead of reducing controls, they increase
tion and aspires to great accomplishments. The sense of them, which causes the adolescent to rebel.
industry is re-enacted when the adolescent chooses a Adolescents may develop brief crushes on adults
career. The extent to which these tasks were achieved outside the family. They sometimes adopt some of the
earlier influences the adolescent’s ability to achieve a attributes of the adults with whom they are infatuated.
healthy self-concept and self-identity. This modelling can be helpful in the maturing process.
The adolescent needs to establish a self-concept that Some of the discord in the family at this time is
accepts both personal strengths and personal weaknesses. caused by the generation gap. Adolescents’ values may
Faced with dramatic changes in body structure and func- differ from those of their parents and be difficult for the
tion, and greater expectations to assume responsibilities, parents to understand and to accept. Restrictions and
many adolescents experience temporary difficulty in devel- guidance need to be presented in a manner that makes
oping a positive self-image (e.g., preoccupation with acne adolescents feel loved. They need consistency in guid-
problem). Adolescents with physical challenges or illnesses ance, fewer restrictions, and as much independence as
are particularly vulnerable to peer rejection or bullying. they can handle, but they need to know that their parents
Those who are accepted, loved, and valued by family and will assist them when necessary.
peers generally tend to gain confidence and feel good Peer groups are defined by like-minded, loosely
about themselves. Those who have difficulty forming rela- bonded, and self-identified cohorts who influence one
tionships or who are perceived by peers as too different another’s ideas, values, behaviours, and lifestyle choices
and or not included in adolescent cliques may develop less and provide one another with a sense of belonging, pride,
favourable self-images and have low self-esteem. social learning, and gender roles (Figure 18.8). Most
It is important to distinguish issues of gender and peer groups have well-defined, gender-specific modes
sexual orientation when supporting adolescents in devel- of acceptable behaviour. Peer groups change with age,
oping self-concept. In Canada, there is ongoing work to starting as same-sex groups, evolving into mixed groups,
move away from viewing gender as binary, that is, either and finally narrowing to couples who share activities.
male or female, to a consideration of gender as more of For gay, lesbian, and transgender youth, adolescence
a continuum of choices (Children’s Hospital of Eastern can be a difficult time. Because peer acceptance is crucial
Ontario [CHEO], 2016). In forming a sexual identity, to self-acceptance, adolescents struggling with gender or
adolescents may first fantasize about the male or female sexual orientation issues may conform to heterosexual
role and then enact various aspects of that imagined roles and behaviours, even though these do not feel
role. Later, adolescents begin to establish intimacy with natural or correct. Adolescents who are open about
a partner or partners. This intimacy lays the groundwork their sexual orientation or gender choices may face the
for the commitments of adulthood. Sexual experimenta- ostracism of their peers as well as misunderstanding and
tion is not part of true intimacy, but once intimacy is
realized, sexual activity follows. Gay, lesbian, and trans-
gender youth can experience a great deal of confusion
during this period, as their questions about self and iden-
tity may go unanswered, or they may feel unsupported.
Many adolescents may engage in masturbation as
well as sexual activity with those of the same or opposite
sex. Frappier and colleagues (2008) reported that 27%
of North American teens were sexually active, with a

mean age of 15 years and a lifetime average of 2.5 part-
ners. Of the sexually active teens, 76% reported using a
condom the last time they had sexual intercourse. The
most valuable sources of information about sex and con-
traception were reported to be schools, parents, friends,
and doctors. In general, teens lacked knowledge about
STIs and their consequences. Most teens stated that they
trusted the information given to them by health care FIGURE 18.8 Adolescent peer group relationships enhance a
professionals. (See Chapter 26.) sense of belonging, self-esteem, and self-identity.
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hostility from parents, teachers, and other important can appear in late adolescence (Toga, Thompson, &
adults in their lives. Providing support and connection Sowell, 2006). Adolescents in communal living, such as
to peer resources for adolescents in these situations is of in college or university dormitories, may have increased
critical importance. (See the Weblinks section online.) risk for infectious diseases, such as measles, mumps,
mononucleosis, and meningitis. Other health problems
include acne, cardiovascular disease, tooth decay, gingi-
Cognitive Development vitis, misalignment of teeth, neglect, and abuse.
Three leading causes of death in the 10- to 24-year
Adolescents begin Piaget’s formal operations phase of cogni-
age group are unintentional injuries (e.g., motor vehicle
tive development (see Table 17.5), with cognitive abilities
collisions, falls, drowning, poisoning), suicide, and can-
maturing at between ages 11 and 15 years. At this stage,
cer (Public Health Agency of Canada, 2008; Canadian
adolescents can think beyond the present and are highly
Cancer Society’s Steering Committee on Cancer
idealistic. They become more informed about the world
Statistics, 2012). Distracted driving, very often caused
and environment. They use new information to solve
by being engaged with electronic devices while behind
everyday problems and communicate with adults on
the wheel, can be especially deadly for teens. Recent
most subjects, such as areas of interest and career plans.
studies have determined that “the highest proportion
of distracted drivers involved in fatal crashes was in the
under-20 age group (16%)” (Transport Canada, 2011).
Moral Development The Health Council of Canada (2006) estimated
According to Kohlberg (1977), the young adolescent is about “1.1 million—or 14%—of Canada’s children
usually at the conventional level of moral development. under age 20 years have mental health conditions that
Although most still want to abide by social order and affect their lives at home, at school, and in the com-
existing laws, many discard the values they have adopted munity.” Suicide accounts for 24% of all deaths among
from parents in favour of those they consider more suit- 15- to 24-year-olds and is the second-leading cause of
able. In the postconventional or principled level, they start to death among Canadians between 10 and 24 years of age
question the rules and laws of society, especially if their (Canadian Mental Health Association [CMHA], 2006).
personal views are in conflict with societal laws and what Females experience more depression and suicidal ide-
they perceive as individual rights. Not all adolescents, or ation compared with males, whereas males act on their
even adults, proceed to this postconventional level. See thoughts four times more often compared with females
Kohlberg’s stages of moral development in Table 17.6. (Cheung & Renaud, 2007). The rate of suicide among
Aboriginal Canadians is twice the national average and
shows no sign of decreasing. Some communities have
Spiritual Development epidemics of youth suicides. The Canadian average is
around 4% for females, and 2% of males report a suicide
According to Fowler (1981), the adolescent reaches
attempt; among Aboriginals, the rate of attempts are
the synthetic–conventional stage of spiritual development.
19% and 13% among males and females, respectively
As they encounter different groups in society, they are
(Government of Canada, 2006). In general, suicide rates
exposed to a wide variety of opinions, beliefs, and behav-
increase with age, poverty, Aboriginal heritage, seasonal
iours regarding religious matters; some may seek advice
darkness, untreated mental disorders, a history of sexual
from a significant other, such as a parent or a minis-
abuse, and location (CMHA, 2006). Motor vehicle colli-
ter. Often, the adolescent believes that various religious
sions, drug and alcohol overdoses, firearm accidents, and
beliefs and practices have more similarities than differ-
even homicides can be disguised suicides.
ences. At this stage, the adolescent’s focus is on interper-
sonal matters, rather than conceptual matters.
Violence
Health Risks School bullying among adolescents can affect school
Adolescents can be at risk for unintentional injuries; achievement and psychological well-being of both vic-
STIs; health problems related to inactivity and unhealthy tims and perpetrators in the short term as well as the
eating; mental health problems; suicide; teen pregnancy; long term. Bullying is generally defined as a specific
and problematic tobacco, alcohol, and other drug use type of aggression that is intended to harm and occurs
(Canadian Institute for Health Information, 2005; repeatedly over time with a more powerful person or
McKay & Barrett, 2010). Common problems related group attacking someone less powerful (Reuter-Rice,
to nutrition and self-esteem among adolescents include 2008). Adolescent bullying can take different forms:
obesity, anorexia nervosa, and bulimia. Psychological physical (e.g., hitting, pushing, and kicking), verbal (e.g.,
and emotional challenges may lead to mental health name calling), or relational or social (e.g., social exclu-
problems, and the first manifestation of schizophrenia sion, spreading rumours). Studies show that boys are
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more involved in direct bullying (physical and verbal), need to help adolescents create a wellness plan that
whereas girls are more involved in indirect bullying addresses body image, diet, weight concerns, and exercise.
(social) (Wang, Iannotti, & Nansel, 2009, p. 368), includ-
ing cyberbullying (CIHI, 2012). In Canada, at least one
in three adolescent students have reported being victims Nonsuicidal Self-Injury
of bullying, including cyberbullying, and the country
ranks ninth highest in bullying among 13-year-olds in a The number of adolescents who engage in nonsuicidal
survey of 35 nations (CIHI, 2012). Increasing rates of self-injury appears to be increasing internationally, with
cyberbullying in Canada are of grave concern, with 73% self-cutting as a primary form of self-harm. Adolescents
of victims reporting threatening e-mails and instant mes- who harm themselves have a wide range of psychosocial
sages as the most common forms of attack (CIHI, 2012). problems, including anxiety disorder, which may con-
In extreme cases, bullying can be fatal due to physical tribute to the behaviour. Eating disorders and self-injury
altercations, or suicide, and many provinces in Canada are often related. Further investigation of this prob-
have created, or are creating, legislation to address bully- lem is needed to clarify its causes and guide treatment
ing and violence in schools (CIHI, 2012). (Hintikka, Tolmunen, Rissanen, Honkalampi, Kylma, &
Laukkanen, 2009; Ross, Heath, & Toste, 2009).
Eating Disorders
Many adolescents engage in unhealthy dietary practices,
and eating disorders are a serious health problem among Adolescents are usually self-directed in meeting their health
them (Sigel, 2008). Increasing obesity rates are making needs. Because of maturational changes, however, they
type 2 diabetes more common among teens, whereas pre- need teaching and guidance, such as screening for hearing
viously it occurred mostly in adults (Edelman & Mandle, and vision; information on avoiding tobacco, alcohol, and
2010). As discussed in Chapter 40, common problems drug use; and facts about healthy sexual practices, blood
related to nutrition and self-esteem among adolescents pressure maintenance, healthy weights, and immunizations.
include obesity, anorexia nervosa, and bulimia. Nurses (See the Health-Promotion Guidelines for Adolescents box.)
Health-Promotion Guidelines for Adolescents

The following are important to the health of adolescents:
HEALTH EXAMINATIONS NUTRITION AND EXERCISE
• Yearly or as recommended by the health care provider • Importance of healthy snacks and appropriate patterns
of food intake and exercise
PROTECTIVE MEASURES
• Control of factors that may lead to nutritional problems
• Immunizations, such as adult diphtheria-tetanus and per- (e.g., obesity, anorexia nervosa, bulimia, orthorexia)
tussis (DTap) vaccine, as recommended; and hepatitis B
vaccine, meningococcal vaccine, and human papillomavi- • Balance of sedentary activities with regular vigorous
rus vaccine (HPV), if not yet immunized exercise, at least three times a week for 1 hour each time
• Screening for tuberculosis (TB) and STIs, as recommended SOCIAL INTERACTIONS
• Periodic vision and hearing screenings • Parents being emotionally available and physically proxi-
• Regular dental assessments mal to adolescents
• Provision of accurate information about sexuality and • Encouragement of relationships that respect feelings,
safe-sex practices concerns, and fears
• Mental health status assessment • Parental encouragement of peer group activities promot-
ing moral and spiritual values
• No salon tanning if under age 16 years
• Parents acting as role models for appropriate social
ADOLESCENT SAFETY interactions
• Motor vehicle safety (e.g., driver’s education course, seat • Parents providing a comfortable home environment for
belts, motorcycle helmets) appropriate adolescent peer group activities
• Implementation of proper precautions during all athletic • Encouragement of adolescents to participate in and
activities (e.g., medical supervision, proper equipment, contribute to family and community activities
hydration, and nutrients)
• Open lines of communication and being alert to signs
of bullying or harassment, problematic substance use,
emotional disturbances, and depression
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Case Study 18
Billy is a 6-year-old boy entering Grade 1. He is scared and
2. On the basis of his age, what strategies might you use to
hesitant to let go of his mother’s hand. As the
teach Billy and his classmates about health promotion?
nursing student working in this setting, you
have the opportunity to work with Billy and
other young children as they start school.
1. How would you help Billy’s mother reassure him?
KEY TERM S
adolescence p. 323 failure to thrive p. 313 peer groups p. 324 shaken baby syndrome
amblyopia p. 317 fetal alcohol spectrum primary sexual (SBS) p. 313
Apgar scores p. 314 disorder p. 310 characteristics p. 323 stereognosis p. 321
apocrine glands p. 323 hyperopic p. 318 puberty p. 321 strabismus p. 317
colic p. 313 identification p. 319 regression p. 317 sudden infant death
Denver Developmental imagination p. 319 repression p. 319 syndrome (SIDS)
Screening Test introjection p. 319 sebaceous glands p. 323 p. 313
(DDST-II) p. 314 lanugo p. 309 secondary sexual teratogen p. 310
eccrine glands p. 323 menarche p. 323 characteristics p. 323 trimesters p. 309
ejaculation p. 323 myopic p. 318 self-concept p. 316 vernix caseosa p. 309
emmetropic p. 318 normocephaly p. 311 separation anxiety p. 316
C HAPTER HIGHLI G HTS

• Intrauterine development takes about 9 months. • Early childhood spans the period from ages 1 to 6 years
and is subdivided into the toddler group, ages 1 to
• Genetic and environmental factors affect the development 3 years, and the preschool group, ages 4 and 5 years.
of the fetus.
• During childhood, dramatic changes occur as the child
• A sense of trust and security in the newborn is essential moves from being a dependent person to becoming an
for subsequent development; the infant derives this sense independent person entering school.
from parental love, warmth, and prompt attention to
physical needs. • As the nervous system develops, body systems mature to
the point at which the child can control his or her body,
• Measurements of length, weight, head and chest circum- achieve finer muscle control, and perform all the activi-
ferences, fontanelle size and status, reflex abilities, and ties of daily living, such as washing and dressing.
motor development are important indicators of the new-
born’s growth and health. • Critical to psychosocial development during childhood is
the development of a sense of autonomy and initiative.
• Infants from ages 1 month to 1 year reveal marked
growth in size and stature with appropriate nutrition and • By the end of early childhood, the child has reached the
care: Birth weight doubles by age 6 months and triples by phase of intuitive thought, has developed some internal
age 12 months. moral controls, and is at the undifferentiated level of
spiritual development.
• During infancy, motor development is notable: At age 3
months, infants can raise their heads from the prone posi- • School-age children perfect their muscular skills and
tion; at age 6 months, they can sit unsupported; and at age coordination and develop a sense of competence, perse-
12 months, they can stand momentarily and walk with help. verance, and self-worth.
• To develop cognitively, the infant needs a variety of sen- • During emotional development, school-age children
sory and motor stimuli. face Erikson’s conflict of industry versus inferiority.
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• School-age children begin to understand relationships • Adolescents between ages 11 and 15 years begin the formal
and change from being egocentric to having cooperative operations stage of cognitive development; they are able to
interactions; according to Piaget, they are in the concrete think logically, rationally, and futuristically and can concep-
operations phase of cognitive development. tualize things as they could be, rather than as they are.
• Most school-age children progress to the conventional • The adolescent is at Kohlberg’s conventional level of
level of moral development and to the mythical–literal moral development, and some proceed to the postconven-
stage of spiritual development. tional, or principled, level.
• The three leading causes of adolescent death are unin-
• Rapid growth in height, secondary sexual characteristics,
tentional injuries, suicide, and cancer.
sexual maturity, and increasing independence from the
family are major landmarks of adolescence. • Adolescents can be at risk for unintentional injuries;
STIs; problems related to inactivity and unhealthy eating;
• Peer groups assume great importance during adolescence; mental health problems; teen pregnancy; and problematic
they provide a sense of belonging and self-esteem and tobacco, alcohol, and other drug use.
facilitate the development of a positive self-concept.
• The four leading causes of adolescent death are motor
• Adolescents are at Fowler’s synthetic–conventional stage vehicle crashes, other unintentional injuries, homicide,
of spiritual development. and suicide.

1. What is the most appropriate strategy for teaching kin- b. Promoting parental accountability for yearly physi-
dergarten children effective hand hygiene techniques? cals, dental examinations, and dietary requirements
a. Explaining and demonstrating the proper procedure c. Providing many free clinics and numerous pamphlets
for hand hygiene to teach families about proper health activities
b. Involving the children in initiative and imaginative d. Creating injury-proof strategies and requiring the
techniques on hand hygiene use of helmets and pads during all sports
c. Developing a colourful poster showing bacteria
growing on hands 5. A parent is worried about his 1-year-old child’s vision
d. Providing a video for the children to watch at home because the child seems to be unable to put his toys into
the correct shapes in the holder held on his lap. What
would be the most accurate information for the nurse to
2. Which indicators are used to assess the health of new- provide to the parent?
borns?
a. “Yes, this is a concern. I recommend that you
a. Muscular skills, vocalization, and feeding contact your physician to have your child’s vision
b. Weight, height, fontanelle size, and head circumfer- evaluated.”
ence b. “Developmentally, a child isn’t able to do shape sort-
c. Tolerance for separation, sleep, and number of wet ing until about 18 months of age.”
diapers c. “By 12 months, depth perception is developed, so
d. Assessment of the levels of formal operations and your child may just be a little slower in reaching this
responses to parental smiles developmental milestone.”
d. “This is normal because babies still have difficulty
3. The nurse has given a 4-year-old an oral analgesic at focusing on close objects.”
11:30 for postoperative pain. The nurse will return to
reassess the child in approximately 30 minutes. What 6. A nurse is providing discharge teaching to a new mother.
would be the most effective way for the nurse to com- Which pamphlet would be the best to provide the client
municate this information to the child? to facilitate the transition from hospital to home?
a. “I’ll be back to check on you in half an hour.” a. Apgar Scoring: The Way to Help Baby Learn
b. “When both hands on the clock point to 12, I’ll b. Safety Proofing Baby: Tips from A to Z
come back to see you.”
c. For Crying Out Loud! Keep That Baby Quiet!
c. “I’ll come back when the lunch trays are handed
out.” d. Better Not Spoil That Baby: Cleaning Up after Baby
d. “I’ll be back at noon to see how you are doing.”
7. A nurse is leading a parenting class on the social devel-
opmental tasks of infants. Place the following social
4. Which of the following approaches by the nurse is best developmental tasks for infants in the correct order of
to facilitate the health care needs of adolescents? mastery. (All options must be used.)
a. Encouraging teens to take responsibility for their a. Laughs
behaviours and actions based on correct knowledge
of health care measures b. Follows simple verbal commands
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c. Attends to adult face and voice 9. Two nursing students are preparing a presentation for
d. Verbalizes one-syllable sounds Grade 10 students on safety. Which topic is most impor-
tant to include in this presentation?
e. Shows emotions, such as anger
a. Drug use
8. A nurse is teaching a parenting class to teen mothers b. Motor vehicle incidents
on how to facilitate cognitive development in toddlers. c. Burns
Which statement, by a participant, best demonstrates d. Infectious diseases, such as mononucleosis
that she understood the course material?
a. “I will have my child push a wagon full of toys 10. Which statement accurately captures the second stage of
around the den.” Kohlberg’s moral development of school-age children?
b. “It is important to set limits for my child in a sup- a. “I sneaked into the amusement park because every-
portive manner.” one else was doing it.”
c. “I will set aside quiet time for my child to use cray- b. “I will leave the book at school because the teacher
ons to scribble on paper.” said I would get in trouble if I took the book home.”
d. “It is important to have my child participate in sing- c. “If I follow the rules, God will grant me my wish.”
alongs.” d. “I’ll pick up my toys because I’ll get a reward for
doing so.”
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Cheung, A., & Renaud, C. (2007). Teen suicide rates in Canada similar to for Canada’s children & youth. Retrieved from http://www.health-
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from http://www.anxiety-and-depression-solutions.com/articles/ Hintikka, J., Tolmunen, T., Rissanen, M. L., Honkalampi, K.,
news/Teen_suicide_rates_in_Canada_similar_to_US_despite_uni- Kylma, J., & Laukkanen, E. (2009). Mental disorders in self-
versal_health_care.php. cutting adolescents. Journal of Adolescent Health, 44, 464–467.
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Oliver, L. N., & Kohen, D. E. (2012). Unintentional injury hospitalizations Sigel, E. (2008). Eating disorders. Adolescent Medicine State of the Art
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Pogodina, C., Brunner Huber, L. R., Racine, E. F., & Platonova, E. N. Kaufman (Eds.), Implementing the U.N. Convention on the Rights of
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Rasmussen, C., Andrew, G., Zwaigenbaum, L., & Tough, S. (2008). Wigle, D. T., Arbuckle, T. E., Turner, M. C., Berube, A., Yang, Q.,
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Chapter 19
Young and Middle
Adulthood
Updated by
Marcella Ogenchuk, RN, PhD
T
LEARNING OUTCOMES
After completing this chapter, you will be able to he adult phase of devel-
1. Compare and contrast attributes that differentiate baby boomers, opment encompasses
Generation X, and Generation Y. the years from the end
2. Describe the normal physical development during young and of adolescence to death. Adulthood
middle adulthood. is often divided into three phases:
3. Identify characteristic tasks of psychosocial development during young adulthood (20–40 years), mid-
young and middle adulthood. dle adulthood (40–65 years), and late
4. Identify changes in cognitive development, according to Piaget, adulthood (65 years and older).
throughout adulthood. The adult period spans three dif-
5. Differentiate moral development, according to Gilligan and ferent generations: the baby boom-
Kohlberg, throughout adulthood. ers (those born between 1945 and
6. Examine spiritual development, according to Fowler, throughout 1964), Generation X (those born
adulthood. between 1965 and 1978), and Gen-
7. Identify developmental assessment guidelines for young and eration Y (the Millennials, born
middle-aged adults. between 1979 and 2000). Baby
8. Identify selected health risks for young and middle-aged adults. boomers are characterized by an
individualistic outlook, tend toward
9. List examples of health-promotion strategies for young and middle
adulthood. a “workaholic” orientation, want to
be respected at work, and are loyal
and dedicated (Sudheimer, 2009).
Many Generation Xers (Gen Xers)
were raised by parents who were
employed in full-time jobs outside
the household. Watching their par-
ents work long hours made Gen Xers
less impressed with corporate val-
ues, more skeptical, and resistant to
authority, but they enjoy challenges c
M19_KOZI2703_04_SE_C19.indd 331 17/03/17 11:28 AM

c and opportunities to creatively solve problems. Generation Y, or Millennials, face an increasingly mul-
ticultural and technologically sophisticated society, and they enjoy public affirmation of their efforts.
Across the life continuum, individuals display differing degrees of physiological, cognitive, psycho-
logical, moral, emotional, and spiritual development. Nurses need to recognize individual variations
when applying theories to meet caregiving.
Young Adults Psychosocial Development

(20–40 Years) Young adults lead busy lives as they acclimatize to new
roles at work, at home, and in the community. The psy-
chosocial development milestones of the young adult are
The age at which a person is considered an adult depends outlined in Box 19.1, which highlights theorists Freud,
on how the term adulthood is defined. In Canada, 18 years Erikson, and Havighurst.
is the legal age for voting in government elections. Some Young adults face new experiences and changes in
mark the passage into adulthood with the legal age for lifestyle as they mature. It is the time in their lives when
smoking and drinking, which is either 18 or 19 years in they are expected to be making choices about education
the Canadian provinces and territories. Others consider and employment; choosing a life partner or to remain
adulthood has been reached when financial indepen- single, deciding whether to marry or to have a common
dence has been obtained. However, some adolescents law relationship; purchasing a home; and having chil-
support themselves as early as 16 years of age, whereas dren. Socially, their activities may include forming new
some persons remain financially dependent on their relationships and taking on roles to establish themselves
families for many years. as responsible members of a community.
One may be considered an adult upon moving away Many young adults have experienced stress related
from home. According to Statistics Canada (2012), an to the divorce of their parents and have experienced
increasing number of young adults in their 20s (42% or life in blended families or stepfamilies. Feelings of
4.3 million, compared with 32% in 1991) had never left divided loyalties for divorced parents can create added
their homes or had moved back to their parents’ homes. stress. Their concerns may be about adequate finan-
A relatively new term, boomerang kids describes cial resources, privacy and personal issues, and worries
young adults who move back after an initial period of about loyalty and disloyalty to others. These childhood
independent living. Returning home is often attributed
to such reasons as increasing housing costs, low wages,
divorce, returning to school, high unemployment rates,
Box 19.1 Psychosocial Development:
and to some extent, cultural expectations.
Young Adult
Young adults’ psychosocial development is contingent on
fulfilling the tasks listed in various stages of development:
Physical Development • According to Freud’s theory, the young adult is in the
People in their early 20s are in their prime physical years. genital stage, where one’s energy is directed toward
The human body is at its most efficient functioning at attaining a mature sexual relationship (Freud, 1923).
about age 25 years, and athletic endeavours reach their • According to Erikson’s stages of development, the
young adult is in the intimacy versus isolation phase
peak. The musculoskeletal system is well developed and (Erikson, 1963).
coordinated. All other systems of the body (e.g., car-
• According to Havighurst (1972), the young adult has the
diovascular, visual, auditory, and reproductive) are also following developmental tasks:
functioning at peak efficiency. Young adults tend to be • Selecting a mate
high-risk takers, placing their high-functioning bodies at
• Learning to live with a partner
substantial risk of serious injury.
• Starting a family
Although physical changes are minimal during this
stage, weight and muscle mass may change as a result • Rearing children
of diet and exercise. Additionally, extensive physical and • Managing a home
psychosocial changes occur in pregnant and lactating • Establishing a career
women. Health outcomes in middle and older adult- • Taking on civic responsibility
hood are somewhat dependent on behaviours during the • Finding a congenial social group
younger adult stage.
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Chapter 19 Young and Middle Adulthood 333
Postformal thought is defined as a concept that

includes creativity, intuition, and the ability to consider
information related to other ideas. Postformal thinkers
can comprehend and balance arguments created by both
logic and emotion and proceed from abstract reasoning
Elena Dorfman/Pearson Education, Inc
to practical considerations. They are aware that most

problems have more than one cause and more than one
answer and some solutions will work better than others.
They are able to comprehend and balance arguments
created by both logic and emotion (Beckmann Murray,
Zentner, Pangman, & Pangman, 2008).
FIGURE 19.1 Many young women combine active careers

Moral Development
with motherhood. Young adults who have mastered the first two stages of
Kohlberg’s theory of moral development (where, as young
adolescents, they want to abide by social order and exist-
experiences can impact the development of intimate rela- ing laws) enter level III, the postconventional level. At this
tionships in young adults (Mustonen, Huurre, Kiviruusu, stage, the person understands human rights and what is
Haukkala, & Aro, 2011). Intimacy, according to Erikson acceptable as determined by societal norms, rules, and
(1963), concerns developing affectionate relationships and obligations. However, when one has a perceived conflict
lengthy attachments and making personal commitments with society’s rules or laws, there is a realization that laws
to another that may include marriage or sexual relations. can be changed if it means improving society or righting
A career choice may determine the educational what they have determined is a wrongful act. This type of
requirements for a chosen path, or inversely, one’s educa- reasoning is called principled reasoning. Gilligan (1982) argued
tion may determine where one can obtain employment. that as individuals approach young adulthood, each gender
Usually, the higher the level of education completed, the tends to define moral problems somewhat differently (see
greater the opportunities for employment and increased the section on Gilligan in Chapter 17, p. 304). Men may
socioeconomic status (SES). The traditional roles of use an ethic of justice and define moral problems in terms
women have evolved from that of wife and mother to one of rules and rights. Women, by contrast, may define moral
that includes employment outside the home (Figure 19.1). problems in terms of obligations to care and to avoid hurt.
Remaining single is becoming a chosen lifestyle
among young adults, perhaps to pursue an education
and then to have the freedom to pursue a chosen voca- Spiritual Development
tion. Some unmarried individuals choose to live with
another person of the opposite or same sex and share According to Fowler (1981), the individual enters the indi-
living arrangements and expenses. They do not consider viduating–reflective period sometime after age 18 years.
themselves to be single. The traditional definition of During this period, the individual focuses on reality. The
marriage has been forever altered with the Canadian religious teaching that the young adult had as a child
government passing Bill C-38, The Civil Marriage Act, may now be accepted or redefined. Murray, Zentner, and
on July 20, 2005 (Department of Justice, 2006). The Yakimo (2009) stated that the young adult searches for a new
act extends equal access to civil marriage to same-sex connectedness with others, nature, the universe, or a higher
couples while respecting religious freedom. being. The mysteries of life, faith, and belief in God are
Although nontraditional lifestyles are becoming explored actively by some young adults.
widely acceptable in society, traditional attitudes can
contribute social pressures that lead to stress. The mul-
tiple roles of adulthood (citizen, worker, taxpayer, home- Health Risks
owner, spouse, grown child, sibling, parent, and friend)
Young adulthood is generally a healthy time in life.
can create stress as a result of role conflict, role ambigu-
Health risks that do occur and are common in this age
ity, and role confusion.
group include accidents, suicide attempts, substance mis-
use, hypertension, sexually transmitted infections (STIs),
Cognitive Development eating disorders, interpersonal violence (bullying), and
certain malignancies.
Young adults in the formal operations stage think abstractly
and employ logic (Piaget, 1966). These young adults relate INJURY AND VIOLENCE Injuries are the leading cause
strongly to the values and norms of their social group and of death and major cause of long-term and short-term
will conduct themselves according to those norms. impairment and disability among Canadians between
M19_KOZI2703_04_SE_C19.indd 333 27/02/17 9:38 AM

the ages of 1 and 44 years (Health Canada, 2011). sensitive communication on the part of the nurse is
Efforts to prevent injury and violence can occur at the imperative in gathering information from both female
primary, secondary, or tertiary levels of prevention. Edu- and male victims of IPV.
cation about safety precautions and accident prevention
Suicide Suicide is the second leading cause of death in
is a major role of the nurse who is promoting the health
the young adult age group (Edelman & Mandle, 2010).
of Canadians. (See the section “Promoting Safety across
Many suicides may be mistaken for accidental death
the Lifespan” in Chapter 32.)
(motor vehicle crashes, combining alcohol and barbitu-
Violence is a concern among Canadians. The prob-
rates, or discharging a gun while cleaning it) (Edelman
lem of battering, or abuse, affects families at all socioeco-
& Mandle, 2010). Suicide may result from problems in
nomic levels. Stresses that predispose families to abuse
close relationships (marriage partners or parents), from
may include financial problems, lack of family and com-
depression, or be related to perceived occupational, aca-
munity supports, and physical as well as social isolation.
demic, or financial failure. In general, suicide results
Females and children continue to be targets of both physi-
from the young adult’s inability to cope with the pres-
cal and sexual assaults (Edelman & Mandle, 2010). Other
sures, responsibilities, and expectations of adulthood.
examples of violence include workplace violence, random
The nurse’s role in the prevention of suicide includes
shootings, and a phenomenon known as homicide–suicide
identifying behaviours that may indicate potential prob-
(H-S). Most H-S offenders are men who kill their partners
lems: depression; physical complaints, including weight
and sometimes also their children, and a close relationship
loss, sleep disturbances, and digestive disorders; and
with the homicide victim predicts subsequent suicide risk
decreased interest in social and work roles along with an
by the H-S offender (Large, Smith, & Neilssen, 2009).
increase in isolation. A young adult identified as at risk
Intimate Partner Violence (IPV) Intimate part- for suicide must be referred to a mental health special-
ner violence refers to dating and cohabiting violence, ist or a crisis centre. A suicide threat should never be
same-sex violence, and violence by heterosexual women ignored. Nurses can reduce the incidence of suicide by
(Hamel, 2009). IPV can include physical violence and being informed about the early signs of suicide.
nonphysical abuses, including emotional, psychological,
Substance Abuse (SA) The use of alcohol, mari-
economic, and social abuse. Factors such as secondary
juana, amphetamines, and cocaine, to name just a few, is
education, high SES, and formal marriage decrease the
on the rise, and it is a major threat to the health of young
incidence of IPV, while alcohol abuse, cohabitation, young
adults. Substance use may seem to help one escape from
age, attitudes supportive of wife beating, having outside
reality when problems are overwhelming. Prolonged use
sexual partners, experiencing childhood abuse, growing
can lead to physical and psychological dependency, and
up with domestic violence, and experiencing or perpe-
deterioration of one’s physical and mental health. Health
trating other forms of violence in adulthood increase the
care providers and educators need to understand SA and
risk of IPV (Abramsky et al., 2011). The perpetration of
work collaboratively and pedagogically to educate about
violence is equal between genders; that is, women initiate
SA in schools (Salm, Sevigny, Mulholland, & Greenberg,
violence as often as men do; and male abuse victims may
2011). Substance abuse and addiction are at epidemic
not report being victimized for fear of being ridiculed or
proportions in Aboriginal communities. Health Canada
discriminated against by health care professionals (Hamel,
(2006a) established the National Native Alcohol and
2009; Outlaw, 2009; Wigman, 2009).
Drug Abuse Program (NNADAP) to assist First Nations
Aboriginal men reported two to three times the risk
and Inuit communities to reduce alcohol, drug, and sol-
of experiencing partner violence in comparison with
vent abuse among on-reserve populations.
men in the general Canadian population. Reports of
Nursing strategies related to problematic substance
violence included severe forms of physical assault, being
use include teaching about the effects of substance use,
choked, being threatened with or having a knife or gun
changing individual attitudes toward problematic sub-
used against them, and being beaten (Brownridge, 2010).
stance use, and counselling clients to learn effective cop-
Lesbian mothers are another vulnerable group with
ing strategies.
regard to IPV. Education, awareness, and understanding
of the lesbian community can assist providers to work Mental Health/Illness Because of the stigma and
with these victims (see Chapter 45). Health care provid- inadequate support services, almost half of depressed
ers need to be able to establish therapeutic relationships; young adults in Canada do not seek or have access to
they can be instrumental in spreading cultural awareness mental health services. Of any age group in Canada,
and lobbying for policy or institutional changes to include teenagers and young adults ages 15 to 24 years have the
same-sex IPV (Oswald, Fonseca, & Hardesty, 2010). highest incidence of mental health issues (Canadian Men-
Nurses need to become familiar with community tal Health Association, 2012). Nurses educate the public,
resources so they can provide safety information for service providers, and politicians about mental health and
health care professionals, parents, and caregivers on how lobby for accessible and timely services to meet the needs
to keep children and the community safe. Culturally of the clients and their families. Through these activities,
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nurses use the primary health care principles of health pro- and exercise patterns with the client for the subsequent
motion, accessibility, intersectoral cooperation, and public participa- development of an individualized wellness plan.
tion to help young adults address these issues.
MALIGNANCIES The Canadian cancer statistics (Cana-
RISK BEHAVIOURS, SMOKING Smoking can lead to dian Cancer Society’s [CCS] Steering Committee on
lung cancer and cardiovascular disease. The nurse’s role Cancer Statistics, 2012) showed that the leading cause
regarding smoking is to (a) serve as a role model by not of cancer morbidity and mortality for both men and
smoking, (b) provide educational information regarding women is lung cancer, followed by colorectal cancer (see
the dangers of smoking and second-hand and third-hand the Evidence-Informed Practice box on colorectal cancer
smoke, (c) help make smoking socially unacceptable, (d) screening among young women in Canada). Close to
suggest resources, such as hypnosis, lifestyle training, 30% of the newly diagnosed cancers and 17% of deaths
and behaviour modification, to clients who want to stop occurred in young and middle-aged adults. Testicular
smoking, and (e) lobby for antismoking legislation. cancer is the most common neoplasm in men 20 to 34
years of age. Monthly testicular self-examination (TSE) is
SEXUALLY TRANSMITTED INFECTIONS STIs, such as
recommended as a health screening strategy (see the
genital herpes, acquired immune deficiency syndrome Teaching: Wellness box on testicular self-examination in
(AIDS), syphilis, and gonorrhea, are common infections Chapter 45, page 1409). Breast cancer is the most com-
in young adults. Chlamydiasis is the most prevalent STI mon cancer in women worldwide. Young women are
(Public Health Agency of Canada, 2010). However, encouraged to be breast aware (CCS, 2010). Average-risk
human papilloma virus (HPV) infection is of growing women less than 50 years of age do not need to have rou-
concern in Canada and worldwide. There is no cure for tine mammography screening and clinical breast exami-
HPV infection, which can lead to skin lesions (i.e., geni- nations, or do breast self-examinations. Women between
tal warts) or cancer (Health Canada, 2010). In 2007, the 50 and 74 years of age should have a mammogram every
National Advisory Committee on Immunization (NACI) 2 to 3 years. After age 74 years, the woman’s health care
recommended the use of Gardasil vaccination for immu- provider will determine the need for any further mam-
nization against HPV in females between 9 and 26 years mograms (Canadian Task Force on Preventive Health
of age. Specifically, Gardasil is recommended for females Care, 2011).
between 9 and 13 years of age, before they become sexu-
ally active, and for females between 14 and 26 years of
age, even if they are already sexually active, have had
previous Papanicolaou (“Pap”) test abnormalities, or
have had a previous HPV infection.
The nurse’s role is to prevent the incidence of STIs
by promoting safe sex practices, such as the use of con-
Prevalence of and Factors Associated
doms, and to educate individuals about the risks attached with Colorectal Cancer Screening in
to multiple sexual relationships. The nurse must be non- Canadian Women
judgmental and accepting of the client’s lifestyle and treat
any information obtained as confidential (see Chapter 45). This study compared women ages 50 to 74 years from
Ontario, who had never been screened for colorectal cancer
EATING DISORDERS Statistics Canada (2011) reported (CRC) (n = 3676) with women who had had CRC screening
that obesity is a growing health concern in Canada. Both (n = 2105). Despite vigorous campaigns by Canadian health
obesity (body mass index [BMI] > 30 kg/m2) and over- organizations for CRC screening, less than 40% of women
weight (BMI between 25 and 30) affect the health of reported ever having CRC screening in 2005. Higher rates of
screening were noted in the group comprising women who
individuals and populations, as they are contributors to a
were older, had higher levels of education, were Caucasian,
wide variety of chronic diseases, such as diabetes, cardio- or had had a cancer diagnosis other than colorectal cancer.
vascular disease, hypertension, and liver disease, as well This group was also more likely to engage in a healthy life-
as to breast, colon, and prostate cancers. Approximately style and had easier access to health care resources. Lower
5.5 million, or 23%, of Canadian adults were reported to socioeconomic status (SES) was a common factor in women
be obese. Obesity rates are rising among 25- to 34-year- who never had CRC screening.
olds, and 23% of Canadian women of childbearing age NURSING IMPLICATIONS: Nurses need to develop
are reported to be obese. Nutrition assessment, diet teach- effective ways to increase CRC screening. Education
ing, and exercise are important elements in developing an of the public regarding early detection of colorectal
individualized wellness plan for clients. Individuals who cancer is lifesaving. Providing easier access to CRC
have anorexia nervosa, orthorexia nervosa, and anorexia screening is essential through community health cen-
tres and walk-in clinics.
bulimia, as well as vegetarians, are at an increased risk of
nutritional deficiencies. Young women require more cal- Source: Based on Brennenstuhl, S., Fuller-Thomson, E., & Popova, S. (2010).
Prevalence and factors associated with colorectal cancer screening in Canadian
cium and proper nutrition during their childbearing years. women. Journal of Women’s Health, 19(4), 775–784. doi:10.1089/jwh.2009.1477
The nurse assesses nutritional concerns and discusses diet
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Assessment Developmental Guidelines
The Young Adult

In these three developmental areas, does the young adult do the following?
1. Physical Development • Like self and direction of life
• Exhibit weight and BMI within normal range for age • Interact well with family
and gender • Cope with the stresses of change and growth
• Manifest vital signs (e.g., blood pressure) within normal • Have well-established bonds with significant others
range for age and gender and intimacy with a partner or close friends
• Demonstrate visual and hearing abilities within normal • Have a meaningful social life
range • Demonstrate emotional, social, and economic respon-
• Exhibit appropriate knowledge (e.g., STIs) and attitudes sibility for own life
about sexuality • Have a set of values that guide behaviour
2. Psychosocial Development 3. Activities of Daily Living

• Feel independent from parents • Have a healthy lifestyle
• Have a realistic self-concept
Young adult females should have a routine Pap Many young adults are reluctant to have these exam-
(Papanicolaou) test starting at age 18 years, or inations and screenings. It is important for nurses to
sooner if they are sexually active. A second test should explain the purpose of these tests and to encourage all
be taken after 1 year. If results are normal, a repeat young women to take preventive measures, such as under-
Pap test should be done every 3 years to age 69 years. going regular screening for early detection of cancer.
No rescreening is necessary if the female has never
had sexual intercourse or if the woman had a hyster-
ectomy and her previous tests were normal. A female
over age 69 years who has had at least two clear Pap
tests, no cervical abnormalities for 9 years, and no his- Assessment guidelines for the growth and development
tory of cancer, does not need regular screening (Health of the young adult are shown in the Assessment: Devel-
Canada, 2006b). opmental Guidelines box.
Health-Promotion Guidelines for Young Adults

Health Tests and Screenings • Tuberculosis skin test every 2 years or as needed
Young adults should engage in the following health-promotion • Smoking: history taking and counselling, if needed
activities: Safety
• Routine physical examination (every 1 to 3 years for • Motor vehicle safety reinforcement (e.g., using designated
females; every 5 years for males) drivers when drinking, not texting or using cell phones
• Immunizations, such as tetanus and diphtheria boosters when driving a car)
every 10 years, as recommended; meningococcal vac- • Sun protection measures
cine, if not given in early adolescence; hepatitis B vaccine
• Workplace safety measures
• HPV vaccine for males and females 9 to 26 years of age
who have not yet received or completed the vaccine • Water safety reinforcement (e.g., no diving in shallow water)
series
Nutrition and Exercise
• Regular dental assessments (every 6 to 9 months)
• Importance of adequate iron intake in diet
• Periodic vision and hearing tests
• Nutritional and exercise factors that may lead to cardio-
• Being breast aware vascular disease (e.g., obesity, cholesterol and fat intake,
• Pap test annually within 3 years of onset of sexual activity lack of vigorous exercise)
and every 3 years if results are normal
Social Interactions
• Testicular examination every year
• Encouraging personal relationships that promote discus-
• Screening for cardiovascular disease (e.g., cholesterol sion of feelings, concerns, and fears
test every 5 years if results are normal; blood pressure to
• Setting short-term and long-term goals for work and
detect hypertension; baseline electrocardiogram at age
career choices
35 years or as needed)
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Young adults are usually interested in meeting their Physical Development

health needs. However, because of the many stresses and
changes that occur throughout this 20-year period, the A number of changes take place during the middle
nurse’s role is to engage the young adult in health pro- years. At age 40 years, most adults function as effectively
motion by disseminating information regarding health as they did in their 20s. Between ages 40 and 65 years,
tests and screening. (See the Health-Promotion Guide- many physical changes take place. See Table 19.1 for a
lines box.) summary of these changes.
Both men and women experience decreasing
hormonal production during the middle years. Meno-
pause refers to the change of life in women and is
Middle-Aged Adults defined as not having had a menstrual period for 1 year.
Menopause usually occurs between ages 45 and 55 years.
(40 to 65 Years) The average is about 47 years. At this time, ovarian
secretion of estrogen and progesterone decreases. Com-
Middle-aged adults (40–65 years) enter a time referred mon symptoms are hot flashes, chills, decrease in breast
to as “generativity versus self-absorption and stagnation” size and loss of elasticity causing breasts to droop, and
in Erikson’s eight developmental stages of life. Children weight gain. Insomnia and headaches also occur with
have grown up, and parents may be experiencing the relative frequency. Psychologically, menopause can be an
“empty nest syndrome.” The partners generally have anxiety-producing time, especially if the ability to bear
more time for each other and to pursue interests they children is an integral part of the woman’s self-concept.
may have deferred for years (Figure 19.2).
Maturity is the state of maximal function and
integration, or the state of being fully developed. Mature
individuals generally have a broader worldview of issues;
Table 19.1 Physical Changes in the Middle-Aged Adult
they demonstrate self-acceptance, are able to be reflec-
tive and insightful about life, and see themselves as
Category Description
others see them. Mature adults assume responsibility
for themselves and expect others to do the same. They Appearance Hair begins to thin, and grey hair
confront the tasks of life in a realistic manner, make deci- appears. Skin turgor and moisture
sions, and accept responsibility for those decisions. decrease, subcutaneous fat decreases,
and wrinkling occurs. Fatty tissue is
redistributed, resulting in fat deposits in
the abdominal area.
Musculoskeletal Skeletal muscle bulk decreases at about
system age 60 years. Thinning of the interverte-
bral discs causes a decrease in height of
about 2 cm or 3 cm. Calcium loss from
bone tissue is more common among
postmenopausal women. Muscle growth
continues in proportion to use.
Cardiovascular Blood vessels lose elasticity and become
system thicker; and the heart has to work harder
to pump blood through these blood
vessels.
Sensory Visual acuity declines, often by the late
perception 40s, especially for near vision (presby-
opia). Auditory acuity for high-frequency
sounds decreases (presbycusis), particu-
larly in men. Taste sensations diminish.
Metabolism Metabolism slows, resulting in weight gain.

Gastrointestinal Gradual decrease in tone of the large
system intestine may predispose the individual
to constipation.
Urinary system Nephron units of the kidneys are lost
during this time, and the glomerular filtra-
tion rate decreases.
Sexuality Hormonal changes take place in both
men and women resulting in decline in
Figure 19.2 Middle-aged adults have time to pursue interests
sexual function with increasing age.
that may have been put aside for childcare.
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Climacteric (andropause) refers to the change of and their aging parents. They are facing two competing
life in men, when sexual activity decreases. Androgen sets of demands. Many employed middle-aged adults
levels decrease very slowly; however, men can father have to adjust their work schedules to care for their aging
children even in late life. Some men may have difficulty parents. The financial implications and the psychologi-
achieving sexual arousal for psychological reasons (e.g., cal stresses for this group can be overwhelming and can
financial worries, fear of aging, concerns about retire- affect their general health (Chassin, Macy, Seo, Presson,
ment, and boredom). (See the section on “Development & Sherman, 2010). Caregiving responsibility tends to lie
of Sexuality: Adulthood” in Chapter 45.) with the female in the family.
Psychosocial Development Cognitive Development

Havighurst (1972) outlined eight tasks for the middle- The middle-aged adult’s cognitive and intellectual
aged adult (see Box 19.2). Erikson (1963) viewed the abilities change very little. Cognitive processes include
developmental choice of the middle-aged adult as gen- reaction time, memory, perception, learning, problem
erativity versus stagnation. Generativity is defined as the solving, and creativity. Reaction time during the middle
concern for establishing and guiding the next generation. years stays much the same or diminishes during the latter
Couples have more time for companionship and recre- part of the middle years. Memory and problem solving
ation, and relationships can be more satisfying. In middle are maintained through middle adulthood. Learning
adulthood, the self seems more altruistic, and concepts continues and can be enhanced by increased motivation
of service to others and love and compassion gain promi- at this time in life.
nence. These concepts motivate charitable actions, such Genetic, environmental, social, and personality fac-
as volunteering at church or fundraising for charitable tors in early and middle adulthood account for the
causes. Generative middle-aged persons have attained a large difference in the ways in which individuals main-
sense of comfort and satisfaction with their lives. tain mental abilities (Edelman & Mandle, 2010). Thus,
Erikson (1963) believed that people who are unable approaches to problem solving and task completion will
to expand their interests at this time and who do not vary considerably in the middle-aged group.
assume the responsibilities of middle age suffer a sense
of boredom and impoverishment known as stagnation.
These individuals have difficulty accepting their aging
bodies and become withdrawn and isolated. They are Moral Development
preoccupied with the self and unable to give to others. According to Kohlberg (1971, 1981), most adults have
Some may regress to younger patterns of behaviour. The moved beyond the conventional level to the postconventional
“midlife crisis” occurs when individuals recognize that level. Extensive experience of personal moral choice
they have reached the halfway mark of life and that life is and responsibility is required before people can reach
finite. Midlife crisis is not universal but is more common the postconventional level. To move from stage 4, a law
in men (Beckmann Murray et al., 2008). and order orientation, to stage 5, a social contract orientation,
The term sandwich generation refers to individu- requires that the individual move to a stage in which the
als who are providing for the needs of both their children rights of others take precedence. Moral development
continues through adulthood, and few individuals attain
stage 5 before age 40 years.
Box 19.2 Psychosocial Development:
Middle-Aged Adult
According to Havighurst (1972), the middle-aged adult has
the following developmental tasks: Spiritual Development
• Achieving adult civic and social responsibilities Not all adults progress through Fowler’s stages to the
• Establishing and maintaining an economic standard of fifth, called the paradoxical-consolidative stage (Fowler, 1981).
living At this stage, the individual can view truth from a num-
• Assisting teenage children to become responsible and ber of viewpoints. Fowler’s fifth stage corresponds to
happy adults Kohlberg’s fifth stage. Fowler believed that only some
• Developing adult leisure-time activities individuals after age 30 years reach these levels.
• Relating to his or her spouse as a person In middle adulthood, people tend to be less dog-
• Accepting and adjusting to the physiological changes of matic about religious beliefs, and religion often offers
middle age more comfort to these individuals than it did previously.
• Adjusting to aging parents They become more in touch with their own mortality
• Balancing the needs of children, parents, work, and so on and often rely on spiritual beliefs to help them deal with
illness, death, and tragedy.
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Health Risks Alcohol Use Disorder The excessive use of alcohol

can lead to unemployment, disrupted families, accidents,
Many middle-aged adults remain healthy; however, the and diseases. Nearly 1 in 10 Canadians report problems
risk of developing a health problem is greater than in with alcohol dependence. Nurses can educate clients
the young adult. Motor vehicle and occupational acci- about the risks related to excessive alcohol use, examine
dents, chronic diseases (e.g., cancer), and cardiovascular the individual causes of abuse, and refer the client to a
disease are the leading causes of death in this age group. support group, such as Alcoholics Anonymous.
Lifestyle patterns, in combination with aging, family
history, developmental stressors (e.g., menopause, cli- Mental Health Alterations Failure to adapt to
macteric), and situational stressors (e.g., divorce), often the physiological and developmental changes of middle
trigger health problems. Smoking and excessive alcohol age can have a negative impact on an individual’s men-
consumption place an individual at greater risk of devel- tal health. Developmental stressors, such as menopause,
oping chronic respiratory problems, lung cancer, and climacteric, aging, and impending retirement, as well as
liver disease. Overeating can result in obesity, diabetes situational stressors, such as divorce, unemployment, and
mellitus, atherosclerosis, and associated risks for hyper- the death of a spouse, can precipitate increased anxi-
tension and coronary artery disease. The nurse’s role is ety and depression. A nurse can help individual clients
to educate about risk factors and emphasize the impor- develop coping strategies to get through difficult times.
tance of a healthy lifestyle, regular medical examination, Sustainable Happiness Sustainable happiness is a
and early screening for detection of health risks. relatively new paradigm in happiness studies. Sustain-
Injuries Changing physiological factors, such as
able happiness is “happiness that contributes to indi-
decreased visual acuity and reaction times, increase the vidual, community and/or global well-being and does
risk of injury in middle-aged people. Occupational acci- not exploit other people, the environment or future
dent is a significant safety hazard during the middle generations” (O’Brien, 2011, para 1). “True happiness is
years. Motor vehicle collisions are the most common a profound, enduring feeling of contentment, capability,
cause of accidental death. Other causes of death include and centeredness” (Foster & Hicks, 1999, p. 6). Happi-
falls, fires, burns, poisonings, and drowning. ness is a life choice. There are nine choices to help one
Cancer In Canada, cancer is the second leading cause

of death in this age group. The incidence of lung and pros-
tate cancers is high among men. In women, breast cancer Box 19.3 The Nine Choices for Happiness
has highest incidence, followed by lung and colon cancers. Intention Committing to a positive attitude and
There is a lifetime probability that 40% of Canadian behaviours that lead to happiness
females and 45% of men will develop cancer, and one in Accountability Assuming personal responsibility for
five Canadians will be diagnosed with some type of cancer, your actions, thoughts, and feelings,
and one in nine people will die from cancer (CCS Steering and refusing to view yourself as a
Committee on Cancer Statistics, 2012). victim
Cardiovascular Disease Coronary artery disease Identification Assessing what makes you uniquely
happy and not what others want
(CAD) is the second leading cause of death in Canada.
Several factors contribute to the risk of CAD: smoking, Centrality Focusing on what is central to your life
obesity, hypertension, hyperlipidemia, diabetes mellitus, that will bring you happiness
and a sedentary lifestyle. A family history of myocardial Recasting Transforming stressful problems into
infarction, such as the sudden death of a father younger something meaningful, important, and
than age 55 years or a mother younger than age 65 years, a source of emotional energy
is of significance. Men over 45 years of age and women Options Opening to new possibilities and
over 55 years of age are at a greater risk of developing adopting a flexible approach to life’s
CAD than are younger adults. Physical inactivity is the journeys
greatest risk factor for developing CAD (Edelman & Appreciation Appreciating your life and the people
Mandle, 2010). in the present and turning each expe-
rience into something precious
Obesity Middle-aged adults who gain weight may not Giving Sharing yourself with friends and com-
be aware of some common facts about this age period. munity without the expectation of a
Decreased metabolic activity and decreased physical return
activity mean a decrease in caloric need. The nurse can Truthfulness Choosing to be honest with yourself
counsel clients to prevent obesity by reducing caloric and others.
intake and participating in regular exercise. (See the
Source: Based on Foster, R., & Hicks, G. (1999). How we choose to be happy. New
Lifespan Considerations box on age-specific physical York, NY: Perigree. pp. 9–10.
activity guidelines in Chapter 7.)
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get through tough times (see Box 19.3). Happy people Assessment guidelines for the growth and develop-
are known to be healthier people. Depression increases ment of the middle-aged adult are shown in the Assess-
the risk of cardiovascular disease 1.5 to 2 times, while ment: Developmental Guidelines box. The nurse can
a positive affect can decrease the risks of disease onset choose to discuss some or all of the health-promotion
(Davidson, Mostofsky, & Whang, 2010; Pitt & Deldin, topics for middle-aged adults outlined in the Health-
2010). Promotion Guidelines box.
The Middle-Aged Adult

In these three developmental areas, does the middle-aged adult do the following?
1. Physical Development • Feel comfortable and respect self
• Exhibit weight within normal range for age and gender • Enjoy new freedom to be independent
• Manifest vital signs (e.g., blood pressure) within normal • Accept changes in family roles (e.g., having teenage
range for age and gender children and aging parents)
• Manifest visual and hearing abilities within normal range • Interact well and share companionable activities with
life partner
• Exhibit appropriate knowledge and attitudes about
sexuality (e.g., about menopause) • Expand and renew previous interests
• Verbalize any changes in eating, elimination, sleep, or • Pursue charitable and altruistic activities
exercise • Have a meaningful philosophy of life
2. Psychosocial Development 3. Development in Activities of Daily Living

• Accept the aging body • Follow preventive health practices
Health-Promotion Guidelines for Middle-Aged Adults

The following are important to the health of middle-aged adults:
Health Tests and Screening • Workplace safety measures (e.g., avoid repetitive strain)
• Routine physical examination (annually for females; every 2 • Home safety measures: keeping hallways and stairways
to 3 years or as directed by health care provider for males) lighted and uncluttered, using smoke and carbon mon-
• Immunizations, such as a tetanus booster every 10 years oxide detectors, using nonskid mats and hand rails in the
and influenza and pneumococcal vaccinations, as bathrooms
recommended • The practice of safe sex
• Regular dental assessments (e.g., yearly), daily brushing, Nutrition and Exercise
flossing, gum massage
• Importance of adequate fibre, protein, calcium, and vita-
• Tonometry (to test pressure in the eye) for signs of min D in diet
glaucoma and eye exams for other eye diseases (e.g.,
macular degeneration) every 2 to 3 years or annually, • Avoidance of excessive intake of caffeine
if indicated • Avoidance of nutritional and exercise factors that may
• Screening for breast cancer: mammography every 2 to lead to cardiovascular disease (e.g., obesity, sedentary
3 years between ages 50 and 74 years lifestyle); monitoring of cholesterol and lipid levels; avoid-
ance of saturated and trans fat intake
• Testicular self-examination monthly
• Vigorous exercise program that emphasizes skill and
• Screenings for cardiovascular disease (e.g., blood pres- coordination; daily exercise for a minimum of 30 minutes
sure measurement; electrocardiographic and cholesterol
tests, as directed by health care provider) Social Interactions
• Screenings for colorectal, cervical, uterine, and prostate • Recognition of the possibility of midlife crisis; need for
cancers discussion of feelings, concerns, depression, and fears
• Screening for tuberculosis every 2 years • Time to expand and review previous interests
Safety • Retirement planning (financial and possible diversional
activities), with partner, if appropriate
• Motor vehicle safety reinforcement, especially when driving
at night
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Case Study 19
Mark Jones, a 22-year-old construction worker, comes into the
health centre for a “physical.” He states that the last time he saw an
2. How would you ask Mr. Jones about his risk for sexually
transmitted infections?
outpatient health care provider for a complete physical exam was
during high school, and he is only here today because his employer 3. What health conditions are young adults at risk for, and
required that he be examined prior to returning to work. Mr. Jones how would you explain these to Mr. Jones?
has been off the job for 2 weeks following an accident in which he 4. What health screening activities would you suggest to
had fallen off a ladder, sustaining multiple contu- Mr. Jones? How would you explain the rationale to him?
sions and a concussion. He mentions that he and
5. How would you assess Mr. Jones’s psychosocial
“his buddies” have enjoyed his 2 weeks off from
development?
work and have used the time to “drink beer and
chase women.”
1. What questions would you ask Mr. Jones about his

usual health-promotion activities?
Key Terms
baby boomers p. 331 generativity p. 338 menopause p. 337 sandwich generation
boomerang kids p. 332 intimacy p. 333 Pap (Papanicolaou) p. 338
climacteric p. 338 intimate partner test p. 336 stagnation p. 338
Generation X p. 331 violence (IPV) p. 334 postformal thought sustainable
Generation Y p. 331 maturity p. 337 p. 333 happiness p. 339

• Distinct characteristics are associated with the three • The developmental choice for middle-aged adults is
generations which make up adulthood: baby boomers, generativity versus stagnation.
Generation Xers, and Generation Yers. • Adults in midlife must balance the needs of many, includ-
• Physical growth and development peaks in the mid-20s. ing their own parents and children.
• Emerging and young adults develop a self-identity and • Health decisions made by middle-aged adults may affect
prepare for intimate relationships with others. their health in later life.
• Moral development continues throughout adulthood. • Health risks, including cancer and heart disease, become
• Spirituality may be important to young adults but is a real threat to individuals categorized as middle-aged.
considered a private matter. Physical activity, healthy nutrition choices, and routine
care by a health care provider are important throughout
• Health problems for young adults are primarily related to the adult years.
lifestyle and behaviour.
• The concept of sustainable happiness and its positive
• Middle-aged adults begin to notice physical changes effects are related to health outcomes.
associated with aging.

1. A client, 52 years old, is experiencing symptoms of b. Advise the client to take estrogen
menopause, including frequent hot flashes and insom- c. Ask the client to keep an exercise diary
nia. The client states that she exercises daily, meditates,
and has consulted a naturopath. The client asks the d. Encourage the client to continue what she has been
nurse what else she could do to handle these symptoms doing
of life changes. How should the nurse respond?
a. Refer the client for a medical checkup
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2. The adult children of a couple have just helped them Program for Working Mothers. Which of the following
celebrate retirement after 35 years of employment. The would be the best focus for the program?
parents are not concerned and seem ready to make a. Health problems of aging
the necessary changes, but their children are worried.
Which of the following must the nurse understand to b. Immunizations and smoking cessation
help this family adapt to the parents’ retirement? c. Personal changes and home safety
a. Young adults are concerned about future caregiver d. Planning for retirement
roles in relation to their parents’ aging.
b. Seniors become worried about their health status, 7. The home health nurse is visiting a client, 56 years old,
ability to travel, and cognitive ability. in his home to provide wound dressing for a chronic leg
ulcer resulting from varicose veins. He is now retired
c. Middle-aged adults can adjust to altered schedules, after 30 years of working on a factory assembly line that
roles, physical strength, and economic changes. required long hours of standing in one spot. He lives
d. Retired persons focus on themselves, avoiding alone with his two cats. He complains of having to get
relationships with peers of bygone days. up to go to the bathroom several times during the night
to urinate, so he feels tired in the morning. He is 26 kg
3. An occupational health nurse (OHN) has a mandate to overweight and eats packaged frozen foods. Which of
do injury and illness prevention and health-promotion the following should the nurse address?
activities with the employees of a large manufactur- a. Personal neglect and complete an ankle-brachial
ing company. Which of the following issues would the pressure index (ABI)
OHN be most concerned about for the middle-aged
cohort in this workplace? b. Chronic disability criterion
a. The promotion of workplace safety c. Measures to prevent constipation
b. Productivity deadlines d. Health concerns, individual strengths, and safety
risks
c. Workplace benefits, including vacations
d. Work contract performance 8. Integration of developmental transitions experienced by
middle-aged adults is necessary for meaningful health
4. A parish nurse has the opportunity to provide nursing teaching. Which of the following are the most relevant
outreach to many individuals from a variety of cultures topics to include in the health teaching session with this
and from across all age groups. The nurse is struck by age group?
the common traits exhibited in the healthy and con- a. Accepting an aging body, handling dependent par-
tented adults. What stage of development describes this ents, and handling departing children
group?
b. Wear and tear, interpersonal stress, and sleep depri-
a. Trust versus mistrust vation as new parents
b. Industry versus guilt c. Education and career preparation, childbearing
c. Autonomy versus shame roles, and increasing free time
d. Generativity versus stagnation d. Formal operations and the law and order orientation
of Havighurst’s theory
5. A client has come to the clinic for a checkup and is
accompanied by her husband. During the history 9. A school nurse is helping parents to create health learn-
taking, the client shares with the nurse that she is afraid ing resources for their teen children. Which of the
her husband may not be able to drive anymore. The following subjects would be the best choice of mutual
client became worried the previous week when he did interest for both parents and teens?
not come home from curling at the usual time. Since a. Sexually transmitted infections
then, on two subsequent outings by himself, he was
brought home by a good Samaritan. What would be b. Internet crime
the nurse’s next step? c. Eating disorders
a. Ask the husband if he and his wife have had a fight d. Rules of the road and drivers’ training
recently
b. Ask the husband about any headaches, visual prob- 10. A nurse is working with a group of young adults to
lems, or unusual symptoms develop an educational campaign on motor vehicle
safety. The group wants to have a slogan for their
c. Ask each, separately, about what they did in the past campaign. What slogan captures the most important
10 days message of motor vehicle safety for this population?
d. Listen to each person’s story, take blood pressures for a. “Stay alive! Don’t drink and drive.”
both, and ask about time, date, persons, and places
b. “A little care makes accidents rare.”
6. The community health nurse at a Family Wellness c. “Buckle up!”
Centre has been asked to create a weekly Wellness d. “You are the key to your safety.”
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diseases-maladies/cervical-uterus-eng.php.
M19_KOZI2703_04_SE_C19.indd 343 08/02/17 6:11 PM

Chapter 20
Older Adults
Updated by
Kathy Pfaff, RN, PhD
Faculty of Nursing, University of Windsor
O
LEARNING OUTCOMES
After studying this chapter, you will be able to lder adults are the fast-
1. Describe the demographic characteristics and the determinants of est growing segment
health of older adults in Canada. of the global popula-
2. Explain ageism and its contribution to the development of negative tion. The proportion of people age
stereotypes about older adults. 60 years and older is projected to
3. Describe the development of gerontological nursing and research double by the year 2050, with an
in Canada. increase from 605 million to 2 million
4. Outline the roles of gerontological nurses in Canada. older adults during this period (World
Health Organization [WHO], 2014).
5. Describe the different care settings for older adults.
In Canada, the number of seniors or
6. Explain the common biological theories of aging and related
older adults is expected to increase
developmental tasks of the older adult.
rapidly over the next 50 years (Statis-
7. Describe cognitive, physical, and psychosocial changes to which
tics Canada, 2014a). The population
the older adult adjusts.
of Canadians age 80 years and over is
8. Compare and contrast Kohlberg’s and Gilligan’s theories of moral
also expected to grow from 1.4 million
reasoning in older adults.
in 2013 to 5 million by 2063. Nurses
9. Describe selected health issues associated with older adults.
must be equipped to care for the
10. Discuss the role of the nurse in promoting the health and well- unique, complex, and changing needs
being of older adults.
of the older adult.
M20_KOZI2703_04_SE_C20.indd 344 17/03/17 11:29 AM

Chapter 20 Older Adults 345
Characteristics of Older Chronic disease and disability increase with age;

however, disease is not a normal outcome of aging.
Adults in Canada Although the majority of older adults have one or more
chronic conditions, aging Canadians report their health
as excellent or very good (Government of Canada,
Older adults represent an increasingly diverse Canadian
2012). Nurses need to be aware that promoting health
population. At one time, all individuals over the age of
continues to be important for older adults, regardless of
65 years were considered old. With advancements in
chronological age.
disease control and health technology, the life expectan-
Frailty is also not a normal outcome of aging. Frailty
cies of Canadians continue to increase. The number of
is a general decline in an older adult’s physical function-
centenarians will increase dramatically from 7000 in
ing that can result in increased vulnerability to illness
2013 to over 62 000 in 2063 (Statistics Canada, 2014a).
and disability. The term frailty is often misinterpreted by
Because the chronological age of older adults can
health care providers. The most accepted definition clas-
span 40 years or more, it is important to note that func-
sifies someone as “frail” if he or she has three or more
tional age is often more useful than chronological age.
of the following: muscle weakness, slow walking speed,
Functional age refers to the individuals’ functional
exhaustion, low physical activity levels, or unintentional
fitness level when compared with others of the same
weight loss (Woods et al., 2005).
gender and of similar chronological, physiological, men-
The characteristics of these older adults can be bet-
tal, and emotional ages (Mosby’s Medical Dictionary, 2012).
ter understood by examining several determinants of
The term baby boomer is used to describe a
health, including socioeconomic status, gender, educa-
person born between 1946 and 1964. Between these
tion, physical environment, culture, and ethnicity.
years, there was a large increase in Canadian birthrates.
Although not all Canadians report healthy aging, many
enter their senior years with better education, higher
household incomes, and very active lifestyles compared
Socioeconomic Status
with previous generations of seniors. The term zoom- Socioeconomic characteristics, such as gender, marital
ers, coined by Demko (1998), refers to older adults who status, education, income, and living arrangements, vary
tend to be informed consumers of health care. In fact, among older adults. Overall, today’s seniors are finan-
seniors are the fastest growing age group using the Inter- cially secure (Elections Canada, 2012). Older adults who
net, with almost half of seniors reporting going online are at highest risk of low income are those who are unat-
(The Canadian Press, 2013). Internet use by older adults tached (living alone, widowed, or never married), those
can result in enhancements of self-esteem, perceived who have worked less than 10 years, new immigrants,
productivity and accomplishment, social interaction, and and Aboriginal peoples. Retirement results in less house-
mental stimulation (Mauk, 2010) (see Figure 20.1). hold income and may also present role and self-esteem
challenges.
Gender
Since women have a longer life expectancy than men,
the majority of older adults are women. Older women
are less financially stable compared with older men
and are more likely than men to participate in regular
caregiving outside the home. Although men and women
tend to have the same illnesses in older years, the signs
and symptoms can differ. Older women are prescribed
more medication than men and, thus, are more prone to
adverse events associated with medication use (Canadian
Women’s Health Network, 2012).
Education
Educational level can affect the socioeconomic status of
Yuri Arcurs/Fotolia
the older adult. Generally, higher education is associ-

ated with higher income, stronger literacy skills, and
better overall health (Public Health Agency of Canada
[PHAC], 2011). The number of older adults with com-
FIGURE 20.1 Half of Canadian seniors use the Internet. pleted high school diplomas is gradually increasing.
M20_KOZI2703_04_SE_C20.indd 345 02/03/17 2:17 PM

Despite increasing educational levels, many Canadian

seniors have literacy and numeracy skills below the Attitudes toward Aging
desired threshold for coping well in a complex society.
The Western world values youth. The term ageism
describes negative societal attitudes toward aging or
Physical Environment older adults (Butler, 1963). Unfortunately, these attitudes
exist among some health care professionals, including
Living arrangements of older adults are linked to income nurses (Kagan & Melendez-Torres, 2013). These ideas
and health. Most live in a variety of community settings, are often influenced by cultural and societal expecta-
with the majority living at home (Elections Canada, tions, family, colleagues, and work experiences. Ageism
2012). A small minority live in nursing homes. Nation- negatively affects how older adults experience health
ally, there is increasing support for aging in place initia- care and can discourage older adults from seeking care,
tives that support active, healthy, and person-centred resulting in poor health outcomes.
aging. Senior-friendly communities support the safety Stereotyping can occur when people do not under-
and accessibility needs of those with changing physical stand older adults as unique individuals; instead, unde-
abilities and provide opportunities for enhanced social sirable characteristics, such as senility, dependency on
interaction (PHAC, 2015). others, and unwillingness to change, are generalized to
all older adults. Negative attitudes about aging are often
based on incorrect information (Table 20.1). It is essen-
Culture and Ethnicity tial that nurses develop awareness of their own values
The Canadian population continues to be increasingly and attitudes toward aging and examine whether myths
diverse. Asian Canadians compose the largest ethnic group or stereotypes influence those attitudes. It is also impor-
in Canada (Statistics Canada, 2013a). Some ethnic older tant for nurses to provide accurate information about
adults experience difficulty accessing health care services aging to reduce stereotypes about aging.
because of language and cultural barriers, inadequate
knowledge of resources, and lack of culturally competent
care. Older adults who are newer immigrants are more Gerontological Nursing
likely to have low income; many may not have worked in
Canada and thus do not qualify for government pensions. in Canada
When compared with the overall Canadian popula-
tion, Aboriginal older adults tend to have lower income, Older adults are unique individuals who may require a
increased rates of chronic disease, lower educational variety of health care professionals to meet their health
levels, and a shorter life expectancy (Statistics Canada, care needs. Gerontology is a term used to define the
2013b). Although the life expectancy of Aboriginals is study of aging and older adults. Gerontology is multidis-
slowly increasing, it remains lower than that of the gen- ciplinary and is a specialized area within such disciplines
eral Canadian population. The Inuit population has the as nursing, psychology, and social work. Geriatrics is
lowest life expectancy. Lack of quality, affordable housing associated with the medical care (e.g., diseases and dis-
is a significant challenge to Aboriginal seniors. Literacy abilities) of older adults.
and cultural identity should be considered when working Gerontological nursing is a separate branch of profes-
with these older adults. (See Chapters 11 and 13.) sional nursing practice. It involves advocating for the
Table 20.1 Myths and Facts about Aging
Myth Fact
Older adults are less productive than younger Older adults possess experience and institutional memory. Although information
workers in the workplace. processing can decline with age, mental competence and learning abilities
continue in older age.
Older adults are to blame for uncontrollable Although the proportion of older adults is increasing and they need more health
health care costs in Canada. care services compared with younger people, other costs, such as inflation
and technology, are causing health care costs to increase.
Memory loss is an inevitable part of aging. Memory lapses are common at any age. Research has shown that memory loss
is influenced by factors other than aging.
Older people have decreased levels of sexual If sexual activity in older people declines, it is because of social reasons or other
activity. factors, such as disease and medication effects.
People get depressed when they grow old; it Depression is not inevitable with age, and it requires treatment and support at
is part of aging. any age.
Sources: Alzheimer’s Society of Canada, 2015; Canadian Foundation for Health Improvement, 2011; Canadian Mental Health Association, 2015; WHO, 2015
M20_KOZI2703_04_SE_C20.indd 346 08/02/17 6:14 PM

health of older persons at all levels of prevention and (Canadian Healthcare Association, 2009). Levels of care
was officially recognized as a specialty in the 1960s. In may include assisted living, long-term care, and chronic
the 1980s, nursing leaders recognized that all nurses continuing care.
needed to be educated in basic gerontological practice. Older adults who do not feel safe living alone or
All nurses need to acquire the requisite knowledge, skills, require additional help with activities of daily living
and expertise to care for the rapidly growing numbers (ADLs) may desire to reside in assisted living facilities.
of older adults in Canada—to understand trends that Also known as retirement settings, these facilities meet the
impact health care delivery, plan for evidence-based functional, safety, and socialization needs of older per-
interventions, and advocate for safe and ethical care. sons. Long-term care clients are those who can no longer
In 1985, the Canadian Gerontological Nursing Asso- live independently and require 24-hour direct nursing
ciation was formed. The Hartford Institute for Geriatric contact. Many long-term care facilities offer special-
Nursing was later established at New York University ized units for clients with dementia. Complex continuing
in 1996. In Canada, gerontological nursing certifica- care units are designed to provide for the needs of clients
tion is available through the Canadian Nurses Associa- whose acuity levels require a higher level of nursing care.
tion (CNA). The National Institute for the Care of the Specialized care may include tube feedings, intravenous
Elderly (NICE) is a champion for improving evidence- therapy, and mechanical ventilation.
based gerontological health care in Canada. Research in
gerontology and aging is increasing rapidly. In 2012, the
Canada Research Chair in Aging, Chronic Disease and Hospice
Health Promotion Interventions was established to con- Gerontological nurses often care for older dying persons
duct research that will promote optimal aging for older and their families. Hospices are centres that provide
Canadian adults living in the community. expert palliative care. Palliative care involves holistic care
of the mind, body, and spirit. It begins at diagnosis of
a life-limiting disease and continues through death and
Care Settings bereavement. Hospice nurses must possess specialized
tools for practice, including knowledge of end-of-life
for Older Adults care, expert assessment and clinical skills, and compas-
sion (Canadian Virtual Hospice, 2015).
Any nurse who works with older adults might be called a
gerontological nurse; however, specific knowledge, skills, and Rehabilitation
attitudes are required in practice. Gerontological nurses
practise in many settings and have many roles: provider Gerontological rehabilitation nursing combines expertise
of care, teacher, manager, and advocate. Care of the in gerontological nursing with rehabilitation practice.
older adult is interprofessional and often involves other Working as a member of an interprofessional team,
health care professionals, such as physicians, social work- gerontological nurses often care for older adults with
ers, physiotherapists, occupational therapists, dieticians, functional limitations (e.g., orthopedic surgery, stroke, or
chaplains, and others. Regardless of the setting, nurses amputation).
can assess and promote the health of older adults.
Community
Acute Care Facilities Gerontological nurses provide nursing care in many
Older adults represent the majority of clients cared for types of community settings. Community practice areas
in acute care. They use the emergency department (ED) may include home health care, adult daycare programs,
at a higher rate compared with some other age groups, and primary health care clinics, some of which may be
spend more time in the ED, and are most likely to be led by nurses.
admitted to the hospital (Canadian Institute for Health
Information, 2015). Nurses in acute care settings focus
on protecting the health of older adults, with the goal
of returning them to their prior level of independence.
Theories of Aging
Many theories of aging have been proposed by scientists
in the biological, psychological, and social disciplines.
Long-Term Care Facilities Biological theories of aging are either intrinsic or extrin-
In Canada, long-term care is not publicly insured under sic. Intrinsic theory addresses factors within the body;
the Canada Health Act; it is governed by provincial and extrinsic theory encompasses factors in the environment.
territorial legislation. Therefore, there is great variation Table 20.2 describes the various biological theories of
in the range of services and costs across the country aging.
M20_KOZI2703_04_SE_C20.indd 347 08/02/17 6:14 PM

Table 20.2 Normal Physical Changes Associated with Aging
Physical Changes Rationale
Integumentary
Increased skin dryness Decreased sebaceous gland activity and tissue fluid
Increased skin pallor Decreased vascularity
Increased skin fragility Reduced thickness and vascularity of the dermis; loss of
subcutaneous fat
Progressive wrinkling and sagging of skin Loss of skin elasticity, increased dryness, and decreased
subcutaneous fat
Lentigo senilis (brown age spots) on exposed body parts (e.g., Clustering of melanocytes (pigment-producing cells)
face, hands, arms)
Decreased perspiration Reduced number and function of sweat glands
Thinning and greying of scalp, pubic, and axillary hairs Progressive loss of pigment cells from the hair bulbs
Slower nail growth and increased thickening with ridges Increased calcium deposition
Neuromuscular
Decreased speed and power of skeletal muscle Decrease in muscle fibres
contractions
Slowed reaction time Diminished conduction speed of nerve fibres and decreased
muscle tone
Loss of height (stature) Atrophy of intervertebral discs, increased flexion at hips and knees
Loss of bone mass Bone reabsorption outpaces bone reformation
Joint stiffness Drying and loss of elasticity in joint cartilage
Impaired balance Decreased muscle strength, reaction time, and coordination,
change in centre of gravity
Greater difficulty in complex learning and abstraction Fewer cells in cerebral cortex
Sensory and Perceptual
Loss of visual acuity Degeneration leading to lens opacity (cataracts), thickening,
and inelasticity (presbyopia)
Increased sensitivity to glare and decreased ability to adjust to Changes in the ciliary muscles; rigid pupil sphincter; decrease
darkness in pupil size
Arcus senilis (partial or complete glossy white circle around the Fatty deposits
periphery of the cornea)
Presbycusis (progressive loss of hearing) Changes in the structures and nerve tissues in the inner ear;
thickening of the eardrum
Decreased sense of taste, especially the sweet sensations at Decreased number of taste buds in the tongue because of
the tip of the tongue tongue atrophy
Decreased sense of smell Atrophy of the olfactory bulb at the base of the brain (respon-
sible for smell perception)
Increased threshold for sensations of pain, touch, and Possible nerve conduction and neuron changes
temperature
Pulmonary
Decreased ability to expel foreign or accumulated matter Decreased elasticity and ciliary activity
Decreased lung expansion, less effective exhalation, reduced Weakened thoracic muscles; calcification of costal cartilage,
vital capacity, and increased residual volume making the rib cage more rigid with increased anteroposte-
rior diameter; dilation of alveoli from inelasticity resulting in
decreased recoil
Dyspnea (difficulty breathing) following intense exercise Diminished delivery and diffusion of oxygen to the tissues
to repay the normal oxygen debt because of exertion or
changes in both respiratory and vascular tissues
M20_KOZI2703_04_SE_C20.indd 348 08/02/17 6:14 PM

Physical Changes Rationale
Cardiovascular
Reduced stroke volume and cardiac output, particularly Increased rigidity and thickness of heart valves (hence
during increased activity or unusual demands; may result decreased filling and emptying abilities); decreased
in shortness of breath on exertion and pooling of blood contractile strength
in the extremities
Reduced elasticity and increased rigidity of arteries Increased calcium deposits in the muscular layer
Increase in diastolic and systolic blood pressure Inelasticity of systemic arteries and increased peripheral resistance
Orthostatic hypotension Reduced sensitivity of the blood pressure–regulating
baroreceptors
Gastrointestinal
Delayed swallowing time Alterations in the swallowing mechanism
Increased tendency for indigestion Gradual decrease in digestive enzymes, reduction in gastric pH,
and slower absorption rate
Increased tendency for constipation Decreased muscle tone of the intestines; decreased peristalsis;
decreased free body fluid
Urinary
Reduced filtering ability of the kidney and impaired renal Decreased number of functioning nephrons (basic functional
function units of the kidney) and arteriosclerotic changes in blood flow
Less effective concentration of urine Decreased tubular function
Urinary urgency and urinary frequency Enlarged prostate gland in men; weakened muscles supporting
the bladder or weakness of the urinary sphincter in women
Tendency for nocturnal frequency and retention of residual urine Decreased bladder capacity and tone
Reproductive
Prostate enlargement (benign) in men Exact mechanism is unclear; possible endocrine changes
Multiple changes in women (shrinkage and atrophy of the vulva, Diminished secretion of female hormones and more alkaline
cervix, uterus, fallopian tubes, and ovaries; reduction in vaginal pH
secretions; and changes in vaginal flora)
Increased time to sexual arousal Changes in blood supply to penis, clitoris
Decreased firmness of erection, increased refractory period (men) Changes in blood supply
Decreased vaginal lubrication and elasticity (women) Loss of estrogen effects
Immunological
Decreased immune response; lowered resistance to infections T cells less responsive to antigens; B cells produce fewer
antibodies
Poor response to immunization Immune system changes may precipitate insulin resistance
Decreased stress response Cortisol (a stress hormone) increases with age and can impair
the immune system’s ability to fight against diseases
Endocrine
Increased insulin resistance Immune system changes may precipitate insulin resistance
Decreased thyroid function Unclear mechanism
Integumentary losses of subcutaneous fat and muscle tissue, muscle

atrophy, and loss of elastic fibre. This results in a double
As chronological age increases, the skin becomes drier, chin, sagging of eyelids and earlobes, and wrinkling
less elastic, and more fragile, making the older person of skin. Bony prominences become visible. In older
more susceptible to skin tears and shearing injuries. women, the breasts become smaller and may sag; if large
These integumentary changes accompany progressive and pendulous, they may cause chafing where the skin
M20_KOZI2703_04_SE_C20.indd 349 02/03/17 2:19 PM

surfaces touch. Loss of subcutaneous fat decreases the As indicated, these age-related changes may affect
older adult’s tolerance of the cold. the mobility and safety of the older adult. The nurse
Health-promotion teaching about skin care for should identify any risk factors that may contribute to
older adults can include information about maintaining decreased functional ability and falls.
healthy skin, avoiding sun damage, and preventing injury Health-promotion interventions include the
to the skin. following:
• Encouraging adequate intake of calcium and vitamin D
Neuromusculoskeletal • Promoting physical activity and proper nutrition to
slow bone density loss and decrease muscle atrophy
With aging comes gradual reduction in the speed and
power of skeletal or voluntary muscle contractions and • Suggesting rest pauses to promote safety
sustained muscular effort. Despite regular exercise, a
steady decrease in muscle fibres occurs (sarcopenia) Sensory and Perceptual
after the age of 50 years, related to denervation of the
muscle. Thus, older adults often report lack of strength Each of the five senses becomes less efficient in older
and early fatigue. Activities can still be carried out but adulthood. Changes in the eye result in loss of visual
at a slower pace and often, balance is impaired. Muscle acuity, less power of adaptation to darkness and dim
endurance also diminishes, resulting in muscle fatigue light, and decrease in accommodation to near and far
after short periods of exercise. objects. Loss of peripheral vision, atrophy of lacrimal
Reaction time slows with age and is further delayed glands resulting in dry eyes, and difficulty in discriminat-
by decreased muscle tone. A slight loss in overall stature ing similar colours, especially blues, greens, and purples,
occurs with age. This can be exaggerated by muscular also occur.
weakness, resulting in a stooping posture and kyphosis. Presbyopia, the inability of the eye to focus or
Imbalance in the rates of absorption and formation of accommodate because of a loss of flexibility of the lens,
bone tissue also occurs. The result is osteoporosis, a causes a decrease in near vision. This generally starts
pathological decrease in bone density that makes older around age 40 years. Visual acuity lessens gradually
adults, both men and women, prone to serious fractures, after age 50 years, and more rapidly after age 70 years.
some of which may be spontaneous (pathological By the age of 80 years, adults have some lens opacity
fractures). Osteoporosis occurs more frequently in (cataracts) that reduces visual acuity and causes glare
people with insufficient intake of dietary calcium and to be a problem. Changes in the ciliary muscles reduce
vitamin D, in postmenopausal women, in Caucasians the power of the lens to adjust to near and far vision.
and Asians, and in individuals who are immobilized or The pupil’s diameter is reduced, and the amount of
physically inactive. Joints and their supporting struc- light entering the eye is thereby restricted. This slows
tures change with age. Decreased elasticity, strength, and the reaction time to decreases in light, a problem com-
hydration of the tendons and ligaments make movement pounded with night driving. Diseases of the eye that can
stiffer and more restricted. Stiffness is aggravated by result in visual impairment and blindness include age-
inactivity (see Figure 20.2). related macular degeneration, glaucoma, and diabetic
retinopathy.
Age-related hearing loss, called presbycusis,
affects people over age 65 years. Gradual loss of hear-
ing is more common among men than among women.
Hearing loss is greater in the higher frequencies than the
lower frequencies. Thus, older adults with hearing loss
usually hear speakers with low, distinct voices best. Hard
consonants (e.g., k, d, t) and long vowel sounds (e.g., ay, ee)
are more easily recognized. Sibilant sounds (e.g., s, th, f )
are the most difficult to hear. If communication prob-

lems or social withdrawal is noted, the nurse should sug-
gest a referral for hearing screening. Ears should also be
checked for impacted earwax. If hearing has diminished,
assistive listening devices are available.
The taste and smell senses are often reduced with
aging. These changes significantly affect appetite, con-
tributing to poor nutrition. Decreased or absent sense
FIGURE 20.2 A regular program of exercise is important for of smell and taste can also lead to safety issues, such as
maintenance of joint mobility and muscle tone and can promote being unable to smell a gas leak. It is important for the
socialization. nurse to teach the older client with alterations in taste
M20_KOZI2703_04_SE_C20.indd 350 02/03/17 2:20 PM

and smell about health and safety strategies (e.g., using pain on exertion (claudication). In addition, there
smoke alarms and carbon monoxide alarms). may be a delay in the circulatory adjustments required
Loss of skin receptors takes place gradually, produc- when a person stands up from the lying or sitting posi-
ing an increased threshold for sensations of pain, touch, tion. The delay results in an abrupt drop in systolic
and temperature. The older person may not be able to blood pressure on standing up, known as orthostatic
distinguish hot from cold, or sense the intensity of heat. hypotension.
This places the older adult at higher risk for burns and Systolic hypertension was previously considered
other injuries. Again, it is important for the nurse to “normal” in older adults. With the exception of the very
teach about safety risks and subsequent interventions. old, target blood pressure of less than 140/90 mm Hg is
For example, water heaters should be set to no more than now recommended, with a further reduction to less than
49°C to prevent scalding. 130/80 mm Hg for people with diabetes (Daskalopoulou
et al., 2015).
Health-promotion activities are aimed at detecting
Pulmonary and reducing risks for cardiovascular disease. The nurse
Respiratory efficiency is reduced with age. The respira- should inform the older adult about the importance of
tory muscles weaken and the chest wall becomes less smoking cessation, maintaining a healthy body weight,
compliant. The muscles used in breathing also tend to exercising daily, reducing sodium and fat intake, and
weaken. Tidal volume (the measurement of air moved in consuming a diet rich in fruits and vegetables.
and out during normal respiration) remains the same;
however, the older adult has a decreased vital capacity.
This means the older adult inhales a smaller volume Gastrointestinal
of air and is unable to compensate for increased oxy- Age-related changes in the gastrointestinal system are
gen need by significantly increasing the amount of air summarized below:
inspired.
Dyspnea (difficulty breathing) occurs frequently • Periodontal disease, which can lead to tooth loss,
with physically demanding activities, such as carrying which, in turn, affects proper diet intake
heavy items upstairs. A greater volume of residual air • Reduced production of saliva, which may lead to
is left in the lungs after expiration, and the capacity to xerostomia (dry mouth), making the oral mucosa
cough efficiently decreases because of weaker expiratory more susceptible to infection
muscles. Mucous secretions tend to collect more readily • Decreased esophageal and gastric motility and emp-
in the respiratory tree, increasing the risk of respiratory tying time, as well as decreased liver and pancreas
infection. functions
Older adults are at great risk of influenza infec-
• Gradual decrease in digestive enzymes and intrin-
tions, and many die as a result of complications. Evi-
sic factor (protein needed by the body to make vita-
dence showed that influenza vaccination could prevent
min B 12 )
influenza-related illness by 20% to 40% and influenza-
related death by 80% (Thomas, Jefferson, & Lasserson, • Decreased intestinal absorption, motility, and blood flow
2010). Health-promotion teaching includes information Health-promotion teaching for the gastrointestinal
about the following: health of older adults includes food safety, effective oral
• Cessation of smoking hygiene, and regular preventive dental care. Nutrition
is also important, including healthy diet and sufficient
• Hand hygiene to prevent respiratory infections
fluid intake. Maintenance of a regular bowel routine and
• Influenza and pneumonia vaccinations screening for colorectal cancer is vital.
Cardiovascular Urinary
The working capacity of the heart diminishes with age. The excretory function of the kidney diminishes slightly
This is particularly evident when increased demands are with age. The kidney’s filtering abilities may also be
made on the heart muscles, such as during exercise or impaired; thus, waste products may be excreted more
emotional stress. The resting heart rate does not change slowly. Drugs that are metabolized predominantly in
with age; however, the heart rate can be slow to respond the kidney may accumulate in the older adult, and the
to stress and slow to return to normal after periods of nurse should watch for signs of toxicity.
physical activity. The capacity of the bladder, and its ability to com-
Changes in the arteries occur concurrently. Reduced pletely empty, noticeably diminish with age. Many older
arterial elasticity may result in diminished blood circula- adults need to get up during the night to void (nocturia)
tion to such areas as the legs, resulting in calf muscle and may experience retention of urine, which predisposes
M20_KOZI2703_04_SE_C20.indd 351 02/03/17 2:22 PM

them to bladder infections. Although older adults are

susceptible to urinary incontinence (UI), UI is never Psychosocial Aging
normal, and it can contribute to falls (caused by rushing
to the washroom), skin breakdown in the genital area (as A number of theories explain psychosocial aging. These
a result of irritation from leaking urine), and social isola- theories focus on behaviour and attitude changes during
tion (because of embarrassment). the aging process. Developed in the early 1960s, disen-
As the thirst mechanism in aging adults is dimin- gagement theory proposed that aging involves mutual
ished, the nurse should encourage regular fluid intake. withdrawal (disengagement) between the older person
The nurse can also teach pelvic muscle exercises to con- and others in the older person’s environment (Tabloski,
trol stress incontinence. 2010). This withdrawal relieves the older person of
societal pressures and gradually reduces the number of
people with whom the older person interacts. It has been
widely criticized for the assumption that disengagement
Reproductive is appropriate for the older adult.
According to Havighurst’s activity theory, the best
Degenerative changes in the gonads (reproductive glands
way to age is to stay physically and mentally active
that produce germ cells) are gradual in men. Production
(Havighurst, 1972). Continuity theory proposes that
of testosterone and sperm continues well into old age,
people maintain their values, habits, and behaviours in old
although sperm production gradually decreases. Older
age. A person who is accustomed to socializing will continue
men will notice several age-related changes in their
to do so, and the person who prefers not to be involved with
sexual response and performance. In general, the older
others will more likely disengage (Tabloski, 2010).
man’s libido may decrease but does not disappear.
Erikson (1982) views the developmental task of late
Older men achieve erection of the penis that is
adulthood to be integrity versus despair. People who attain
less firm than in younger men but still capable of pen-
ego integrity view life with a sense of wholeness, derive sat-
etration. Ejaculation may take longer to occur, and the
isfaction from past accomplishments, and accept death and
older man may have difficulty anticipating or delaying
other serious events as part of the life cycle. Acknowledging
ejaculation.
that older adults differ in both physical characteristics and
The risk of erectile dysfunction (ED) increases with
psychosocial responses, many people have difficulty with
each decade of age (Tabloski, 2010). ED is the subjec-
Erikson’s singular developmental task. Peck (1968) pro-
tive complaint of an inability to achieve or maintain an
posed three developmental tasks of the older adult:
erection that is satisfactory for the completion of sexual
activity (Ellsworth & Kirshenbaum, 2008). The possible 1. Ego differentiation versus work-role preoccupation
causes of ED include atherosclerosis, diabetes, medica- 2. Body transcendence versus body preoccupation
tions, and psychological factors.
3. Ego transcendence versus ego preoccupation
In women, the degenerative changes in the ovaries
are noticed by the abrupt cessation of menses in mid- See Chapter 12. See Box 20.1 for the developmental
dle age. Changes in the gonads of older women result tasks of the older adult.
from diminished secretion of the ovarian hormones.
Some changes, such as the shrinking of the uterus and
ovaries, go unnoticed. Other changes are obvious. The Retirement
breasts atrophy, and lubricating vaginal secretions are
Retirement is a period of adjustment for most older
reduced.
adults. Although retirement is a challenging transition
Older women also experience changes in their sex-
for many older adults, people who live well-balanced and
ual responses. It takes longer for the woman to become
fulfilling lives may adjust more easily. In fact, some con-
sexually aroused and produce vaginal lubrication, mak-
tinue to work on a full-time or part-time basis; working
ing penetration slightly more difficult and uncomfortable
can provide a sense of self-worth and continued income.
(Wallace Kazer, 2012). During orgasm, the uterus will
Retirement can also be a time when recreational activi-
contract less frequently, but contractions remain vigor-
ties can be pursued. Older adults find outlets in travel-
ous, and orgasm is as intense as in younger women.
ling, volunteering, physical fitness, intellectual pursuits,
The nurse needs excellent communication skills
and hobbies (Figure 20.3).
when providing sexual health education. The process
must be open, respectful, and nonjudgmental. Older
men and women are fully capable of enjoying sexual
activity. The nurse should assess sexual function and
Economic Change
preferences if relevant to the older adult’s plan of care. The financial needs of older adults vary considerably.
Problems with sexual function that are beyond the scope Although many older adults are mortgage free and
of the nurse should be referred to an appropriate health require less money for living expenses, rising costs can
care provider (see Chapter 45). make it difficult for some to manage financially. Food
M20_KOZI2703_04_SE_C20.indd 352 02/03/17 2:22 PM

BOX 20.1 DEVELOPMENTAL TASKS OF THE as economical as possible. The nurse should also refer
OLDER ADULT the client to social assistance programs that can help with
financing health care–related supplies.
65 TO 75 YEARS
• Adjusting to decreasing physical strength and health

Relocation
• Adjusting to retirement and lower and fixed income
• Adjusting to the death of parents, spouses, and friends Most Canadian older adults live independently in the
• Adjusting to new relationships with adult children community and desire to remain in their homes. Only
7% live in an institution (OECD, 2011). During late
• Adjusting to leisure time
adulthood, a variety of factors can lead to the decision to
• Adjusting to slower physical and cognitive responses
relocate to other living accommodations. Unfortunately,
• Keeping active and involved
relocation is often stressful for many older adults and
• Making satisfying living arrangements as aging progresses their families, especially if the move is not voluntary.
75 YEARS AND OLDER The decision to relocate to a long-term care facility is
frequently made when older adults can no longer care
• Adapting to living alone for themselves because of mobility problems or memory
• Safeguarding physical and mental health impairment. It is important for nurses to assist in facili-
• Adjusting to the possibility of moving into a nursing home tating the older adult’s decision making. During transi-
• Remaining in touch with other family members tion, the older adult may require professional services,
• Finding meaning in life such as nursing and occupational therapy.
• Adjusting to the prospect of one’s own death
Source: Murray, Ruth Beckman; Zentner, Judith Proctor; Yakimo, Richard. (2009). Maintaining Independence
Health promotion strategies through the lifespan (8th ed.). Reprinted and electroni-
cally reproduced by permission of Pearson Education, Inc., Upper Saddle River, N.J. and Self-Esteem
Most older Canadians thrive on independence. Aging in
place describes a process that enables older adults to age
and medical costs are a significant financial burden for within the comfort and familiarity of their own homes.
older adults. Challenges are often related to low retire- To maintain the older adult’s sense of self-respect, the
ment benefits, lack of pension and health insurance nurse and caregivers need to encourage independence
plans, and the increased length of the retirement years. and acknowledge the older adult’s ability to think, rea-
Older women and senior members of minority groups son, and make decisions. The values and decisions held
often experience financial difficulty. In Canada, the old- by older people need to be accepted whether they are
est women tend to be the poorest (Organisation for Eco- related to ethical, religious, or household matters. For
nomic Co-operation and Development [OECD], 2013). example, the nurse should respect an older person’s deci-
Nurses should be aware of health care costs. For sion to bathe rather than shower.
example, supplies used in an older adult’s care should be Some older adults experience discomfort when
doing activities they enjoyed in their younger years.
Assistive devices can ease the strains of daily activities.
They include medical equipment and mobility aids.
These devices can help older adults improve their quality
of life and maintain their independence.
Social Relationships
Older adults with increased social contacts tend to receive
more support and usually demonstrate health-promoting

behaviours. Grandparenting provides a unique oppor-
tunity to form special relationships with grandchildren.
This role is now changing, and grandparents are increas-
ingly functioning as the primary caregivers for their
grandchildren. This trend is occurring for a variety of
reasons, including teen pregnancy, parental mental health
issues, and parental death. While grandparenting, older
FIGURE 20.3 Many older adults find creative outlets during adults can experience stress related to personal health
retirement. challenges and parental caregiving. Older adults may also
M20_KOZI2703_04_SE_C20.indd 353 27/02/17 9:42 AM

feel family pressure to care for their grandchildren. In Cognitive Agility

some cases, external pressure from family members may
become a form of emotional abuse. See the section titled Changes in cognitive abilities are more often a difference
“Mistreatment of Older Adults” in this chapter. in speed than ability. Overall, the older adult maintains
Relatively little is known about the social relation- problem-solving, judgment, creativity, and other well-
ships of lesbian, gay, transgender, and bisexual older practised cognitive skills. Most older adults do not expe-
adults. In addition, unmarried older adults may form rience cognitive impairments. A cognitive impairment
companion and living relationships. As prevalence of that interferes with social or occupational functions is not
human immunodeficiency virus (HIV) infections increase considered part of normal aging and should always be
in Canada, many face unique challenges, such as the loss regarded as abnormal. Intellectual loss generally reflects
of a partner and social isolation. When these older adults a disease process, such as atherosclerosis, which causes
relocate to assisted living facilities, they may encounter the blood vessels to narrow and diminishes perfusion
stigmatization, even from some health care practitioners. of nutrients to the brain. Prompt medical evaluation is
It is important for nurses to promote the social needed. Lifelong mental activities, particularly verbal
relationships of all older adults, regardless of the care activity, help the older adult retain a high level of cogni-
setting. tive function.
Facing Death and Grieving Memory

Well-adjusted aging couples usually thrive on each other’s Memory is also a component of intellectual capacity that
companionship. When a mate dies, the partner often involves the following steps:
experiences loss, emptiness, and loneliness. Many are
capable of living alone; however, reliance on family and 1. The first step is momentary perception of stimuli from
community may increase with advancing age. Older peo- the environment, referred to as sensory memory.
ple are often reminded of their own mortality by the death 2. The second step involves storage in short-term
of friends. A person who has successful relationships with memory. An example of this type of memory is call-
family, meaningful friendships, economic security, ongoing ing information for a telephone number and remem-
interests, and a peaceful philosophy of life generally copes bering the number for only the brief time needed to
more easily with bereavement. See Chapter 48. dial it. Short-term memory that deals with activities
It is the role of every nurse to support those who are or the recent past (minutes to a few hours) is often
grieving. There are support programs in many commu- referred to as recent memory.
nities that assist older adults to cope with bereavement. 3. The final stage is encoding, by which information enters
Nurses need to be aware of these programs and refer long-term memory, the repository for information
their clients to appropriate support services. stored for long periods. For example, older people who
remember the names of their childhood pets are draw-
ing from long-term memory.
Cognitive Abilities In older adults, retrieval of information from long-
and Aging term memory can be slower, especially if the information

is not frequently used. Most age-related differences occur
in short-term memory. Older adults tend to forget the
Piaget’s (1981) phases of cognitive development end recent past. This forgetfulness can be improved by the
with the formal operations phase; however, considerable use of memory aids, making lists, and placing objects in
research on cognitive abilities and aging is currently consistent locations.
being conducted. Intellectual capacity includes percep-
tion, cognitive agility, memory, and learning.
Learning
Perception Older adults need additional time for learning, largely
Perception, or the ability to interpret the environment, because of difficulty retrieving information. Active par-
depends on the acuteness of the senses. If the aging ticipation and motivation are also important. Older
person’s senses are impaired, the ability to perceive adults can have difficulty learning information they do
the environment and react appropriately is diminished. not consider meaningful; therefore, the nurse should
Changes in the nervous system can also affect perceptual discover what is meaningful to the older adult, including
capacity. Changes in the cognitive structures occur with their learning needs and experiences, before attempting
age: neurons are progressively lost; blood flow to the client education. Refer to Chapter 26 for strategies to
brain decreases; and brain metabolism slows. enhance learning among seniors.
M20_KOZI2703_04_SE_C20.indd 354 08/02/17 6:14 PM

Moral Development Promoting Healthy Aging

According to Kohlberg (1984), moral development is A primary role of nurses is to promote healthy aging,
completed in the early adult years. Older adults at the the goals of which are to maintain physical and emo-
conventional level follow society’s rules of conduct in tional health, avoid disease and injury, and remain active
response to the expectations of others. Kohlberg based and independent. Health-promoting behaviours, such
his stages on concepts of justice, objectivity, and preserva- as healthy nutrition and regular physical exercise, have
tion of rights, whereas Gilligan (1982) developed a theory been shown to reduce the risk of developing several dis-
of moral reasoning based on the concept of caring. She orders that commonly occur with age.
believed that women base moral judgments on connect-
edness to others and the value of relationships. Research
has demonstrated that men and women make moral deci- Health Assessment
sions differently. Older adults make moral decisions that The initial step in promoting health is a detailed assess-
are consistent with both Kohlberg and Gilligan (Pinch & ment of the older adult. The accompanying Assessment:
Parsons, 1997). Older men consider relationships as well Developmental Guidelines box provides the types of
as justice in moral decisions, and older women add justice information that should be gathered. Because of the
to the factors they consider in moral situations. increased complexity of an older client, the assessment
Factors such as cultural background, life experi- is often very comprehensive. It may also address other
ences, and religion influence people’s values. Therefore, areas, such as chronic illness, drug use, and mental
the values and beliefs that are important to older adults health.
may be different from those held by younger people. The A number of guidelines and screening tools have
nurse must identify and consider the specific values of
been developed to promote valid and reliable assessment
the older client when nursing care is planned.
of the older adult. The tools that are used depend on
the purpose and the setting. Assessment by the nurse also
requires an ability to listen, ask questions, obtain data
Spirituality and Religion from multiple sources, and differentiate normal aging
changes from abnormal ones. Assessment includes a
relevant physical examination (see Chapter 28). A health
Religious and spiritual practices are important to many
history should include questions about the following:
older adults; religious expression is a way of life (Lawlor-
Row & Elliott, 2009) and is very important to their care. • Usual dietary pattern
Other older adults may describe themselves as spiritual • Bowel or urinary elimination problems
but not necessarily religious. Regardless, involvement in • Activity, exercise, sleep, and rest patterns
spiritual and religious practices can enhance mortality,
recovery, and coping (Puchalski, 2001). Assisting the • Family and social activities and interest
older person to participate in religious and spiritual prac- • Reading, writing, and problem solving
tices is an important nursing responsibility. • Adjustment to retirement or to loss of partner
The Older Adult

In these developmental areas, does the older adult do the following?
1. Physical Development • View life as worthwhile
• Adjust to physiological changes (e.g., appearance, • Have high self-esteem
sensory and perceptual, musculoskeletal) • Gain support from value system or spiritual philosophy
• Adapt lifestyle to diminishing energy and ability • Adjust to the death of significant others
• Maintain vital signs (especially blood pressure) within
the recommended target range 3. Development in Activities of Daily Living
• Exhibit healthy practices in nutrition, exercise, recre-
2. Psychosocial Development ation, sleep patterns, and personal habits
• Have the ability to care for self or to secure appropriate
• Manage retirement years in a satisfying manner
help with activities of daily living
• Participate in social and leisure activities • Have satisfactory living arrangements and income to
• Have a social network of friends and support persons meet changing needs
M20_KOZI2703_04_SE_C20.indd 355 08/02/17 6:14 PM

• Economic situation also be helpful and may be used alongside pharmaco-

• Mental and emotional status logical interventions.
Individuals with dementia experience increased
• The older adult’s desired goals of care
risk for injury as the disease advances. Judgment often
becomes impaired, and some environmental modifica-
tion is needed to maintain safety, including rendering
Health Problems kitchen stoves inoperable and installing warning devices
and Chronic Disabling Illnesses on doors for older adults who may wander. Attention
Many Canadian older adults are afflicted with one or more should be given to these safety risks, whether the person
health problems or chronic illnesses that may seriously lives at home or in a health facility.
impair their functioning. Examples of these are arthritis, Nurses can promote environmental safety by identi-
osteoporosis, cardiovascular disease, chronic obstructive fying and eliminating specific hazards. See the Evidence-
pulmonary disease, diabetes, hypertension, and cogni- Informed Practice box. Injury prevention is detailed in
tive dysfunctions. Acute illnesses, such as pneumonia and Chapter 32.
fractures, may create chronic health problems. Frequently, CANCER Cancer affects Canadians of all ages, and age
pain accompanies chronic disease and acute illnesses. is a risk factor for cancer (Canadian Cancer Society,
Chapter 30 provides a description of pain management. 2015a). The vast majority of all new cancer cases are in
Older adults with cognitive impairment require a special- the age group of 50 years and over, and for both males
ized approach to pain assessment and management. and females, the median age of diagnosis is 65 to 69 years.
In Canada, the presence of chronic conditions var- More than one-half of the newly diagnosed lung and
ies regionally; for example, rates of chronic disease are colorectal cancers occur among those who are 70 years
higher in low-income populations in the Atlantic region
and in Western Canada (Fang, Kmetic, Millar, & Drasic,
2009). Chronic illness often impacts adaptation and role
performance. For example, the client may need increas-
ing help with ADLs, such as ambulation and hygiene. EVIDENCE-INFORMED
Health care expenses may become an economic con- PRACTICE
cern. Family roles may need to be altered, and family
members may need to change their lifestyle to achieve Fall Prevention
caregiving needs and optimal family functioning. in Community-Based Older Adults
INJURIES Injury prevention is a major concern for older Gillespie et al. (2013) conducted a systematic review of the
people. Many accidents are preventable and are directly health care literature to determine interventions to prevent
related to the environment and the physiological changes falls in older people living in the community. The litera-
that accompany normal aging. Falls are a leading cause ture sample included 159 randomized controlled trials with
of morbidity and mortality among older adults (Statis- 79 193 participants. The interventions included exercise and
tics Canada, 2014b). Nurses should emphasize safety in multifactorial programs. The authors concluded that group
and home-based exercise, combined with environmental
everyday activities, particularly at night and in poorly lit
safety interventions, can reduce the risk of falling, the rate
environments. that falls occur, and fractures. They also found Tai Chi to be
Fires are a hazard for the older adult. Safety is impor- an effective intervention that helps increase strength and bal-
tant when operating stoves, microwave ovens, and barbe- ance and reduce the risk of falls.
cues. Because of reduced sensitivity to pain and heat, care
NURSING IMPLICATIONS: The majority of older adults
must be taken to prevent scalding burns when the person live in the community. Among these individuals, 20% to
bathes or uses heating devices. 30% experience a fall each year, and some will expe-
Each year, many older adults die from hypothermia. rience permanent disability or death (PHAC, 2014a).
Hypothermia occurs when the body temperature goes When assessing the older adult, nurses should inquire
below normal. A lowered metabolism and loss of subcu- about exercise habits and activities, and inspect
taneous tissue decrease the older client’s ability to retain the home for safety risks. Health education should
include activities that are shown to be effective (Tai
heat. The older adult who spends time outdoors in cold
Chi, strength and balance training). Community health
weather or does not turn on the heat in the home is at nurses can work with occupational and physiothera-
significant risk for hypothermia. pists to facilitate safe exercise among older adults and
Older clients who take opioid analgesics or sedatives advocate for group exercise programs as part of an
are at an increased risk for falls. Use of these drugs by age-friendly community.
older adults should be avoided unless other options are Source: Based on Gillespie, L. D., Robertson, M., Gillespie, W. J., Sherrington, C.,
ineffective and quality of life is negatively affected. In Gates, S., Clemson, L. M., & Lamb, S. E., (2013). Interventions for preventing falls in
these cases, careful titration is necessary. Nonpharma- older people living in the community. Cochrane Database of Systematic Reviews, 9.
doi: 10.1002/al14651858.CD007146.pub3
cological measures to reduce pain and induce sleep can
M20_KOZI2703_04_SE_C20.indd 356 21/02/17 11:52 AM

and older. The most common cancer in men ages Older individuals with a chronic disease should be
60 to 69 years is prostate cancer (40%) and in women is screened regularly for depression (DeJean, Giacomini,
breast cancer (26%). Vanstone, & Brundisini, 2013). Signs and symptoms
The burden of cancer in older Canadians has seri- include a lack of interest in people and things, trouble
ous implications for cancer prevention and cancer care. sleeping, significant changes in appetite, visible sadness,
As older adults are the fastest growing population in withdrawal from social activities, and feelings of worth-
Canada, it is expected that many will be diagnosed lessness. Depression may also be triggered by personal
with cancer. Because of new technologies, including losses, such as the loss of a spouse. In some cases, depres-
enhanced screening, detection, and cancer treatments, sion can lead to suicide. Caregivers and health care pro-
survival is improving. Nurses are challenged to develop fessionals must be alert to the warning signs of suicide
and implement cancer prevention strategies into the and access mental health services immediately.
daily lives of older persons to promote healthy aging. For Some older adults may use alcohol to cope with the
older adults with cancer, nurses play a key role in treat- changes of aging. Chronic drinking has negative effects
ment, pain and symptom management, and education. on all body systems and can lead to injuries and death.
Where cure is not possible, the nurse facilitates holistic Risk factors include living alone, having experienced
palliative and end-of-life care. multiple losses, a history of alcohol abuse, a debilitat-
ing disease, or all of these factors. Alcohol interacts
Drug Use and Misuse Polypharmacy refers to the
with various drugs, altering the effect of the medication
use of five or more medications by an individual. Accord-
on the body and possibly leading to a serious over-
ing to statistics, it occurs among 30% of Canadians
dose. Some medications have an increased effect when
between 65 and 79 years of age (Rotermann, Sanmartin,
taken with alcohol (e.g., anticoagulants and narcotics),
Hennessy, & Arthur, 2015). Although many older adults
whereas the action of other medications (e.g., antibiot-
require several medications to manage chronic illnesses,
ics) is inhibited.
polypharmacy can result in adverse effects. Many older
Clients who have an alcohol addiction should not be
adults also purchase over-the-counter (OTC) drugs to
stereotyped; rather, the nurse should support the older
remedy discomforts, such as constipation and pain. The
adult and advocate for appropriate treatment. It is also
use of vitamins, food supplements, and herbal remedies
important for the nurse to review the interaction effects
has increased as well.
of alcohol with the older adults’ medications. Referral to
The complexities involved in the self-administration
community support services is appropriate.
of medication may lead to misuse, including combining
prescribed medications with alcohol or OTC drugs, tak- Dementia Dementia is a progressive loss of cognitive
ing medications at the wrong time, or taking someone function and is not a normal part of aging. The most
else’s medication. Misuse can also occur when more than common type of dementia is Alzheimer’s disease
one care provider prescribes medications, unaware of (AD). The course of this disease is slow and insidious,
what the other has prescribed. Additionally, because the and it affects approximately 800 000 people in Canada
pharmacodynamics of drugs is altered in older adults, (Alzheimer’s Society of Canada, 2015). It is estimated
variations in absorption, distribution, metabolism, and that this number will increase to 1.4 million by the year
excretion of drugs can occur. These variations are dis- 2031.
cussed in Chapter 33. The symptoms of AD vary from person to person.
Nurses should complete an accurate medication his- The most prominent symptoms are cognitive dysfunc-
tory, including an assessment of all prescription and OTC tions, including decline in memory, learning, attention,
drugs, many of which can interact with other medications. judgment, orientation, and language skills. The symp-
Mental Health and Addiction Problems toms are progressive, leading to a steady decline in cogni-
Although older Canadians report a high level of life sat- tive and physical abilities, lasting between 7 and 15 years
isfaction, factors such as retirement, disability, and relo- and ending in death.
cation can result in mental health challenges (Canadian There is no cure for AD. Although several drugs
Mental Health Association [CMHA], 2015). Depression have been developed, none reverses the progression of
is common in the older adult population, especially the disease. Depression and social isolation are common
among those with a chronic disease or social isolation. In among those who are diagnosed with AD. The nurse’s
long-term care settings, the majority of residents have a responsibility is to monitor the impact of cognitive func-
mental health diagnosis, including dementia and depres- tion on all aspects of the client’s health and provide
sion (Canadian Coalition for Seniors’ Mental Health, supportive person-centred and family-centred care. The
2010). It is difficult to determine the prevalence of men- nurse also provides accurate information, and referral
tal health issues among older adults, as many are hesitant assistance from diagnosis through the various adjust-
to disclose their illness because of fear of stigmatization. ment periods. Referral to home care and respite services
In addition, mental health conditions are often masked is helpful for the caregiver. The financial, physical, and
or confused by physiological aging. psychological impact on family caregivers is significant
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and difficult to enumerate. Canada is one of only a few in detecting and intervening in elder abuse (National Ini-
countries that offer financial support for individuals who tiative for the Care of the Elderly [NICE], 2015).
leave work to care for an aging family member (Govern-
ment of Canada, 2015a).
It is critical that dementia be differentiated from
delirium (see Chapter 37). In contrast to dementia, Planning for Health
delirium is an acute and reversible syndrome charac-
terized by onset of disorientation. The most common
Promotion
causes of delirium are infection, medications, and dehy-
It is important that older adults take an active role in
dration. Nurses need to identify when delirium is super-
the care planning process. Most older adults want to
imposed on dementia and intervene immediately (Fick &
be involved in decision making about their health. It is
Mion, 2013).
important to set goals that are mutually agreed upon
Although there is no cure for dementia, there is
and realistic for the older adult to achieve. Smaller goals
some evidence that moderate physical activity and diets
that can be accomplished in shorter time frames may
high in cereals, fish, legumes, and vegetables may pre-
enhance motivation and success.
vent or delay the progression of AD (Alzheimer’s Disease
As older Canadians enjoy longer lives, they are faced
International, 2014; Forbes, Thiessen, Blake, Forbes, &
with the potential burden of chronic illness and disabil-
Forbes, 2015).
ity. Nurses use health-promotion strategies to engage older
Mistreatment of Older Adults One in five Cana- adults so that their clients will learn about healthy aging
dians reports knowing a senior who might be experienc- and how to reduce the risks of illness and injury. (See
ing some form of abuse (Government of Canada, 2015b, the Health-Promotion Guidelines box for older adults.)
para 1). Elder abuse is defined as “any action by someone The emergence of community health centres and use
in a relationship of trust that results in harm or distress of health-focused Internet sites (technology) can increase
to an older person.” Neglect is as serious as abuse and is accessibility to health services for older adults living in the
defined as lack of action by a person in a trusting rela- community. In providing seamless, quality care for older
tionship, which results in harm or distress. All seniors are adults and their caregivers, nurses can invite interprofes-
vulnerable to elder abuse. sional and family input in the planning process. Reflect
Mistreatment can be classified as physical, psy- on how public participation and intersectoral cooperation can
chological, financial, or neglect. Sexual abuse has also lead to one-stop shopping or multiservice agencies in
been documented. Abuse can be a single incident or a many communities (e.g., community health centres).
repeated pattern of behaviour. Often, more than one
type of abuse occurs simultaneously. Financial abuse is
the most commonly reported form of abuse. Abusers can Nursing Interventions for Health
be family members, a friend, caregivers, or health care
providers. In many situations, the abuser is dependent on Promotion and Protection
the older adult for money, food, or housing. A variety of nursing interventions and health-promotion
The following are some signs and symptoms that guidelines for older adults have been provided through-
may indicate that an older adult is being mistreated: out this chapter. Communicating with older adults can
• Fear, anxiety, depression, agitation, or passivity also be challenging (see Chapter 22 for the box Lifespan
Considerations: Communication with Older Adults). To
• Unexplained physical injuries
support nurses in their work with older adults, the Reg-
• Poor nutrition, dehydration, or poor hygiene istered Nurses’ Association of Ontario (RNAO) has pub-
• Confusion about legal documents, such as a will lished a number of guidelines related to the care of older
clients. These guidelines are intended to help nurses
Older adults at home may fail to report abuse or
make evidence-informed decisions specific to their prac-
neglect for many reasons. They may be ashamed or fear
tice circumstances. The following selected guidelines are
retaliation, including institutionalization, if they seek
available on the RNAO website:
help. Some older adults lack the mental capacity to be
aware of the situation. • Prevention of falls and injuries in the older adult
Nurses should also be familiar with governmental • Prevention of constipation in the older adult population
laws regarding the reporting of suspected or known
abuse. They can intervene by educating caregivers about • Screening for delirium, dementia, and depression in
the needs of older adults and about available resources older adults
to increase home support. The nurse also needs to ask Other guidelines are available through a variety of
about family structure and relationships, caregiving, and professional organizations. See the Weblinks online for
lifestyle practices. Screening tools are available to assist two information-rich sources.
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Health-Promotion Guidelines for Older Adults

The following are important to the health of older adults:
Health Tests and Screening • Sexually transmitted infections (STIs) testing, if in high-risk
• Annual health examination, including height and weight group
• Blood pressure screening at each primary care visit Safety
• Total cholesterol and lipid profile every 1 to 5 years, • Home injury prevention measures to prevent falls, burns,
dependent on cardiovascular risk score (Canadian and poisoning
Cardiovascular Society, 2013) • Working smoke detectors and carbon monoxide detectors
• Screening for type 2 diabetes using a fasting plasma in the home
glucose and/or hemoglobin A1C every 3 years, or more • Motor vehicle safety reinforcement, especially when driving
frequently with high risk factors (Canadian Diabetes at night
Association, 2013)
• Precautions to prevent pedestrian accidents
• Smoking cessation
• Older-driver skills evaluations
• Immunizations, as recommended, including tetanus and
diphtheria booster every 10 years; herpes zoster (shingles) • Education about safe medication use
at 60 years, pneumococcal vaccination at age 65 years, Nutrition and Exercise
annual influenza vaccine (PHAC, 2014b)
• A well-balanced diet using Canada’s Food Guide, with
• Dental assessments every 6 to 9 months fewer calories to accommodate lower metabolic rate and
• Annual eye examination decreased physical activity
• Routine prostate screening for men, although not recom- • Sufficient amounts of vitamin D and calcium to prevent
mended, should be discussed with the health care prac- osteoporosis
titioner (Canadian Task Force on Preventive Health Care, • Diet low in saturated fats and cholesterol and high in cere-
2014) als, fish, legumes, and vegetables
• Colorectal screening, including a fecal occult blood test, • One hour of moderate physical exercise daily to protect
every 2 years after the age of 50 years (Canadian Cancer against cardiovascular disease
Society, 2015b)
• Mammography every 2 to 3 years between the ages of 50 Elimination
and 69 years for those who are at average risk for cancer • Adequate fibre, exercise, and fluids to prevent constipation
(Canadian Cancer Society, 2015b)
Social Interactions
• Cervical cancer screening every 3 years. Screening may
be discontinued after the age of 70 years if there are • Intellectual and recreational pursuits
three successive negative results of the Papanicolauo • Personal relationships that promote discussion of feelings,
(“Pap”) test in the previous 10 years (Canadian Task concerns, and fears
Force on Preventive Health Care, 2014) • Assessment of risk factors for abuse and neglect
• Depression screening periodically • Availability of community centres, programs, and support
• Family violence screening periodically groups for older adults
Case Study 20
Mrs. Alice Green, a 78-year-old female, has had a bone density
scan as part of a regular physical examination and has been
2. What risk factors related to osteoporosis should be
included in an assessment of Mrs. Green?
told that she has severe osteoporosis. Her primary care health
practitioner has ordered a new medication that is supposed to 3. Which of the risk factors are modifiable or can be altered
maintain bone mass in clients with osteo- by a change in lifestyle?
porosis. Mrs. Green lives alone in her own 4. What medication teaching is essential when a client is
home and is able to perform her activities of taking medications to increase or maintain bone mass in
daily living (ADLs) independently. osteoporosis?
5. What preventive measures should be taught to decrease
risks of fractures and to maintain bone mass?
1. How would you define osteoporosis to Mrs. Green?
M20_KOZI2703_04_SE_C20.indd 359 08/02/17 6:14 PM

Ke y Terms
activity theory p. 352 dementia p. 357 long-term memory presbycusis p. 350
ageism p. 346 disengagement p. 354 presbyopia p. 350
aging in place p. 353 theory p. 352 nocturia p. 351 recent memory p. 354
Alzheimer’s disease dyspnea p. 351 orthostatic sarcopenia p. 350
p. 357 frailty p. 345 hypotension p. 351 sensory memory
baby boomer p. 345 functional age p. 345 osteoporosis p. 350 p. 354
cataracts p. 350 geriatrics p. 346 pathological short-term memory
claudication p. 351 gerontology p. 346 fractures p. 350 p. 354
continuity theory p. 352 hypothermia p. 356 perception p. 354 xerostomia p. 351
delirium p. 358 kyphosis p. 350 polypharmacy p. 357 zoomers p. 345

• The Canadian older adult population is steadily growing • Psychosocial theories about aging include the disengage-
and is projected to outnumber young people by 2036. ment, activity, and continuity theories.
• It is important for nurses to be aware of their own values • The older adult has to adjust to psychosocial changes,
and attitudes toward the aged and to examine whether including retirement, grandparenting, relocation, increas-
myths or stereotypes influence their personal attitudes ing dependence on others, and coping with losses and
and beliefs. death.
• Older adults are primary users of health care services • The cognitive abilities of the healthy older adult undergo
in different types of care settings, including acute care, changes in perception, cognitive agility, memory, and
rehabilitation, long-term care, and community set- learning.
tings. Regardless of the setting, the older adult requires • In the realm of moral reasoning, most older adults begin
health assessment, health promotion, and injury to blend concepts of justice and caring relationships into
protection. their moral decision making.
• Several theories have been proposed to account for the • Health problems of older adults include injuries, chronic
biological aging process: wear-and-tear, genetic, immu- disabling disease, drug abuse and misuse, addictions,
nity, cross-linking, free radicals, genetics cross-linking, and mental health disorders, and mistreatment.
neuroendocrine theories.
• Health-promotion information for all adults needs to
• Older adults experience many physical changes associated include positive health practices that can promote health
with aging. All body systems undergo change. and wellness.

1. A nurse is doing a presentation on early detection and 2. A long-term care resident has multiple chronic health
prevention of cancer with a group of older adults. A problems and disability. Which of the following health
participant asks the nurse, “What is the most important problems should the nurse regularly assess for in this
cancer screening test for our age group?” What is the client?
nurse’s best response to this question? a. Dementia
a. Papanicolau (Pap) test b. Delirium
b. Fecal occult blood test (FOBT) c. Depression
c. Prostate-specific antigen (PSA) test d. Diabetes
d. Breast self-examination
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3. A client was recently admitted to a long-term care facil- filtration rate (eGFR). How will this information be used
ity. She refuses to interact with other residents, appears by the nurse to provide care to the client?
sad, and has not been eating. How should the nurse a. Client will likely experience nocturia and will require
intervene? assistance
a. Ask other residents to visit with the client b. Excretion of medications may be altered
b. Speak with the client about her feelings c. Monitor heart rate because the client will have
c. Suggest that the physician prescribe an antidepressant decreased cardiac output
d. Take the client to social events in the facility d. Anticipate urinary frequency and the need for a
urinal
4. A nurse has been invited by a seniors group to do a pre-
sentation on strategies for healthy aging. Which of the 8. A client, 76 years old, has been a widow for about
following theories of aging would be best for the nurse 7 months. She recently sold her house and moved
to use for this presentation? into a seniors’ complex, following the advice of her
daughter, who lives about 600 km away. Influencing
a. Cumming and Henry’s disengagement theory
her decision was the fact that she has never driven a
b. Havighurst’s activity theory car. What should the nurse be aware of ?
c. Erickson’s developmental theory a. The client may be vulnerable to social isolation.
d. Dilman and Dean’s neuroendocrine theory b. The client may be subject to abuse by her daughter.
c. The client may be experiencing dementia.
5. A nurse is doing the first home visit with an older adult
d. Retirement may be stressful to the client.
client. Which of the following observations by the nurse
raises concerns about environmental safety and the cli-
ent’s risk for a fall? 9. An 82-year-old retired engineer likes to ride his bicycle
to the library twice a week. What might this indicate to
a. Kyphotic posture the nurse?
b. Hardwood floors in the living and dining room areas a. Chronological age is a more accurate indicator of
of the home abilities than is functional age.
c. Presbyopia b. Functional age is the same as chronological age.
d. Poorly lit hallway between the master bedroom and c. Functional age is a more accurate indicator of
bathroom abilities than is chronological age.
d. This is an example of continuity theory.
6. Six months ago, a client experienced a right-sided cere-
brovascular accident (stroke). During a home care visit, 10. A client was admitted to a long-term care facility with
the nurse observes that the client is reluctant to perform Alzheimer’s disease (senile dementia of Alzheimer’s
the exercises suggested by the physiotherapist. How type) about 6 months ago and is on a number of medi-
should the nurse intervene? cations. Over the past several days, she has demon-
a. Encourage the client to perform the exercises on a strated bizarre behaviour, hallucinations, and increased
regular basis verbal rambling. How should the nurse intervene?
b. Help the client verbalize his feelings a. Ask other residents to visit the client as she is experi-
c. Refer the client to mental health services encing sensory deprivation because of lack of social
d. Talk to his wife about the reason why her husband is interaction
reluctant b. Assess the client for signs of adverse effects from the
medications she is taking
7. An older male client was admitted to a medical unit c. Inform the other staff of the changes in the client
to treat complications associated with the influenza. behaviour
A nurse is reviewing the client’s blood work. The d. Request that a sedative be given to reduce the client’s
only abnormal result is the low estimated glomerular aggressive behaviour
R e f ere nc es
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21
UNIT 4
Chapter Integral Aspects

of Nursing
Clinical Reasoning and

Critical Thinking
Updated by
Linda Ferguson, RN, PhD
A
LEARNING OUTCOMES
After studying this chapter, you will be able to key component to the
1. Describe the significance of developing critical thinking abilities to transition of layperson

practise safe and competent nursing care. to nurse is the devel-
2. Discuss ways of engaging in critical thinking in nursing practice. opment of one’s knowledge and
acquisition of, or refinement of,
3. Discuss the attitudes and skills needed to be critical thinkers.
one’s thinking skills. Dr. Christine
4. Distinguish clinical reasoning from clinical judgment and critical
Tanner, an American nurse educator,
thinking.
described this process as learning
5. Explain the relationship between clinical knowledge, experience,
to think like a nurse (Tanner, 2006).
clinical reasoning, and critical thinking.
An expectation of professionalism in
6. Describe the role of critical thinking and clinical reasoning in the
nursing is the use of one’s knowledge
nursing process.
and thinking skills for the benefit of
7. Discuss the use of concept mapping in facilitating critical thinking
the patients and families with whom
and clinical reasoning in nursing practice
one is working (College of Nurses of
Ontario, 2014). Nurses use a vari-
ety of thinking strategies to address
the health and health care issues,
concerns, challenges, and opportuni-
ties that present to patients, families,
and communities. Nursing students
enter their educational programs with
varying levels of thinking skills, and
throughout their nursing programs,
they will have the opportunities to
refine these skills and apply their
developing knowledge within the
classroom, in simulation experiences,
and with patients and clients. c
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Chapter 21 Clinical Reasoning and Critical Thinking 365
c The nature of nursing and the complexity of nurses’ work require that nurses use multiple thinking
strategies for effective clinical practice. In this chapter, these thinking strategies will be explored, recogniz-
ing that nurses need skill in all thinking strategies. Nursing students will be provided with opportunities to
reflect on their thinking, a term known as metacognition, which literally means thinking about thinking. In
doing so, they can identify their strengths and limitations in terms of thinking strategies and depth and
understanding of the knowledge of nursing and other supporting disciplines, such as physiology, micro-
biology, and pharmacology. Thinking strategies include critical thinking, clinical reasoning, clinical judg-
ment, evidence-based or evidence-informed practice, and reflection, all interrelated and fluid processes.
Nursing as a discipline has a number of ways of knowing, including empirics (the science or
knowledge of nursing), aesthetics (the art of nursing), personal knowing, and ethics (Carper, 1978),
and emancipatory knowing that provides the sociopolitical knowledge to facilitate change (Chinn
& Kramer, 2011) (see Chapter 4). It is important to use a variety of thinking strategies, particularly
reflection, to enhance knowledge development in each of these areas. Enhancing one’s knowledge
contributes to the quality of the care provided to patients and their families.
Critical Thinking Association of Schools of Nursing (CASN, 2014) promotes

and supports the use of critical thinking, defined as
the skills needed to use relevant information, knowledge,
Nurses need to be critical thinkers. Through critical thinking, and communication technologies to support evidence-
nurses help patients and clients solve problems or issues informed nursing practice. The CASN acknowledges the
by clearly defining the issue, critically analyzing contrib- importance and relevance of critical thinking to the disci-
uting factors, seeking evidence for particular approaches, pline and practice of nursing. Reflection on prioritization
generating a number of solutions, and enacting the one of nursing care requires substantive knowledge of nursing
that seems most likely to achieve desired outcomes. Criti- sciences such as physiology, pharmacology, and psychol-
cal thinking is a systematic process that facilitates the nurse ogy, as well as clinical experience to support critical think-
and client in making more informed decisions. Nurses, ing in practice. This expectation is reflected in the licensure
as members of a team of health care professionals, are examinations, where the emphasis is on assessing nurses’
often involved in critically analyzing an issue and system- competency in decision-making, problem-solving, and
atically exploring alternatives. critical-thinking skills in varied clinical or client situations.
Clinical reasoning, a similar process, involves many of
the same strategies to address patient and client issues, but
it also focuses on the alternatives generated. Many patient
issues are complex and difficult to address, resulting in Critical Thinking:
nurses, patients and families, and other health care pro-
fessionals hypothesizing about possible causes and, thus, Definitions and Purposes
solutions. In medicine, the terms “differential diagnoses”
and “diagnostic reasoning” are often used to reflect the The thinking process that guides nursing practice must
hypotheses that need further investigation. In nursing, be organized, purposeful, self-regulatory, and disci-
we often refer to these alternatives as possible solutions plined. Alfaro-LeFevre described critical thinking as
that need further exploration, or application and evalua- including clinical reasoning and clinical judgment and
tion. Creativity, the process of seeking novel or innovative being purposeful, informed outcome-focused thinking
approaches, can enhance the effectiveness of proposed (Alfaro-LeFevre, 2013). According to Alfaro-LeFevre
solutions or decisions and individualize care for patients (2014), critical thinking
and clients. Clinical judgment refers to the process of evalu- • is guided by standards, policies, and ethical codes and
ating alternatives and coming to a conclusion about the laws;
best approach—the outcome of critical thinking.
Nurses use critical thinking to make meaningful obser- • is based on the principles of the nursing process, prob-
vations, draw sound conclusions, create new information lem solving, and the scientific method;
and ideas, evaluate lines of reasoning, question prevailing • identifies key problems, issues, and risks involved;
assumptions, and improve self-knowledge. The Canadian • applies logic, intuition, and creativity;
M21_KOZI2703_04_SE_C21.indd 365 08/02/17 6:34 PM

366 UNIT FOUR Integral Aspects of Nursing
• is driven by patient, family, and community needs;

• calls for strategies to address those problems and
CT Characteristics
needs; and (Attitudes/Behaviours)
• focuses on patient safety and quality of care.
Critical thinking involves calling into question the
assumptions that underlie usual ways of thinking and
Technical Skills/ Critical Theoretical & Experiential
acting in situations and then being prepared to think Competencies Thinking Knowledge Intellectual Skills/
Ability
and act differently on the basis of this critical question- Competencies
ing (Brookfield, 1987). It is purposeful thinking wherein

the thinker systematically and habitually imposes criteria
and intellectual standards on thinking (Paul, 1993).
Critical thinking is a complex process, and it moves Interpersonal Skills/
Competencies
thinking into purposeful action. A landmark study involv-
ing internationally diverse expert nurses from nine coun-
Starting at the top and going clockwise around the circles above, here’s what
tries defined 10 habits of the mind (affective components) you need to do to develop your ability to think critically:
and seven skills (cognitive components) of critical think- 1. Develop a critical thinking character. Hold yourself to high standards. Make
ing in nursing (Scheffer & Rubenfeld, 2000). The habits a commitment to developing critical thinking characteristics such as
honesty, fair-mindedness, creativity, patience, and confidence.
of the mind are those affective components that pre- 2. Take responsibility and seek out learning experiences to help you get the
theoretical and experiential knowledge to think critically. Practise intellectual
dispose individuals to be strong critical thinkers. These skills such as assessing systematically and comprehensively. Just as
components include having a contextual perspective and practising physical skills improves your ability to perform physically,
practising thinking skills improves your ability to perform intellectually.
intellectual integrity and being confident, creative, flex- 3. Gain interpersonal skills such as teamwork, resolving conflict, and being
an advocate. Keep in mind that “being too nice” problems (e.g., not giving
ible, reflective, open-minded, persevering, intuitive, and constructive criticism because of concerns of not offending someone)
can be as bad as “not being very nice” problems (e.g., demonstrating
inquisitive. These personal attributes can be enhanced arrogance, sarcasm, or intolerance of other ways of doing things). Learn
by purposefully trying to incorporate actions that reflect how to give and take feedback. To improve you must get through the
negative aspects of criticism.
them. The skills of critical thinking are cognitive attri- 4. Practise related technical skills (e.g., using computers, managing IV’s).
Until these skills become like second nature, they create a “brain drain”
butes that can be learned, including skills in seeking making it difficult to focus on other important things such as monitoring
patient responses to care.
information, analyzing information or situations, dis-
criminating among aspects of situations or information,
transferring knowledge to other situations, applying stan- FIGURE 21.1 Alfaro-LeFevre’s Four-Circle Critical Thinking
dards, predicting outcomes, and using logical reasoning. Model.
Source: Reprinted with permission from Alfaro-LeFevre, R. (2014). Critical thinking
Nurses are expected to help patients and clients make indicators. Florida, MI: Stuart. Retrieved from http://www.alfaroteachsmart.com/cti.htm
decisions and address problems by critically analyzing
contributing factors. This critical analysis, or critical
thinking, allows the nurse and the patient or client to situation. When unanticipated situations arise, criti-
make better decisions, particularly when clear answers cal thinking enables the nurse to recognize important
are not available and when conflicting forces make deci- cues, respond quickly by drawing on relevant knowl-
sions complex. Critical thinking is not negative thinking edge, and adapt best practice interventions at the right
or the inclination to find fault but, rather, is a systematic time to meet specific client needs. Box 21.1 lists some
approach to analyzing issues and determining alternatives personal critical thinking indicators.
for action. Alfaro-LeFevre’s Four-Circle Critical Thinking • Nurses make important decisions. Nurses use critical think-
Model provides a visual representation of critical thinking ing skills to collect, compile, and interpret the informa-
abilities and promotes making meaningful connections tion needed to make clinical decisions and judgments.
between nursing research and positions on critical think- For example, nurses must use prudent judgment to
ing and practice (Alfaro-LeFevre, 2013) (Figure 21.1). decide which observations to report to the appro-
Nurses use critical thinking skills in a variety of ways: priate member of the health care team immediately
• Nurses use knowledge from other disciplines. Nurses use critical and which can be noted in the patient record for
thinking skills when they reflect on knowledge derived the appropriate member of the health care team to
from other interdisciplinary subject areas, such as the address later, during the routine client visit.
biophysical and behavioural sciences, and the humani- Creativity—original thinking—is an important
ties to provide holistic nursing care. For example, reg- component of critical thinking. When nurses incorporate
istered nurses might use information from nutrition, creativity into their thinking, they are able to find unique
physiology, and physics to promote wound healing and solutions to unique problems. As an example, a pediatric
prevent further injury to a client with a pressure ulcer. nurse who was experiencing difficulty encouraging a very
• Nurses deal with change in stressful environments. A client’s young child to increase fluid intake came up with the
condition may rapidly change, and routine proto- idea of a game that required the child to drink nutritious
cols may not be adequate to cover every unexpected fluids. Another nurse addressed the same challenge by
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Box 21.1 Personal Critical Thinking Indicators: Behaviours Demonstrating Critical

Thinking Characteristics and Attitudes
• Self-aware: Clarifies biases, inclinations, strengths, and • Sensitive to diversity: Expresses appreciation of human
limitations; acknowledges when thinking may be influ- differences related to values, culture, personality, or
enced by emotions or self-interest learning style preferences; adapts to preferences, when
• Genuine: Shows authentic self; demonstrates behaviours feasible
that indicate stated values • Creative: Offers alternative solutions and approaches;
• Self-disciplined: Stays on task as needed; manages time comes up with useful ideas
to focus on priorities • Realistic and practical: Admits when things are not fea-
• Healthy: Promotes a healthy lifestyle; uses healthy behav- sible; looks for user-friendly solutions
iours to manage stress • Reflective and self-corrective: Carefully considers mean-
• Careful and prudent: Knows own limits—seeks help, as ing of data and interpersonal interactions, asks for feed-
needed; suspends or revises judgment as indicated by back; corrects own thinking, alert to potential errors by
new or incomplete data self and others, finds ways to avoid future mistakes
• Confident and resilient: Expresses faith in ability to reason • Proactive: Anticipates consequences, plans ahead, acts
and learn; overcomes disappointments on opportunities
• Honest and upright: Seeks the truth, even if it sheds • Courageous: Stands up for beliefs, advocates for others,
unwanted light; upholds standards; admits flaws in does not hide from challenges
thinking • Patient and persistent: Waits for right moment; perse-
• Curious and inquisitive: Looks for reasons, explana- veres to achieve best results
tions, and meaning; seeks new information to broaden • Flexible: Changes approaches, as needed, to get the
understanding best results
• Alert to context: Looks for changes in circumstances that • Empathetic: Listens well; shows ability to imagine others’
warrant a need to modify thinking or approaches feelings and difficulties
• Analytical and insightful: Identifies relationships; • Improvement-oriented (self, patients, systems): Self—
expresses deep understanding identifies learning needs; finds ways to overcome limita-
• Logical and intuitive: Draws reasonable conclusions (if tions, seeks out new knowledge. Patients—promotes
this is so, then it follows that . . . because . . .); uses intu- health; maximizes function, comfort, and convenience.
ition as a guide to search for evidence; acts on intuition Systems—identifies risks and problems with health care
only with knowledge of risks involved systems; promotes safety, quality, satisfaction, and cost
containment.
• Open and fair-minded: Shows tolerance for different
viewpoints; questions how own viewpoints are influencing
thinking Source: Reprinted with permission from Alfaro-LeFevre, R. (2014). Critical thinking indi-
cators. Florida, MI: Stuart. Retrieved from http://www.alfaroteachsmart.com/cti.htm
using a playful and colourful circular straw to encourage These techniques include cognitive abilities, such as
the child’s fluid intake. Creative thinking is thinking that critical analysis, inductive and deductive reasoning, mak-
results in the development of new ideas, approaches, or ing valid inferences, differentiating facts from opinions,
products. It is a vital part of providing competent patient evaluating the credibility of information sources, clarify-
care, particularly for unusual situations that require adap- ing concepts, and recognizing assumptions.
tation of current approaches to individual patients. These Critical analysis is the application of questions
approaches must still be based on principles of nursing to a particular situation or idea to determine essential
care and patient safety, requiring critical thinking to elements and discard superfluous information and ideas.
determine their appropriateness. Critical thinking skills The questions are not sequential steps; rather, they form
and abilities, including creative thinking and flexibility, a set of criteria for judging an idea. Not all questions will
are developed over time through practice experience and need to be applied to every situation, but one should be
with reflection and constructive feedback. aware of all the questions and choose those appropriate
to a given situation.
Socrates was a Greek philosopher and the first criti-
cal thinker who modelled a method of questioning to
Techniques in Critical foster critical thinking. Socratic questioning is a tech-
nique one can use to look beneath the surface, recognize
Thinking and examine assumptions, search for inconsistencies,
examine multiple points of view, and differentiate what
In addition to the affective and cognitive components is known from what is merely believed. Box 21.2 lists
of critical thinking skills, nurses use other techniques to Socratic questions to use in critical analysis. Nurses can
ensure effective problem solving and decision making. employ this questioning when reviewing a patient health
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BOX 21.2 SOCRATIC QUESTIONS history or progress notes, planning care, or discussing
a patient’s care with the patient, colleagues, and other
Nurses can use Socratic questions to help them think health care professionals.
critically. Two skills used in complex thinking are inductive
QUESTIONS ABOUT THE QUESTION (OR PROBLEM) and deductive reasoning. In inductive reasoning,
conclusions are formed from a set of facts or observa-
• Is this question clear, understandable, and correctly tions. When viewed together, certain bits of information
identified? suggest a particular interpretation. For example, the
• Is this question important? nurse who observes that a patient has dry skin, poor
• Could this question be broken down into smaller parts? tissue turgor, sunken eyes, and dark amber urine may
• How might state this question? make the generalization that the patient is dehydrated.
In inductive reasoning, one proceeds from specific facts
QUESTIONS ABOUT ASSUMPTIONS to a general conclusion.
Deductive reasoning, in contrast, is reasoning
• You seem to be assuming ; is that so? from a general approach to a specific conclusion. If the
• What could you assume instead? Why? nurse accepts the premise (fact) that immobility is harm-
• Does this assumption always hold true? ful to a patient after surgery, the nurse will ensure that
the patient is ambulated postoperatively to avoid com-
QUESTIONS ABOUT POINT OF VIEW plications. The premise, which may be a fact, theory, or
opinion, needs to be examined to determine if it is valid
• You seem to be using the perspective of . Why? in particular situations. For instance, early postoperative
• What would someone who disagrees with your mobilization may be contraindicated following certain
perspective say?
surgical procedures, and nurses will need to implement
• Can you see this any other way? other nursing interventions to avoid complications.
In critical thinking, the nurse also differentiates
QUESTIONS ABOUT EVIDENCE AND REASONS statements of fact, inference, judgment, and opinion.
Table 21.1 shows how these statements may be applied
• What evidence do you have for that?
to nursing care. Evaluating the credibility of informa-
• Is there any reason to doubt that evidence?
tion sources is an important step in critical thinking. The
• How do you know?
nurse will need to determine whether the basic underly-
• What would change your mind? ing premise is fact or opinion and ascertain the accuracy
of information by checking reliable documents or cred-
QUESTIONS ABOUT IMPLICATIONS AND ible sources of information. Hence, the expanding need
CONSEQUENCES for evidence-based nursing practice is important for safe
• What effect would that have? nursing practice.
• What is the probability that will actually happen? REASONING PROCESS A clear reasoning process is par-
• What are the alternatives? ticularly important when problems are complex and have
• What are the implications of that? multiple potential solutions. According to Gaberson,
Oermann, and Schellenbarger (2014), the critical think-
Source: From Paul, R. (1993). Socratic questioning in critical thinking: How to prepare ing process comprises the following elements of reasoning:
students for a rapidly changing world (pp. 335–365). Copyright © 1993 by Founda-
tion for Critical Thinking. Used by permission of Foundation for Critical Thinking. 1. Purpose of the critical thinking
2. Question, issue, or problem that requires resolution
TABLE 21.1 Differentiating Types of Statements
Statement Description Example

Facts Can be corroborated through investigation Blood pressure is affected by blood volume.
Inferences Conclusions drawn from the facts; going beyond If blood volume is decreased (e.g., in
facts to make a statement about something not hemorrhagic shock), blood pressure will drop.
currently known
Judgments Evaluation of facts or information that reflect Blood pressure dropping to very low levels is
values or other criteria; a type of opinion harmful to the client’s health.
Opinions Beliefs formed over time; include judgments Nursing intervention can assist in maintaining
that may fit facts or be in error the client’s blood pressure within normal limits.
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3. Assumptions about the problem Various types of knowledge are drawn upon when
4. Analysis of own and others’ points of view using clinical reasoning (Simmons, 2010). Tanner, who
developed the Clinical Judgment Model, defined clini-
5. Data and evidence to support
cal judgment as “. . . the interpretation or conclusion
6. Concepts and theories used in thinking about a patient’s needs, concerns or health problems,
7. Inferences and conclusions based on given data and/or the decision to take action (or not), use or modify
8. Implications and consequences of reasoning standard approaches, or improvise new ones as deemed
appropriate by the patient’s response” (Tanner, 2006,
p. 204). Clinical judgment is the decision or outcome
that results from clinical reasoning. Clinical judgment
Clinical Reasoning can never be reduced to a technical decision but, rather,
is based on the experience of the nurse, knowledge
Nurses uses both critical thinking and clinical reasoning about the person (client), and the context of the situa-
in practice. These concepts are similar but different. In tion (Benner, Hughes, & Sutphen, 2008; Tanner, 2006).
nursing practice, clinical reasoning is a thought pro- Clinical reasoning is described as the thought process by
cess used to assess a client’s evolving situation and health which these judgments are made.
care concerns, gather data, and make decisions to solve The Clinical Judgment Model includes four
problems within a particular clinical context to achieve aspects that can be used within continuously evolving
better client outcomes (Benner, Hughes, & Sutphen, practice environments. Noticing is the nurses’ initial grasp
2008; Benner, Sutphen, Leonard, & Day, 2010; Tanner, of the patient’s situation and can include expectations
2006). Clinical reasoning is the thinking process of man- based on the nurses’ previous experience with patients in
aging patient issues at the point of care, generally using similar situations. Reasoning is triggered after noticing,
the nursing process (Alfaro-LeFevre, 2014). Clinical rea- and in the interpreting aspect, the meaning of the data gath-
soning focuses on the thinking strategies nurses use to ered from the patient is examined. This leads to taking an
make judgments or decisions and/or solve problems appropriate course of action—the responding aspect.
along with clients, and involves critical thinking. There are two components in the reflection aspect.
Context is an important aspect of clinical reasoning. Reflection-in-action refers to the nurse’s ability to determine
The nurse is aware not only of how he or she performs how the patient is responding to the nursing care or inter-
a task with the patient but also of the patient’s reaction vention delivered and to make adjustments as appropriate.
to the task and his own situation. For example, if the Reflection-on-action takes into account what nurses learn
patient requires assistance with ambulating, how did he from practice situations and how their experiences con-
usually do this task at home, who was available to assist tribute to their overall knowledge development and build
him, and how would he prefer that this assistance be their expertise for future practice situations. For example, a
made available? If the client wishes to ambulate without nurse who is changing a dressing for a patient with a burn
assistance in the hospital, is he aware of the effects of injury recognizes that the patient is experiencing signifi-
his treatment, and is the nurse aware of standards for cant pain. The nurse uses reflection-in-action to make the
patient safety? Clinical reasoning involves awareness of, judgment that the patient needs medication for pain prior
assessment of, and reaction to all aspects of the patient’s to the dressing change. In future practice, reflection-on-
care on an ongoing basis (Benner et al., 2010). action would lead the nurse to assess a patient’s need for
Another component of clinical reasoning is priority pain control prior to starting nursing procedures.
setting. Nurses recognize the importance of assessing and Nurses use clinical reasoning to think about a
prioritizing patient care needs. In this process, nurses patient’s health care situation and use their knowledge
think about what patient care to provide first, what patient and experience to gather and assess patient data, weigh
care goals are more urgent, and how to evaluate, reassess, alternative interventions, and plan appropriate care.
and adapt, as needed. Time management is critical in This process evolves and is ongoing as the patient’s situ-
complex practice settings. Confidence and autonomy in ation changes (Simmons, 2010; Tanner, 2006).
practice grow and develop with experience, making prior-
ity setting easier (Benner et al., 2010). Nurses must make
decisions about priorities in patient care constantly, using Attitudes That Foster
critical thinking skills. For example, one patient is to be
repositioned in bed; however, after a respiratory assess- Critical Thinking
ment, the nurse notices that the patient is having difficulty
breathing, and the patient complains of tightness in the Certain attitudes enhance one’s critical thinking. A crit-
chest. Although the nurse recognizes the importance of ical thinker works to develop the following attitudes
repositioning the patient every 2 hours, the respiratory or traits: independence of thought, fair-mindedness,
complaint is the more urgent situation, requiring immedi- insight, intellectual humility, intellectual courage, integ-
ate attention and change in the plan of care. rity, perseverance, confidence, and curiosity.
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Independence light of new knowledge. They never assume that their

knowledge or beliefs will always be right, as new evi-
Critical thinking requires that individuals think for them- dence may emerge. A hospital nurse might assume that
selves. People acquire many beliefs in their childhood an 80-year-old woman would be unable to care for her
that are not necessarily based on reason or evidence. husband, who has recently had a stroke. More effective
These beliefs provide an explanation they can compre- assessment of the couple’s situation could negate this
hend or offer rational reasons for believing. Alternatively, assumption and allow the nurse to effectively support this
these beliefs may be an outcome of not questioning the couple in their desire to live in their own home.
authorities promoting them. As critical thinkers mature
and acquire knowledge and experience, they examine
their own beliefs and assumptions in light of new evi- Intellectual Courage
dence. As part of interprofessional teams, nurses are
exposed to both personal and professional beliefs, values, With an attitude of courage, people are willing to con-
and practices of other health care professionals. Critical sider and examine their own ideas or views, especially
thinkers consider a wide range of ideas, learn from them, those ideas to which they have a strong negative reac-
state their own perspectives clearly, and make their own tion. This type of courage comes from recognizing that
judgments about them. values, beliefs, or assumptions are acquired through
one’s life experience, based on one’s culture, religion,
experience, or society. These values and beliefs have not
necessarily been acquired rationally or based on valid
Fair-Mindedness data. They may be false or misleading and may not apply
Critical thinkers are fair-minded, assessing all viewpoints to others.
against the same standards and not basing judgments Rational beliefs are those that have been examined
on personal or group bias or prejudice. Fair-mindedness and found to be supported by solid reasons and data.
helps people consider opposing points of view and try After such examination, it is inevitable that some ideas,
to understand new ideas fully before rejecting or accept- previously held to be true, are found to contain question-
ing them. Critical thinkers strive to be open to the pos- able elements. In other instances, previously dismissed
sibility that new evidence or information, or different ideas may hold truth supported by credible data. It is
approaches could change their minds. difficult to admit to oneself that previously held beliefs
are wrong. It takes courage to accept new beliefs and
to incorporate them into one’s thinking. For example,
Insight some nurses may believe that allowing family members
to observe an emergency measure (e.g., cardiopulmonary
Critical thinkers are open to the possibility that their per- resuscitation [CPR]) would be psychologically harmful
sonal biases, social pressures, customs, and cultural back- to the family and that members would get in the health
ground affect their thinking. They actively try to examine care team’s way. Others may feel that exclusion of family
their own biases and bring them to awareness each time members would be unnecessary and, in fact, extremely
they make a decision. For example, consider a nurse stressful for some family members. As a result, nurses can
who spent extensive time trying to teach a client how to initiate research to demonstrate that the family can be
prevent recurrence of a problem but was mystified when present in such a situation without detrimental effects to
the client appeared uninterested and did not follow the the nurse, the client, or the family.
nurse’s advice. The nurse had presumed that the patient
would be interested in preventive self-care (just because
the nurse was), and this had resulted in an inaccurate Integrity
assessment of the client’s readiness to learn. Analysis of
this situation resulted in the nurse realizing that better Intellectual integrity requires that individuals apply the
assessment of the patient’s understanding of his condi- same rigorous standards of proof to their own knowl-
tion and his cultural background, beliefs, and support edge and beliefs as to the knowledge and beliefs of
systems would have resulted in a more effective teaching others. Critical thinkers question their own knowledge
plan. Such insights add to the nurse’s practice knowledge. and beliefs or assumptions as quickly and thoroughly
as they challenge those of another. They are readily
able to admit and evaluate inconsistencies within their
own beliefs and between their own beliefs and those
Intellectual Humility of another. For example, a nurse might believe that
Intellectual humility means having an awareness of the wound care always requires sterile technique. Reading
limits of one’s own knowledge. Critical thinkers are willan evidence-based article on the use and outcomes of
ing to admit what they do not know; they are willing to clean technique for some wounds leads the critically
seek new information and rethink their conclusions in thinking nurse to reconsider his or her belief.
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Perseverance Table 21.2 Universal Intellectual Standards
Nurses who are critical thinkers show perseverance in Standard Sample Question
seeking effective solutions to client and nursing problems.
Clarity What is an example of this?
This determination enables them to clarify concepts and
sort out related issues in spite of difficulties and frustra- Accuracy How can I find out if that is true?
tions. Confusion and frustration are uncomfortable, but Precision Can I be more specific?
critical thinkers resist the temptation to find a quick and Relevance How does that help me with the issue?
easy solution. Important nursing practice questions tend Depth What makes this a difficult problem?
to be complex and therefore often require a great deal Breadth Do I need to consider another point of view?
of thought and research to get the right answer. The
Logic Does that follow from the evidence?
nurse needs to continue to address the issue until it is
resolved and to resist the temptation to come to a hasty Significance Which of these facts is most important?
conclusion. Fairness Am I considering the thinking of others?
Source: Paul, R., & Elder, L. (2005). A guide for educators to critical thinking compe-
tency standards (p. 57). Dillon Beach, CA: Foundation for Critical Thinking. Adapted
Confidence
with permission.
Critical thinkers believe that well-reasoned thinking will

lead to trustworthy conclusions. Therefore, they have
an attitude of confidence in the reasoning process and
Applying Critical Thinking
examine emotion-laden discussions by using the stan-
dards for evaluating thoughts, by asking questions such
to Nursing Practice
as the following: Is that argument fair? Is it based on Critical thinking, clinical reasoning, problem solving,
sufficient evidence? decision making, and reflective thinking are interrelated
The critical thinker develops skill in both inductive processes of thinking in nursing practice. Of these, criti-
reasoning and deductive reasoning. As a critical thinker cal thinking is a broad process that relies on examination
gains greater awareness of the thinking process and of knowledge and assumptions as well as on exploration
more experience in improving such thinking, confidence of alternatives. It can include both problem solving and
in the thinking process grows. The confident thinker is decision making. Problem solving and decision mak-
not afraid of disagreement. ing are often used interchangeably, but they are differ-
ent. Reflective thinking focuses on the critique and
evaluation of actions taken and lessons learned. Each
Curiosity process is discussed in more detail in the following sec-
The mind of a critical thinker is filled with questions: tion. Although the trial-and-error approach can be
Why do we believe this? What causes that? Does it have used for problem solving in some circumstances, it is
to be this way? Could something else work? What would not a safe approach in health care, and more thoughtful
happen if we did it another way? Who says that is so? approaches to patient care must be used.
The curious individual may value tradition but is not
afraid to examine traditions to be sure that they are still
valid. The nurse may, for example, apply these ques- Problem Solving
tions and strategies to practice issues, such as moving the Problem solving involves working through a process
responsibility for a procedure (e.g., drawing an arterial of recognizing, clearly defining, and then solving a prob-
blood sample) to the nursing, respiratory therapy, or lem. Many alternative solutions may be considered and
laboratory department staff. implemented in resolving the problem. In decision making,
alternatives are examined and the one most appropriate
to the situation is selected. Decision making may or may
Standards of Critical not involve a problem.
In problem solving, the nurse obtains information
Thinking that clarifies the nature of the problem and suggests pos-
sible solutions. Defining a patient problem or issue often
How can one know whether one’s thinking is critical involves discussion with the patient, the patient’s family,
thinking and whether it is conscious and systematic? and other health care professionals. The nurse, possibly
Paul and Elder (2005) proposed universal standards in collaboration with other health care professionals,
(Table 21.2) as a guide that nurses can use to evaluate then carefully evaluates the possible solutions, chooses
their thinking so that they can provide competent care the best one to implement, and continues to monitor
based on evidence-based practice. outcomes to determine the effectiveness of the solution.
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If the outcome is not as anticipated, an alternative it is not recommended for use by novices or students
solution may be implemented. Therefore, problem solv- because they usually lack the knowledge base and clini-
ing for one situation contributes to the nurse’s body of cal experience that would enable them make a rapid but
knowledge that can be used for problem solving in other valid judgment.
similar situations.
Research Process The research process is a for-
Heuristics Heuristics are thinking shortcuts that malized, logical, systematic approach to problem solving.
result from experiences of thinking critically and system- It is becoming increasingly important that nurses apply
atically about a patient issue and determining an approach the research process to identify evidence that supports
that has proven to be effective. It is a way of thinking effective nursing care. One critical source of this evi-
about the issue, a way that can be used for other similar dence is research (see Chapter 3).
situations in the future. The benefit of heuristics is that
the nurse has spent time thinking critically, and the same
thought processes can be applied to the new situation Decision Making
more quickly. Heuristics are time-saving thinking tools.
The nurse must still determine, through clear definition Nurses use critical thinking skills in decision making
of the problem, that the situations are similar and that the to help them choose the best action to meet a desired
solution applies to the new situation as well. Many experi- goal. Decisions must be made whenever several mutu-
enced nurses use heuristics to address commonly encoun- ally exclusive choices exist. For example, the individual
tered problems in their practice settings and use clinical who wants to become a nurse in Canada can choose
reasoning and critical thinking when new patient issues from programs in different universities throughout the
emerge. For example, a nurse is performing the admission country. To make the appropriate decision, a prospective
of a very old woman who has a chronic movement-limiting student must evaluate the programs and consider per-
illness and lives alone. From past experience, the nurse sonal circumstances, as well as any other relevant data
knows that many clients who have this pattern of living (e.g., geography, entry-to-program requirements) that
can often be malnourished and dehydrated. The nurse, may influence his choice.
using a heuristic, performs a nutritional assessment of Nurses make decisions on an ongoing basis in their
this client. Heuristics represent knowledge gained through personal as well as professional lives. For example, when
experience and critical reflection. faced with meeting several clients’ needs at the same time,
the nurse must prioritize and decide which client to assist
Intuition Intuition is the understanding or learning first. When a client is trying to make a decision about what
of things without the conscious use of reasoning. It is course of treatment to receive, the nurse may need to
also referred to as “sixth sense,” “hunch,” “instinct,” provide the client with information or sources of informa-
“feeling,” or “suspicion.” Some people consider intuition tion. The nurse is constantly making decisions about which
a form of guessing, and, as such, an inappropriate basis patient to attend to first and in what order to provide nurs-
for nursing decisions. However, others view intuition as ing care measures. Decision making is an important pro-
an essential and legitimate aspect of clinical judgment cess and takes place at many levels on an ongoing basis..
acquired through knowledge and experience. Clinical In practice, nurses use evidence to guide their deci-
experience allows the nurse to recognize cues and pat- sion making about patient care. Evidence-based
terns in the patient situation, interpret those patterns practice (EBP) is “the integration of best research
quickly, and reach the right conclusion even without evidence with clinical expertise and patient values to
employing systematic thinking. Use of the nurse’s experi- facilitate clinical decision making” (DiCenso, Ciliska, &
ence and heuristics may be part of this process. Guyatt, 2005, p. 4). EBP involves consciously questioning
Experience is important in intuition because the practice and using evidence to guide the care provided
rapidity of the judgment process depends on the nurse to patients. Evidence consists of information acquired
having encountered similar client situations many times through research (quantitative and qualitative studies)
before. Sometimes nurses use the words “I had a feel- and meta-analysis, EBP guidelines, or case studies. Sev-
ing” to describe a leap in the critical thinking element eral models exist to assist health care agencies to imple-
of considering data and evidence. These nurses are ment EBP in their organizations. The Ottawa Model
able to judge quickly and decisively which evidence is of Research Use is one example (Titler & Cameron,
most important and to act on that limited evidence. If 2012). The Registered Nurses’ Association of Ontario
nurses intuitively feel a patient’s situation has changed, (RNAO) offers best practice guidelines (BPGs) for
they assess the patient in greater depth to confirm their nurses to use in hospital and community agencies. These
suspicions, validate their assessment, and obtain the data BPGs are one example of how research is summarized
needed as a basis for interventions or to report to other and synthesized into guidelines to provide nurses with
health care professionals. an evidence-based standard of care to guide problem
Although the intuitive method of problem solving solving and decision making in practice. The Cochrane
is gaining some recognition as part of nursing practice, Collaboration is an independent network of researchers
M21_KOZI2703_04_SE_C21.indd 372 08/02/17 6:34 PM

that conducts synthesis of research studies and makes guide their decision making in practice and thus practise
recommendations about best evidence for practice (www. from an evidence-informed perspective (CNA, 2010;
cochrane.org). Titler & Cameron, 2012).
Evidence-informed nursing practice is “the The decision-making process can be described as
ongoing process that incorporates evidence from research, comprising the following steps:
clinical expertise, client preferences, and other avail- • Identify the purpose of the decision.
able resources to make nursing decisions about clients”
(CNA, 2010, p. 3). Evidence-informed decision making • Set the criteria for judging the appropriateness of the
in practice is different from EBP in that it is broader, not decision outcome.
only including the use of evidence but also incorporat- • Weight the criteria.
ing patients’ values, beliefs, choices, and cultural and/ • Seek alternatives.
or religious practices, as well as ethics, legislation, policy, • Evaluate alternatives, and select the most appropriate
health care resources, and the resources and context choice.
of the practice setting, all of which influence decision
• Implement.
making (CNA, 2010). Evidence for evidence-informed
practice may also include documents from commissioned • Evaluate the outcome according to criteria.
reports, expert panels, policy/practice standards or regu- A clinical example of the phases of the nursing pro-
lations, and historical or experiential information (CNA, cess and the decision-making process, demonstrating the
2010). It is the responsibility of all nurses to use evidence use of critical thinking with an individual client, is given
(research or other) and incorporate patient values to in Table 21.3.
Table 21.3 Phases of the Nursing Process, the Decision-Making Process, and a Clinical Example of Critical Thinking
Nursing Process Decision-Making Process Clinical Application

Assessing Identify the patient problem or purpose. The Data: A 45-year-old Aboriginal male complains of severe
nurse identifies why a decision is needed headache; 10 kg overweight; blood pressure (BP)
and what needs to be determined. 180/95 mm Hg; states that he has been taking pills
for high BP only when he has a headache; is self-
employed as a gardener; lives with wife, mother-in-law,
and four children
Given these data, a critical thinker is aware that more data
must be obtained about the client’s health values and
reasons for stated behaviour. Failure to think critically
and to obtain additional data leads to inaccurate goals,
diagnosis, and interventions.
Diagnosing/ A critical thinker will defer identifying the client’s diagnosis
Analyzing until more data are obtained and the client’s priorities
are known.
As a critical thinker, the nurse is aware that the client’s
point of view may differ from the nurse’s.
The critical thinker recognizes that the client’s erratic
use of the prescribed medication may have multiple
causes and will not infer a diagnosis until more data are
obtained. Failure to think critically can lead to interpreta-
tions that are irrelevant, inadequate, and superficial.
The critical thinker examines assumptions, for example,
that an increase in knowledge will increase this client’s
compliance.
Planning The critical thinker uses concepts of motivation, change
theory, and multicultural nursing to understand the cli-
ent’s behaviour and motivation to change.
Set the criteria. When the nurse sets the cri- Goal: To increase compliance with medication regimen to
teria for decision making, three questions relieve headaches and prevent a cerebrovascular acci-
must be answered: dent. Thinking critically, a nurse will try to determine the
• What is the desired outcome? client’s goals and agree to mutual goals.
• What needs to be preserved?
• What needs to be avoided?
(continued)
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Table 21.3 (continued )
Nursing Process Decision-Making Process Clinical Application

Weight the criteria. In this step, the decision
maker sets priorities or ranks activities or
services from least important to most impor-
tant as they relate to the specific situation.
Seek alternatives. The decision maker identi-
fies possible ways to meet the criteria. In
clinical situations, the alternatives may be
selected from a range of nursing interven-
tions or client care strategies.
Examine alternatives. The nurse analyzes
the alternatives to ensure that there is an
objective rationale for choosing one strat-
egy over another.
Implementing Implement. The decision plan is placed into The critical thinker considers the implications and conse-
action. quences of selected nursing strategies before imple-
menting plans of care. Plans of care, including goals
and outcomes, are based on ongoing assessment of
the client’s cultural values, beliefs, and needs. Failure
to think critically may lead to ineffective interventions,
such as client teaching that focuses only on resolving a
knowledge deficit about the prescribed medication.
Evaluating Evaluate the outcome. As with all n ursing The critical thinker bases evaluation of client outcomes
care, in evaluating, the nurse determines and the effectiveness of nursing interventions on well-
the effectiveness of the plan and whether developed, measurable criteria and considers rationally
the initial purpose was achieved. whether the outcomes have been validated.
Developing Critical own actions. This process may also be referred to as

self-regulated inquiry or professional inquiry. Reflection
Thinking Attitudes on one’s own actions is an important part of the critical
thinking process, the process of making clinical judgments,
and Skills and learning to “think like a nurse” reflected through the
Clinical Judgment Model (Tanner, 2006). To become a
After gaining an appreciation of what it means to think caring practitioner, reflection on practice must be personal
critically, solve problems, and make decisions, nurses and meaningful. Reflective practice is a form of self-evaluation
need to become aware of their own thinking style and and is a requirement of ongoing competence in nursing
abilities. Acquiring critical thinking skills and a critical and a practice required by provincial and territorial regula-
attitude is a matter of practice. Critical thinking is not tion (College of Nurses of Ontario [CNO], 2014). Reflec-
an “either/or” phenomenon; people develop and use it tive journalling, as a tool for learning, is usually shared
more or less effectively along a continuum. Some people with a mentor or teacher, who works in partnership with
make better evaluations than others do; critical thinking the student. Reflection could be done in dialogue with a
is not easy. Solving problems and making decisions can partner or as a group. The process of debriefing after criti-
be challenging, and sometimes the outcome is not the cal incidents in practice is a reflective process that nurses
desired one. With effort and practice, however, almost on a unit conduct as a group, usually with the assistance of
everyone can develop critical thinking skills and become a facilitator. The intent of reflective practice is to improve
an effective problem solver and decision maker. nursing practice and the care provided.
The nurse can reflect on situations in which he or
she made decisions that were later regretted and can
analyze thinking processes and attitudes or ask a trusted
Reflection on Practice colleague to assess them. Identifying weak or vulnerable
Reflection is thinking from a critical point of view— skills and attitudes is important as well, as is the process
analyzing the reasons and assessing the results of one’s of reflecting on successful interventions and why the
M21_KOZI2703_04_SE_C21.indd 374 08/02/17 6:34 PM

FIGURE 21.2 Mind map for critical thinking in nursing.

Source: Pearson Education Inc.
outcomes were positive, although many nurses reflect appears as part of three of the steps: the starting points,
on success less often. Figure 21.2 shows a mind map processes, and outcomes.
that provides a visual depiction of the interactive con- A framework such as the one in Box 21.3 offers a
cepts used in critical thinking. The action of reflection structure for the journalling process. Writing reflections
BOX 21.3 A FRAMEWORK FOR REFLECTIVE JOURNALLING

To engage in meaningful reflection, students must bring 3. What did it mean?
special skills to the process: self-awareness, descrip- Analyze the meaning of the event to those involved. How
tion, critical analysis, synthesis, and evaluation (Bulman & did the environment or context of the event influence the
Schutz, 2008). Using a framework is especially helpful to participants? Bring in ideas from outside of the experi-
the beginner who is establishing the process of reflection. ence to enlighten and compare.
The framework listed below includes suggestions from sev- 4. How do you evaluate the situation?
eral different models on reflection and can be further devel- What was good or bad about the experience, in light of
oped by the individual practitioner. your own values and feelings?
5. What did you learn?
1. What happened?
What conclusions did you reach about the situation, in a
Describe the situation or event, including who was
general sense? More specifically, what did you learn about
involved, the associated events, and the outcomes. Avoid
yourself and your own way of thinking and working?
making judgments; simply describe.
6. Now what?
2. What did you do and think? What are you going to do differently (or the same) based
Describe your role in the situation, what you did, and your on what you learned from this experience? Where can
thoughts at the time. Again, focus on description only. you get more information to improve your understanding
and approach to practice?
M21_KOZI2703_04_SE_C21.indd 375 02/03/17 2:23 PM

in a journal provides a space for the student to look at

and acknowledge personal strengths and limitations. Evidence-Informed
Guidance from a mentor or teacher can help the student Practice
view a nursing situation from different perspectives. It
helps the student find meaning in the event, understand Expert Nurses’ Facilitation
and learn through it, and emerge at a higher level of
understanding. The purpose of this reflection is to deter-
of Evidence-Based Practice
mine what was learned from the experience, examine in Clinical Settings
what was thought and felt about it, whether the current
Canadian researchers conducted a study of 20 nurses who
course of action was the best, and what one would do had a role in facilitating evidence-based practice in clinical
differently the next time to improve future actions. See settings across Canada. In a symposium in Toronto, Ontario,
the Evidence-Informed Practice box for supports for nurses identified critical incidents in their facilitation roles.
nurses in practice. Analysis of this data revealed that nurses are motivated to
implement evidence to support high priority needs and that
relevant evidence was readily accessible and applicable to
their patient populations. Partnerships, project teams, the
Tolerating Dissonance and Ambiguity expertise and credibility of the facilitator, and stakeholder
involvement all supported evidence-based practice (EBP).
Nurses need to make deliberate efforts to cultivate Negative factors included lack of ownership of EBP, resource
critical thinking attitudes. For example, to develop fair- deficits, poor team functioning, and lack of sustainability.
mindedness, nurses could deliberately seek out infor-
Nursing Implications: EBP and translation of
mation that is opposed to their own views. This action
research findings into practice are facilitated by expert
provides practice in understanding and learning to nurses who can help nurses address relevant practice
be open to other viewpoints. Nurses should increase issues using credible evidence. Nurses need readily
their tolerance for ideas that contradict previously held accessible evidence and assistance in determining its
beliefs, and they should practise suspending judgment. implementation in their settings.
Suspending judgment means tolerating ambiguity Source: Based on Dogherty, E. J., Harrison, M. B., Graham, I. D., & Keeping-Burke,
for a time. If an issue is complex, it may not be resolved L. (2013). Turning knowledge into action at the point-of-care: The collective experi-
ence of nurses facilitating the implementation of evidence-based practice. World-
quickly or neatly, and judgment should be postponed. For views on Evidence-Based Nursing, 10(3), 129–139.
a while, the nurse will need to say, “I don’t know” and
be comfortable with that answer until more is known.
Although postponing judgment may not be feasible in
emergency situations, where fast action is required, it is and family structures. As leaders, nurses should encour-
often feasible in other situations. age their colleagues to examine evidence carefully before
they come to conclusions. Interprofessional groups also
allow for discussions from different professional perspec-
tives and enrich the discussion of alternatives, often
Seeking Environments That Support benefiting the patient through better outcomes of care.
Critical Thinking
Nurses will find it valuable to engage in discussions
that support open examination of all sides of issues Concept Mapping
and respect opposing viewpoints. Nursing rounds or Concept mapping is a technique that uses a graphic
interprofessional rounds offer opportunities for thought- depiction of linear and nonlinear relationships to rep-
ful discussions of complex patient issues and possible resent critical thinking. Also known as mind mapping,
approaches to care. Cultivating a questioning attitude is concept maps are context dependent and can be used to
vital. Nurses need to review the standards for evaluating develop analytical skills. Concept maps allow one to orga-
thinking and apply them to their own thinking. If nurses nize (and reorganize) and connect information, making
are aware of their own thinking and assumptions—while meaning of the concept or concepts that they represent.
they are doing the thinking—they can detect errors in Concept maps provide an opportunity to “see” thinking;
their thinking. mapping is an effective method to facilitate creative,
A nurse will have difficulties developing or main- reflective, and critical thinking (Chabeli, 2010).
taining critical thinking attitudes in a vacuum. Nurses
in leadership positions can use a variety of strategies to
create learning environments that foster and encourage
differences of opinion and fair examination of ideas and
Concept Mapping and Critical Thinking
options (Mundy & Denham, 2008). Nurses must also Concept mapping can be used to bridge nursing the-
embrace exploration of the perspectives of persons from ory and practice by enhancing critical thinking pro-
different ages, cultures, religions, socioeconomic levels, cesses when trying to understand complex phenomena
M21_KOZI2703_04_SE_C21.indd 376 08/02/17 6:34 PM

A. B.
INPUT
OUTPUT
C. D.
FIGURE 21.3 Types of concept maps: A, Hierarchical; B, Spider; C, Flowchart; D, Systems.
(Alfaro-LeFevre, 2013). Visual mapping of relationships and are expected to consider more than one possibil-
enables students to develop and clarify links among ity, recognize emerging client problems, and intervene
key pieces of information. As a conceptual approach appropriately in life-threatening situations, concept
with active involvement, concept mapping promotes mapping may be a valuable tool to improve nurses’ criti-
higher-level thinking and decision-making skills. Because cal thinking, clinical decision making, and performance.
nurses are faced with copious amounts of information Four basic types of maps are shown in Figure 21.3.
Case Study 21
You are taking the bus to downtown Vineland, an area that is
unfamiliar to you. As a nursing student involved in a community
2. What further information would be relevant to support
your conclusions?
health practice experience, you assess the neighbourhood along
the bus route. There is graffiti on both residential and commercial 3. How can you, as a nursing student, begin to address
buildings, trash is blowing along the road outside a number of some of the actual and potential issues within the
premises, and some shops are closed, with boarded-up win- neighbourhood that you assessed?
dows. You see a home with the front porch falling away, another 4. What assumptions do you hold about this neighbour-
home with a few broken windows, and a home with a roof that hood and the residents you saw in the area?
is missing many shingles. In your assessment, you notice that
5. Do any of your assumptions reflect biases or prejudices?
children reside in each of these residences, as older-model
bikes and a few toys are scattered around each property. As the 6. What critical thinking skills were used to respond to this
bus passes a gas station and a convenience store, you notice a case study?
group of youth painting a mural depicting community develop-
ment on the side of the gas station wall. When you pass by a city Visit MyNursingLab for answers and explanations.
park in this neighbourhood, you see a child less than 10 years of
*Source: Questions adapted from Green, C. (2000). Critical thinking in nursing: Case
age playing on a rusty swing set, while his young mother is close studies across the curriculum. Upper Saddle River, NJ: Prentice Hall Health.
by, rocking her newborn. In the distance, a woman is pushing a
grocery cart that is filled with items in garbage bags. The woman
looks to be in her 50s and has a slow gait as she struggles
with the cart. On your return to your nursing
school, you meet with the community health
faculty adviser to discuss the neighbourhood
assessment experience.
CRITICAL THINKING QUESTIONS*
1. What conclusions can you draw about this neighbour-

hood on the basis of your assessment?
M21_KOZI2703_04_SE_C21.indd 377 27/02/17 9:45 AM

Ke y Term s
best practice critical thinking p. 365 inductive reasoning Socratic questioning
guidelines p. 372 decision making p. 372 p. 368 p. 367
clinical judgment p. 369 deductive reasoning intuition p. 372 thinking strategies
Clinical Judgment p. 368 knowledge of nursing p. 365
Model p. 369 evidence-based p. 365 trial-and-error
clinical reasoning p. 369 practice p. 372 metacognition p. 365 approach p. 371
concept mapping evidence-informed problem solving p. 371 ways of knowing
p. 376 nursing practice reflection p. 374 p. 365
creativity p. 366 p. 373 reflective thinking p. 371
critical analysis p. 367 heuristics p. 372 research process p. 372

• Nurses need critical thinking skills and attitudes to be (g) inferences and conclusions, and (h) implications and
safe, competent, skillful practitioners. Critical thinking is a consequences. Critical thinkers consider these elements
purposeful cognitive activity in which ideas are produced when solving problems and making decisions.
and evaluated and judgments are made. • The nursing process and critical thinking are interrelated
• Critical thinking is reasonable, rational, reflective, and interdependent, but they are not identical. Both
autonomous, creative, and fair, and inspires an attitude of involve problem solving, decision making, and creativity.
inquiry that focuses on deciding what to believe or do. • Decisions must be made whenever several mutually
• Critical thinkers have certain attitudes and traits: inde- exclusive choices exist. Nurses must make decisions in
pendence of thought, fair-mindedness, insight, intellec- both their personal and professional lives. The steps of
tual humility, intellectual courage, integrity, perseverance, the decision-making process are identifying the purpose
confidence, curiosity, and contextual awareness. of the decision, setting the criteria, weighting the criteria,
• Nurses use critical thinking as they apply knowledge from seeking alternatives, testing alternatives, troubleshooting,
other disciplines to nursing practice, deal with change and evaluating the action.
in stressful environments, and make important decisions • Almost everyone has at least some level of critical think-
related to client care. When nurses incorporate creativity ing skill, and this skill can be developed with practice.
into their thinking, they are able to find unique solutions Some guidelines to enhance critical thinking skills and
to challenging problems. attitudes include making a self-assessment, tolerating
• Critical thinking consists of high-level cognitive processes dissonance and ambiguity, seeking situations in which
that include problem solving and decision making. Three good thinking is practised, and creating environments
problem-solving methods are heuristics, intuition, and the that support critical thinking.
nursing process. • Clinical reasoning is described as a thought process used
• The elements of reasoning include (a) the purpose of for a specific purpose in a practice setting. Context and
critical thinking, (b) the question, issue, or problem, priority setting are important components of clinical
(c) assumptions, (d) analysis of points of view, (e) infor- reasoning and various types of knowledge are drawn
mation, data, and evidence, (f) concepts and theories, upon during this process.

1. Mr. Richard runs into the emergency department. He d. Tell Mr. Richard that he must calm down because
screams, “My wife is bleeding in the car! She is going his screaming is only making the situation worse and
to die! Quick, do something! We are losing our baby!” his cooperation is required
What should the nurse do as a priority?
a. Ask Mr. Richard to say where the car is and then 2. A client with diarrhea has a physician’s order for a bulk lax-
conduct a summary assessment of the situation ative daily. The nurse, not realizing that bulk laxatives can
help solidify certain types of diarrhea, concludes that the
b. Tell a colleague to perform a vaginal examination as physician does not know the client has diarrhea. What is
quickly as possible the most accurate way to characterize the nurse’s thinking?
c. Inform the physician of the urgency of the situation a. A fact
and suggest that the operating room be prepared b. An inference
M21_KOZI2703_04_SE_C21.indd 378 08/02/17 6:34 PM

c. A judgment blood pressure medication. He continues to receive oxy-

d. An opinion gen via nasal prongs. The nurse enters his room to do
his morning assessment, including vital signs. The client
3. A client reports feeling hungry but does not eat when tells the nurse he is having trouble catching his breath.
food is served. What should the nurse do? The nurse notes his pulse is above the normal range,
and his respirations seem laboured. The nurse interprets
a. Assess why the client is not eating the food provided the situation, draws a conclusion about the client’s needs
b. Leave the food at the bedside until the client is hun- and decides to take action. What is the best description
gry enough to eat of this process?
c. Notify the health care provider that tube feeding a. Clinical reasoning
may be needed soon
b. Clinical judgment
d. Believe the client is not really hungry
c. Priority setting
4. A client who is short of breath benefits from the head d. Critical thinking
of the bed being elevated. Because this position can
result in skin breakdown in the sacral area, the nurse 8. A nurse is about to interview a new resident as part
decides to learn more about the amount of sacral of the admission process to the long-term care facility.
pressure occurring in other positions. What type of The admission process includes taking complete his-
decision making is the nurse demonstrating in this tory from the resident. Which of the following should
scenario? the nurse do?
a. The scientific method a. Ensure proper health history forms are on hand,
b. The trial and error method enter the room, pull up a chair and sit down, intro-
c. Intuition duce self, and begin the history
d. The nursing process b. Ensure proper health history forms are on hand,
knock, enter the room, introduce self, and explain
what needs to be done
5. A nurse is engaged in the planning phase of the
decision-making process and has set criteria, weighed c. Enter the room, find the resident sleeping, and
the priorities, and examined the alternatives. What is decide to wait until tomorrow or the next day to
the next step the nurse should take before implementing complete the history
the plan? d. Ensure proper health history forms are on hand,
a. Re-examine the purpose for making the decision enter the room, introduce self, stand at the resident’s
b. Consult the client and family members to determine bedside, and complete the forms
their view of the criteria
c. Identify and consider various means for reaching the 9. The manager of the transplantation unit is concerned
outcomes about having adequate staffing on the unit for the
summer as several nurses have requested the same
d. Determine the logical course of action should inter- weekends off. How might the manager best resolve
vening problems arise the problem?
6. A client had hip replacement surgery 2 weeks ago and a. Call a unit meeting to consider what solutions the
is now on the rehabilitation unit. Today is the first day nursing staff might propose
the nurse is caring for this client. The nurse returns b. Propose that no holidays be permitted during the
the client to his room and helps him into bed for the peak summer months
night. The client had a difficult time at physiotherapy c. Ask each nurse for his or her preferences and have a
this afternoon, and the nurse has just spent an hour lottery
with him, listening to his concerns about regaining his
independence and mobility. What should the nurse do d. Let everyone take the holidays they want and see
before leaving the client’s room? what happens
a. Inform the client about continued care the next day
10. A nurse is assisting to mobilize a client the first day fol-
and wish him goodnight
lowing surgery. The client is struggling to walk down
b. Tell the client that the lights are being turned out the hallway because he is experiencing incisional pain,
and leave the door ajar while leaving rated 6 out of 10 on the pain scale. The nurse makes
c. Ensure the client’s call bell is within reach and the the decision to return the client to the client’s room and
bedside rails are in the upright position to get him an analgesic. What aspect of clinical reason-
d. Knowing the client has an as-needed (prn) order ing was the nurse demonstrating when the walk was cut
for a sleeping pill, ask if he feels he will need a pill short and the client was given an analgesic?
tonight a. Noticing
b. Reflection-on-action
7. A client had a myocardial infarction 3 weeks ago.
This client has been started on one acetylsalicylic acid c. Interpreting
(Aspirin) a day, a new anticoagulant, and a different d. Reflection-in-action
M21_KOZI2703_04_SE_C21.indd 379 08/02/17 6:34 PM

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informed_2010_e.pdf. Scheffer, B. K., & Rubenfeld, M. G. (2000). A consensus statement
Carper, B. A. (1978). Fundamental patterns of knowing in on critical thinking in nursing. Journal of Nursing Education, 39,
nursing. In P. G. Reed & N. B. C. Shearer (Eds.), Perspectives on 352–362.
nursing theory (6th ed.). Philadelphia, PA: Lippincott, Williams & Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of
Wilkins. Advanced Nursing, 66, 1151–1158.
Chinn, P., & Kramer, M. (2011). Integrated theory and knowledge Tanner, C. A. (2006). Thinking like a nurse: A research-based
development in nursing (8th ed.) St. Louis, MO: Mosby. model of clinical judgment in nursing. Journal of Nursing
College of Nurses of Ontario (CNO). (2014). Competencies for Education, 45(6), 204–211.
entry-level registered nurse practice. Ottawa, ON: Author. Titler, M. G., & Cameron, C. (2012). Use of research in practice.
Chabeli, M. M. (2010). Concept-mapping as a teaching method to In G. Lobiondo-Wood, J. Haber, C. Cameron, & M. D. Singh
facilitate critical thinking in nursing education: A review of the (Eds.), Nursing research in Canada: Methods and critical appraisal for
literature. Health SA Gesondheid, 15(1), 1–7. evidence-based practice (3rd ed.). Toronto, ON: Elsevier.
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Chapter 22
Caring and
Communicating *
Updated by
Evelyn Kennedy, RN, PhD
Nursing, School of Professional Studies, Cape Breton University
M
LEARNING OUTCOMES
After studying this chapter, you will be able to any students enter
1. Discuss the concept of caring and relevant nursing theories that the nursing profession
focus on caring. because they want to
2. Discuss the importance of the four types of knowledge that guide care for people. In this caring profes-
nursing practice. sion, communication is both a criti-
3. Describe how nurses demonstrate caring in practice. cal and a vital skill and is an integral
part of the nurse–client relationship.
4. List the essential aspects of the communication process.
Nurses use communication to gather
5. Describe factors that facilitate and hinder the effective
information, to teach and persuade,
communication process.
and to express caring and comfort.
6. Compare and contrast therapeutic communication techniques that
Caring is central to all helping pro-
facilitate communication and focus on client concerns.
fessions, and it enables people to
7. Discuss characteristics of an effectively functioning group.
create meaning in their lives. Nurses
8. Describe how nurses use communication skills in each phase of need strong communication skills to
the nursing process to establish a helping relationship.
effectively care for their clients and to
9. Describe how incivility, lateral violence, and bullying could affect interact effectively with other mem-
the health care environment and client safety.
bers of the health care team.
10. Differentiate the major characteristics of assertive and
nonassertive communication.
*The editorial team would like to acknowledge and to thank Lucia Yiu for preparing and
writing sections of Chapter 22.
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Professionalization (Leininger & McFarland, 2006). Transcultural nurs-

ing focuses on both the differences and the similarities
of Caring among persons of diverse cultures. Although different
cultures have unique ways of caring for others, certain
universal behaviours are common to all cultures of the
Caring is an essential aspect of nursing. Caring practice
world. To provide care that is congruent with cultural
involves connection, mutual recognition, and involve-
values, beliefs, and practices, the nurse must understand
ment between the nurse and the client. Consider these
these differences and similarities. To understand the care
examples of caring:
desired by clients, the nurse requires knowledge of the
• A nurse talks quietly and holds the hand of a client culture and local language. When nursing care fails to be
who is in pain. The nurse’s presence provides comfort reasonably congruent with the client’s beliefs, lifeways,
for the client. and values, signs of conflict, noncompliance, and stress
• A student nurse helps an older woman who is immobi- may arise.
lized apply her makeup before she greets her daughter Leininger believed that culturally competent
and grandchildren. The woman’s sense of dignity is care is provided in three ways: (a) by preserving the cli-
enhanced by this personal care. ent’s familiar lifeways, (b) by making accommodations in
care that are satisfying to clients, and (c) by repatterning
The nurses involved in these situations experience nursing care appropriately to help the client move toward
caring through knowing that they have made a difference wellness. Creative nursing approaches that incorporate
in their clients’ lives. The caring process has benefits the above activities are needed to make care both mean-
for the one giving care. By caring and being cared for, ingful and helpful to clients. She further defined caring as
each person finds his or her place in the world. By serv- “those assistive, supportive, and enabling experiences or
ing others through caring, persons live the meaning of ideas towards others with evident or anticipated needs,
their own lives. The essence of caring is often found in to ameliorate or improve a human condition or lifeway”
the process itself—that of engagement and connection (Leininger & McFarland, 2006, p. 12).
between the nurse and the client and between the nurse
and the community (Hills & Watson, 2011; Watson,
2008). Caring includes assistive, supportive, and facilita-
tive acts for individuals or groups. Theory of Caring (Swanson)
Swanson (1991) defined caring as “a nurturing way of
relating to a valued “other,” toward whom one feels
Nursing Theories a personal sense of commitment and responsibility”

(cited in Wojnar, 2010, p. 743). An assumption of her
on Caring theory is that a client’s well-being should be enhanced
through the care of a nurse who understands the com-
mon human responses to a specific health problem. The
The focus of any professional discipline is derived from its
theory focuses on caring processes as nursing interven-
belief and value system, the nature of its service, and its
tions. Swanson’s theory was developed through interac-
area of knowledge development. The focus of nursing as
tions with parents at the time of pregnancy, miscarriage,
a discipline has been defined as the study of caring in the
and birth.
human health experience (Newman, Sime, & Corcoran-Perry,
Swanson’s Theory of Caring (Jansson & Adolfsson,
2009). Nurse scholars have reviewed the literature, con-
2011; Swanson, 1991) described the following five caring
ducted research, and analyzed nurses’ experiences, which
processes to guide nursing interventions:
has resulted in the development of theories and models
of caring. These theories and models are grounded in 1. “Knowing” involves the need for the nurse to under-
humanism and the idea that caring is the basis for human stand the life event/situation experienced by the cli-
science. Each theory develops different aspects of caring, ent and family. To do this, nurses engage themselves
describing how caring in nursing is unique. Several nurs- and centre their care on the client. As they conduct
ing theorists have focused on caring: Leininger, Swanson, their thorough assessment, nurses must avoid making
Watson, Benner and Wrubel, and Roach. assumptions and must look for cues as part of their
data collection.
Culture Care Diversity 2. “Being with” encompasses how nurses convey caring
and centre their presence on their clients. To do this,
and Universality (Leininger) nurses must be empathic, and they must listen and
Madeleine Leininger’s theory of culture care diversity attend to their clients’ needs. Nurses must also con-
and universality is based on the assumption that nurses vey their ability in providing care and share feelings or
must understand various cultures to function effectively perspectives without burdening their clients.
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Chapter 22 Caring and Communicating 383
3. “Doing for” refers to the need for nurses to do what A caring relationship requires a certain amount of
needs to be done for their clients as the clients cope openness and capacity to respond to care on the part of
with their life situations. To do this, nurses carry out the client. In caring practice, being with someone can be
therapeutic caring actions, such as comforting, antici- just as important as doing something for that person, if not
pating, and performing care skillfully, while protecting more so. As the nurse gains expertise, he or she learns how
and preserving the dignity of their clients. to interact with people, to respect who they are and where
4. “Enabling” refers to how nurses facilitate their clients they are at, and to accompany people as they do things for
to move through life transitions and unfamiliar events. themselves. Thus, caring practice involves client advocacy
To do this, nurses empower their clients by provid- and provides the necessary conditions to help the client
ing information and explanation. Nurses support and grow and develop (Gordon, Benner, & Noddings, 1996).
allow their clients to focus, to think through the situa-
tion and thereby to generate alternatives, and to seek
validation and feedback for their actions. Caring: The Human
5. “Maintaining belief ” is the foundation of caring. Nurses Mode of Being (Roach)
maintain faith and a belief that people have the capac- Simone Roach focused on caring as a philosophical
ity to get through an event and find meaning and ful- concept and proposed that caring is the human mode
fillment as they move through their various life stages. of being, or the “most common, authentic criterion
To do this, nurses regard their clients with high esteem, of humanness” (Roach, 2004, p. 28). Most persons are
maintain a hope-filled attitude, offer realistic optimism, caring and develop their caring abilities by being true
help them to find meaning of the event or crisis, and to self and interacting with others in a genuine and
offer the needed support during that particular time. authentic manner. Roach defined the following attributes
as the “six Cs of caring”: (a) compassion, (b) compe-
tence, (c) confidence, (d) conscience, (e) commitment,
Theory of Human Care (Watson) and (f) comportment (Box 22.1). The six Cs are used as
Watson’s theory of human care views caring as the
essence and the moral ideal of nursing. Human care is BOX 22.1 THE SIX Cs OF CARING IN NURSING
the basis for nursing’s role in society; and nursing’s contri-
bution to society lies in its moral commitment to human COMPASSION
care. Jean Watson (1999a, 1999b, 2008) described caring Awareness of one’s relationship to others, sharing their
as being grounded in a set of universal human values: joys, sorrows, pain, and accomplishments; participation in
kindness, concern, and love of oneself and others. It is the experience of another
the moral ideal of nursing, and it involves the will to care,
the intent to care, and the caring actions. Caring actions COMPETENCE
include communication, positive regard, and support, or Having the knowledge, judgment, skills, energy, experience,
physical interventions by the nurse. Caring goes beyond and motivation to respond adequately to others within the
the notion of “curing at all costs.” Within the caring situ- demands of professional responsibilities
ation, the nurse enters the experience of the client, and
the client can enter the nurse’s experience. The nurse CONFIDENCE
maintains professional objectivity; both the nurse and the The quality that fosters trusting relationships; comfort with
client seek a sense of harmony within mind, body, and self, client, and family
soul, thereby actualizing the real self. Such interpersonal
contact, which touches the soul, has the power to gener- CONSCIENCE
ate the self-healing process. See Box 4.2 for Watson’s Morals, ethics, and an informed sense of right and wrong;
assumptions about caring. awareness of personal responsibility
COMMITMENT
The Primacy of Caring (Benner Convergence of one’s desires and obligations and the
deliberate choice to act in accordance with them
and Wrubel)
Benner and Wrubel (1989) viewed caring as the essence COMPORTMENT
of excellence in nursing. Nursing is described as a rela- Appropriate bearing, demeanour, dress, and language that
tionship in which caring is primary because it sets up the are in harmony with a caring presence; presenting oneself
possibility of giving and receiving help. Caring practice as someone who respects others and demands respect
requires attending to the particular client over time, Source: Adapted from Roach, M. S. (2004). Caring: The human mode of being (2nd
determining what matters to the person, and using this rev. ed.). Ottawa, ON: CHA Press.
knowledge in clinical judgments.
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a broad framework, suggesting categories of behaviour (e.g., anatomy, physiology, chemistry) to theoretical
that describe professional caring. analysis (e.g., developmental theory, adaptation theory).
Empirical knowledge forms the substantive knowledge of
nursing derived from scientific research and theoretical
Types of Knowledge orientation.
in Nursing Personal Knowing:

Professional nursing is both an art and a science. Nurs- The Therapeutic Use of Self
ing involves different types of knowledge (or ways of
Personal knowledge is concerned with the knowing,
knowing) that are integrated to guide nursing practice.
encountering, and actualizing of the concrete, individual
Nurses require scientific competence (empirical knowing),
self. Because nursing is an interpersonal process, the
therapeutic use of self (personal knowing), moral/ethical
way in which nurses view their own selves and the client
awareness (ethical knowing), and creative action (aesthetic
is of primary concern in any therapeutic relationship.
knowing). These four types of knowledge were originally
Personal knowing promotes wholeness and integrity
identified by Barbara Carper in the 1960s from her obser-
in the personal encounter, achieves engagement rather
vations of nurses’ activities (Carper, 2009). Because these
than detachment, and rejects a manipulative or imper-
ways of knowing in nursing are so fundamental to nursing,
sonal approach.
we continue to use and expand on this framework for nurs-
ing knowledge. An understanding of each type of knowl-
edge is important for the student of nursing because only
by integrating all ways of knowing can the nurse develop Ethical Knowing: The Moral Component
a professional practice. Figure 22.1 illustrates the intercon- The goals of nursing include the conservation of life, alle-
nection of these different types of knowledge. viation of suffering, and promotion of health. Ethical
knowing focuses on matters of obligation or what ought
to be done and goes beyond following the ethical codes
Empirical Knowing: of the discipline. Nursing care involves a series of delib-
The Science of Nursing erate actions or choices that are subject to the judgment
of right or wrong. Occasionally, the principles and norms
Knowledge about the empirical world is systematically that guide choices may be in conflict. The more sensitive
organized into laws and theories for the purpose of and knowledgeable the nurse is to these issues, the more
describing, explaining, and predicting phenomena of “ethical” the nurse will be. The Canadian Nurses Asso-
special concern to the discipline of nursing. Empirical ciation (CNA) Code of Ethics (CNA, 2008) is the document
knowing ranges from factual, observable phenomena that sets the standards for nurses’ ethical practice.
Aesthetic Knowing: The Art of Nursing

Empirical
Knowing Aesthetic knowing is the art of nursing and is expressed
by the individual nurse through his or her creativity and
style in meeting the needs of clients. The nurse uses aes-
thetic knowing to provide care that is both effective and
satisfying. Empathy, compassion, holism, and sensitivity
are important modes in the aesthetic pattern of knowing.
Personal Ethical
Knowing Knowing
Emancipatory Knowing (Chinn & Kramer)
In 2008, Chinn and Kramer expanded on Carper’s
ways of knowing to add emancipatory knowing that
focuses on change and the ability to initiate, support, and
advocate for change through an understanding of the
Aesthetic
socioeconomic, political, and environmental factors that
Knowing create barriers affecting the health and health care of
specific clients. This knowledge is related to how social
FIGURE 22.1 The four ways of knowing. inequities and injustices have emerged and how change
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can be initiated to address these issues, thus making her uniqueness. This knowledge is gained by observing and
social and political change possible. Kramer and Chinn talking with the client and family while using effective lis-
(2008) envisioned emancipatory knowing as the way of tening and communication skills. The nurse cannot remain
knowing that integrates the other four ways of knowing detached but is actively engaged with the client.
(empirical, personal, ethical, and aesthetic) and empow- Take, for example, an older client experiencing post-
ers clients and nurses for change within the self and the operative pain after removal of a cancerous prostate.
larger community, organization, or society. The nurse assesses the client’s pain, using an appropri-
ate pain scale. The client’s positioning, hygiene, amount
of rest, and other physiological variables are assessed
for their effect on pain. Is this surgery likely to cure the
Developing Ways of Knowing cancer, or is it primarily palliative? The meaning of the
The methods for developing each type of knowledge diagnosis and surgery to this client affects his pain expe-
mentioned above are unique (Chinn & Kramer, 2008). rience. The nurse discovers that this man lost his wife to
For example, personal knowing is developed through cancer 2 years ago. His daughter, who is at his bedside, is
critical reflection on one’s own actions and feelings in his primary support. The nurse discusses with his daugh-
practice. Empirical knowing is gained from studying ter how she can make her father more comfortable.
scientific models and theories and from making objec- Knowing the client and family ultimately involves
tive observations. Ethical knowing involves confronting the nurse and client in a caring transaction. By attend-
and resolving conflicting values and beliefs. Aesthetic ing broadly to personal, ethical, aesthetic, and empirical
knowing arises from a deep appreciation of the unique- knowledge, the nurse understands events as they have
ness of each individual and the meanings that individual meaning in the life of the client. The nurse’s knowing the
ascribes to a given situation. The nurse who practises client ultimately increases the possibilities for therapeutic
effectively is able to integrate all types of knowledge to interventions to be perceived as relevant.
understand situations more holistically. Caring in nursing always takes place in a relation-
ship. Caring encounters are influenced by the diversity
of human responses. In addition to knowing the client,
nurses need to establish mutuality in their relationships
Caring in Practice with their clients, empower them, and provide compas-
sionate and competent care. Caring for self is central to
How does a nurse demonstrate caring? Given similar situa- caring for others. Self-care includes a healthy lifestyle (e.g.,
tions, why is one nurse judged to be “caring” while another nutrition, activity and exercise, recreation) and mind–
is said to be “uncaring”? Nurse theorists and researchers body therapies (e.g., guided imagery, meditation, yoga).
have studied this question and identified caring attributes Relational ethics (RE) is an action ethic. One
and behaviours. Consider, for example, Roach’s six Cs, acts in ways that lead to goodness through attention
Watson’s carative factors (see Chapter 4), and Swanson’s given to the moral space created through relationships
structure of caring. Because caring is contextual, a nursing between nurses and their clients, wherein the nurse acts
approach used with a client in one situation may be inef- both responsively and responsibly for the other (the cli-
fective in another. Caring responses are as varied as clients’ ent) and oneself (Storch, Rodney, & Starzomski, 2013).
needs, environmental resources, and nurses’ imaginations. Nurses act using relational ethics as a guide for practice.
When clients perceive the encounter to be caring, their Nurses often do not know the whole picture and there-
sense of dignity and self-worth is increased, and feelings fore act knowing that something must be done.
of connectedness are expressed. Common caring patterns
include knowing the client, nursing presence, empowering
the client, compassion, and competence.
Communicating
Communication is a critical skill for nursing. It is the
Knowing the Client process by which humans meet their survival needs, build
Caring attends to the universality of the client’s experience. relationships, and experience emotions. In nursing, com-
The nurse asks, Who is this person? What is the client’s his- munication is a dynamic process used to gather assessment
tory? What are the client’s needs? desires? dreams? spiri- data, to teach and encourage, and to express caring and
tual beliefs? Who loves and cares for this person at home? comfort. It is an integral part of the helping relationship.
Where is home, and what resources are there? What does The term communication has various meanings,
this person need today, from me, right now? Can this depending on the context in which it is used. To some,
person tell me what is needed? Personal knowledge of the communication is the interchange of information
client is a key in the caring relationship between nurse and between two or more people; in other words, it is the
client. The nurse aims to know who the client is, in his or exchange of ideas or thoughts, a transmission of feelings,
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or a more personal and social interaction between two Walton, 2010). Because the intent of communication is to
or more people. This kind of communication uses such elicit a response, the process is ongoing; the receiver of the
methods as talking and listening or writing and reading; message then becomes the sender of a response, and the
however, painting, dancing, storytelling, and gestures are original sender then becomes the receiver.
also means of communication. SENDER The sender, a person or group that wants to
Communication is often synonymous with relating. convey a message to another, can be considered the source
Frequently, one member of a couple comments that encoder. This term suggests that the person or group send-
the other is not communicating (e.g., some teenagers ing the message must have an idea or reason for communi-
complain about a generation gap—being unable to com- cating (source) and must put the idea or feeling into a form
municate with understanding or feeling to a parent or that can be transmitted. Encoding involves the selection
authority figure). The intent of any communication is to of specific signs, words, or symbols (codes) to transmit the
elicit a response. When individuals communicate, they message, such as which language and words to use, how
have a purpose. Thus, communication is a process. It to arrange the words, and what tone of voice and gestures
has two main purposes: (a) to influence others and (b) to to use. For example, if the receiver speaks English, the
obtain information. Helpful communication encourages sender usually selects English words. If the message is
a sharing of information, thoughts, or feelings between “Mr. Johnson, smoking is not permitted in patient rooms
two or more people. Unhelpful communication hinders in this hospital,” the tone of voice selected will be one of
or blocks the transfer of information and feelings. firmness, and a shake of the head or a pointing index fin-
Nurses who communicate effectively are better able ger can reinforce it. However, each of these two gestures
to collect assessment data, initiate interventions, evalu- conveys additional meaning, one reinforcing the message
ate outcomes of interventions, and initiate change that about not smoking, and the other conveying the subordi-
promotes health and patient safety. The communication nate relationship of the listener. The nurse not only must
process is built on a trusting relationship with a client deal with dialects and foreign languages but also must
and support persons. Effective communication is essen- cope with two language approaches—that of laypersons
tial for the establishment of a nurse–client relationship. and that of health care professionals.
Communication can occur on an intrapersonal level
within a single individual, as well as on interpersonal and MESSAGE The message refers to what is actually said
group levels. Intrapersonal communication is the com- or written, the body language that accompanies the
munication that one has with oneself (i.e., self-talk) as one words, and how the message is transmitted. The medium
thinks about the message and how to interpret it. Both used to convey the message is the channel. It is important
the sender and the receiver of a message usually engage for the channel to be appropriate for the message, and it
in this type of communication. It involves thinking about should help make the intent of the message clearer.
the message before it is sent, while it is being sent, and Talking face to face with a person can be more
after it is sent, and it occurs constantly. Consequently, it effective in some instances than telephoning or writing a
is important for the nurse to understand that intraper- message. Recording messages on tape or communicating
sonal communication can interfere with a person’s ability by radio or television may be more appropriate for larger
to hear a message as the sender intended. audiences. Written communication is often appropriate
for long explanations or for a communication that needs
to be preserved or remembered over time. The nonverbal
The Communication Process channel of touch is often highly effective (Figure 22.3).
Communication involves a sender, a message, a receiver,
and a response or feedback (Figure 22.2). It is a two-way
process that involves the sending and receiving of messages
between at least two individuals (Burkhardt, Nathaniel, &
Alain McLaughlin/Pearson Education, Inc.
Sender Receiver
Encode Message Decode
Decode Message Encode

(response)
FIGURE 22.2 The communication process. The dashed

arrows indicate intrapersonal communication (self-talk). The FIGURE 22.3 Appropriate forms of touch can
solid lines indicate interpersonal communication. communicate caring.
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RECEIVER The receiver is the listener, who must lis- individuals, according to their culture, socioeconomic
ten, observe, and attend. This person is the decoder, who background, age, and education. As a result, countless
must interpret what the sender intended. Perception uses possibilities exist for the ways ideas are exchanged. An
all the senses to receive verbal and nonverbal messages. abundance of words can be used to form messages.
To decode means to relate the message perceived to the In addition, a wide range of feelings can be conveyed
receiver’s storehouse of knowledge and experience and when people talk.
to sort out the meaning of the message. Whether the When choosing words to say or write, nurses need to
message is decoded accurately by the receiver, according consider (a) pace and intonation, (b) simplicity, (c) clar-
to the sender’s intent, depends largely on their similari- ity and brevity, (d) timing and relevance, (e) adaptability,
ties in knowledge and experience and sociocultural back- (f) credibility, and (g) humour.
ground. If the meaning of the decoded message matches
Pace and Intonation The manner of speech, as in the
the intent of the sender, then the communication has
pace or rhythm and intonation, will modify the feeling
been effective. Ineffective communication occurs when
and impact of the message. The intonation can express
the message sent is misinterpreted by the receiver. For
enthusiasm, sadness, anger, or amusement. The pace
example, Mr. Johnson may perceive the message accu-
of speech can indicate interest, anxiety, boredom, or
rately—“No smoking is allowed in my room.” However,
fear.
if experience has taught him that he can smoke in his
room if a certain nurse is on duty, he will interpret the Simplicity Many complex technical terms are under-
intent of the message differently. stood by nurses; however, laypersons often misunderstand
these terms. Words such as vasoconstriction or cholecystectomy
RESPONSE Response is the message that the receiver returns
are common terms for nurses but may be incomprehen-
to the sender. It is also called feedback. Feedback can be
sible to clients and, thus, categorized as jargon. Nurses
verbal, nonverbal, or both. Nonverbal examples are a nod
need to select simple, appropriate, and understandable
of the head or a yawn. Either way, feedback allows the
terms, depending on the age, knowledge, culture, and
sender to correct or reword a message. In the case of Mr.
education of the client. For example, instead of say-
Johnson, the receiver may appear irritated or say, “Well,
ing to a client, “The nurses will be catheterizing you
the nurse on evening shift lets me smoke.” The sender
tomorrow for a urinalysis,” it may be more appropriate
then knows the message was interpreted accurately. How-
and understandable to say, “Tomorrow we need to get
ever, now the original sender becomes the receiver, who is
a sample of your urine, so we will collect it by putting
required to decode and respond.
a small tube into your bladder.” Because the client can
better understand the message being conveyed by the
latter statement, it is more likely to provide the answer
Modes of Communication to the client asking why it is needed and whether it will
be uncomfortable.
Communication is generally carried out in two different
modes: (a) verbal and (b) nonverbal. Verbal commu- Clarity and Brevity Clarity refers to saying precisely
nication uses the spoken or written word; nonverbal what is meant, and brevity refers to using the fewest words
communication uses other forms, such as gestures necessary. The result is a message that is simple and
or facial expressions and touch. Although both kinds clear. An aspect of this is congruence or consistency, in
of communication occur concurrently, the majority of which the nurse’s behaviour or nonverbal communica-
communication is nonverbal. Learning about nonverbal tion matches the words spoken. When the nurse tells
communication is thus important for nurses in develop- the client, “I am interested in hearing what you have to
ing effective communication patterns and relationships say,” the nonverbal behaviour would be the nurse fac-
with clients (O’Hagan et al., 2013). ing the client, making eye contact, and leaning forward.
Another form of communication has evolved with The goal is to communicate clearly so that all aspects of
technology—electronic communication. One com- a situation or circumstance are understood. To ensure
mon form of electronic communication is e-mail. Nurses clarity in communication, nurses need to face the client,
must decide when it is appropriate or not appropriate to speak clearly, and enunciate carefully.
use e-mail when communicating with clients and follow
agency policies regarding privacy and confidentiality as Timing and Relevance No matter how clearly or sim-
well as therapeutic nurse–client relationships and bound- ply words are stated or written, the timing needs to be
aries. In some instances, agencies may prohibit e-mail appropriate to ensure that words are heard, and the mes-
and other forms of social media communication for sages are related to the person or to the person’s interests
health care professional services. and concerns. This approach involves sensitivity to the
client’s needs and concerns. For example, a client who
VERBAL COMMUNICATION Verbal communication is extremely fearful of cancer may not hear the nurse’s
is largely conscious communication because people explanations about the expected procedures before and
choose the words they use. The words used vary among after gallbladder surgery. In this situation, the nurse first
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has to encourage the client to express his or her concerns to help clients adjust to difficult and painful situations.
and then deal with those concerns. The necessary expla- The physical act of laughter can be both an emotional
nations can be provided at another time when the client and physical release, reducing tension by providing a dif-
is ready to listen. ferent perspective and promoting a sense of well-being.
Another problem in timing is asking several ques- When using humour, it is important to consider the cli-
tions at once. For example, a nurse enters a client’s room ent’s perception of what is considered humorous. Tim-
and says in one breath, “Good morning, Mrs. Brody. ing is also important to consider. Although humour and
How are you this morning? Did you sleep well last night? laughter can help reduce stress and anxiety, the feelings
Is your partner coming to see you before your surgery?” of the client need to be considered first and foremost
The client no doubt wonders which question to answer (Moore, 2008).
first, if any. Avoid asking a question and then not waiting
NONVERBAL COMMUNICATION Nonverbal commu-
for an answer before asking another question.
nication is sometimes called body language. It includes
Adaptability Spoken messages need to be altered gestures, body movements, use of touch, and physical
in accordance with behavioural cues from the client. appearance, including adornment. Nonverbal commu-
This adjustment is referred to as adaptability. What the nication often tells others more about what a person is
nurse says and how it is said must be individualized and feeling than what is actually said (Figure 22.4). Nonverbal
carefully considered. This adjustment requires astute communication either reinforces or contradicts what is
assessment and sensitivity on the part of the nurse. For said verbally. For example, if a nurse says to a client,
example, a nurse who usually smiles, appears cheerful, “I’d be happy to sit here and talk to you for a while”
and greets the client every afternoon with an enthusiastic and yet glances impatiently at his or her watch every
“Hi, Mrs. Brown!” notices that the client is not smiling few seconds, the actions contradict the verbal message.
and appears distressed. It is important for the nurse to The client is more likely to believe the message in the
modify the tone of speech and express concern in facial nonverbal behaviour, which conveys, “I am very busy
expression while moving toward the client. and need to leave.”
Observing and interpreting the client’s nonverbal
Credibility Credibility means “worthiness of belief, trust-
behaviour is an essential skill for nurses to develop.
worthiness, and reliability.” Nurses foster credibility by
To observe nonverbal behaviour efficiently requires a
being consistent, dependable, and honest. The nurse needs
systematic assessment of the person’s overall physical
to be knowledgeable about what is being discussed and to
appearance, posture, gait, facial expressions, and ges-
have accurate information (Gillett, O’Neill, & Bloomfield,
tures. Whatever is observed, the nurse must exercise
2016). Nurses should convey confidence and certainty in
caution in interpretation and must always clarify any
what they are saying while being able to acknowledge their
observation with the client.
limitations: “I don’t know the answer to that, but I will find
Transculturally, nonverbal communication varies
out for you as soon as soon as I can.”
widely (Hearnden, 2008). Cultures differ even with regard
Humour The use of humour can be a positive and pow- to common behaviours, such as smiling and hand shaking.
erful tool in the nurse–client relationship, but it must be For example, to many Hispanics, smiling and hand shak-
used with care. When appropriate, humour can be used ing are an integral part of an interaction and essential to
FIGURE 22.4 Nonverbal communication sometimes conveys meaning more effectively compared with words. Left: The postures of
these women indicate openness to communication. Right: The listener’s posture suggests resistance to communication.
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establishing trust. The same behaviour might be perceived

by a Russian as insolent and frivolous.
The nurse cannot always be sure of the correct
interpretation of the feelings expressed nonverbally. The
same feeling can be expressed nonverbally in more than

one way, even within the same cultural group. For exam-
ple, anger may be communicated by aggressive or exces-
sive body motion, or it may be communicated by frozen
stillness. Therefore, the interpretation of such observa-
tions requires validation with the client. For example, the
nurse might say, “You look as if you are angry. Do you
want to talk about it?”
Clients who have altered thought processes, such
as in schizophrenia or dementia, may experience times
when expressing themselves verbally is difficult or impos- FIGURE 22.5 The nurse’s facial expression communicates
warmth and caring.
sible. During these times, the nurse needs to be able to
interpret the feeling or emotion that the client is express-
ing nonverbally. An attentive nurse who clarifies observa- Facial Expression No part of the body is as expressive
tions portrays caring and acceptance to the client. This as the face (see Figure 22.5). Feelings of surprise, fear,
can be a beginning for establishing a trusting relationship anger, disgust, happiness, and sadness can be conveyed
between the nurse and the client, even with clients who by facial expressions. Although the face can express the
have difficulty communicating appropriately. person’s genuine emotions, it is also possible to control
these muscles so the emotion expressed does not reflect
Personal Appearance Clothing and adornments can what the person is feeling. Many facial expressions con-
be rich sources of information about a client. Although vey a universal meaning. The smile generally expresses
choice of apparel is highly personal, it can convey social happiness. In North American cultures, contempt is
and financial status, culture, religion, group association, conveyed by the mouth turned down, the head tilted
and self-concept. Charms and amulets may be worn for back, and the eyes directed down the nose. The culture
decorative or for health-protection purposes. When the of the sender is very significant. No single expression can
symbolic meaning of an object is unfamiliar, the nurse be interpreted accurately, however, without considering
can inquire about its significance, which may foster rap- other reinforcing physical cues, the setting in which it
port with the client. occurs, the expression of others in the same setting, and
How a person dresses is often an indicator of how the cultural background of the client.
the person feels. Someone who is tired or ill may not Nurses need to be aware of their own expressions
have the energy or the desire to maintain normal groom- and what they are communicating with clients. Clients
ing. When a person known for immaculate grooming are quick to notice the nurse’s facial expression, particu-
becomes lax about appearance, the nurse may suspect larly when a client feels unsure or uncomfortable. The
a loss of self-esteem, low energy, or a physical illness. client who questions the nurse about a feared diagnostic
The nurse must validate these observed nonverbal data result will watch whether the nurse maintains eye contact
by asking the client. A change in grooming habits may or looks away when answering. The client who has had
signal that the client is feeling better; for example, a man disfiguring surgery will examine the nurse’s face for signs
may request a shave, or a woman may request a sham- of shock or aversion. It is impossible to control all facial
poo and some makeup following surgery. expression, but the nurse must learn to control expression
of feelings like fear or aversion in some circumstances.
Posture and Gait The ways people walk and carry
Eye contact is another essential element of facial
themselves are often reliable indicators of self-concept,
communication. In many cultures, mutual eye contact
current mood, and health. Erect posture and an active,
acknowledges recognition of the other person and a
purposeful stride suggest a feeling of well-being.
willingness to maintain communication. Often, a per-
Slouched posture and a slow, shuffling gait suggest
son initiates contact with another person with a glance,
depression or physical discomfort. Tense posture and
capturing the person’s attention before communicating.
a rapid, determined gait suggest anxiety or anger. The
A person who feels weak or defenceless often averts the
posture of people when they are sitting or lying can also
eyes or avoids eye contact; in some cultures, avoiding eye
indicate feelings or mood. Again, the nurse must clarify
contact is a sign of respect.
the meaning of the observed behaviour by describing to
the client what the nurse sees and then asking what it Gestures Hand and body gestures can emphasize and
means or whether the nurse’s interpretation is correct. clarify the spoken word, or they can occur without words
For example, “You look as if it really hurts to move. Are to indicate a particular feeling or to give a sign. A par-
you in pain?” ent awaiting information about his child in surgery may
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wring his hands or pick his nails. A gesture may more Factors Influencing
clearly indicate the size or shape of an object. A wave
goodbye and the motioning of a visitor toward a chair the Communication Process
are gestures that have relatively universal meanings. Many factors influence the communication process.
Some gestures, however, are culture specific. The North Some of these are developmental level, gender, val-
American gesture meaning “shoo” or “go away” means ues and perceptions, personal space, territoriality, roles
“come here” or “come back” in some Asian cultures. and relationships, environment, congruence, attitudes,
In the Hmong culture, it is considered rude to point at boundaries, and the topic under discussion.
something with your toe.
DEVELOPMENTAL LEVEL Language development, psy-
For people with special communication problems,
such as those with hearing impairment, the hands are chosocial development, and intellectual development
invaluable in communication, and thus many learn sign move through stages across the lifespan. Knowledge of a
language. Persons with illnesses who are unable to reply client’s developmental stage will allow the nurse to mod-
verbally can similarly devise a communication system ify the message accordingly. The use of dolls and games
that uses hands. The client may be able to raise an index with simple language can help explain a procedure to an
finger once for “yes” and twice for “no.” Other signals 8-year-old. With adolescents who have developed more
can often be devised by the client and the nurse to denote abstract thinking skills, a more detailed explanation can
other meanings. be given, whereas a well-educated, middle-aged business
executive may want to have detailed technical informa-
ELECTRONIC COMMUNICATION Informatics play an
tion provided. Older clients are apt to have had a wider
increasing role in nursing practice. Many health care range of experiences with the health care system, which
agencies are moving toward electronic medical records can influence their response or understanding. With
in which nurses document their assessments and nurs- aging also come changes in vision and hearing acuity
ing care. E-mail can be used in health care facilities for that can affect nurse–client interactions.
many purposes: to schedule and confirm appointments, GENDER From an early age, females and males com-
to report laboratory results, to conduct client educa- municate differently. Girls tend to use language to seek
tion, and to follow up with discharged clients (Macon & confirmation, minimize differences, and establish inti-
Mendiola, 2008). macy. Boys use language to establish independence and
It is extremely important for the nurse to know the negotiate status within a group. These differences can
advantages and disadvantages of informatics (including continue into adulthood, so the same communication
e-mail and texting correspondence) and to strictly follow all may be interpreted differently by a man and a woman.
agency guidelines to ensure client confidentiality. Nursing
VALUES AND PERCEPTIONS Values are beliefs that
informatics is defined as a “science and practice [which]
influence behaviours, and perceptions are personal views
integrates nursing, its information and knowledge, and
of events. Because each person has unique personality
their management, with information and communication
traits, values, and life experiences, each will perceive
technologies to promote the health of people, families and
and interpret messages and experiences differently. For
communities worldwide” (International Medical Informat-
example, if the nurse draws the curtains around a crying
ics Association [IMIA], 2009).
woman and leaves her alone, the woman may interpret
The Canadian Association of Schools of Nursing
this as “The nurse thinks that I will upset others and
(CASN) has developed a document entitled Nursing Infor-
that I shouldn’t cry” or “The nurse respects my need to
matics: Entry-To-Practice Competencies for Registered Nurses. The
be alone.” It is important for the nurse to be aware of a
overarching competency that Canadian registered nurses
client’s values and to validate or correct perceptions to
are expected to have acquired over the course of their
avoid creating barriers in the nurse–client relationship.
undergraduate education is stated as “uses information
and communication technologies to support information PERSONAL SPACE Personal space is the distance
synthesis in accordance with professional and regulatory people prefer to maintain during interactions with oth-
standards in the delivery of patient/client care” (CASN, ers. North Americans tend to use definite distances in
2012). These communication strategies are dependent on various interpersonal relationships, along with specific
the client’s literacy and language competencies, and, as voice tones and body language. Communication, thus,
always with communication, require clear and concise, alters in accordance with four distances, each with a
non-jargon language. Nursing informatics can enhance close and a far phase. Tamparo and Lindh (2008) listed
relationships with clients. It is not, however, a substitute the following example:
for effective verbal and nonverbal communication. Nurses 1. Intimate: Touching to 0.5 m
need to use their professional judgment about what forms
of communication will best meet their client’s health care 2. Personal: 0.5 m to 1.3 m
needs. (See Chapter 25 for a more in-depth discussion of 3. Social: 1.3 m to 4 m
communication via electronic means.) 4. Public: 4 m and beyond
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Intimate distance communication is characterized by be recognized by all health care workers. Patients often
body contact, heightened sensations of body heat and feel the need to defend their territory when it is invaded
smell, and vocalizations that are low. Intimate distance by others; for example, when a visitor or a nurse moves a
is frequently used by nurses. Examples include cuddling chair in the client’s area to use at another area, the terri-
a baby, touching the sightless client, positioning clients, toriality of the client whose chair was removed has been
observing an incision, and restraining a toddler for an inadvertently violated. Nurses need to obtain permission
injection. from patients to remove, rearrange, or borrow objects in
It is a natural protective instinct for people to main- their hospital area.
tain a certain amount of space immediately around
them, and the amount varies with individuals and cul- ROLES AND RELATIONSHIPS The roles and the rela-
tures. When someone who wants to communicate comes tionship between sender and receiver affect the com-
too close, the receiver automatically steps back a pace or munication process. Such roles as nursing student and
two. In their therapeutic roles, nurses often are required instructor, client and physician, or parent and child
to violate this personal space. However, it is important affect the content and responses in the communication
for them to be aware when this reaction will likely process. Choice of words, sentence structure, and tone
occur and to forewarn the client. In many instances, the of voice vary considerably from role to role. In addition,
nurse can respect a person’s intimate distance. In other the specific relationship between the communicators is a
instances, the nurse can come within intimate distance to significant factor. The nurse who meets with a client for
communicate warmth and caring. the first time communicates differently from the nurse
Personal distance is less overwhelming than intimate who has developed a longer relationship with the client.
distance. Physical contact, such as hand shaking or
ENVIRONMENT People usually communicate most
touching a shoulder, is possible during an interaction.
effectively in a comfortable environment. Temperature
More of the person is perceived at a personal distance
extremes, excessive noise, and a poorly ventilated envi-
so that nonverbal behaviours, such as body stance or full
ronment can all interfere with communication. Also, lack
facial expressions, are seen with less distortion. Much
of privacy may interfere with a client’s communication
communication between nurses and clients happens at
about matters the client considers private. For example,
this distance. Examples occur when nurses are sitting
a client who is worried about his wife’s ability to care for
with clients, giving medications, or establishing an intra-
him after discharge from the hospital may not wish to
venous infusion. Communication at a close personal dis-
discuss this concern with a nurse within the hearing of
tance can convey involvement by facilitating the sharing
other clients in the room. Environmental distraction can
of thoughts and feelings. At the outer extreme of 1.3 m,
impair and distort communication.
however, less involvement is conveyed.
Social distance is characterized by a clear visual percep- CONGRUENCE In congruent communication, the
tion of the whole person. This communication is formal verbal and nonverbal aspects of the message match. Cli-
and is limited to seeing and hearing. It is expedient in com- ents more readily trust the nurse when they perceive the
municating with several people at the same time or within nurse’s communication as congruent. Both nurse and cli-
a short time. Examples occur when nurses make rounds or ent can easily determine if there is congruence between
wave a greeting to someone. Social distance is important verbal expression and nonverbal expression. Nurses are
in accomplishing the business of the day. However, it is taught to assess clients, but clients are often just as adept
frequently misused. For example, the nurse who stands in at reading a nurse’s expression or body language. If there
the doorway and asks a client, “How are you today?” will is incongruence between verbal and nonverbal expres-
receive a more noncommittal reply than the nurse who sions, the body language or nonverbal communication
moves to a personal distance to inquire. is usually the one with the true meaning. For example,
Public distance requires loud, clear vocalizations with when teaching a client how to care for a colostomy bag,
careful enunciation. Although the faces and forms of the nurse might say, “You won’t have any problem with
people are seen at this distance, individuality is lost. this.” However, if the nurse looks worried or concerned
Instead, the perception is of the group of people or the while making this statement, the client is less likely to
community. An example is when the nurse teaches a trust the nurse’s words.
group of clients about cardiac rehabilitation.
INTERPERSONAL ATTITUDES Attitudes convey beliefs,
TERRITORIALITY Territoriality is the concept of the thoughts, and feelings about people and events. Atti-
space and things that an individual considers as belong- tudes are communicated convincingly and rapidly to
ing to himself or herself. Territories marked off by others. Such attitudes as caring, warmth, respect, and
people can be visible to others. For example, patients in acceptance facilitate communication and are essential
a hospital often consider their territory as bounded by elements of relational practice, wherein a nurse con-
the curtains around the bed unit or by the walls of a pri- siders the client holistically and interprets the client mes-
vate room. This human tendency to claim territory must sages from that person’s perspective (Storch et al., 2013).
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Attitudes of condescension, lack of interest, or coldness thoughts in words, but their emotions may contradict
negatively affect and inhibit communication and effec- their words. For example, a client says, “I am glad my
tive practice. spouse has left me; my spouse was very cruel.” How-
Caring and warmth convey a feeling of emotional ever, the nurse observes that the client is in tears while
closeness and deep and genuine concern for the person. saying this. To respond to the client’s words, the nurse
Warmth conveys friendliness and consideration, shown might simply rephrase, saying, “You are pleased that
by such actions as smiling and attention to physical com- your spouse has left you.” To respond to the client’s
forts (Boyd, 2008). Caring is more enduring and intense feelings, the nurse would need to acknowledge the tears
than a warm feeling. Caring involves giving feelings, in the client’s eyes, saying, for example, “You seem sad-
thoughts, skill, and knowledge. It requires psychological dened by all this.” Such a response helps the client to
energy, but little may be received in return. focus on feelings. In some instances, the nurse may need
Respect is an attitude that emphasizes the other per- to know more about the client and resources for coping
son’s worth and individuality. It conveys that the person’s with these feelings.
hopes and feelings are special and unique, even though Strong emotions are often draining. People usually
similar to others in many ways. A nurse conveys respect need time to deal with their feelings before they can
by listening with an open mind to what the other person cope with other matters, such as learning new skills or
is saying, even if the nurse disagrees. Respect is a critical planning for the future. This is most evident in hospitals
element of relational practice and is essential for effec- when patients learn that they have a terminal illness.
tive caring relationships with clients. Nurses can learn Some require hours, days, or even weeks before they are
new ways of approaching situations when they conscien- ready to start other tasks. Some need time to themselves,
tiously listen to another person’s perspective. and others need someone to listen to them; some need
Acceptance emphasizes neither approval nor disap- assistance identifying and verbalizing feelings, and others
proval. The nurse willingly receives the client’s honest need assistance making decisions about future action.
feelings and actions without judgment. An accepting
ATTENTIVE LISTENING Attentive listening is listen-
attitude encourages clients to express personal feelings
ing actively by using all the senses, as opposed to listening
freely and to be themselves. The nurse may need to
passively with just the ears. Attentive listening involves
restrict acceptance in situations in which clients’ actions
paying attention to the total message, both verbal and
are harmful to themselves or to others.
nonverbal, and absorbing both the message content and
BOUNDARIES Boundaries are “limits in which a per- the feeling the person is conveying, without selectivity.
son may act or refrain from acting within a designated The listener does not select or listen solely to what the
time or place” (Boyd, 2008, p. 900). To keep clear listener wants to hear; the nurse focuses not on his or her
boundaries, the nurse keeps the focus on the client and own needs but rather on the client’s needs. Attentive lis-
avoids sharing personal information or meeting his or tening conveys an attitude of caring and interest, thereby
her own needs through the nurse–client relationship. encouraging the client to talk (Figure 22.6).
If the client seeks friendship with the nurse or a rela- Nurses must be aware of their own biases and be
tionship outside the work environment, the nurse must careful not to react quickly to the message. The speaker
affirm his or her professional role and decline the invi- should not be interrupted, and the nurse (the responder)
tation. Some boundary issues include gift giving by the should take time to think about the message before
nurse or the client, the nurse spending more time than
necessary with a client, or the nurse believing that only
he or she understands the client (Boyd, 2008).
Therapeutic Communication
Therapeutic communication promotes understand-

ing and can help establish a constructive relationship
between the nurse and the client. Unlike the social
relationship, which may not have a specific purpose or
direction, therapeutic communication is goal-directed
and can promote understanding (Hawthorne, 2015).
Nurses need to respond not only to the content
of a client’s verbal message but also to the feelings
and thoughts expressed. It is important to understand
how the client views the situation and feels about it FIGURE 22.6 The nurse conveys attentive listening through a
before responding. Sometimes, people may convey their posture of involvement.
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responding. As a listener, the nurse also should ask ques- BOX 22.2 ACTIONS OF PHYSICAL ATTENDING
tions either to obtain additional information or to clarify.
The message sender (i.e., the client) should decide when The following actions of physical attending help nurses
to close a conversation. When the nurse ends the conver- comfort clients:
sation, the client may assume that the nurse considers the 1. Face the other person squarely. This position says, “I am
message unimportant. It is also important that nurses be available to you.” Moving to the side lessens the degree of
aware of their own biases. A message from a client that involvement.
reflects different values or beliefs should not be discred- 2. Adopt an open posture. The nondefensive position is
one in which neither the arms nor the legs are crossed.
ited for that reason (Dearing & Steadman, 2008).
It conveys that the person wants to encourage the pas-
Attentive listening is a highly developed skill, and it sage of communication, as the open door of a home or
can be learned with practice. A nurse can communicate an office does.
attentive listening to clients in various ways. Common 3. Lean toward the person. People move naturally toward
responses are nodding the head, uttering “Uh-huh” or each other when they want to say or hear something—by
“Mm-hmm,” repeating the words that the client has moving to the front of a class, by moving a chair nearer a
used, or saying “I see what you mean.” friend, or by leaning across a table with arms propped in
front. The nurse conveys involvement by leaning forward,
closer to the client.
PHYSICAL ATTENDING Egan (2009) has outlined five
4. Maintain good eye contact. Mutual eye contact, prefer-
specific ways to convey physical attending, which he ably at the same level, recognizes the other person and
defines as the manner of being present to another or denotes willingness to maintain communication. Eye con-
being with another. Listening is what a person does tact is natural, and the person making eye contact does
while attending. The five actions of physical attend- not glare at or stare down the other person.
ing, which convey a “posture of involvement” and 5. Try to be relatively relaxed. Being totally relaxed is not
specifically focus on comforting a client are shown in feasible when the nurse is listening with intensity, but the
nurse can show relaxed listening by taking time in respond-
Box 22.2. Therapeutic communication techniques facili-
ing, allowing pauses as needed, balancing periods of ten-
tate communication and focus on the client’s concerns sion with relaxing, and using gestures that are natural.
(as described in Table 22.1).
These five attending postures need to be adapted to the
specific needs (and culture) of clients in a given situation.
For example, leaning forward may not be appropriate at the
Barriers to Communication beginning of an interview. It may be reserved until a closer
relationship develops between the nurse and the client. The
Nurses need to recognize barriers to effective commu- same applies to eye contact, which is generally uninterrupted
nication. See Table 22.2. Failure to listen, improperly when the communicators are very involved in the interaction.
decoding the client’s intended message, and placing the
Source: Egan, G. (2009). The skilled helper: A problem-management approach to
nurse’s needs above the client’s needs are major barriers helping. Reproduced with permission of BROOKS/COLE in the format Republish in a
to communication. book via Copyright Clearance Center.
TABLE 22.1 Therapeutic Communication Techniques
Technique Description Examples
Using silence Accepting pauses or silences that extend for Sitting quietly (or walking with the client) and waiting
several seconds or minutes without interject- attentively until the client is able to put thoughts
ing any verbal response and feelings into words
Providing general Using statements or questions that do the “Perhaps you would like to talk about …”
leads following: “Would it help to discuss your feelings?”
(1) Encourage the client to verbalize “Where would you like to begin?”
(2) Choose a topic of conversation “And then what?”
(3) Facilitate continued verbalization “Tell me more. . . .”
Being specific Making statements that are specific, rather than “You scratched my arm.” (specific statement)
general, tentative, or absolute You seem in pain. (general statement)
“You seem unconcerned about Mary’s diabetes.”
(tentative statement)
(continued)
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TABLE 22.1 Therapeutic Communication Techniques (continued)
Using open-ended Asking broad questions that lead or invite the “I’d like to hear more about that.”
questions client to explore (elaborate, clarify, describe, “Could you tell me about . . .”
compare, or illustrate) thoughts or feelings. “How have you been feeling lately?”
Open-ended questions specify only the topic “What brought you to the hospital?”
to be discussed and invite answers that are “What is your opinion?”
longer than one or two words. “You said you were frightened yesterday. How do you
feel now?”
Using touch Providing appropriate forms of touch to reinforce Putting an arm over the client’s shoulder or placing
caring feelings. Because tactile contacts vary your hand over the client’s hand, with permission
considerably among individuals, families, and
cultures, the nurse must be sensitive to the
differences in attitudes and practices of cli-
ents and self.
Restating or Actively listening for the client’s basic message Client: “I couldn’t manage to eat any dinner last
paraphrasing and then repeating those thoughts and/or night—not even the dessert.”
feelings in similar words. This conveys that Nurse: “You had difficulty eating yesterday.”
the nurse has listened and understood the cli- Client: “Yes, I was very upset after my family left.”
ent’s basic message and also offers the client Client: “I have trouble talking to strangers.”
a clearer idea of what was said by the client. Nurse: “You find it difficult talking to people you do
not know?”
Seeking clarification A method of making the client’s broad overall “I’m puzzled.”
meaning of the message more understand- “I’m not sure I understand that.”
able. It is used when paraphrasing is difficult “Would you please say that again?”
or when the communication is rambling or “Would you tell me more?”
garbled. To clarify the message, the nurse “I meant this rather than that.”
can restate the basic message or confess “I guess I didn’t make that clear—I’ll go over it again.”
confusion and ask the client to repeat or
restate the message.
Nurses can also clarify their own messages with
statements.
Checking percep- A method similar to clarifying that verifies the Client: “My husband never gives me any presents.”
tion or seeking meaning of specific words, rather than the Nurse: “You mean he has never given you a present
consensual overall meaning of a message for your birthday or Christmas?”
validation Client: “Well—not never. He does get me something for
my birthday and Christmas, but he never thinks of
giving me anything at any other time.”
Offering the self Suggesting a presence, interest, or wish to under- “I’ll stay with you until your daughter arrives.”
stand the client without making any demands “We can sit here quietly for a while; we don’t need to
or attaching conditions that the client must talk unless you would like to.”
comply with to receive the nurse’s attention “I’ll help you dress to go home.”
Giving information Providing, in a simple and direct manner, specific “Your surgery is scheduled for 11 a.m. tomorrow.”
factual information the client may or may not “You will feel a pulling sensation when the tube is
request. When information is not known, the removed from your abdomen.”
nurse states this and indicates who has it or “I do not know the answer to that, but I will find out
when the nurse will obtain it. from Mrs. King, the nurse in charge.”
Acknowledging Giving recognition, in a nonjudgmental way, of a “You trimmed your beard and moustache and
change in behaviour, an effort the client has washed your hair.”
made, or a contribution to a communication. “I notice you keep squinting your eyes. Are you hav-
Acknowledgment may be with or without ing difficulty seeing?”
understanding and verbal or nonverbal. “You walked twice as far today with your walker.”
Clarifying time or Helping the client clarify an event, situation, or Client: “I vomited this morning.”
sequence happening in relationship to time Nurse: “Was that after breakfast?”
Client: “I feel that I have been asleep for weeks.”

Nurse: “You had your operation Monday, and today
is Tuesday.”
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TABLE 22.1 (continued)
Presenting reality Helping the client differentiate the real from the “That telephone ring came from the program on
unreal television.”
“That’s not a dead mouse in the corner; it is a dis-
carded washcloth.”
“Your magazine is here in the drawer. It has not been
stolen.”
Focusing Helping the client expand on and develop a topic Client: “My wife says she will look after me, but I
of importance. It is important for the nurse to don’t think she can, what with the children to
wait until the client finishes stating the main take care of, and they’re always after her about
concerns before attempting to focus. The focus something—clothes, homework, what’s for dinner
may be an idea or a feeling; however, the nurse that night.”
often emphasizes a feeling to help the client Nurse: “You are worried about how well she can
recognize an emotion disguised behind words. manage.”
Reflecting Directing ideas, feelings, questions, or content Client: “What can I do?”
back to clients to enable them to explore their Nurse: “What do you think would be helpful?”
own ideas and feelings about a situation Client: “Do you think I should tell my husband?”
Summarizing and Stating the main points of a discussion to clarify “You seem unsure about telling your husband.”
planning the relevant points discussed. This technique “During the past half hour we have talked about . . .”
is useful at the end of an interview or to “Tomorrow afternoon we may explore this further.”
review a health teaching session. It often acts “In a few days I’ll review what you have learned
as an introduction to future care planning. about the actions and effects of your insulin.”
TABLE 22.2 Barriers to Communication
Barrier Description Examples

Stereotyping Offering generalized and oversimplified beliefs “Two-year-olds are brats.”
about groups of people that are based on “Women are complainers.”
experiences too limited to be valid. These “Men don’t cry.”
responses categorize clients and negate their “Most people don’t have any pain after this type of
uniqueness as individuals. surgery.”
Agreeing and Implying that the client is either right or wrong and Client: “I don’t think Dr. Broad is a very good doctor. He
disagreeing that the nurse is in a position to judge this. Sim- doesn’t seem interested in his patients.”
ilar to judgmental responses, these responses Nurse: “Dr. Broad is head of the Department of Surgery and
deter clients from thinking through their position is an excellent surgeon.”
and may cause a client to become defensive.
Being defensive Attempting to protect a person or health care ser- Client: “Those night nurses must just sit around and talk
vices from negative comments. These responses all night. They didn’t answer my light for over an hour.”
prevent the client from expressing true concerns. Nurse: “I’ll have you know we literally run around on
The nurse is saying, “You have no right to com- nights. You’re not the only client, you know.”
plain.” Defensive responses protect the nurse
from admitting weaknesses in the health care
services, including personal weaknesses.
Challenging Giving a response that makes clients prove their state- Client: “I felt nauseated after that red pill.”
ment or point of view. These responses indicate Nurse: “Surely you don’t think I gave you the wrong pill?”
that the nurse is failing to consider the client’s feel-
Client: “I feel as if I am dying.”
ings, making the client feel it necessary to defend
Nurse: “How can you feel that way when your pulse is 60?”
a position.
Client: “I believe my husband doesn’t love me.”
Nurse: “You can’t say that; why, he visits you every day.”
Probing Asking for information chiefly out of curiosity, rather Client: “I was speeding along the street and didn’t see
than with the intent to assist the client. These the stop sign.”
responses are considered prying and violate the Nurse: “Why were you speeding?”
client’s privacy. Asking “why” is often probing
Client: “I didn’t ask the doctor when he was here.”
and places the client in a defensive position.
Nurse: “Why didn’t you?”
(continued)
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TABLE 22.2 Barriers to Communication (continued)
Barrier Description Examples

Testing Asking questions that make the client admit to “Who do you think you are?” (forces people to admit their
something. These responses permit the client status is only that of client)
only limited answers and often meet the nurse’s “Do you think I am not busy?” (forces the client to admit
need, rather than the client’s. that the nurse really is busy)
Rejecting Refusing to discuss certain topics with the client. “I don’t want to discuss that. Let’s talk about …”
These responses often make clients feel that “Let’s discuss other areas of interest to you rather than
the nurse is rejecting not only their communica- the two problems you keep mentioning.”
tion but also the clients themselves. “I can’t talk now. I’m on my way for coffee break.”
Changing topics Directing the communication into areas of self- Client: “I’m separated from my wife. Do you think I should
and subjects interest, rather than considering the client’s have sexual relations with another woman?”
concerns, is often a self-protective response to Nurse: “You like gardening. This sunshine is good for my
a topic that causes anxiety. These responses roses. I have a beautiful rose garden.”
imply that what the nurse considers important
will be discussed and that clients should not
discuss certain topics.
Unwarranted Using clichés or comforting statements of advice “You’ll feel better soon.”
reassurance as a means to reassure the client. These “I’m sure everything will turn out all right.”
responses block the fears, feelings, and other “Don’t worry.”
thoughts of the client.
Passing Giving opinions and approving or disapproving “That’s good (bad).”
judgment responses, moralizing, or implying one’s own “You shouldn’t do that.”
values. These responses imply that the client “That’s not good enough.”
must think as the nurse thinks, fostering client “What you did was wrong (right).”
dependence.
Giving common Telling the client what to do. These responses deny Client: “Should I move from my home to a nursing
advice the client’s right to be an equal partner. Note home?”
that giving expert, rather than common, advice Nurse: “If I were you, I’d go to a nursing home where
is therapeutic. you’ll get your meals cooked for you.”
The Helping Relationship on the one before. Nurses can identify the progress of
a relationship by understanding these phases: (a) pre-
interaction phase, (b) introductory phase, (c) working
Helping is a growth-facilitating process (Egan, 2009). (maintaining) phase, and (d) termination phase.
The keys to a helping relationship are (a) the develop-
ment of trust and acceptance between the nurse and the PRE-INTERACTION PHASE Before an interview and in
client, and (b) an underlying belief that the nurse cares most situations, the nurse has information about the cli-
about and wants to help the client. ent before the first face-to-face meeting. Such information
The helping relationship is influenced by the per-
sonal and professional characteristics of the nurse and
the client. Age, gender, appearance, diagnosis, educa-
BOX 22.3 CHARACTERISTICS OF A HELPING
tion, values, ethnic and cultural background, personality,
RELATIONSHIP
expectations, and setting can all affect the development
of the nurse–client relationship. Consideration of all A helping relationship has the following characteristics:
these factors, combined with good communication skills • It is an intellectual and emotional bond between the
and sincere interest in the client’s welfare, will enable the nurse and the client and is focused on the client.
nurse to create a helping relationship. Characteristics of • It respects the client as an individual, including the
helping relationships are described in Box 22.3. following:
a. Maximizing the client’s abilities to participate in deci-
sion making and treatments
b. Considering ethnic and cultural aspects
Phases of the Helping Relationship c. Considering family relationships and values
The helping relationship process can be described in • It respects client confidentiality.
terms of four sequential phases, each characterized by • It focuses on the client’s well-being.
identifiable tasks and skills. The relationship must prog- • It is based on mutual trust, respect, and acceptance.
ress through the stages in succession because each builds
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can include the client’s name, address, age, medical his- WORKING PHASE During the working phase of a help-
tory, and social history. Planning for the initial visit may ing relationship, the nurse and the client begin to view
generate some anxious feelings in the nurse. If the nurse each other as unique individuals. They begin to appreci-
recognizes these feelings and identifies specific informa- ate this uniqueness and care about each other. Caring is
tion to be discussed, positive outcomes can evolve. sharing deep and genuine concern about the welfare of
another person. Once caring develops, the potential for
INTRODUCTORY PHASE This phase, also referred to
empathy increases.
as the orientation phase or the prehelping phase, is important
The working phase has two major stages: exploring
because it sets the tone for the rest of the relationship.
and understanding thoughts and feelings and facilitating and tak-
During this initial encounter, the client and the nurse
ing action. The nurse helps the client to explore thoughts,
closely observe each other and form judgments about the
feelings, and actions and helps the client plan a program
other’s behaviour. The goal of the nurse in this phase is
of action to meet established goals.
to get to know the client and develop trust and security
within the nurse–client relationship (Boyd, 2008). Exploring and Understanding Thoughts and Feel-
After introductions, the nurse may initially engage ings The nurse requires the following skills for this
in some social interaction to put the client at ease. For phase of the helping relationship:
example, the nurse and client may talk about what a • Empathetic listening and responding. Nurses must lis-
nice day it is and what they would like to do if they ten attentively and communicate (respond) in ways
were at home. that indicate they have listened to what was said and
During the initial parts of the introductory phase, understand how the client feels. The nurse responds
the client may display some resistive behaviours. Resistive to content or feelings, or both, as appropriate. The
behaviours are those that inhibit involvement, cooperation, nurse’s nonverbal behaviours are also important. Non-
or change. They may result from difficulty acknowl- verbal behaviours indicating empathy include moder-
edging the need for help and, thus, a dependent role, ate head nodding, a steady gaze, moderate gesturing,
fear of exposing and facing feelings, anxiety about the and little activity or body movement. Empathy is
discomfort involved in changing problem-causing behav- “the ability to experience, in the present, a situation
iour patterns, and fear or anxiety in response to the as another did at some time in the past” (Boyd, 2008,
nurse’s approach, which may, in the client’s opinion, be p. 143). Empathetic listening focuses on a kind of
inappropriate. “being with” clients to develop an understanding of
Resistive behaviours can be overcome by convey- them and their world. This understanding, however,
ing a caring attitude, genuine interest in the client, and must also be communicated effectively to the client in
competence. These behaviours of the nurse also foster the form of an empathetic response. The end result of
the development of trust in the relationship. Trust can empathy is comforting and caring for the client and a
be described as a reliance on someone without doubt or helping, healing relationship.
question, or the belief that the other person is capable of • Respect. The nurse must show respect for the client’s
assisting in times of distress and, in all likelihood, will do willingness to be available, as well as a desire to work
so. To trust another person involves risk; clients become with the client, and a manner that conveys the idea of
vulnerable when they share thoughts, feelings, and atti- taking the client’s point of view seriously.
tudes with the nurse. Trust, however, enables the client
to express thoughts and feelings openly. • Genuineness. The genuine person is spontaneous, is
By the end of the introductory phase, clients should nondefensive, displays few discrepancies, and uses
begin to do the following: self-disclosure appropriately (Egan, 2009). Personal
statements can be helpful in solidifying the rapport
• Develop trust in the nurse between the nurse and the client. Nurses need to
• View the nurse as a competent professional capable exercise caution when making references about them-
of helping selves. These statements must be used with discretion.
• View the nurse as honest, open, and concerned about • Concreteness. The nurse must assist the client to be
their welfare concrete and specific, rather than to speak in gener-
• Believe the nurse will try to understand and respect alities. When the client says, “I’m stupid and clumsy,”
their cultural values and beliefs the nurse narrows the topic to the specific by pointing
out, “You tripped on the scatter rug.”
• Believe the nurse will respect client confidentiality
• Confrontation. The nurse points out discrepancies
• Feel comfortable talking with the nurse about feelings among thoughts, feelings, and actions that inhibit the
and other sensitive issues client’s self-understanding or exploration of specific
• Understand the purpose of the relationship and the roles areas. This is done empathetically, not judgmentally.
• Feel that they are active participants in developing a During this first stage of the working phase, the
mutually agreeable plan of care intensity of interaction increases, and such feelings as
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anger, shame, or self-consciousness may be expressed. If

the nurse is skilled in this stage, and if the client is willing EVIDENCE-INFORMED PRACTICE
to pursue self-exploration, the outcome is a beginning of
understanding on the part of the client about behaviour What Is the Relationship between
and feelings.
Patient-Centred Care and Patient
Facilitating and Taking Action Ultimately, the client Outcomes?
must make decisions and take action to become more
effective. The responsibility for action belongs to the cli- The investigators examined the extent of relationship
ent. The nurse, however, collaborates in these decisions, between patient-centred care (PCC) and patient outcomes
provides support, and may offer options or information. (i.e., patient needs, patient health-related problems, patients’
preferences, levels of self-care, and satisfaction with care).
TERMINATION PHASE The termination phase of the Data were collected through a self-completed questionnaire
relationship is often expected to be difficult and filled from 63 staff nurses and 44 patients in acute care settings.
with ambivalence. However, if the previous phases have The patients completed the questionnaire on admission
and 1 week following hospital discharge. Both nurses and
evolved effectively, the client generally has a positive
patients reported a moderate association of PCC and patient
outlook and feels able to handle problems independently. outcomes.
However, because caring attitudes have developed, it is
natural to expect some feelings of loss, and each person NURSING IMPLICATIONS: PCC is linked to improved
satisfaction with care and quality of life outcomes.
needs to develop a way of saying goodbye.
When attending to patient needs and their health prob-
Many methods can be used to terminate relation- lems, providing care according to patient preferences,
ships. Summarizing or reviewing the process can produce and encouraging self-care, it is important for nurses
a sense of accomplishment. This can include sharing to consider patients’ perception of their care received
reminiscences of how things were at the beginning of through communication, caring, and decision making.
the relationship and comparing them with how they are Source: Based on Poochikian-Sarkissian, S., Sidani, S., Ferguson-Pare, M., & Doran,
now. It is also helpful for both the nurse and the client D. (2010). Examining the relationship between patient-centred care and outcomes.
Canadian Journal of Neuroscience Nursing, 32(4), 14–21.
to express their feelings about termination openly and
honestly. Thus, termination discussions need to start in
advance of the termination interview. This allows time
for the client to adjust to independence. In some situa-
• Consider the other person’s perspective (i.e., empathize).
tions, referrals are necessary, or it may be appropriate to
offer an occasional standby meeting to give support, as • Be honest and genuine.
needed. Follow-up phone calls are another intervention • Use your ingenuity. There are always many courses
that eases the client’s transition to independence. (See of action to consider in handling problems. Whatever
the Evidence-Informed Practice box on the relationship course is chosen, it needs to further the achievement
between patient-centred care and patient outcomes.) of the client’s goals (outcomes), be compatible with
the client’s value system, and offer the probability of
success.
• Be aware of cultural differences.
Developing Helping Relationships
• Maintain client confidentiality.
Whatever the practice setting, the nurse establishes some
• Know your role and limitations, and refer the client
type of helping relationship in which mutual goals are
to the appropriate health care professional, as needed.
set with the client or, if the client is unable to participate,
with support persons. Although special training in coun-
selling techniques is advantageous, there are many ways
of helping clients that do not require special training.
The following are key elements for developing a helping Group Communication
relationship:
People interact with others at all stages of life in various
• Listen actively. groups: family, peer groups, work groups, recreational
• Help clients identify what they are feeling. Often cli- groups, religious groups, and so on. A group is made
ents who are troubled are unable to label their feel- up of two or more people with shared needs and goals,
ings and consequently have difficulty working them who take each other into account in their actions, and
out or talking about them. Responses such as “You who, thus, are held together and set apart from others by
seem angry about taking orders from your boss” or virtue of their interactions. Groups exist to help people
“You sound as if you’ve been lonely since your wife achieve goals (outcomes) that would be unattainable by
died” can help clients recognize what they are feeling individual effort alone. For example, groups can often
and talk about it. solve problems more effectively than one person by
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pooling the ideas and expertise of several individuals; Types of Health Care Groups
in addition, information can be disseminated to groups
more quickly than to individuals. Much of a nurse’s professional life is spent in a wide
variety of groups. Common types of health care groups
include task groups, teaching and learning groups, self-
Group Dynamics help groups, self-awareness or growth groups, therapy
groups, work-related social support groups, and profes-
The communication that takes place between members
sional organizations. There are similarities and differ-
of any group is known as group dynamics. Members of
ences among the characteristics of these different types
the group can affect the group dynamics on the basis of
of groups and the nurse’s role.
their motivation for participating and their similarity to
other group members and the goal of that group. The TASK GROUPS The task group is one of the most
unique dynamics of each group will influence its matura- common types of work-related groups that nurses belong
tion or group process, as well as the effectiveness of the to. The focus of such groups is the completion of a
group. Three main functions are required for any group specific task, and the leader and/or members define the
to be effective: (a) It must maintain a degree of group format at the beginning. The methods vary according
unity or cohesion; (b) it needs to develop and modify to the task to be completed. Examples are health care
its structure to improve its effectiveness; and (c) it must planning committees, nursing service committees, nurs-
accomplish its goals. The characteristics of an effectively ing team meetings, nursing care conference groups, and
functioning group are shown in Table 22.3. hospital staff meetings.
TABLE 22.3 Comparative Features of Effective and Ineffective Groups
Factor Effective Groups Ineffective Groups

Atmosphere Comfortable and relaxed: It is a working Tense: This atmosphere lacks privacy or voluntary
atmosphere in which people demonstrate commitment to the group.
their interest and involvement.
Purpose Goals, tasks, and outcomes are clarified, The purposes are unclear, misunderstood, or imposed.
understood, and modified so that mem-
bers of the group can commit themselves
to purposes through cooperation.
Leadership and member Leadership is democratic with a shift in lead- Authoritarian: The leader may dominate the group, or
participation ership from time to time, depending on the members may defer unduly. Member participa-
knowledge or experience. tion is unequal, with some members dominating.
Communication Open: Ideas and feelings are encouraged. Closed: Only idea production is encouraged. Feelings
are ignored. Members may have “hidden agen-
das” (personal goals at cross-purposes with group
goals).
Decision making Although done by the group, various decision- This is done by the highest authority in the group, or
making procedures appropriate to the situ- one or two strong members of the group, with
ation may be instituted. minimal involvement by members. Disagreements
are ignored.
Cohesion Facilitated through valuing other group mem- The leader claims full credit for achievements.
bers, open expression of feelings, trust, Comments are critical and focus on personal
and support. characteristics.
Conflict tolerance The reasons for disagreements or conflicts are Fear of conflict prevents decisions and growth.
carefully examined, and the group seeks to
resolve them.
Power Determined by the members’ abilities and the Determined by position in the group. Obedience to
information they possess. Power is shared. authority is strong. The issue is who is in control
based on individual emotional needs of members.
Problem solving High: Constructive criticism is frequent, frank, Low: Criticism may be destructive, taking the form of
relatively comfortable, and oriented toward either overt or covert personal attacks.
problem solving.
Creativity Encouraged. Discouraged.
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The leader of a task group, usually called the chairper- BOX 22.4 POSITIVE ASPECTS OF SELF-HELP
son, must be accepted by the members as an appropriate GROUPS
leader and, therefore, should be an expert in the area of
task emphasis. The chairperson’s role is to identify the Self-help groups have many positive aspects:
specific task, clarify communication, and assist in express- • Members can experience almost instant kinship because
ing opinions and offering solutions. Committee members are the essence of the group is the idea that “you are not
alone.”
generally selected in terms of their individual functional
• Members can talk about their feelings and listen to
role and employment status, rather than in terms of their
the concerns of others, knowing they all share this
personal characteristics. Member participation is deter- experience.
mined by the task. A target date for termination of the • The group atmosphere is generally one of acceptance,
group is usually set in advance. support, encouragement, and caring.
TEACHING GROUPS The major purpose of teaching • Many members act as role models for newer members
and can inspire them to attempt tasks they might con-
groups is to impart information to the participants. Exam-
sider impossible.
ples of teaching groups include continuing education and
• The group provides the opportunity for people to help
client health care groups. Numerous subjects are often and be helped—a critical component in restoring
handled via the group teaching format: childbirth tech- self-esteem.
niques; birth control methods; effective parenting; nutri-
tion; management of a chronic illness, such as diabetes;
exercise for middle-aged and older adults; and instructions for example, to study communication patterns, group
to family members about follow-up care for discharged process, or problem solving. Because the focus of these
clients. A nurse who leads a group in which the primary groups is interpersonal concerns around current situa-
purpose is to teach or learn must be skilled in the teach- tions, the work of the group is oriented to reality testing,
ing–learning process (see Chapter 26). with an emphasis on the here-and-now. Members are
responsible for correcting inefficient patterns of relat-
SELF-HELP GROUPS A self-help group is a small, vol-
ing and communicating with each other. They learn
untary organization composed of individuals who share a
group process through participation and involvement
similar health, social, or daily living problem. One of the
and guided exercises.
central beliefs of the self-help movement is that people who
experience a particular social or health problem have an THERAPY GROUPS Therapy groups work toward self-
understanding of that condition which those without it do understanding, more satisfactory ways of relating or han-
not. Self-help groups are available for a range of problems dling stress, and changing patterns of behaviour toward
(e.g., stillbirth, parenting, pregnant adolescents, divorce, health. Members of the therapy group are referred to as
problematic drug use, cancer, menopause, mental illness, clients or, in some settings, as patients. They are selected
diabetes, acquired immunodeficiency syndrome [AIDS], by health care professionals after extensive selection
women’s health, caregivers of people, and grief). Alcohol- interviews that consider the pattern of personalities,
ics Anonymous (AA) was the first self-help group. Positive behaviours, needs, and identification of group therapy
aspects of self-help groups are outlined in Box 22.4. as the treatment of choice. Duration of therapy groups
The major functions of the nurse’s role in self-help is not usually set. A termination date is usually mutually
groups include the following: determined by the therapist and the members.
• Helping clients form such groups by identifying key WORK-RELATED SOCIAL SUPPORT GROUPS Many
people who can act as facilitators nurses, for example, hospice, emergency, and acute care
• Sharing expertise with clients and helping them gain nurses, experience high levels of vocational stress. Vari-
appropriate knowledge and skills ous aspects of group support can help deal with such
stress. For example, a nurse may help another team
• Informing clients and support persons about existing member consider alternative strategies for intervention.
self-help groups available to them Members also can share the joys of success and the frus-
• Participating as a member of a self-help group when tration of failure through active listening without giving
this is appropriate; the nurse’s role is that of a resource advice or making judgments. This type of social support
person, that is, being “on tap but not on top” is best given outside of the work environment.
• Helping out in times of crisis
SELF-AWARENESS OR GROWTH GROUPS The pur-

pose of self-awareness or growth groups is to develop
Communication
or use interpersonal strengths. The overall aim is to and the Nursing Process
improve the person’s functioning in the group to which
they return, whether workplace, family, or community. Communication is an integral part of the nursing process.
From the beginning, broad goals are usually apparent, Nurses use communication skills in each phase of the
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nursing process. Communication is also important when

caring for clients who have communication problems, such
as those with sensory, language, or cognitive deficits.
COMMUNICATION WITH OLDER ADULTS
Older adults may have physical or cognitive problems that
necessitate nursing interventions for improvement of commu-
Assessing nication skills. Some of the common problems are as follows:
• Sensory deficits, such as vision and hearing deficits
To assess the client’s communication, the nurse deter- • Cognitive impairment, as in dementia
mines communication impairments or barriers and • Neurological deficits from strokes or other neurological
communication style. Remember that culture can influ- conditions, such as aphasia (expressive or receptive) and
ence when and how a client speaks. Obviously, language lack of movement
varies according to age and development. With children, • Psychosocial problems, such as depression
the nurse observes sounds, gestures, and vocabulary. Recognizing specific needs and obtaining appropriate
resources for clients can greatly increase their socialization
IMPAIRMENTS TO COMMUNICATION Various barriers and quality of life. Interventions directed toward improving
can alter a client’s ability to send, receive, or compre- communication in clients with these special needs are as
hend messages. These include language deficits, sensory follows:
deficits, cognitive impairments, structural deficits, and • Make sure that assistive devices, glasses, and hearing
paralysis. The nurse must assess each client to determine aids are being used and are in good working order.
their presence. • Make referrals to appropriate resources, such as for
speech therapy.
Language Deficits Determine the client’s primary lan- • Make use of communications aids, such as communica-
guage for communicating and whether a fluent inter- tion boards, computers, or pictures, when possible.
preter is required. Some clients for whom English is a • Keep environmental distractions to a minimum.
second language may have limited language skills to • Speak in short, simple sentences and on one sub-
ject at a time. Reinforce or repeat what is said, when
express their needs. necessary.
• Always face the person when speaking. Coming up from
Sensory Deficits The ability to hear, see, feel, and smell behind can startle the person.
are important adjuncts to communication. Deafness • Include family and friends in conversation.
can significantly alter the message the client receives;
• Use reminiscing, either in individual conversations or
impaired vision alters the ability to observe nonverbal in groups, to maintain memory connections and to
behaviour, such as a smile or a gesture; the inability enhance self-identity and self-esteem in the older adult.
to feel and smell can impair the client’s capabilities to • When verbal expression and nonverbal expression are
report injuries or detect the smoke from a fire. For clients incongruent, believe the nonverbal expression. Clarifica-
tion of this and attentiveness to their feelings will help
with severe hearing impairments, follow these steps:
promote a feeling of caring and acceptance.
• Look for a MedicAlert bracelet (or necklace or tag) • Find out what has been important and has meaning to
indicating hearing loss. the person, and try to maintain these things as much
as possible. Even simple things, such as bedtime ritu-
• Determine whether the client wears a hearing aid and als, become important if they are lost in a hospital or
whether it is functioning. extended care setting.
• Observe whether the client is attempting to see your

face to read your lips.
• Observe whether the client is using his or her hands to assesses the following: Is the client’s speech fluent or
communicate with sign language. hesitant? Can the client comprehend and follow direc-
tions? In addition, the nurse assesses the client’s ability
Cognitive Impairments Any disorder that impairs to understand written words: Can the client follow writ-
cognitive functioning (e.g., cerebrovascular disease, ten directions? Can the client read aloud? Can the client
Alzheimer’s disease, and brain tumours or injuries) can recognize words or letters if unable to read whole sen-
affect a client’s ability to use and understand language tences? The nurse uses large, clearly written words when
(see the Lifespan Considerations box). These clients trying to establish abilities in this area.
lose the ability to speak, have impaired articulation, When the client is unconscious, the nurse looks for any
or may not be able to find the correct words. Certain indication that suggests comprehension of what is commu-
medications, such as sedatives, antidepressants, and nicated (e.g., tries to arouse the client verbally and through
neuroleptics, can also impair speech, causing the client touch). The nurse can ask a closed question, such as “Can
to use incomplete sentences or slurred words. you hear me?” and watch for a nonverbal response, such as
The nurse assesses whether the client responds when a nod of the head for yes, or the nurse can ask for a hand
asked a question, and if he or she does, the nurse then squeeze or blink of the eyes once for yes.
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Structural Deficits Structural deficits of the oral and (i.e., transmits meaning)” (Wilkinson & Ahern, 2009,
nasal cavities and respiratory system can alter a person’s p. 110). Communication problems may be receptive (e.g.,
ability to speak clearly and spontaneously. Examples difficulty hearing) or expressive (e.g., difficulty speaking),
include cleft palate; artificial airways, such as an endotra- and the nursing analysis or nursing diagnosis may be
cheal tube or tracheostomy; and laryngectomy (removal expressed in these terms.
of the larynx). Extreme dyspnea (shortness of breath) The nursing diagnosis or problem statement Impaired
can also impair speech patterns. Verbal Communication may not be useful when an individu-
al’s communication problems are caused by a psychiatric
Paralysis If verbal impairment is combined with paral-
illness. For example, a client with depression may exhibit
ysis of the upper extremities that impairs the client’s
certain symptoms, such as difficulty expressing feelings,
ability to write, the nurse should determine whether the
or have slowed thinking or responses; clients who have
client can point, nod, shrug, blink, or squeeze a hand.
anxiety have decreased ability to focus; and clients with
Any of these could be used to devise a communication
schizophrenia may have auditory hallucinations (hearing
system.
voices) and have difficulty hearing the nurse’s voice at the
STYLE OF COMMUNICATION In assessing communica- same time (Boyd, 2008).
tion style, the nurse considers both verbal and nonverbal If the communication issue is caused by the cli-
communication. In addition to physical barriers, some ent having a problem coping, the diagnoses of Fear or
psychological illnesses (e.g., depression or psychosis) Anxiety may be more appropriate. Other nursing diag-
influence the ability to communicate. The client may noses (North American Nursing Diagnosis Association
demonstrate constant verbalization of the same words [NANDA] International, 2015) used for clients experi-
or phrases, a loose association of ideas, or flight of ideas. encing communication problems that involve impaired
verbal communication as the etiology could include the
Verbal Communication When assessing verbal com-
following:
munication, the nurse focuses on three areas: (a) the
content of the message, (b) the themes, and (c) verbalized • Anxiety, related to impaired verbal communication
emotions. In addition, the nurse considers the following: • Powerlessness, related to impaired verbal communication
• Whether the communication pattern is slow, rapid, • Situational Low Self-Esteem, related to impaired verbal
quiet, spontaneous, hesitant, evasive, and so on communication
• The vocabulary of the individual, particularly noting • Social Isolation, related to impaired verbal communication
any changes from the vocabulary normally used; for • Impaired Social Interaction, related to impaired verbal
example, a person who normally never swears may communication.
indicate increased stress or illness by uncharacteristic
use of profanity
• The presence of hostility, aggression, assertiveness,
reticence, hesitance, anxiety, or loquaciousness (inces- Planning
sant verbalization) in communication When a nursing diagnosis or nursing assessment related
• Difficulties with verbal communication, such as slur- to impaired communication has been made, the nurse
ring, stuttering, an inability to pronounce a particular and client determine goals or outcomes and begin plan-
sound, a lack of clarity in enunciation, an inability to ning ways to promote effective communication. The
speak in sentences, loose association of ideas, flight of overall client goal for persons with difficulties commu-
ideas, or an inability to find or name words or identify nicating is to reduce or resolve the factors impairing the
objects communication. Specific nursing interventions will be
planned from the stated etiology. Examples of outcome
• Refusal or inability to speak
criteria to evaluate the effectiveness of nursing interven-
tions and achievement of client goals includes the client
Nonverbal Communication Consider nonverbal
doing the following:
communication in relation to the client’s culture. Pay
particular attention to facial expression, gestures, body • Communicates that needs are being met.
movements, affect, tone of voice, posture, and eye • Begins to establish a method of communication:
contact.
a. Signals yes or no to direct questions by using
vocalization or an agreed-on physical cue (e.g., eye
Diagnosing or Nursing Analysis blink, hand squeeze).
Impaired Verbal Communication may be used as a nursing b. Uses verbal or nonverbal techniques to indicate
diagnosis when “an individual experiences a decreased, needs.
delayed, or absent ability to receive, process, transmit, • Perceives the message accurately, as evidenced by
and use a system of symbols—anything that has meaning appropriate verbal or nonverbal responses.
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• Communicates effectively in any of the following an interpreter. Ways to enhance communication include
ways: keeping words simple and concrete and discussing topics
a. Uses the predominant language. of interest to the client. It is often helpful to use alter-
native communication strategies, such as word boards,
b. Uses a translator or an interpreter.
pictures, or paper and pencil.
c. Uses sign language. Often, interpreters can help a client and nurse
d. Uses a word board or a picture board. to communicate when the client lacks fluency in the
e. Uses a computer. predominant language. Some hospitals have a list of
interpreters for various languages who can assist at the
• Regains maximum communication abilities.
bedside. If the client’s support person offers to interpret,
• Expresses minimum fear, anxiety, frustration, and it is important to ask the client’s permission, for the sake
depression. of confidentiality. Then, instruct the person to translate
• Uses resources appropriately. as precisely as possible, without interpretation.
In adopting a holistic and caring approach in nurs-
ing practice, nurses work with clients, their significant
Implementing others, and members of the multidisciplinary team to
gather the needed information for nursing care planning
Nursing interventions to facilitate communication with (intersectoral cooperation). Effective communication skills are
clients who have problems with speech or language used to elicit input so that a plan of care can be mutu-
include manipulating the environment, providing sup- ally developed (public participation). In caring for acutely
port, employing measures to enhance communication, ill clients, nurses must consider how best to use technology
and educating the client and his or her support person. to help the client obtain the needed quality of life, care,
MANIPULATE THE ENVIRONMENT A quiet environ- and comfort.
ment with limited distractions will make the most of the EDUCATE THE CLIENT AND SUPPORT PERSONS
communication efforts of both the client and the nurse Sometimes, clients and support people can be prepared
and increase the possibility of effective communication. in advance for communication problems, for example,
Sufficient light will aid in conveying nonverbal messages, before an intubation or throat surgery. When anticipated
which is especially important if visual or auditory acuity problems are explained, the client is often less anxious
is impaired. Initially, the nurse needs to provide a calm, when those problems do arise.
relaxed environment that will help reduce any anxiety
the client may have.
PROVIDE SUPPORT The nurse should convey encour- Evaluating
agement to the client and provide nonverbal reassurance,
Evaluation is useful for both client and nurse
perhaps by touch, if appropriate. If the nurse does not
communication.
understand, it is critical to let the client know so that
the nurse can provide clarification with other words or CLIENT COMMUNICATION To establish whether client
through some other means of communication. When goals have been met in relation to communication, the
speaking with a client who has difficulty understanding, nurse must listen actively, observe nonverbal cues, and
the nurse should check frequently to determine what the use therapeutic communication skills to determine that
client has heard and understood. The use of open-ended communication was effective. Examples of evaluative
questions will help the nurse obtain accurate informa- statements indicating goal achievement could be “using
tion about the effectiveness of communication (Moore, picture board effectively to indicate needs” or “the client
Rivera Mercado, Grez Artigues, & Lawrie, 2015). For stated, ‘I listened more closely to my daughter yesterday
example, Maria Perez, who has limited English skills, is and found out how she feels about our divorce.’”
being taught about a diet related to her Crohn’s disease.
NURSE COMMUNICATION For nurses to evaluate the
If the nurse asks, “Do you understand what to eat?”
effectiveness of their own communication with clients,
Maria may nod her head to indicate yes. However, this
process recordings are frequently used. A process
does not give her nurse confirmation that the message
recording is a verbatim (word-for-word) account of a
given has been received. Rather, the nurse needs to say,
conversation. It can be taped or written and includes all
“What do you think will be good for you to eat when you
verbal and nonverbal interactions of both the client and
go home?” The nurse’s body language (e.g., gestures,
the nurse. One method of writing a process recording is
posture, facial expression, and eye contact) should con-
to make two columns on a page. The first column lists
vey acceptance and approval.
what the nurse and the client said along with the associ-
EMPLOY MEASURES TO ENHANCE COMMUNICA- ated nonverbal behaviour. The second column contains
TION Determine how the client can best receive mes- interpretive comments about the nurse’s responses. An
sages: by listening, by looking, through touch, or through example of a process recording is shown in Table 22.4.
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TABLE 22.4 Sample Process Recording
Mary Jane Adams, a nursing aide, reports to Irene Olsen, the staff nurse, that Sandra Barrett, the client in room 815, had finished
only her orange juice when Ms. Adams collected the breakfast trays. Mrs. Barrett had been admitted 2 days earlier for diagnostic
studies. Concerned about her client, Ms. Olsen walks down the corridor to room 815, knocks, and enters the room. As Ms. Olsen
enters, Mrs. Barrett turns away from the window, tears in her eyes.
Nurse–Client Dialogue Analysis
Nurse: Good morning, Mrs. Barrett. Acknowledging
Client: Hello.
Nurse: I understand you didn’t eat your breakfast. Making a specific statement but ignoring
Client: I wasn’t hungry. the nonverbal expression
Nurse: Is something wrong? Asking a closed question that fails to
Client: No. (Eyes fill with tears.) facilitate exploration
Nurse: You look sad, as if you’re about to cry. Giving feedback
Client: (Cries)
Nurse: I’ll sit here awhile with you. (Sits down.) Offering self
Client: (Continues to cry.)
Nurse: (After a 30-second pause) Sometimes it’s hard to share the things you’re Empathizing
concerned about with someone you don’t know well. I’d like to be able to help. Supporting
Client: (Angrily) You can help me by telling me the truth. Offering self
Nurse: (Leans forward and maintains eye contact) Actively listening and demonstrating
Client: Everyone beats around the bush when I ask them what’s wrong with me. interest
The nurse manager said, “What do you think is wrong?” That kind of put-off
drives me up the wall!
Nurse: You’re angry because you’re not getting any answers. It seems as if the Paraphrasing
nurses know something about your condition and they’re keeping it from you.
Client: They all seem to be in cahoots. Nobody tells me anything. (Pause.) (Softly) If
the news was good, they wouldn’t beat around the bush.
Nurse: I’m wondering if you’re worried that because people haven’t answered your Paraphrasing
question, it means that you have a serious illness.
Client: Good news is always easy to give.
Nurse: Yes, people do seem to be able to deliver good news easier and faster. I also Giving information
know that we don’t have any news—good or bad—to give you because none of Supporting
the laboratory or x-ray results are back yet. I know that doesn’t help answer your
questions, but I hope it relieves you a bit from worrying that there is some bad
news that’s being withheld.
Client: Well, when my father-in-law had surgery for a bleeding ulcer, the x-ray and
laboratory results were available immediately.
Nurse: When there’s a question of emergency surgery being needed, then test Giving information
results are asked for immediately. Usually, though, it’s preferable to wait for an
accurate reading and a thorough written report.
Client: Are you absolutely sure?
Nurse: You don’t sound convinced. Acknowledging the implied
Client: Listen, I don’t mean to give you a hard time. It’s just that . . . it may not seem
like an emergency to my doctor or the lab people, but it sure is to me. I can’t
stand not knowing. I don’t know the results of the tests I had yesterday. I don’t
know how many more tests I have to have. Will I have to have surgery? When
can I go home?
Nurse: The problem you need help with now is finding out the answers to four ques- Summarizing
tions: What are the results of yesterday’s tests? Is your doctor considering any Encouraging problem solving
other tests for you, and, if so, what are they? Is surgery being planned? And
when can you go home? Let’s try to figure out how you can get the answers to
these questions.
Client: Well, I can’t call my doctor on the phone. All his receptionist will do is take
the message. And, anyway, I’m afraid that he’ll be offended if he thinks I’m com-
plaining about him. You won’t tell him, will you?
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Nurse–Client Dialogue Analysis

Nurse: No, not unless you and I decide together that it would be the best solution. Encouraging collaboration
Client: I suppose I could try to forget about it and be patient, just like everyone tells
me to.
Nurse: You’ve tried that, but you’re still worried, fearful, and angry. Let’s think of Encouraging further exploration
some other possibilities.
Client: Maybe you could call his office for me! Since you’re a nurse, they’ll probably
put your call right through.
Nurse: So far, we have identified three possible solutions—calling his office your- Focusing on solutions
self, waiting until he comes to visit you later this afternoon, or having me call his
office. Are there any other possible solutions that we haven’t considered?
Client: I can’t think of any other.
Nurse: Okay, then, which do you think would be best? Demonstrating respect for the client
Client: I guess I’d feel better if you called his office. I just don’t want him to think that
I’m criticizing him.
Nurse: You’re concerned about what he might think of you because of this phone Paraphrasing
call. Let’s discuss how I should handle the call and what I should say. Encouraging collaboration and problem
solving
Source: Based on material by Carol Ren Kneisl, president and educational director, Nursing Transitions, Williamsville, NY.
Once a process recording has been completed, it 2009a; Woelfle & McCaffrey, 2007). These disruptive
should be analyzed in terms of the content and mean- behaviours have a negative impact on the work envi-
ing of the interaction based on communication theory. ronment and are one of the reasons nurses leave the
Each of the nurse’s statements is interpreted in terms profession, which subsequently contributes to nursing
of the communication skill used, with the rationale for shortages. Workplace violence destroys the ideal orga-
and effectiveness of its use. Any barriers to effective nizational climate of mutual respect and has negative
communication can be identified, with a possible alter- health consequences and impairs productivity. Examples
native response noted. The outcome for nurses should include absenteeism, emotional exhaustion, decreased
be increased awareness and insight regarding their com- commitment to the organization, decreased effort at
munication strengths, as well as identification of areas work, incivility toward others, decreased communica-
for future skills development. tion, decreased reporting of problems, and leaving the
organization (Hutton & Gates, 2008).
The CNA and the Canadian Federation of Nurses
Communication among
Unions (CFNU) support zero workplace violence and
promote a healthy workplace for all nurses (CNA &
Health Care Professionals CNFU, 2010). Workplace intimidation jeopardizes client

safety and subsequently requires health care facilities to
design and implement a systemwide approach for ensur-
Effective communication among the health care profes- ing employee awareness of the consequences of disrup-
sions is as important as the promotion of therapeutic tive behaviours. One example is the implementation of
communication between the nurse and the client. For Ontario’s Bill 168, Occupational Health and Safety Act,
example, communication problems among health care by all workplaces to halt and prevent such behaviours
personnel have been implicated as a cause of most client (Legislative Assembly of Ontario, 2009).
errors (Dillon, Noble, & Kaplan, 2009). Sirota (2007)
reported that poor communication between nurses and
physicians was the most important factor causing dis- Disruptive Behaviours
satisfaction with nurse–physician working relationships.
Many nurses report verbal abuse, lateral violence, inci- Three common disruptive behaviours reported among
vility, and bullying from physicians and other nurses nurses are (a) incivility, (b) lateral violence, and (c)
(Johnson, Martin, & Markle-Elder, 2007; Olender-Russo, bullying.
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INCIVILITY Incivility is described as rude, discourteous, important information. (See Chapter 24, “Document-
or disrespectful behaviour that reflects a lack of regard for ing and Reporting.”)
others (Hutton & Gates, 2008; Olender-Russo, 2009b).
Common actions that characterize incivility include per-
sonal insults, invading personal territory, uninvited physi- Emotional Intelligence
cal contact, threats and intimidation, sarcastic jokes and
teasing, abusive e-mails, humiliation, public shaming, Emotional intelligence is the ability to form work
rude interruptions, two-faced attacks, dirty looks, and relationships with colleagues, display maturity in a vari-
treating people as if they are invisible (Sutton, 2010). ety of situations, manage emotions, consider the emo-
tions of others, and resolve conflicts by interacting with
LATERAL VIOLENCE Lateral violence, horizontal vio- colleagues constructively to achieve a positive outcome
lence, and horizontal hostility are all terms that describe (Momeni, 2009). A nurse or primary care provider
physical, verbal, or emotional abuse or aggression with emotional intelligence may be viewed as mature,
directed at coworkers at the same organizational level. approachable, or easygoing.
Examples of these behaviours include undermining
activities, withholding information, sabotage, scapegoat-
ing, infighting, backstabbing, and broken confidences Assertive Communication
(CNA & CFNU, 2010). Newly registered nurses are at
Assertive communication promotes client safety by min-
risk for lateral violence (Sheridan-Leos, 2008).
imizing miscommunication with colleagues. People who
BULLYING Bullying is an abusive, intimidating treat- use assertive communication are honest, direct, and
ment of someone who is in a vulnerable position or a appropriate while being open to ideas and respecting
position with less power. The person being bullied feels the rights of others. An important characteristic of
threatened and humiliated and suffers stress. The perpe- assertive communication includes the use of “I” state-
trator usually is at a higher level of authority (e.g., nurs- ments versus “you” statements. The “you” statement
ing supervisor to staff nurse). To be considered bullying places blame and puts the listener in a defensive posi-
behaviour, it must occur repeatedly (e.g., twice a week or tion. In contrast, the “I” statement encourages discus-
more) and for at least 6 months, and target an individual sion. For example, a nurse who states “I am concerned
who is unable to defend herself or himself (Olender- about . . .” will be gaining the attention of the primary
Russo, 2009b). care provider while also giving a message about the
importance of working together for the benefit of the
client. It is then important for the nurse to be clear,
concise, organized, and fully informed when verbally
Nurse and Physician presenting the client concern.
Communication Nonassertive Communication

There are few guidelines for the frequent verbal com- Two types of interpersonal behaviours are considered
munication that occurs between nurses and doctors. This nonassertive: (a) submissive and (b) aggressive.
lack of guidelines or format may contribute to medical
errors as a result of communication problems. SUBMISSIVE When people use a submissive communica-
tion style, they meet the demands and requests of others
without regard to their own feelings and needs because
Communication Styles they believe their own feelings are not important. People
who use submissive communication style usually are inse-
The differences between nurse communication and cure with low self-esteem and want to avoid conflict (e.g.,
physician communication can make collaboration diffi- negative criticism and disagreement from others).
cult. In general, nurses have been taught to be descrip-
tive in verbal and written communication. Physicians, AGGRESSIVE There is a fine line between assertive and
however, are trained to be brief, to the point, and aggressive communication. Assertive communication is an
focused on a problem. Therefore, they may become open expression of ideas and opinions while respecting the
impatient waiting for the nurse to come to the point rights, opinions, and ideas of others. Aggressive communica-
(Johnson et al., 2007; Pope, Rodzen, & Spross, 2008). tion can be blaming and delivered in a rushed manner, thus
One model, called SBAR (situation, background, becoming ineffective and leading to frustration for the nurse
assessment, recommendations) provides a standardized and the primary care provider (Cleary, Walter, & Horsfall,
framework for effective and accurate communication of 2009; Mascioli, Laskowski-Jones, Urban, & Moran, 2009).
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Case Study 22
You are the nursing student assigned to care for Mr. McIntyre, a
2. Evaluate the nurse’s response to Mrs. McIntyre on the
65-year-old man, who is an inpatient in a Halifax, Nova Scotia,
basis of the concepts of caring and comforting.
hospital that is 372 kilometres away from his home in Ben Eion,
Cape Breton. His wife was the only member of his family able 3. Why is it important for the nurse to effectively communi-
to accompany him on the journey. He will be returning from the cate with Mrs. McIntyre at this time?
recovery room after undergoing removal of a mass from his 4. The nurse was described as listening attentively to Mrs.
abdomen. While you are preparing his room for his return from McIntyre. Cite actions that portray attentive listening.
surgery, the nurse and the physician arrive to talk with Mrs. 5. Think about your past experiences when you or a family
McIntyre about her husband’s surgery. The physician explains member has been ill. What relationship characteristics
that the mass was malignant and invasive. Mr. McIntyre is a can- did you most value on the part of the nurse caring for
didate for chemotherapy, but his prognosis is guarded because you?
of the extent of tumour growth. Mrs. McIntyre looks away, closes
her eyes, and only nods her head. After the physician leaves, the 6. What have you learned today through the actions of this
nurse approaches Mrs. McIntyre, sits next to her, and puts her nurse?
arm around Mrs. McIntyre, who begins to cry. The nurse uses
a soothing voice to tell Mrs. McIntyre that it is okay to cry and Visit MyNursingLab for answers and explanations.
provides assurance by remaining with her. The two of them sit
in silence until Mrs. McIntyre is able to express her feelings. The
nurse listens attentively. Later, the nurse offers to get a cup of
coffee for Mrs. McIntyre and offers to assist
her at this difficult time. The nurse discusses
her actions with you and tells you that she
will remember to inform her colleagues dur-
ing report that Mrs. McIntyre has no family
support to help her during this difficult time.
1. Interpret Mrs. McIntyre’s nonverbal behaviour in

response to the news about her husband’s surgery.
KEY TERM S
aesthetic knowing culturally competent ethical knowing p. 384 process recording
p. 384 care p. 382 feedback p. 387 p. 403
attentive listening decode p. 387 group p. 398 receiver p. 387
p. 392 electronic communica- group dynamics p. 399 relational ethics p. 385
boundaries p. 392 tion p. 387 incivility p. 406 relational practice
bullying p. 406 emancipatory lateral violence p. 406 p. 391
caring p. 381 knowing p. 384 message p. 386 sender p. 386
caring practice p. 382 emotional nonverbal task group p. 399
communication p. 385 intelligence p. 406 communication territoriality p. 391
congruent empathy p. 397 p. 387 therapeutic communica-
communication empirical knowing personal knowing tion p. 392
p. 391 p. 384 p. 384 verbal communica-
encoding p. 386 personal space p. 390 tion p. 387
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• Communication is a critical nursing skill that is used disadvantages and nurses must guard against a risk to cli-
to gather information, to teach and encourage, and to ent confidentiality.
express caring and comfort. • The factors that influence the communication process
• Caring is said to be the essence of nursing. It includes assis- include development, gender, values and perceptions,
tive, supportive, and facilitative acts for individuals or groups. personal space (intimate, personal, social, and public dis-
• Caring acts promote individual growth, preserve human tances), territoriality, roles and relationships, environment,
dignity and worth, augment self-healing and comfort, and congruence, and attitudes.
relieve distress. • Many techniques facilitate therapeutic communication:
• Comfort needs can be viewed in a framework of physical, attentive listening; paraphrasing; clarifying; using open
psychospiritual, social, and environmental needs. Nurses questions and statements; focusing; being specific; using
need to be knowledgeable, skilled, and innovative to indi- touch and silence; clarifying reality, time, or sequence;
vidualize comforting strategies. providing general leads; and summarizing.
• Caring is a key concept in the nurse–client process. When • Techniques that inhibit communication include offering
clients feel cared for, they report higher levels of health invalidated reassurance, stating approval or disapproval,
satisfaction and quality of life. Client-centred care is giving common (not expert) advice, stereotyping, and
focused on effective nurse–client interaction. being defensive.
• Communication is a two-way interpersonal process • The effective nurse–client relationship is a helping rela-
involving the sender of the message and the receiver of tionship that facilitates growth and provides support,
the message. It also involves intrapersonal messages, or comfort, and hope.
self-talk, which can affect the message, the interpretation
• To help clients with communication problems, the nurse
of the message, and the response.
manipulates the environment, provides support, employs
• Because the sender must encode the message and deter- measures to enhance communication, and educates the
mine the appropriate channels for conveying it, and client and support persons.
because the receiver must perceive the message, decode
it, and then respond, the communication process includes • Nurses interact with groups of clients and colleagues in
four elements: sender, message, receiver, and feedback. a wide variety of settings. To use groups rationally and
effectively, nurses must understand the features of effec-
• Verbal communication is effective when the criteria of tive groups.
pace and intonation, simplicity, clarity and brevity, timing,
relevance, adaptability, and credibility are met. • Effective groups produce outstanding results, succeed in
spite of difficulties, and have members who feel respon-
• Nonverbal communication often reveals more about a sible for the output of the group. They accomplish their
person’s thoughts and feelings than verbal communica- goals, maintain cohesion, and develop and modify their
tion; it includes personal appearance, posture and gait, structure in ways that improve effectiveness.
facial expressions, and gestures.
• Process recordings are frequently made by nurses to
• When assessing verbal and nonverbal behaviours, the nurse
evaluate their own communication. With them, nurses
needs to consider cultural influences and be aware that a
can analyze both the process and the content of the
single nonverbal expression can indicate any of a variety of
communication.
feelings and that words can have various meanings.
• When communication is effective, verbal and nonverbal • Effective communication among health care professionals
expressions are congruent. is vital. Communication styles may differ between nurses
and physicians.
• Electronic communication is evolving in nursing
practice. Nursing informatics has advantages and • Assertive communication can promote client safety.

1. A client has suffered a left cerebral vascular accident 2. A nurse discovers a young woman crying on a chair
(CVA) resulting in expressive asphasia. Wernicke’s beside her bed. What is the best response by the
area of the brain is not damaged. The nurse is plan- nurse?
ning strategies to facilitate communication with the a. “You look sad. Why are you crying?”
client. Which strategy would be most effective for this
client? b. “Are you in pain?”
a. Arrange for a translator to be available c. “Tell me more about how you are feeling.”
b. Talk more slowly and use simple words d. “Do you want to go home?”
c. Use a word board 3. A nurse working on a fast-paced medical unit is
d. Arrange for a speech pathologist to see the client approached by a client who asks where his nurse is.
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Knowing that his nurse is on break, which of the fol- termination phase of the nurse–client relationship. As the
lowing is the most caring response? nurse is summarizing the relationship the client states, “I
a. “I am not sure, but your nurse will be back soon to would enjoy seeing you again over coffee.” How should
assist you.” the nurse respond to this statement?
b. “Your nurse is having coffee. He has had a very busy a. “I must decline the invitation because this would be
morning.” crossing the boundary of our professional relationship.”
c. “Your nurse is having coffee. Is there anything that I b. “I’ll need to check with my manager whether this is
may assist you with?” appropriate or not.”
d. “Your nurse is having coffee, and I am very busy. c. “That would be nice. I can then see how you are
Can you wait until he comes back”? progressing.”
d. “It’s against agency policy to have coffee with
4. A nurse delivers a message to a client that the surgeon clients.”
has just cancelled the client’s surgery, which had been
scheduled for later in the day. The client yells and 8. A supervisor states to a nurse, “You are spending too
swears at the nurse, stating, “The lot of you are incom- much time talking with clients and not enough time
petent!” What is the best response by the nurse? training the new staff on the unit.” Which of the fol-
a. “I don’t like how you are treating me. Please show a lowing is the nurse’s best response?
little respect.” a. “Don’t worry about it. I will work overtime tonight
b. “I’ll come back when you have calmed down, and to make sure they are all trained.”
then we can talk.”
b. “My priority is care of clients. How can you expect
c. “I see that you are upset, but I feel uncomfortable me to have enough time to do both?”
when you swear at me.”
c. “It is important for me to discuss clients’ issues and
d. “Swearing at me isn’t going to help, but I do sympa-
concerns with them. I will arrange new staff training
thize with you.”
times.”
5. A health care team on an acute geriatric unit meets on d. “It is my role as a nurse to speak with my clients
a weekly basis to review clients’ progress. The nurse and address their concerns as much as possible. You
observes that one team member consistently dominates know that.”
the discussion. Which of the following actions is most
appropriate for the nurse to take? 9. After breakfast, a client states that he wants to rest
a. Continue observing and note any changes in in bed for the morning and not go to physiotherapy.
behaviour Which of the following is the best response by the
b. Discuss these observations with the group nurse?
c. Speak to group members individually to validate a. “It is best if you go. The physiotherapist will help
these observations you walk better.”
d. Speak with the individual privately regarding these b. “Please tell me more about this.”
observations c. “Are you in pain?”
d. “What would you like me to tell her?”
6. A colleague says, “You do not know what you are
doing!” How should the nurse respond to build effective
10. A nurse is talking with a client who has recently lost a
communication?
child. The nurse states, “Would it help to discuss your
a. “Of course I do! You don’t know what you are saying.” feelings about the loss of your child?” What communi-
b. “Let’s talk about this later when we’ve both had time cation technique is the nurse using with the client?
to think.” a. Offering the self
c. “You have hurt my feelings. I am going to speak with b. Acknowledging
the manager.”
d. “Let’s go to a quieter area, and you can tell me what c. Seeking clarification
you mean.” d. Leading
7. What method of communicating is a barrier to com-
munication? The nurse is preparing a client for the
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Chapter 23
The Nursing Process
Updated by
Noelle Rohatinsky, RN, PhD

T
LEARNING OUTCOMES
After studying this chapter, you will be able to he nursing process
1. Describe the five phases of the nursing process. is a systematic, client-

centred, rational method
2. Identify the relevance of each phase of the nursing process in
guiding nursing practice. of planning and providing individual-
ized nursing care. Its purpose is to
3. Identify methods of data collection.
identify client strengths and potential
4. Differentiate objective and subjective data and primary and
or actual health problems or needs,
secondary data.
and to develop specific nursing inter-
5. Describe the characteristics and formulations of writing nursing
ventions to achieve mutually agreed-
diagnoses or stating nursing problems.
upon outcomes. At every stage of
6. Identify factors that the nurse must consider in planning for,
the process, the nurse works closely
implementing, and evaluating patient care.
with the client to tailor care and build
7. Outline how critical pathways and concept maps are used to
a relationship of mutual regard and
create a comprehensive nursing care plan.
trust. The client may be an individual,
8. Formulate client health outcome evaluation criteria as part of the
a family, a community, or a group.
planning process.
9. Explain how evaluation relates to various phases of the nursing
process.
10. Identify the importance of quality improvement processes to guide
ongoing improvement in client care.
M23_KOZI2703_04_SE_C23.indd 411 17/03/17 11:32 AM

Overview of the Nursing process is a regularly repeated event or sequence of

events (cyclical) that is continuously changing and
Process dynamic.
• Client-centredness. The nurse organizes the plan of care
Lydia Hall coined the term nursing process in 1955, whereas according to identified client problems. In the assess-
others (Johnson, 1959; Orlando, 1961; Wiedenbach, ment phase, the nurse collects data to determine the
1963) referred to the phases of the process to describe client’s health status, habits or routines, preferences,
the practice of nursing. There are five phases of the nurs- and needs, enabling the nurse to adapt the plan of
ing process: (a) assessment, (b) diagnosis, (c) planning, care to the client as much as possible.
(d) implementation, and (e) evaluation, the competencies
• Focus on problem solving. The nursing process uses both
for professional nursing practice (see Figure 23.1). The
problem-solving technique (see Chapter 21) and
use of the nursing process in clinical practice gained addi-
systems theory (see Chapter 12) to organize care. Both
tional legitimacy in 1973 when the phases were included
processes (a) begin with data gathering and analysis,
in the American Nurses Association standards of nurs-
(b) base action (intervention or treatment) on a prob-
ing practice. These phases of nursing process are also
lem statement (nursing diagnosis, problem statement,
expected competencies for professional nursing practice
or medical diagnosis), and (c) include an evaluative
in Canada (Canadian Nurses Association [CNA], 2015).
component. The nursing process is directed toward
Since the 1970s, the CNA has endorsed the nurs-
a client’s responses to disease and illness and adapta-
ing process in guiding nursing practice (CNA, 2015).
tions to his or her altered health status, whereas the
The nursing process remains a fundamental process that
medical model of care tends to focus on physiological
facilitates a thoughtful, informed, evidence-based, and
systems and the disease process.
ethical nursing practice. This process guides nursing care
with individual, family, group, and community clients in • Focus on decision making. Decision making is involved
a variety of practice settings. It is a process that fosters in every phase of the nursing process. Nurses can be
critical thinking and decision making. Regulatory nurs- highly creative in determining how to intervene on the
ing bodies in each province have standards of nursing basis of client data. Nurses are not bound by standard
practice to support the centrality of the nursing process in responses and can apply their repertoire of skills and
guiding nursing practice to meet client health outcomes. knowledge to assist clients.
• Interpersonal and collaborative style. Nurses communicate
directly and consistently with clients to meet their
Phases of the Nursing Process needs. They also collaborate, as members of the
health care team, in a joint effort to provide quality
As mentioned above, the nursing process has five phases. client care.
These phases of the nursing process are not separate
entities but overlapping, continuing subprocesses. For • Use of critical thinking. Nurses must use a variety of critical
example, while administering medications (implement- thinking skills to carry out the nursing process (Alfaro-
ing), the nurse continuously notes the client’s skin colour, Lefevre, 2013) (see Chapter 21). Table 23.1 provides
level of consciousness (assessment), and response to med- examples of critical thinking in the nursing process.
ication (evaluation). Each phase of the nursing process
affects the others; they are closely interrelated. If inad-
equate data are obtained during assessing, the nursing
diagnoses will be incomplete or incorrect because of this
Assessing
omission, and inaccuracy could thus be reflected in the Assessing is the systematic collection, organization, vali-
planning, implementing, and evaluating phases. dation, and documentation of data (information). It is a
An overview of the five-phase nursing process is continuous process that is carried out during all phases of
shown in Figure 23.1. the nursing process. For example, in the implementation
phase, reassessment of the client is completed to update
the data collected. All phases of the nursing process
Characteristics of the Nursing Process depend on the accurate and complete collection of data.
The nurse completes a holistic assessment of the
The nursing process has distinctive characteristics that
client, who may be an individual, a family, a group,
enable the nurse to respond to the changing health status
or a community. The broad spectrum of social determi-
of the client. These characteristics include the following:
nants of health and how these determinants are affect-
• Cyclical and dynamic nature. Data from each phase ing human responses are considered during assessment
provide input into the next phase. Findings from eval- (see Chapter 7). Assessment comes in four different types:
uation feed back into assessment. Hence, the nursing (a) initial assessment, (b) problem-focused assessment,
M23_KOZI2703_04_SE_C23.indd 412 03/03/17 11:04 AM

Chapter 23 The Nursing Process 413
THE NURSING PROCESS IN ACTION

The nursing process is a systematic, rational method of planning and providing nursing care. Its
purpose is to identify a client’s health care status and actual or potential health problems, to
establish plans to meet the identified needs, and to deliver specific nursing interventions to
address those needs. The nursing process is cyclical; that is, its components follow a logical
sequence, but more than one component can be involved at one time. At the end of the first cycle,
care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the
plan of care may be modified.
ASSESSING
• Collect data
• Organize data
ASSESSING
• Validate data
• Document data
DIAGNOSING
• Analyze data
DIAGNOSING • Identify health problems, risks,
and strengths
• Formulate diagnostic statements
PLANNING
PLANNING • Prioritize problems and diagnoses
• Formulate goals and design health
outcomes
• Select nursing interventions
• Write nursing interventions
IMPLEMENTING
• Reassess the client
IMPLEMENTING • Determine the nurse’s need for
assistance
• Implement the nursing
interventions
• Supervise delegated care
• Document nursing activities
EVALUATING
EVALUATING
• Collect data related to outcomes
• Complete data with outcomes
• Relate nursing actions to client
goals/outcomes
• Draw conclusions about problem
status
• Continue, modify, or terminate the
client’s care plan
FIGURE 23.1 The nursing process in action.
M23_KOZI2703_04_SE_C23.indd 413 03/03/17 11:05 AM

Amanda Aquilini, a 28-year-old

married lawyer, was admitted
to the hospital with an elevated
ASSESSING Mary’s physical health
temperature, a productive assessment reveals that Amanda’s vital
cough, and rapid, laboured signs are temperature, 39.3°C; pulse, 92;
respirations. In taking a respirations, 28; blood pressure 122/90 mm Hg;
nursing history, Nurse Mary and pain scale 6/10.
Mary observes that Amanda’s skin is dry,
Medina, RN, finds that
her cheeks are flushed, and she is
Amanda has had a “chest experiencing chills. Auscultation reveals
cold” for 2 weeks, and has inspiratory crackles with diminished breath
been experiencing shortness sounds in the right lung.
of breath on exertion.
Yesterday she developed
an elevated temperature
and began to
experience
DIAGNOSING After analysis, Mary
“pain” in formulates a nursing diagnosis,
her “lungs.” Ineffective Airway Clearance related to
viscous secretions obstructing airways.
PLANNING Mary and Amanda develop

a plan of care that includes, but is not
limited to, deep breathing and coughing
q3h*, fluid intake of 3000 mL per day,
and daily postural drainage.
IMPLEMENTING Mary encourages

Amanda to practise deep breathing and
coughing exercises q3h, to intake 3 L of
fluid per day, and to schedule time for
postural drainage.
EVALUATING On assessment of chest

expansion, Mary detects failure of the
client to achieve maximum ventilations.
She and Amanda modify the care plan to
increase deep breathing and coughing
exercises to q2h, including incentive
spirometry.
FIGURE 23.1 (continued)

*The abbreviation “q3h” indicates “deep breathing and coughing every 3 hours.”
M23_KOZI2703_04_SE_C23.indd 414 03/03/17 11:05 AM

(c) emergency assessment, and (d) time-lapsed reassess-

ment (see Figure 23.2 and Table 23.2). Assessments vary
according to their purpose, timing, time available, and
client status.
Assessing Nursing assessments focus on a client’s responses
• Collect data
• Organize data to a health challenge or problem. A nursing assessment
• Validate data should include the client’s strengths, perceived needs,
• Document data health problems, related experience, health practices,
values, culture, social network, and lifestyle preferences.
Diagnosing
The nursing assessment includes collaborating with the
client to prioritize the client’s concerns and health issues.
Evaluating
Planning
Collecting Data
Data collection is the process of gathering information
Implementing
about a client’s health status. It must be both systematic
and continuous to prevent the omission of significant
data and to reflect a client’s changing health status.
The following questions are generally collected via the
admission process and the initial nursing admission
FIGURE 23.2 Assessing: The assessment process involves documentation.
four closely related activities.
TABLE 23.1 Overview of the Nursing Process Component and Description
Components and
Description Purpose Activities
Assessing
Collecting, organizing, validat- • To establish a database about • Establish a database:
ing, and documenting cli- the client’s response to health –– Consult with the client to obtain a nursing health history
ent data concerns or illness and the abil- concerning the following:
ity to manage health care needs
° History of present illness
° Understanding of present illness
° Beliefs about this illness
° Other health concerns
° Social concerns relative to this illness
–– Conduct a physical assessment.
–– Review client records.
–– Review relevant literature.
–– Consult support persons.
–– Consult other health care professionals.
• Update data, as needed.
• Organize data.
• Validate data.
• Communicate and document data.
Diagnosing/Analyzing*
Analyzing and synthesizing • To identify client strengths and • Interpret and analyze data:
data and identifying client health problems that can be –– Cluster or group data.
health outcomes prevented or resolved by collab-
–– Identify gaps and inconsistencies.
orative and independent nursing
interventions • Determine client’s strengths, risks, and problems.
• To develop a list of nursing • Formulate nursing diagnoses/client problems and collab-
diagnoses or client strengths/ orative problem statements.
problems and collaborative • Document nursing diagnoses/client problems on the care
problems that will focus care plan.
(continued)
M23_KOZI2703_04_SE_C23.indd 415 03/03/17 3:39 PM

TABLE 23.1 Overview of the Nursing Process Component and Description (continued)
Components and
Description Purpose Activities
Planning
Determining how to prevent, • To develop an individualized care • Set priorities and goals or health outcomes in collaboration
reduce, or resolve the plan that specifies client goals with client.
identified priority client and desired health outcomes • Write goals, or desired outcomes.
problems; how to support and related nursing interventions • Select nursing strategies or interventions.
client strengths; and how • Consult other health care professionals.
to implement nursing inter- • Write nursing orders and the nursing care plan.
ventions in an organized, • Communicate the care plan to relevant health care providers.
individualized, and goal-
directed manner to achieve
client health outcomes
Implementing
Carrying out (or delegat- • To assist the client to meet • Reassess the client to update the database.
ing) and documenting desired goals and desired health • Determine the client’s need for nursing assistance.
the planned nursing outcomes; promote wellness; • Perform (or delegate) the planned nursing interventions.
interventions prevent illness and disease; • Communicate what nursing actions were implemented:
restore health; and facilitate –– Document care and client responses to care.
coping with altered functioning
–– Give verbal reports, as necessary.
Evaluating
Measuring the degree to • To determine whether to con- • Collaborate with the client, and collect data related to
which goals/outcomes tinue, modify, or terminate the desired health outcomes.
have been achieved and plan of care • Document the achievement of health outcomes and modi-
identifying factors that fications of the care plan.
positively or negatively • Judge whether goals or outcomes have been achieved.
influence this achievement • Relate nursing actions to client health outcomes.
• Make decisions about the status of the problem.
• Review and modify the care plan, as indicated, refer or ter-
minate nursing care.
*In some provinces, the term diagnosis is reserved as a function of the medical profession; the nursing profession in these provinces uses the term nursing analyses or nursing
conclusions in place of diagnosis.
TABLE 23.2 Types of Assessment
Type Time Performed Purpose Example

Initial assessment Performed within specified To establish a complete database for Nursing admission assessment
time after client admis- problem identification, reference, and
sion to a health care future comparison
agency
Problem-focused Ongoing process inte- To determine the status of a spe- Hourly assessment of client’s fluid
assessment grated with nursing cific problem identified in earlier intake and urinary output in an
care assessment intensive care unit (ICU)
Initial assessment when To identify new or evolving problems Assessment of client’s ability to per-
client presents for brief, form self-care while assisting a
episodic care client to bathe
Emergency During any physiological or To identify life-threatening, new, or over- Rapid assessment of a person’s air-
assessment psychological crisis looked problems way, breathing status, and circu-
lation during a cardiac event
Assessment of suicidal tendencies or
potential for violence
Time-lapsed Follow-up several months To compare the client’s current status Reassessment of a client’s functional
reassessment after initial assessment to baseline data previously obtained health patterns in a home care or
outpatient setting.
M23_KOZI2703_04_SE_C23.indd 416 03/03/17 11:05 AM

A database contains all the information about a cli- Client data should include past history as well as
ent; it includes the health history (see Box 23.1), physical current problems. For example, a history of an allergic
assessment, health care provider’s history and physical reaction to penicillin is a vital piece of data. Past surgical
examination, results of laboratory and diagnostic tests, procedures, folk healing practices, and chronic diseases
and material contributed by other health care personnel. are also examples of historical data. Current data relate to
BOX 23.1 COMPONENTS OF A NURSING HEALTH HISTORY
BIOGRAPHICAL DATA LIFESTYLE
Client’s name, address, age, gender, marital status, occu- • Personal habits: the amount, frequency, and duration
pation, religious preference, next of kin, and usual sources of substance use (tobacco, alcohol, and illicit or recre-
of health care, including health care providers ational drugs)
CHIEF CONCERN OR REASON FOR VISIT • Diet: description of a typical diet on a normal day or any
special diet, number of meals and snacks per day, ethni-
The answer given to the question, “What is troubling you?” cally distinct food patterns, and food allergies
or, “What brought you to the hospital or clinic?” The chief • Sleep and rest patterns: usual daily sleep and wake times,
concern should be recorded in the client’s own words. difficulties sleeping, remedies used for difficulties, napping
HISTORY OF PRESENT ILLNESS OR HEALTH • Activities of daily living (ADLs): any difficulties experienced
in the basic activities of eating, grooming, dressing, elimi-
CONCERN
nation, and mobility
• Symptoms: description of each; steady, episodic, or • Recreation and hobbies: exercise activity and tolerance,
worsening pattern hobbies and other interests
• Onset of symptoms: sudden or gradual, how long ago, SOCIAL DATA
circumstances at time of onset
• Frequency of the problem • Family relationships, social networks, and friendships: the
client’s support system; the effect of the client’s illness on
• Exact location of the distress the family; and any family problems affecting the client (See
• Character of the complaint (e.g., intensity of pain or qual- also the discussion of family assessment in Chapter 13.)
ity of sputum, emesis, or discharge) • Ethnic and religious affiliation: health customs and beliefs;
• Other symptoms associated with the chief concern cultural and religious practices that may affect health
• Factors that aggravate or alleviate the problem care and recovery (See also detailed ethnic and cultural
assessment guide in Chapter 11.)
PAST HISTORY • Educational history: data about the client’s highest level of
education attained and any past difficulties with learning
• Medications: all currently used prescription and over-the- • Occupational history: current employment status, the
counter medications number of days missed from work because of illness,
• Hospitalization for serious illnesses: reasons for the hos- occupational hazards, employment status of spouse/
pitalization, dates, surgery performed, course of recovery, partner, and childcare needs
and any complications • Economic status: financial concerns for medical care
• Immunizations: date of the last tetanus injection, influenza and coverage
immunization • Home and neighbourhood conditions: home layout,
• Accidents and injuries: how, when, and where the inci- safety measures, and possible modifications needed in
dent occurred, type of injury, treatment received, and physical facilities; the availability of neighbourhood and
complications community services to meet the client’s needs
• Childhood illnesses: for example, chickenpox, mumps, PSYCHOLOGICAL DATA
measles, rubella (German measles), rubeola (red mea-
sles), streptococcal infections, scarlet fever, rheumatic • Major stressors: those experienced in the past year and
fever, and other significant illnesses the client’s perception of them
• Allergies: drugs, animals, insects, or other environmental • Usual coping pattern: used to cope with a serious prob-
agents and the type of reaction that occurs lem or a high level of stress
• Infectious disease exposure • Communication style: ability to verbalize appropriate con-
cerns or emotions, nonverbal communication patterns,
FAMILY HISTORY OF ILLNESS and interactions with support persons
To ascertain risk factors for certain diseases, the ages of PATTERNS OF HEALTH CARE
siblings, parents, and grandparents and their current state All the health care resources the client is currently using and
of health or (if they are deceased) the cause of death are has used in the past. These include the family health care
obtained. Particular attention should be given to such disor- providers, specialists (e.g., ophthalmologist or gynecologist),
ders as heart disease, cancer, diabetes, hypertension, obe- dentist, alternative practitioners (e.g., herbalist or faith heal-
sity, allergies, arthritis, tuberculosis, bleeding, alcoholism, ers), health clinic, or health centre; and whether access to
and mental illnesses. health care is a problem.
M23_KOZI2703_04_SE_C23.indd 417 03/03/17 11:05 AM

present circumstances, such as pain, nausea, sleep patterns, professionals, records and reports, laboratory and diag-
and religious practices. Data can be subjective or objective nostic analyses, and relevant literature are secondary or
and constant or variable, and come from a primary or sec- indirect sources. All sources other than the client are
ondary source, and are labelled as such (see Chapter 24). considered secondary sources.
Client The best source of data is usually the client,

Types of Data unless the client is too ill, too young, or too confused to
Subjective data, also referred to as symptoms or covert communicate clearly. Some clients are reluctant to pro-
data, are based on client’s perceptions, sensations, feel- vide accurate data because they are afraid, embarrassed,
ings, beliefs, attitudes, and understanding of personal or distrustful. In addition, depending on the client’s
health status and life situations and can be described culture, he or she may be reluctant to discuss certain
by that person. Itching, pain, and feelings of worry are personal topics or share specific information. All clients
examples of subjective data. should be assured of confidentiality of all data collected
Objective data, also referred to as signs, are detect- and that they will be shared only with persons who have
able by an observer or can be tested against an accepted a legitimate health care–related need to know it.
standard. They can be seen, heard, felt, or smelled, and
Support People Family members and caregivers can
they are obtained by observation or physical examina-
supplement information provided by the client. Clients
tion. For example, discoloration of skin and blood pres-
should indicate those family members with whom the
sure readings are objective data. Nurses should obtain
nurse can discuss their health issues. Support people
any objective data that substantiates subjective data
might convey information about the client’s response to
although client experiences may not be evident in objec-
illness, cultural beliefs and practices, stresses the client
tive data (see Box 23.2).
has been experiencing, important information about the
Constant data refers to information that does not
client’s home or work environment, usual behaviour pat-
change over time, such as race or blood type. Variable
terns, family attitudes toward health, and any prior health
data can change quickly, frequently, or rarely and include
directive. The nurse should also indicate on the nursing
such data as blood pressure, level of pain, and age.
history what data were obtained from a support person.
Both subjective and objective data provide a base-
line for determining clients’ responses to nursing and Client Records Client records include information docu-
medical interventions. To identify the key symptoms that mented by various health care professionals. By reviewing
should be the primary focus of care, clients are asked to such records before interviewing the client, the nurse can
indicate what symptoms are of the most concern. avoid asking questions for which answers have already
SOURCES OF DATA Sources of data are primary or sec- been supplied. Repeated questioning can be stressful and
ondary. The client is the primary source of data. Family annoying to clients and cause concern about the lack of
members or other support persons, other health care communication among health care professionals.
BOX 23.2 EXAMPLES OF SUBJECTIVE AND OBJECTIVE DATA
SUBJECTIVE OBJECTIVE
“I feel weak all over when I exert myself.” Blood pressure 90/50 mm Hg
Apical pulse 104/min
Skin pale and diaphoretic
Client states he has a cramping pain in his abdomen. Vomited 100 mL green-tinged fluid
States, “I feel sick to my stomach.” Abdomen firm and slightly distended
Active bowel sounds auscultated in all four quadrants
“I’m short of breath.” Lung sounds clear bilaterally; diminished in right lower lobe
Wife states: “He doesn’t seem so sad today.” (This is Client cried during interview
subjective and secondary source data.)
“I would like to see the chaplain before surgery.” Holding open Bible
Has small silver cross on bedside table
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• Medical records (e.g., medical history, physical examina- TABLE 23.3 Observational Skills
tion, progress notes, and consultations) can provide
nurses with information about the physician’s assess- Sense Example of Client Data
ment of the current health issue, client’s coping behav- Sight Overall appearance (body size, general weight,
iours, health practices, previous illnesses, and allergies. posture, grooming); signs of distress or
discomfort; facial and body gestures; skin
• Records of therapies by other health care professionals include colour and lesions; abnormalities of move-
records by social workers, dietitians, or physiothera- ment; nonverbal demeanour (e.g., signs of
pists, for example. anger or anxiety); religious or cultural arti-
facts (e.g., books, icons, beads)
• Laboratory records also provide health information per-
tinent to the nurse to compare with established norms Smell Body or breath odours
for that particular test and for the client’s age, gender, Hearing Lung and heart sounds; bowel sounds; ability
geographical location, or present situation. For exam- to communicate; language spoken; ability to
ple, the determination of blood glucose level allows initiate conversation; ability to respond when
spoken to; orientation to time, person, and
health care professionals to monitor the effects of oral place; thoughts and feelings about self, oth-
hypoglycemic medications on a 60-year-old newly ers, and health status; noise level
diagnosed person with diabetes. Similarly, if the most
Touch Skin temperature and moisture; muscle strength
recent health record is 5 years old, it is likely that the (e.g., hand grip); pulse rate, rhythm, and vol-
client’s health practices, family situations, and coping ume; palpatory lesions (e.g., lumps, masses,
behaviours have changed. nodules)
Health Care Professionals Nurses, social workers, phy-

sicians, and physiotherapists may have information from
either previous or current contact with the client. Shar- Observing To observe is to gather data by using the
ing of information among professionals is especially five senses. Observation is a conscious, deliberate skill
important to ensure continuity of care when clients are that is developed through effort and with an organized
transferred to and from home and health care agencies. approach. Examples of client data observed through
four of the five senses are shown in Table 23.3.
Literature The review of nursing and related literature, Observation has two aspects: (a) attending to the
such as professional journals and reference texts, can stimuli and (b) selecting, organizing, and interpreting the
provide additional information for the database. A lit- data. A nurse who observes that a client’s face is flushed
erature review includes but is not limited to the following must relate that observation to, for example, body tem-
information: perature, activity, environmental temperature, and blood
• Standards or norms against which to compare find- pressure. Nurses often need to focus on specific stimuli
ings (e.g., height and weight tables, normal develop- to avoid being overwhelmed by a multitude of stimuli.
mental tasks for an age group) Observing, therefore, involves distinguishing stimuli in
a meaningful manner. For example, nurses caring for
• Cultural and social health practices
newborns learn to ignore the usual sounds of machines
• Clinical practice guidelines in the nursery but respond quickly to an infant’s cry or
• Research evidence for nursing interventions and eval- movement.
uation criteria relevant to a client’s health problems The experienced nurse is often able to attend to an
• Information about medical diagnoses, treatments, and intervention (e.g., giving a bed bath or monitoring an
prognoses intravenous infusion) and, at the same time, make impor-
tant observations (e.g., noting a change in respiratory
status or skin colour). The beginning student must learn
DATA COLLECTION METHODS The primary methods
to make observations and complete tasks simultaneously.
used to collect data are observing, interviewing, and
Nursing observations must be organized so that
examining. Observation occurs whenever the nurse is
nothing significant is missed. Most nurses develop a par-
in contact with the client. Interviewing is used mainly
ticular sequence for observing events, usually focusing on
while taking the nursing health history. Examining is
the client first. For example, a nurse walks into a client’s
the major method used in the physical health assess-
room and observes, in the following order:
ment. The nurse uses all three methods simultaneously
when assessing clients. For example, during the client • The client (e.g., response to greeting, verbalizations)
interview, the nurse observes, listens, asks questions, and • Clinical signs of client distress (e.g., pallor or flushing,
mentally retains information to explore in the physical laboured breathing, and behaviour indicating pain or
examination. emotional distress)
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• Threats to the client’s safety, real or potential (e.g., a clarify, or explore their thoughts or feelings. An open-
lowered side rail, a fire threat) ended question specifies only the broad topic to be
• The presence and functioning of associated equip- discussed and gives clients the freedom to divulge only
ment (e.g., intravenous equipment and oxygen) the information that they are ready to disclose. Responses
may also convey clients’ attitudes and beliefs. The open-
• The immediate environment (e.g., appropriateness of
ended question is useful at the beginning of an interview
lighting level, accessibility to personal items), includ-
or to change topics and to elicit attitudes.
ing the people in it and assistive equipment
Open-ended questions usually begin with what or
Interviewing An interview is a planned communica- how. Examples of open-ended questions are “How have
tion with a purpose. For example, nurses may gather data you been feeling lately?” “What brought you to the
to identify problems of mutual concern during the nurs- hospital?” “How did you feel in that situation?”
ing admission assessment, evaluate change, teach, provide Open-ended and closed questions each have advan-
support, or provide counselling or therapy. Interviewing tages and disadvantages. See Box 23.3 for a summary.
is a process that the nurse applies in most phases of the The type of question a nurse chooses depends on the
nursing process. Clients are considered the experts in needs of the client at the time. For example, the nurse
their knowledge of themselves. The goal of the nurse is to asks closed questions in an emergency or other acute
listen actively, demonstrate caring in the development of situation when information must be obtained quickly.
a caring relationship, and encourage clients to participate Nurses may use a combination of closed and open-ended
in their own care. Interviews should be characterized by questions throughout an interview to accomplish the
mutuality between nurse and client. goals of the interview and obtain needed information.
Two approaches to interviewing are used: directive A neutral question is a question the client can
and nondirective. The directive interview is highly answer without feeling direction or pressure from the
structured and elicits specific information. The nurse nurse. Examples are “How do you feel about that?” and
establishes the purpose of the interview and guides “Why do you think you had the operation?” A leading
the interview by asking closed questions (see the next question, by contrast, directs the client’s answer. The
section) that call for specific data, as in the admission phrasing of the question suggests what answer is expected.
process. The client responds to questions but may have Examples are “You’re stressed about surgery tomorrow,
limited opportunity to ask questions or discuss concerns. aren’t you?” Leading questions create problems if the
Nurses frequently use directive interviews to gather and client, in an effort to please the nurse, gives inaccurate
to give information when time is limited (e.g., in an responses. This can result in inaccurate data.
emergency situation). Use the “why” questions carefully. Clients may not be
During a nondirective interview, or rapport- able to explain the rationale behind their behaviour and
building interview, by contrast, the nurse facilitates the can view such questions as threatening. Because the goal of
client’s control of purpose, subject matter, and pacing. questioning is to elicit as much purposeful information as
Rapport is a relationship between two or more people possible, anything that puts the client on the defensive will
that facilitates effective communication. interfere with reaching that goal.
A combination of directive and nondirective Planning the Interview and Setting Before beginning
approaches is usually used during the interview to collect an interview, the nurse reviews available information,
data and to begin to establish rapport. The nurse begins such as the medical history, information about the cur-
by asking open-ended questions to determine areas of rent illness, or literature about the client’s health prob-
concern for the client. If, for example, a client expresses lem. Nurses may also prepare an interview guide to
worry about surgery, the nurse pauses to explore the cli- determine what important questions to ask or use a
ent’s worry and to provide support. Simply noting the standardized form such as an admission form.
worry without dealing with it can leave the client feeling Effective interviews are influenced by time, place,
that the nurse does not care about the client’s concerns seating arrangement, distance, and language:
or dismisses them as unimportant.
• Time: Nurses need to plan interviews with clients when
Types of Interview Questions Questions are often clas- the client is physically comfortable and free of pain,
sified as closed or open-ended and as neutral or leading. and when interruptions by friends, family, and other
Closed questions, used in the directive inter- health care professionals are minimal.
view, are restrictive and generally require only “yes” or • Place: A well-lit, well-ventilated, moderate-sized room
“no” or short factual answers giving specific informa- that is relatively free of noise, movements, and inter-
tion. Examples of closed questions are “Did you take ruptions encourages communication. In addition, a
this medication?” “Are you having pain now? Show me place where others cannot overhear or see the client
where it is.” “How old are you?” “When did you fall?” is desirable. Although many interviews are conducted
Open-ended questions, associated with the non- at the client bedside, privacy is often compromised in
directive interview, invite clients to discover, elaborate, multiclient rooms.
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BOX 23.3 SELECTED ADVANTAGES • Seating Arrangement: A seating arrangement in which the
AND DISADVANTAGES OF OPEN-ENDED parties sit on two chairs placed at right angles to a desk
AND CLOSED QUESTIONS or table or a few feet apart, with no table between, cre-
ates a less formal atmosphere, and the nurse and cli-
OPEN-ENDED QUESTIONS ent tend to feel comfortable. In groups, a horseshoe or
circular chair arrangement can facilitate comfortable
Advantages
group discussion. When a client is in bed, a nurse in
1. They let the interviewee do the talking.
a sitting position is less formal and intimidating than
2. The interviewer is able to listen and observe.
standing at the foot of the bed or positioned standing
3. They are easy to answer and nonthreatening. near the client’s head.
4. They reveal what the interviewee thinks is important.
• Distance: People feel uncomfortable when talking to
5. They may reveal the interviewee’s lack of information,
someone who is too close or too far away. Most peo-
misunderstanding of words, frame of reference, preju-
dices, or stereotypes. ple feel comfortable maintaining a distance of about
6. They can provide information the interviewer may not ask
1 m (metre) during an interview. Communication at
for. a distance greater than this tends to be more imper-
7. They can reveal the interviewee’s degree of feeling about sonal and may suggest a lack of involvement on the
an issue. part of the nurse.
8. They can convey interest and trust because of the free- • Language: The nurse must avoid using complicated
dom they provide. medical terminology and instead use common English.
Disadvantages Translators are needed if the client and the nurse do not
1. They take more time. speak the same language. If giving written documents to
clients, the nurse must determine that the client can read
2. Only brief answers may be given.
in the document language. Live translation is preferred,
3. Valuable information may be withheld.
since the client can then ask questions for clarification.
4. They often elicit more information than necessary.
Nurses must be cautious when asking family members,
5. Responses are difficult to document and require skill in client visitors, or agency nonprofessional staff to assist
recording.
with translation. Issues of confidentiality or gender mis-
6. The interviewer requires skill in controlling an open-ended
match can interfere with effective communication. The
interview.
nurse must always confirm accurate understandings.
7. Responses require psychological insight and sensitivity
from the interviewer. Stages of an Interview An interview has three major
CLOSED QUESTIONS stages: (a) the opening or introduction, (b) the body or
Advantages development, and (c) the closing.
1. Questions and answers can be controlled more effectively. The Opening The opening is the most important part of the
2. They require less effort from the interviewee. interview because what is said and done at that time sets
3. They may be less threatening, since they do not require the tone for the remainder of the interview. The purposes
explanations or justifications. of the opening are to establish rapport and orient the
4. They take less time. interviewee. Depending on the situation and the relation-
5. Information can be asked for sooner than it would be ship between the two parties, the rapport and orientation
volunteered. stages may occur at the same time.
6. Responses are easily documented. Establishing rapport is a process of creating rela-
7. Questions are easy to use and can be handled by tionship and trust. It can begin with a greeting (“Good
unskilled interviewers. morning, Mr. Johnson.”) or a self-introduction (“Good
Disadvantages morning. I’m Jennifer Thomas, a nursing student.”)
accompanied by nonverbal gestures, such as a smile, a
1. They may provide too little information and require follow-
up questions. handshake, and a friendly manner. The nurse continues
2. They may not reveal how the interviewee feels. to develop rapport by asking questions about the person
and may proceed with some small talk about the weather,
3. They do not allow the interviewee to volunteer possibly
valuable information. sports, families, and the like. The nurse must be careful
4. They may inhibit communication and convey lack of inter- not to overdo this; too much superficial talk can arouse
est by the interviewer. anxiety about what is to follow and may appear insincere.
5. The interviewer may dominate the interview with In the introduction stage, the nurse explains the
questions. purpose and nature of the interview, for example, what
information is needed, how long it will take, and what is
Source: Stewart, C. J., & Cash, W. B., Jr. (2011). Interviewing: Principles and
practices (13th ed.). Boston, MA: McGraw-Hill. Reprinted with permission from The expected of the client. The nurse usually states that the
McGraw-Hill Companies. client has the right to refuse to answer a question and
tells the client how the information will be used.
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The following is an example of an interview 2. Conclude by saying, “That’s about all I need to
introduction: know for now” or “Those are all the questions I have
Step 1—Establish Rapport for now.”
3. Thank the client. “Thank you for your time.” “The
Nurse: Hello, Ms. Goodwin, I’m Jim Fellows. I’m a
questions you have answered will be helpful in plan-
nursing student, and I’ll be assisting with your care
ning your nursing care.”
here.
Client: Hi. Are you a student from the university? 4. Express concern for the person’s welfare and future:
“I’ll see you on Thursday.” “I hope all goes well for
Nurse: Yes, I’m in my final year. Are you familiar
you. If you run into additional problems, be sure to
with the campus?
contact me.”
Client: Oh, yes! I’m an avid hockey fan. My nephew
5. Plan for the next meeting, if there is to be one, or next
graduated in 2012, and I often attend hockey games
steps in client care. Include the day, time, place, topic,
with him.
and purpose: “Let’s get together again tomorrow,
Nurse: That’s great! Sounds like fun. here, at 9 a.m. to see how you are managing then.”
Client: Yes, I enjoy it very much. 6. Reveal what will happen next. For example, “Ms.
Step 2—Orientation Goodwin, I will be responsible for giving you care on
Monday, Tuesday, and Wednesday in the morning. At
Nurse: May I sit with you here for about 10 minutes
those times, we can adjust your care, if we need to,
to talk about how I can help you while you’re here?
and prepare for discharge.”
Client: All right. What do you want to know?
7. Signal that the time is up if a time limit was agreed
Nurse: Well, to plan your care after your operation,
on, or explain why the interview must close at that
I’d like to get some information about your normal
time: “I see our time is up; it went so quickly today.”
daily activities and what you expect here in the hos-
pital. I’d like to make notes while we talk to get the 8. Provide a summary to verify accuracy and agreement.
important points and have them available to other Summarizing serves several purposes: It helps terminate
staff members who will also look after you. the interview; it reassures the client that the nurse has lis-
Client: OK. That’s all right with me. tened; it checks the accuracy of the nurse’s perceptions;
it clears the way for new ideas; and it helps the client to
Nurse: If there is anything you don’t want to talk note progress and forward direction. “Let’s review what
about, please feel free to say so. we have covered in this interview.” Summaries are par-
Client: Sure, that will be fine. ticularly helpful for clients who are anxious or who have
The Body In the body of the interview, the client commu- difficulty staying with the topic: “It seems to me that you
nicates what he or she thinks, feels, knows, and perceives are especially worried about your hospitalization and
in response to questions from the nurse. The nurse can chest pain because your father died of a heart attack
ask an open-ended question that is related to the stated 5 years ago. Is that correct?”
purpose, is easy to answer, and does not embarrass or
place stress on the person. For example, “What brought Examining The physical examination or physical health
you to the hospital today?” assessment is a systematic data collection method that
Effective development of the interview demands uses observational skills (i.e., the senses of sight, hearing,
that the nurse use communication skills that make both smell, and touch) to detect health problems. To conduct
parties feel comfortable and serve the purpose of the the examination, the nurse uses techniques of inspec-
interview. See the discussion of communication skills in tion, auscultation, palpation, and percussion. These
Chapter 22. techniques are discussed in Chapter 28.
The nurse may also focus on a specific problem area
The Closing The nurse terminates the interview when the
noted from the nursing assessment, for example, the cli-
needed information has been obtained. In some cases,
ent’s inability to urinate. On occasion, the nurse may
however, a client terminates it, for example, when deciding
find it necessary to resolve a client complaint or problem
not to give any more information or when unable to offer
(e.g., shortness of breath) before completing the exami-
more information for some other reason, such as fatigue.
nation. This type of assessment is called a focused
The closing is important in maintaining the rapport and
assessment. Alternatively, the nurse may perform a
trust and in facilitating future interactions. The following
screening examination, which is a brief review of
techniques are commonly used to close an interview:
essential functioning of various body parts or systems.
1. Offering to answer questions: “I would be glad to An example of a screening examination is the nursing
answer any questions you have.” Be sure to allow time admission assessment form shown in Figure 23.3.
for the person to answer, or the offer will be regarded Figure 23.3 is a concise data collection tool that
as insincere. is organized according to body systems and specific
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ADMISSION DATA
Date 11-04-16 Time 1515h Primary Language English
Arrived via: Wheelchair / Stretcher / Ambulatory From: Admitting / ER / Home / Nursing Home / Other
Admitting MD R. Katz Time Notified 1700h Family MD R. Katz
Weight 57 kg Height 158 cm BP:R – L 122/80 Temp. 39.4°c Pulse 92. weak Resp. 28. shallow
Source Providing Information: Patient / Other Unable to Obtain History? Y / N
Reason for Admission “Chest cold” x 2 weeks. S.O.B. on exertion. “Lung pain, fever,” “Dr. says I have pneumonia.”
Orientation to Unit
Y / N Arm Band Correct Y / N Educational Material
Y / N Allergy Band Y / N Visiting
Y / N Telephone Y / N TV, Lights, Bed Controls, Call Lights, Side Rails
Y / N Electrical Policy Y / N Nurses Station
Y / N Smoking Policy
ALLERGIES AND REACTIONS

Drugs, food, dyes, etc: Y / N (If yes) Specify Penicillin Blood Reaction: Y / N
Signs and Symptoms rash, nausea
MEDICATIONS
Current Meds Dosage / Frequency Last Dose
Synthroid 0.1 mg daily 11-04-16, at 0800
MEDICAL HISTORY
Y / N No Major Problems Y /N Gastro
Y / N Cardiac Y / N Arthritis
Y / N Hyper/Hypeotension Y / N Stroke
Y / N Diabetes Y / N Seizures
Y / N Cancer Y / N Glaucoma
Y / N Respiratory Y / N Other Childbirth - 2004
Surgery/Procedures Date
Appendectomy 2000
Partial thyroidectomy 2004
SPECIAL ASSISTIVE DEVICES

Wheelchair Contacts Venous Access Device
Braces Hearing Aid Epidural Catheter
Cane/Crutches Prosthesis Dentures ( partial / upper / lower )
Walker Glasses Other None
PSYCHOSOCIAL HISTORY
Recent Stress None Coping Mechanism Not assessed because of fatigue
Support System Husband, coworkers, friends
Calm: Y / N Anxious: Y / N Facial muscles tense; trembling
Religion Catholic, would want Last Rites
Tobacco Use: Y / N Alcohol Use: Y / N Drug Use: Y / N
NEUROLOGICAL STATUS
Oriented: Person / Place / Time / Confused / Sedated / Alert / Restless / Lethargic / Comatose
Pupils: Equal / Unequal / Reactive / Sluggish / Other 3 mm.
Extremity Strength: Equal / Unequal
Speech: Clear / Slurred / Other
MUSCULO-SKELETAL STATUS
Normal ROM of Extremities: Y / N
Weakness / Paralysis / Contractures / Joint Swelling / Pain / Other weakness related to fatigue; pain when coughing
RESPIRATORY STATUS
Pattern: Even / Uneven / Shallow / Dyspnea / Other diminished breath sounds
Breathing Sounds: Clear / Other inspiratory crackles
Secretions: None / Other pink, thick sputum
Cough: None / Productive / Nonproductive
FIGURE 23.3 Assessment for Amanda Aquilini. Nursing assessment tool.

Note: The patient and information on this form are fictitious.
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CARDIOVASCULAR STATUS
Pulses: Apical Rate 92-W ( Regular / Irregular / Pacemaker ) [ S=Strong W=Weak A=Absent D=Doppler ]
Radial R 92 L – Pedal R – L –
Edema: Absent / Present (Site )
Perfusion: Warm / Dry / Diaphoretic / Cool / Hot
ELIMINATION PATTERNS
Gastrointestinal
Oral Mucosa: Normal / Other pale and dry Bowel Sounds: Normal / Other Abd. soft
Stool Frequency / Character 1/day ; soft Last Bowl Movement 11-04-16
Ostomy (type) Equipement
Genitourinary Amount & frequency
Urine: Last Voided This morning (Normal / Anuria / Hematuria / Dysuri / Incontinent / Other since ill )
Catheter (type) Other LMP 11-02-16 Vaginal / Penile Discharge: Y / N
SELF CARE
while fatigued
Need Assist with: Ambulating / Elimination / Meals / Hygiene / Dressing
NUTRITION
General Appearance: Well Nourished / Emaciated / Other
Appetite: Good / Fair / Poor – x 2 days
Diet Liquid Meal Pattern 3 / day ( Feeds Self / Assist / Total Feed )
SKIN ASSESSMENT
Colour: Normal / Flushed / Pale / Dusky / Cyanotic / Jaundiced / Other cheeks flushed, hot
General Description Surgical scars; RLQ abdomen; anterior neck
Note Cultures Obtained
EDUCATION/DISCHARGE PLANNING
1.What do you know about your present illness? “Dr. says I have pneumonia.” “I will have an I.V.”
2. What information do you want or need about your illness?
3. Would you like family involved in your care? Husband, Michael
4. How long do you expect to be in the hospital? “1-2 days”
5. What concerns do you have about leaving the hospital?
Will patient need post discharge assistance with ADLs/physical functioning? Y / N / Unknown
Does patient have family to provide assistance post discharge? Y / N / Unknown / No family
Is assistance needed beyond what family can provide? Y / N / Unknown
Previous admission in the last six months? Y / N / Unknown
Social Services Notified? Y / N
Patient lives with Husband and 1 child Planned discharge to Home
Comments: Fatigue and anxiety may have interfered with learning. Re-teach anything covered at admission, later.
NARRATIVE NOTES
S--c/o sharp chest pain when coughing and dyspnea on exertion. States unable to carry out regular daily exercise for past week.
Coughing relieved “if I sit up and sit still.” Nausea associated with coughing. Having occasional “chills.” Occasionally becomes frightened,
stating, “I can’t breathe.” Well groomed but “too tired to put on make-up.”
O--chest expansion < 3 cm, no nasal flaring or use of accessory muscles. Breath sounds and insp. crackles in R upper and lower chest.
Assesses own supports as “good” (eg. relationship with husband). Is “worried” about daughter. States husband will be out of town untill
tomorrow. Left 5-year-old daughter with neighbour. Concerned too about her work (is lawyer). “I’ll never get caught up.” Had water at
noon—no food today. Informed of need to save urine for 24 h specimen. IV D5W LR 1000 mL started in R arm, 100 mL/h slow
capillary refill. Keeping head of bed to facilitate breathing.
Amanda Aquilini [ F. age 28 ] Mary Medina, RN 11-04-16 1530h

#4637651 Nurse Signature / Title Date Time
FIGURE 23.3 (continued)
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nursing concerns (e.g., screening for falls and aller- 11 functional health patterns. Note how the categories in
gies); it does not use one particular nursing model. In Box 23.4 differ from those in Figure 23.3. As a rule, the
Box 23.4, the data from Amanda Aquilini are shown nurse organizes data by using the same model on which
after they have been organized according to Gordon’s the data collection tool is based.
BOX 23.4 DATA FOR AMANDA AQUILINI, ORGANIZED ACCORDING TO FUNCTIONAL HEALTH PATTERNS
HEALTH PERCEPTION AND HEALTH MANAGEMENT SELF-PERCEPTION AND SELF-CONCEPT
• Aware and understands medical diagnosis • Expresses “concern” and “worry” over leaving daughter
• Gives thorough history of illnesses and surgeries with neighbours until husband returns
• Complies with Synthroid regimen • Well-groomed, says, “Too tired to put on makeup”
• Relates progression of illness in detail
ROLES AND RELATIONSHIPS
• Expects to have antibiotic therapy and “go home in a day
or two” • Lives with husband and 7-year-old daughter
• States usual eating pattern “three meals a day” • Husband out of town; will be back tomorrow afternoon
• Child with neighbour until husband returns
NUTRITIONAL AND METABOLIC • States “good” relationships with friends and coworkers
• 158 cm tall; weighs 57 kg • Working mother, lawyer
• Usual eating pattern “three meals a day”
• “No appetite” since having “cold” COPING AND STRESS
• Has not eaten today; last fluids at noon • Anxious: “I can’t breathe”
• Nauseated • Facial muscles tense; trembling
• Oral temperature 39.4°C • Expresses concerns about work: “I’ll never get caught up”
• Decreased skin turgor
VALUES AND BELIEFS
ELIMINATION
• Catholic
• Usually no problem • Anointing of the sick requested
• Decreased urinary frequency and amount 2–3 days • Middle-class, professional orientation
• Last bowel movement yesterday, formed, “normal” • No wish to see chaplain or priest at present
ACTIVITY AND EXERCISE MEDICATION AND HISTORY
• No musculoskeletal impairment • Synthroid 0.1 mg per day

• Difficulty sleeping because of cough • Client has history of appendectomy, partial thyroidectomy
• “Can’t breathe lying down”
NURSING PHYSICAL ASSESSMENT
• States, “I feel weak”
• Short of breath on exertion • 28 years old
• Exercises daily • Height 158 cm; weight 57 kg
• Temperature, pulse, and respiration (TPR): 39.4°C, 92, 28
COGNITIVE AND PERCEPTUAL • Radial pulses weak, regular

• Blood pressure: 122/80 mm Hg sitting
• No sensory deficits • Skin hot and pale, cheeks flushed
• Pupils 3 mm, equal, brisk reaction • Mucous membranes dry and pale
• Oriented to time, place, and person • Respirations shallow; chest expansion <3 cm
• Responsive but fatigued • Cough productive of small amounts of pale pink sputum
• Responds appropriately to verbal and physical stimuli • Inspiratory crackles auscultated throughout right upper
• Recent and remote memory intact and lower chest
• States “short of breath” on exertion • Diminished breath sounds on right side
• Reports “pain in lungs,” especially when coughing • Abdomen soft, not distended
• Experiencing chills • Old surgical scars: anterior neck, right left quadrant (RLQ)
• Reports nausea abdomen
• Diaphoretic
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Organizing Data BOX 23.6 OREM’S SELF-CARE MODEL

The nurse uses a written or computerized format that UNIVERSAL SELF-CARE REQUISITES
organizes the assessment data systematically. This format
1. The maintenance of a sufficient intake of air
is often referred to as a nursing health history, nursing assess-
2. The maintenance of a sufficient intake of water
ment, or nursing data base form. The format can be modi-
3. The maintenance of a sufficient intake of food
fied according to the client’s physical status, such as one
4. The provision of care associated with elimination pro-
focused on musculoskeletal data for orthopedic clients.
cesses and excrement
NURSING CONCEPTUAL MODELS/FRAMEWORKS Most 5. The maintenance of a balance between activity and rest
schools of nursing and health care agencies have devel- 6. The maintenance of a balance between solitude and
oped their own structured assessment tools. Many of these social interaction
are based on selected nursing theories (see Chapter 4). 7. The prevention of hazards to human life, human function-
Three examples are Gordon’s functional health pating, and human well-being
tern framework (Gordon, 2016), Orem’s self-care model 8. The promotion of human functioning within social groups
in accord with human potential, known human limitations,
(Orem, 2001), and Roy’s adaptation model (Roy, 2008).
and human desire to be normal (Normalcy is used in the
Gordon (2016) provided a framework of 11 functional sense of that which is essentially human and that which is
health patterns (see Box 23.5). Gordon used the word in accord with the genetic and constitutional characteris-
pattern to signify a sequence of recurring behaviour. The tics and the talents of individuals.)
nurse collects data about dysfunctional as well as functional Source: Permission granted by the estate of Dorothea Orem.
behaviour. Thus, by using Gordon’s framework to organize
data, nurses are able to discern emerging patterns.
Orem (2001) delineated eight universal self-care

BOX 23.5 GORDON’S TYPOLOGY OF requisites of humans (see Box 23.6). Roy (2008) outlined
11 FUNCTIONAL HEALTH PATTERNS the data to be collected according to the Roy adaptation
The following 11 functional health patterns can be used to model and classified observable behaviour into four cat-
organize data: egories: (a) physiological, (b) self-concept, (c) role func-
tion, and (d) interdependence (see Box 23.7).
1. Health-perception/health-management pattern:
Describes the client’s perceived pattern of health and
well-being and how health is managed
BOX 23.7 THE ROY ADAPTATION MODEL
2. Nutritional–metabolic pattern: Describes the client’s
pattern of food and fluid consumption relative to meta- The Roy adaptation model classifies observable behaviour
bolic need and pattern indicators of local nutrient supply into the following categories:
3. Elimination pattern: Describes the patterns of excre-
tory function (bowel, bladder, and skin) ADAPTIVE MODES
4. Activity–exercise pattern: Describes the pattern of 1. Physiological/Physical
exercise, activity, leisure, and recreation
• Activity and rest
5. Sleep–rest pattern: Describes patterns of sleep, rest,
and relaxation • Nutrition
6. Cognitive–perceptual pattern: Describes sensory– • Elimination
perceptual and cognitive patterns • Fluid and electrolytes
7. Self-perception/self-concept pattern: Describes the cli- • Oxygenation
ent’s self-concept pattern and perceptions of self (e.g.,
self-conception/worth, comfort, body image, feeling • Protection
state) • Regulation: temperature
8. Role–relationship pattern: Describes the client’s pattern • Regulation: the senses
of role participation and relationships • Regulation: endocrine system
9. Sexuality–reproductive pattern: Describes the client’s
patterns of satisfaction and dissatisfaction with sexu- 2. Self-Concept
ality pattern; describes reproductive patterns • Physical self
10. Coping/stress-tolerance pattern: Describes the client’s • Personal self
general coping pattern and the effectiveness of the pat-
tern in terms of stress tolerance 3. Role Function
11. Value–belief pattern: Describes the patterns of values, 4. Interdependence
beliefs (including spiritual), and goals that guide the
client’s choices or decisions Source: Roy, Sister Callista; Andrew, H. A. The Roy adaptation model (3rd ed.).
Upper Saddle River, NJ: Pearson Education, Inc.; 2009. © 2009. Reprinted and
Source: Gordon, M. (2016). Manual of nursing diagnosis (12th ed.; pp. 2–5). Boston, Electronically reproduced by permission of Pearson Education, Inc., Upper Saddle
MA: Jones & Bartlett. Reprinted with permission. River, New Jersey.
M23_KOZI2703_04_SE_C23.indd 426 03/03/17 11:05 AM

WELLNESS MODELS Nurses use wellness models to Validating Data

assist clients to identify health risks and to explore lifestyle
habits and health behaviours, beliefs, values, and attitudes The information gathered during the assessment phase
that influence levels of wellness. See Chapter 7 for details. must be complete and accurate for the nurse to ana-
Such models generally include the following: lyze the data and determine appropriate interventions.
Validation is the act of “double-checking” or verifying
• Health history
data (cues) to confirm that they are accurate and factual.
• Physical fitness evaluation Validating data helps the nurse:
• Nutritional assessment
• Ensure that assessment information is complete.
• Life-stress analysis
• Ensure that objective and related subjective data agree.
• Lifestyle and health habits
• Health beliefs • Obtain additional information that may have been
missed initially.
• Sexual health
• Differentiate between cues and inferences. Cues are
• Spiritual health
subjective or objective data that can be directly heard
• Relationships or observed by the nurse, that is, what the client says
• Health risk appraisal or what the nurse can see, hear, feel, smell, or measure.
NON-NURSING MODELS Frameworks and models from Inferences are the nurse’s conclusions or interpreta-
other disciplines may also be helpful for organizing data. tion of the cues (e.g., a nurse observes the cues that an
The nurse usually combines these with other approaches incision is red, hot, and swollen; the nurse makes the
to obtain a complete history. inference that the incision is infected).
• Avoid jumping to conclusions and focusing too quickly
BODY SYSTEMS MODEL The body systems model
on what seem like obvious problems.
focuses on abnormalities of the following systems:
The nurse validates data when discrepancies exist
• Integumentary
between data obtained in the nursing interview (sub-
• Respiratory jective data) and the physical examination (objective
• Cardiovascular data), or when the client’s statements differ at different
• Nervous times in the assessment. Some subjective data provided
• Musculoskeletal by clients cannot be verified and must be accepted as
provided, as for instance, their level of fear about an
• Gastrointestinal
upcoming surgery. Guidelines for validating data are
• Genitourinary
shown in Table 23.4.
• Reproductive To collect data accurately, nurses need to be aware
of their own biases, values, and beliefs and to separate
MASLOW’S HIERARCHY OF NEEDS Maslow’s hierarchy
fact from inference, interpretation, and assumption. They
of needs clusters data pertaining to the following:
must validate assumptions regarding the client’s physical
• Physiological needs or emotional behaviour. For example, a nurse seeing a
• Safety and security needs man holding his arm to his chest might assume that he
is experiencing chest pain, when, in fact, he has a painful
• Love and belonging needs
hand. The nurse should ask the client why he is holding
• Self-esteem needs his arm to his chest. The client’s response may validate
• Self-actualization needs the nurse’s assumptions or prompt further questioning.
Figure 23.3 (see pages 423 and 424) shows that the nurse
See Chapter 12 for detailed information.
auscultated Amanda Aquilini’s heart and lungs to validate
DEVELOPMENTAL THEORIES Several physical, psycho- her statement that she had “pain” in her “lungs” and
social, cognitive, and moral developmental theories can “shortness of breath” on exertion. Failure to validate
be used by the nurse in specific situations. Examples assumptions can lead to an inaccurate or incomplete nurs-
include the following: ing assessment and could compromise client safety.
• Havighurst’s age periods and developmental tasks
• Freud’s five stages of development
• Erikson’s eight stages of development
Documenting Data
• Piaget’s phases of cognitive development To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
• Kohlberg’s stages of moral development
should include all data collected about the client’s health
See Chapters 17, 18, 19, and 20 for further information. status. Data are recorded in a factual manner and not
M23_KOZI2703_04_SE_C23.indd 427 03/03/17 11:05 AM

TABLE 23.4 Validating Assessment Data
Guideline Example
Compare subjective and objective data to verify Client’s perceptions of “feeling hot” need to be compared with measurement
the client’s statements with your observations. of the body temperature.
Clarify any ambiguous or vague statements. Client: “I’ve felt sick on and off for 6 weeks.”
Nurse: “Describe what your sickness is like. Tell me what you mean by ‘on
and off’.”
Be sure your data consist of cues and Observation: Dry skin and reduced tissue turgor
not inferences. Inference: Dehydration
Action: Collect additional data that are needed to make the inference in the
diagnosing phase. For example, determine the client’s fluid intake, amount
and appearance of urine, and blood pressure.
Double-check data that are extremely abnormal. Observation: A resting pulse of 50 beats per minute or a blood pressure of
180/96 mm Hg
Action: Recheck or use another piece of equipment as needed to confirm
abnormalities.
Determine the presence of factors that may A crying infant will have an abnormal respiratory rate and will need quieting
interfere with accurate measurement. before accurate assessment can be made.
Use references (textbooks, journals, research A nurse considers tiny purple or bluish-black swollen areas under the tongue
reports) to explain phenomena. of an older client to be abnormal until reading about physical changes of
aging. Such varicosities are not uncommon.
interpreted by the nurse. For example, the nurse records around nursing diagnoses, nursing analyses, or nursing conclu-
the client’s breakfast intake (objective data) as “coffee sions, including approaches using best practice statements.
240 mL, juice 120 mL, 1 egg, and 1 slice of toast,” rather Different approaches to nursing analysis are used in vari-
than as “appetite good” (a judgment). A judgment or ous health regions and provinces. Therefore, throughout
conclusion, such as “appetite good” or “normal appe- this book, we use the terms nursing analysis, including
tite,” may have different meanings for different people. client problem statements and nursing diagnosis, using the
To increase accuracy, the nurse records subjective data predefined diagnoses established by the North Ameri-
in the client’s own words. Restating in other words what can Nursing Diagnosis Association (NANDA) as well as
someone says increases the chance of changing the alternative ways of summarizing nursing assessments
original meaning. Details of recording are discussed in and analyses.
Chapter 24.
Diagnosing/Analyzing Diagnosing
• Analyze data
In this phase, nurses use critical thinking skills to inter- • Identify health
pret assessment data and identify client strengths, prob- Assessing problems, risks,
lems, and desired health outcomes. In some provinces and strengths
of Canada, the term diagnosis is reserved as a function • Formulate diagnostic
statements
of the medical profession: in these provinces, nurses use
the term nursing analysis or nursing conclusion to identify this
phase of the nursing process. Diagnosing or analyzing is a Evaluating
pivotal step in the nursing process. All activities preceding
this phase are directed toward formulating the nursing
analyses, hypotheses, or diagnoses, which are followed by Planning
all the care-planning activities (see Figure 23.4).
There are various approaches to analyzing client Implementing
issues, concerns, or problems in nursing. Nonetheless,
the role of the nurse is to thoroughly assess and analyze
the health status of each client and to carry out holistic
interventions that are specifically tailored to meet the
unique needs of the individual. In some educational FIGURE 23.4 Diagnosing/Analyzing: The pivotal second phase
programs and practice areas, nursing care is organized of the nursing process.
M23_KOZI2703_04_SE_C23.indd 428 03/03/17 11:05 AM

Nursing Diagnoses/Problem Statements 2. A potential nursing diagnosis/problem state-

ment is one in which evidence about a health prob-
The nursing diagnosis/analysis phase of the nursing pro- lem is incomplete or unclear. A potential diagnosis
cess includes identifying one or more nursing diagnoses requires more data either to support or to refute it. For
or problem statements and collaborating with the client example, an older woman who is a widow and lives
to establish priority health outcomes. The term diagnosing alone is admitted to the hospital. The nurse notices
or analyzing refers to the reasoning process, whereas the that she has no visitors and that she is pleased with
term diagnosis or problem statement is a statement or con- attention and conversation from the nursing staff.
clusion regarding the nature of a phenomenon. Client Until more data are collected, the nurse may write a
health outcomes are the anticipated, predetermined nursing diagnosis of Potential Social Isolation related to
outcomes that the client selects in collaboration with unknown etiology.
the nurse to guide and inform nursing practice. Nurs-
ing diagnoses or problem statements can be stated in a 3. A risk nursing diagnosis/problem statement
number of ways; the process of determining the patient is a clinical judgment that a problem does not yet
issues is essentially the same and will be described. exist, but the presence of risk factors indicates that
Some health care organizations use the NANDA diag- a problem is likely to develop unless the nurse inter-
nostic statements in their care plans, whereas others use venes. For example, all people admitted to a hospi-
problem statements for those areas in which nurses can tal have some possibility of acquiring an infection;
appropriately intervene. however, a client with diabetes or a compromised
immune system is at higher risk than others. There-
• The domain of nursing diagnosis or conclusion fore, the nurse would appropriately use the label Risk
includes only those health states that nurses are edu- for Infection to describe the client’s health status.
cated and licensed to treat. For example, generalist
4. A wellness nursing diagnosis/problem state-
nurses are not trained to diagnose or treat such dis-
ment “describes human responses to levels of well-
eases as diabetes mellitus; this task is defined legally
ness in an individual, family or community that have
as within the practice of medicine. Yet nurses can
a readiness for enhancement” (NANDA Interna-
diagnose and treat Knowledge Deficit, Ineffective Coping,
tional, 2012, p. 501). Wellness diagnosis sometimes
or Fluid Deficit, all of which are human responses to a
is referred to as health promotion diagnosis, which relates
medical diagnosis of diabetes mellitus.
to clients’ preparedness to implement behaviours to
• A nursing analysis or diagnosis is a judgment made improve their health condition. Examples of wellness
only after thorough, systematic data collection. diagnoses would be Readiness for Enhanced Spiritual Well-
• Nursing diagnoses or problem statements describe a Being or Readiness for Enhanced Family Coping.
continuum of health states: deviations from health,
presence of risk factors, and areas of enhanced per-
sonal growth.
• The problem statement or nursing diagnosis should NANDA International Nursing Diagnoses
include the anticipated cause or related factor To develop a common language for nursing analyses, the
that needs to be addressed directly by the nursing first national conference to identify nursing diagnoses
interventions. occurred in 1973. International recognition followed and
• Problem statements and nursing diagnoses are devel- in 1982, the name North American Nursing Diagnosis Asso-
oped collaboratively by the nurse and client, arising ciation (NANDA) was adopted. NANDA International is
from both client experience and nursing knowledge of the premier international nursing diagnosis association
the client’s symptoms and condition. (NANDA International, 2015). Its purpose is to define,
• Priority of the problem statements/nursing diagnoses refine, and promote a taxonomy (a classification system)
is determined by the urgency of the problem in terms of nursing diagnostic terminology of general use to pro-
of patient safety or the prominence of the symptom or fessional nurses. Nursing diagnosis is defined as “a
problem in the client’s experience. clinical judgment about individual, family, or commu-
nity responses to actual and potential health problems/
life processes. A nursing diagnosis provides the basis for
TYPES OF NURSING DIAGNOSES/PROBLEM STATE-
selection of nursing interventions to achieve outcomes for
MENTS Four types of nursing diagnoses/problem state-
which the nurse is accountable” (NANDA International,
ments are actual, potential, risk, and wellness.
2012, p. 499). Currently, there are more than 217 nurs-
1. An actual nursing diagnosis/problem state- ing diagnosis labels for clinical use and testing (NANDA
ment is a client problem that is present at the time of International, 2015). Nurses are constantly using research
the nursing assessment. Examples are Ineffective Breathing to expand the nursing diagnoses that are added to the
Pattern and Anxiety. An actual nursing diagnosis is based taxonomy (Garbulo, de Carvalho, & Napoloao, 2015;
on the presence of associated signs and symptoms. Pehler, Markwardt, & Hibbard, 2015).
M23_KOZI2703_04_SE_C23.indd 429 03/03/17 11:05 AM

TABLE 23.5 Comparison of Nursing Diagnoses/Analyses, Medical Diagnoses, and Collaborative Problems
Nursing Diagnoses/ Nursing

Category Analyses Medical Diagnoses Collaborative Problems
Example Activity intolerance related to Myocardial infarction Potential complication of myocar-
decreased cardiac output dial infarction: heart failure
Description Describe human responses to dis- Describe disease and pathology; Involve human responses—mainly
ease process or health problem; do not consider other human physiological complications of
consist of a one-, two-, or three- responses; usually consist of disease, tests, or treatments;
part statement, usually including not more than three words consist of a two-part statement
problem and etiology of situation/pathophysiology
and the potential complication
Orientation and Oriented to the individual; nurses Oriented to pathology; physician Oriented to pathophysiology;
responsibility responsible for diagnosing/ responsible for diagnosing; nurses responsible for diagnos-
for diag- analyzing diagnosis not within the scope ing or analyzing
nosing or of nursing practice
analyzing
Nursing focus Treat and prevent Implement medical orders for Prevent and monitor for onset or
treatment, and monitor status status of condition
of condition
Duration Can change frequently Remains the same while disease Present when disease or situation
is present is present
Classification Classification system is developed Well-developed classification sys- No universally accepted classifica-
system and being used but is not univer- tem accepted by the medical tion system in nursing
sally accepted profession
The standardized NANDA International names for or related factors of the health problem, gives direction
the diagnoses are called diagnostic labels; and the to the required nursing therapy, and enables the nurse to
client’s problem statement, consisting of the diagnos- individualize the client’s care. An example is shown in
tic label plus etiology (causal relationship between a Table 23.5. Differentiating among possible causes in the
problem and its related risk factors), is called a nursing nursing diagnosis is essential because each may require
diagnosis. In provinces where this term is not considered different nursing interventions. Defining characteris-
part of the nurse’s role, the term nursing analysis or nursing tics are the cluster of signs and symptoms that indicate
conclusion may be used. the presence of a particular diagnostic label.
COMPONENTS OF A NANDA INTERNATIONAL NURS- DIFFERENTIATING NURSING DIAGNOSES FROM MED-

ING DIAGNOSIS A NANDA nursing diagnosis usually ICAL DIAGNOSES A nursing diagnosis is a statement
has three components: (a) the diagnostic label or the of nursing judgment and refers to a condition that
problem and its definition, (b) the etiology, and (c) the nurses are licensed to treat. A medical diagnosis is made
defining characteristics. These diagnostic statements by a physician and refers to a condition that only a
are very specifically defined by NANDA International physician or nurse practitioner can treat. Medical
and published in a manual that is updated frequently diagnoses refer to disease processes—specific patho-
(NANDA, 2014). physiological responses that are fairly uniform from
The problem statement, or diagnostic label, describes one client to another. In contrast, nursing diagnoses
the client’s health problem or response for which nurs- describe a client’s physical, sociocultural, psychologi-
ing therapy is given. Each diagnostic label approved by cal, and spiritual responses to an illness or a health
NANDA International carries a definition that clarifies problem (see Table 23.5). These responses vary among
its meaning. The purpose of the diagnostic label is to individuals. A client’s medical diagnosis remains the
direct the formation of client goals and desired health same for as long as the disease process is present,
outcomes. It may also suggest some nursing interven- but nursing diagnoses change as the client’s responses
tions. Diagnostic labels need to be specific. When the change, as in the following example:
word Specify follows a NANDA International label, the
nurse states the area in which the problem occurs, as Seventy-year-old Mary Cain and 20-year-old Kristi
for example, Deficient Knowledge (Medications) or Deficient Vidan both have rheumatoid arthritis. Their disease pro-
Knowledge (Dietary Adjustments). cesses are much the same. Radiological studies show that
The etiology, or related factors, component of a in both clients, the extent of inflammation and the number
nursing diagnosis identifies one or more probable causes of joints involved are similar, and both clients experience
M23_KOZI2703_04_SE_C23.indd 430 03/03/17 11:05 AM

almost constant pain. Ms. Cain views her condition as components, that is, breaking down the whole into its parts
part of the aging process and is responding with accep- (deductive reasoning). Synthesis is the opposite, that is, put-
tance. Ms. Vidan, however, is responding with anger and ting together the parts into the whole (inductive reasoning).
hostility because she views her disease as a threat to her The diagnostic process has three steps:
personal identity, role performance, and self-esteem.
1. Analyzing data
Nurses have responsibilities related to both medical 2. Identifying health problems, risks, and strengths
and nursing diagnoses/analyses and work collabora- 3. Formulating diagnostic statements or patient problems
tively in carrying out physician-prescribed therapies and
treatments (Canadian Nurses Association, Canadian ANALYZING DATA In the diagnostic process, analyzing
Medical Association & Health Action Lobby, 2013). involves the following steps:
Nursing diagnoses/analyses relate to the nurse’s inde-
pendent functions, that is, the areas of health care 1. Compare data against standards (identify significant cues).
that are unique to nursing and separate and distinct 2. Cluster the cues (generate tentative hypotheses).
from medical management. Nurses may not prescribe 3. Identify gaps and inconsistencies.
all the care for a nursing diagnosis/analysis, but if the
problem is a nursing diagnosis/analysis, the nurse can For experienced nurses, these activities occur contin-
prescribe most of the interventions needed for preven- uously rather than sequentially. Novice nurses, however,
tion or resolution. For example, most clients with a need guidelines to understand and formulate nursing
nursing diagnosis/analysis of Pain have medical orders diagnoses.
for analgesics, but many independent nursing interven-
Comparing Data with Standards Nurses draw on
tions can also alleviate pain (e.g., guided imagery or
knowledge and experience to compare client data
teaching a client to splint an incision). With regard to
with standards and norms and identify significant and
medical diagnoses, nurses are obligated to carry out
relevant cues. A standard, or norm, is a generally
physician-prescribed therapies and treatments, that is,
accepted measure, rule, model, or pattern. The nurse
dependent functions.
uses a wide range of standards, such as growth and
DIFFERENTIATING NURSING DIAGNOSES FROM
development patterns, normal vital signs, and labora-
COLLABORATIVE PROBLEMS Carpenito (2013) has tory values. Data are considered significant if they do
suggested that all collaborative problems begin with the any of the following:
label Potential Complication to indicate both the possible • Point to negative or positive change in a client’s health status or
complications they are monitoring and the disease or pattern. For example, the client states, “I have recently
treatment that is present to produce it (see Table 23.5). experienced shortness of breath while climbing stairs,”
For example, if the client has a head injury and or “I have not smoked for 3 months.”
could develop increased intracranial pressure, the nurse • Vary from norms of the client population. The client’s pattern
should write the following: may fit within cultural norms but vary from norms
of the general society. The client may consider a
Potential complication of head injury: Increased intracra-
pattern—for example, eating very small meals and
nial pressure.
having little appetite—to be normal. This pattern,
When monitoring for a group of complications however, may not be productive and may require fur-
associated with a medically diagnosed disease or pathol- ther exploration.
ogy, the nurse states the disease and follows it with a list • Indicate a developmental delay. To identify significant data,
of the possible complications. the nurse must be aware of the normal patterns and
changes that occur as the person grows and develops.
Potential complications of pregnancy-induced hyperten- For example, by age 9 months, an infant is usually able
sion: seizures, fetal distress, pulmonary edema, hepatic/ to sit without support. The infant who has not accom-
renal failure, premature labour, central nervous system plished this task needs further assessment for possible
hemorrhage developmental delays.
Refer to Table 23.6 for specific examples of client
data and norms to which they may be compared. Sig-
The Diagnostic/Analytical Process nificant cues and data clusters for Amanda Aquilini that
The diagnostic/analytical process uses the critical think- were extracted from Figure 23.3 (pages 423–424) and
ing and clinical reasoning skills of analysis and synthesis. Box 23.4 (page 425) are shown in Table 23.7.
These skills are a cognitive process during which a nurse
reviews data and considers explanations before forming Clustering Data/Cues Clustering or grouping data/
an opinion (see Chapter 21). Analysis is the separation into cues is a process of determining the relatedness of
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TABLE 23.6 Comparing Cues to Standards and Norms
Type of Cue Client Cues Standard/Norm

Deviation from population norms Client height is 158 cm. The body mass index (BMI) indicates that the BMI
The woman has a small frame. for a woman 158 cm tall who weighs 109 kg
She weighs 109 kg. is 43.7. Normal BMI ranges from 18.5 to 24.9.
Developmental delay The child is 18 months old. Children usually speak their first word by 10 to
Parents state child has not yet attempted 12 months of age.
to speak.
The child laughs aloud and makes cooing
sounds.
Changes in client’s usual health The client states, “I’m just not hungry these The client usually eats three balanced meals per
status days.” day. Adults typically maintain stable weight.
She ate only 15% of food on breakfast tray.
She has lost 13 kg in the past 3 months.
Dysfunctional or unusual Tanya’s mother reports that Tanya has not Adolescents usually like to be with their peers;
behaviour left her room for 2 days. social groups are very important. Functional
Tanya is 16 years old. behaviour includes school attendance.
Tanya has stopped attending school and
has withdrawn from social contact.
facts and determining whether any patterns are pres- Identifying Gaps and Inconsistencies in Data Skillful
ent, whether the data represent isolated incidents, and assessment minimizes gaps and inconsistencies in data.
whether the data are significant. This is the beginning However, data analysis should include a final check to
of synthesis. ensure that data are complete and correct.
The nurse may cluster data inductively (as in Inconsistencies are conflicting data. Possible sources
Table 23.7) by combining data from different assessment of conflicting data include measurement error, expecta-
areas to form a pattern, or the nurse may begin with a tions, and conflicting or unreliable reports. For example,
framework, such as Gordon’s functional health patterns, a nurse may learn from the nursing history that the client
and cluster the subjective and objective data into the reports not having seen a doctor in 15 years, yet during
appropriate categories (see Box 23.4 on page 425). The the physical health examination, he states, “My doctor
latter is a deductive approach to data clustering, or pattern takes my blood pressure every week.” All inconsistencies
formation. must be clarified before a valid pattern can be established.
Experienced nurses may cluster data as they collect
IDENTIFYING HEALTH PROBLEMS, RISKS, AND
and interpret it, as evidenced in such remarks or thoughts
STRENGTHS After data are analyzed, the nurse and
as, “I’m getting a picture of . . .,” or “This cue doesn’t fit
client can together identify strengths and problems. This
the picture.” The novice nurse does not have the knowl-
is primarily a decision-making process. See Chapter 21.
edge base or the clinical experience that aids in recogniz-
ing cues. Thus, the novice must take careful assessment Determining Problems and Risks After grouping
notes, search data for abnormal cues, and use textbook and clustering data, the nurse and client together iden-
resources for comparing the client’s cues with the defin- tify tentative diagnoses. In addition, the nurse must
ing characteristics and etiological factors of the accepted determine whether the client’s problem is a nursing,
nursing diagnoses. medical, or collaborative problem (see Table 23.5). See
Data clustering involves making inferences about the Figure 23.5 for a decision tree to aid in this decision.
data. An inference is the nurse’s judgment or interpreta- For examples, refer to the cue clusters and tenta-
tion of cues. The nurse interprets the possible meaning tive identification of problems for Amanda Aquilini in
of the cues and labels the cue clusters with tentative Table 23.7. In this example, the nurse and client identi-
diagnostic hypotheses. Data clustering or grouping for fied nine tentative problems: Imbalanced Nutrition; Deficient
Amanda Aquilini is illustrated in Table 23.7, in which Fluid Volume; Disturbed Sleep Pattern; Self-Care Deficit; Acute
data are clustered according to standardized diagnostic Pain (Chest); Interrupted Family Processes; Anxiety; Activity Intol-
labels. erance; and Ineffective Airway Clearance.
Another technique used to cluster data is by using Determining Strengths At this stage, the nurse and
concept mapping. Data are clustered in the same manner client also establish the client’s strengths, resources, and
described above, but are developed into a visual format abilities to cope. Most people focus more on their prob-
(see Concept Map: Ineffective Airway Clearance [Gas lems or weaknesses than on their strengths and assets,
Exchange]). which they often take for granted. By taking an inventory
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TABLE 23.7 Formulating Nursing Diagnoses/Nursing Analyses for Amanda Aquilini
Inferences (Tenta-
Functional Health tive Identification of Formulating Diagnostic
Pattern Client Cue Clusters Problems) Statements
Health percep- No significant cues No problem No problem
tion/health Strength: Has healthy life-
management style, understanding of
and compliance with
treatment regimens
Nutritional/meta- “No appetite” since having “cold” Imbalanced Nutrition: Altered Nutrition: Less
bolic (includes Has not eaten today; last fluids at noon today Less Than Body Than Body Require-
hydration) Nauseated 3 2 days Requirements ments related to
decreased appetite and
nausea and increased
metabolism
Strength: Normal weight for
height
Last fluids at noon today Deficient Fluid Volume Deficient Fluid Volume
Oral temperature 39.4°C related to intake insuf-
Skin hot and pale; cheeks flushed ficient to replace fluid
Mucous membranes dry loss secondary to fever,
Poor skin turgor diaphoresis, anorexia
Cues from elimination pattern: Decreased
urinary frequency and amount 3 2 days
Elimination Decreased urinary frequency and amount 3 Cues consist of elimination No elimination problem
2 days data but are actually
symptoms of a fluid
volume problem in the
nutritional/metabolic
functional health pattern
Activity/exercise States, “I feel weak standing at the sink and Activity Intolerance Activity Intolerance related
in the shower” to general weakness
Short of breath on exertion Strength: No musculoskel-
Cues from cognitive/perceptual pattern: etal impairment
Responsive but fatigued
“I can think OK, just weak”
Cues from cardiovascular pattern: Radial
pulses weak, regular
Pulse rate 92
Sleep/rest Difficulty sleeping because of cough Disturbed Sleep Pattern Disturbed Sleep Pattern
“Can’t breathe lying down” related to cough, pain,
orthopnea, fever, and
diaphoresis
Cognitive/perceptual Reports pain in chest, especially when Acute Pain Acute Pain (Chest) related
coughing to cough secondary to
Responsive but fatigued pneumonia
“I can think OK, just weak” Strength: No cognitive or
sensory deficits
Roles/relationships Husband out of town; will be back tomorrow Interrupted Family Risk for Interrupted Fam-
afternoon Processes related to ily Processes related
Child with neighbour until husband returns mother’s illness and to mother’s illness and
temporary unavailabil- temporary unavailabil-
ity of father to provide ity of father to provide
childcare childcare
Cues also related to a Strength: Neighbours avail-
problem in the coping/ able and willing to help
stress pattern
Self-perception/ Expresses “concern” and “worry” over leaving Cue is a symptom of a No self-perception/self-
self-concept daughter with neighbours until husband problem in the coping/ concept problem
returns stress pattern
(continued)
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TABLE 23.7 Formulating Nursing Diagnoses/Nursing Analyses for Amanda Aquilini (continued)
Inferences (Tenta-
Functional Health tive Identification of Formulating Diagnostic
Pattern Client Cue Clusters Problems) Statements
Coping/stress Anxious: “I can’t breathe” Anxiety related to diffi- Anxiety related to difficulty
Facial muscles tense; trembling culty breathing, inability breathing and concerns
Expresses concerns about work: “I’ll never to work, and provide over work and parenting
get caught up” childcare roles
Cues from role/relationship pattern:
Cues from self-perception/self-concept
patterns:
Expresses “concern” and “worry” over leaving
daughter with neighbours
Medication/history No significant cues No problem No problem
Physical
assessment
Cardiovascular Radial pulses weak, regular Cues are symptoms only; No cardiovascular problem
Pulse rate 92 symptoms of exercise/
rest and oxygenation
problems
Oxygenation Skin hot, pale, and moist Ineffective Airway Clear- Ineffective Airway Clear-
Respirations shallow; chest expansion, 3 cm ance related to disease ance related to viscous
Cough productive of small amounts of pale process secretions and shallow
pink sputum chest expansion second-
Inspiratory crackles auscultated throughout ary to pain, deficient fluid
right upper and lower chest volume, and fatigue
Diminished breath sounds on right side
Mucous membranes pale
Skin Old surgical scars, anterior neck, right left No problem now Old problems; resolved
quadrant (RLQ) abdomen
Identification of
significant cue cluster
(problem)
Can the nurse take independent action

to prevent or treat the problem?
yes no
Are these the primary interventions Are both medical and nursing orders
needed to achieve the goal? needed to prevent or treat the problem?
yes no yes no
Nursing Collaborative Medical

diagnosis problem diagnosis
FIGURE 23.5 Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses.
M23_KOZI2703_04_SE_C23.indd 434 03/03/17 11:05 AM

CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)
• Cold 3 2 weeks • T: 39.4°C P: 92 R: 28, shallow BP: 122/80

• Dyspnea on exertion • Dry mucous membranes; skin hot, pale
AA • Fever • Cheeks flushed
28-year-old female Assess • Orthopnea • Decreased breath sounds
Possible • Occasional chills • Inspiratory crackles RUL and RLL
pneumonia • Decreased oral intake 3 2 days • Ineffective cough—small amount thick, pale pink sputum
• Lethargic, c/o being weak, fatigued
Generate nursing diagnosis
Ineffective Airway Clearance r/t viscous secretions, & shallow chest expansion,
secondary to deficient fluid volume, pain, and fatigue
Outcome
Respiratory status: Gas Exchange aeb

• Absent of pallor & cyanosis
• Use of correct breathing and coughing technique after
instruction
• Productive cough
Within 48–72h
• Symmetrical chest excursion
Nursing intervention • Lungs clear to auscultation

• Respirations 12–22/min; pulse <100 bpm
Respiratory Monitoring • Inhales normal volume air on incentive spirometer
Nursing intervention
Activity
Activity Respiratory Monitoring
Activity
Activity
Monitor results of blood
Activity gases, X-radiography rays,
Activity Activity Administer
and incentive spirometry Activity antibiotics
Activity
Auscultate
Activity
breath Instruct in breathing &
sounds q4h coughing techniques.
Assist with postural
Monitor level Remind and assist q3h
drainage @ 0930 h
of consciousness Administer
Monitor rate, depth, effort analgesics
of respirations,
skin colour, mucous Administer
membranes, amount and expectorants Administer
colour of sputum q4h O2 per NC
of strengths, the client can develop a more well-rounded 1. Problem (P): statement of the client’s response
self-concept and self-image. Strengths can be an aid to
2. Etiology (E): factors contributing to or probable
mobilizing health and regenerative processes.
causes of the responses
A client’s strengths can be found in the nursing
assessment record (health, home life, education, recre- The two parts are joined by the words related to
ation, exercise, work, family and friends, religious beliefs, rather than because of. The phrase because of implies that
and sense of humour, for example), the health examina- one part causes or is responsible for the other part. By
tion, and the client’s records. See Table 23.7 for strengths contrast, the phrase related to merely implies a relation-
identified for Amanda Aquilini. ship. Some examples of two-part nursing diagnoses are
shown in Box 23.8.
FORMULATING DIAGNOSTIC STATEMENTS Most
nursing diagnoses are written as two-part statements. Using Diagnostic Statements Effectively Beginning
Basic Two-Part Statements The basic two-part state- nurses often prepare long lists, but checking initial state-
ment includes the following: ments (hypotheses) with the client helps both nurse
M23_KOZI2703_04_SE_C23.indd 435 03/03/17 11:05 AM

BOX 23.8 BASIC TWO-PART DIAGNOSTIC nursing colleagues, and other health care profession-
STATEMENT als are all appropriate resources.
• Base diagnoses on patterns—that is, on behaviour over time—
PROBLEM RELATED TO ETIOLOGY
rather than on an isolated incident. For example, even
Constipation related to prolonged laxative though Amanda Aquilini is concerned today about
use
needing to leave her child with a neighbour, it is likely
Ineffective related to breast engorgement that this concern will be resolved without intervention
breast-feeding by the next day. Therefore, the admitting nurse should
not diagnose Interrupted Family Processes, and this tenta-
tive nursing diagnosis should be reconsidered.
• Improve critical thinking skills. These skills help the nurse
and client narrow down the list to those that are most to be aware of and avoid errors in thinking, such as
important in the current clinical context. Next, through overgeneralizing, stereotyping, making unwarranted
negotiating with the client and consideration of patient assumptions, and so on. See Chapter 21.
safety, the nurse clusters nursing diagnoses and identifies
priority client health outcomes to guide nursing care.
AVOIDING ERRORS IN DIAGNOSTIC/ANALYTICAL Planning

REASONING Error can occur at any point in the diag-
nostic/analytical process: data collection, data interpre- Planning is a deliberative, systematic phase of the nursing
tation, and data clustering. It is important that nurses process that involves decision making and problem solv-
make accurate nursing diagnoses or problem statements. ing. In planning, the nurse refers to the client’s assessment
Nurses can avoid some common errors of reasoning by data, diagnostic or conclusion statements, and client pri-
recognizing them and applying the appropriate critical orities when designing the nursing interventions required
thinking skills. to achieve the client’s health outcomes. (See Figure 23.6.)
The following suggestions should help minimize The product of the planning phase is a client care plan.
diagnostic/analytical error: Although planning is basically the nurse’s responsi-
bility, input from the client and support persons is essen-
• Verify. Hypothesize possible explanations of the data, tial if a plan is to be effective. Nurses do not plan for the
but realize that all diagnoses/problem statements are client but encourage the client to participate actively to
only tentative until they are verified. Begin and end the extent possible. In a home setting, the client’s support
the diagnostic/analytical process by talking with the people or caregivers are the ones who assist in imple-
client and family. Recognize that some nursing diag- menting the plan of care; thus, its effectiveness depends
noses/problem statements are related to patient safety largely on them.
and the client’s medical diagnosis, and thus, must be
prioritized at times above patient concerns.
• Build a good knowledge base, and acquire clinical experience.
Nurses must apply knowledge from many different
areas to recognize significant cues and patterns and
generate hypotheses about the data. Assessing
• Have a working knowledge of what is normal. Nurses need Diagnosing
to know the population norms for vital signs, labora-
tory tests, speech development, breath sounds, and so
on. In addition, nurses must determine what is nor-
Planning
mal for a particular person, taking into account age, Evaluating
• Prioritize problems and
physical makeup, lifestyle, culture, and the person’s diagnoses
own perception of what is normal. For example, high • Formulate goals and
normal blood pressure for adults is in the range of desired health outcomes
130–139/85–89 mm Hg (Canadian Hypertension • Select nursing interventions
Implementing • Write nursing interventions
Education Program, 2012). However, a nurse might
obtain a reading of 90/50 mm Hg that is normal for a
particular client. The nurse should compare findings
with the client’s baseline, when possible.
• Consult resources. Both novices and experienced nurses FIGURE 23.6 Planning: The third phase of the nursing
should consult appropriate resources whenever in process, in which the nurse and client develop a mutually
doubt about a diagnosis. Professional literature, agreed-upon plan of care.
M23_KOZI2703_04_SE_C23.indd 436 03/03/17 11:05 AM

Types of Planning be documented in client progress notes and as a guide for

delegating and assigning staff to care for clients.
Planning begins with the first client contact and contin- Care plans include the actions nurses must take to
ues until the nurse–client relationship ends, usually when address the nursing diagnoses or client problems and to
the client is discharged from the health care agency. produce the desired health outcomes. The nurse begins
Planning involves interacting with the client and family the plan when the client is admitted to the agency
to the fullest extent possible. and constantly updates it throughout the client’s stay in
INITIAL PLANNING The nurse who performs the admis- response to changes in the client’s condition and evalu-
sion assessment usually develops the initial comprehen- ations of goal achievement. The plan of care should be
sive plan of care. Planning should be initiated as soon as mutually established with the client and with input from
possible after the initial assessment, especially because of the client’s family, if appropriate. During the planning
the trend toward shorter hospital stays. phase, the nurse must do the following:
ONGOING PLANNING As nurses obtain new informa- 1. Decide which of the client’s problems need individu-
tion and evaluate the client’s responses to care, they can alized plans and which problems can be addressed by
individualize the initial care plan further. Ongoing plan- standardized plans and routine care
ning also occurs at the beginning of a shift, home visit, 2. Choose and adapt standardized, preprinted interven-
or clinic appointment. Ongoing assessment and planning tions and care plans, where appropriate
serve the following purposes (Wilkinson, 2012): 3. Write individualized desired health outcomes and
1. To determine whether the client’s health status has nursing interventions for client problems that require
changed nursing attention beyond preplanned, routine care
2. To set the priorities for the client’s care during the 4. Decide when referrals to other health care professionals
contact period (e.g., shift, home visit) are needed
3. To decide which problems to focus on during the con- The complete plan of care for a client is made up of
tact period several different documents that (a) describe the routine
care needed to meet basic needs, (b) address the client’s
4. To coordinate the nurse’s activities so that more than
nursing diagnoses and identified health outcomes, and
one problem can be addressed at each client contact
(c) specify nursing responsibilities in carrying out the cli-
ent’s plan of care. A complete plan of care integrates all
DISCHARGE PLANNING Discharge planning, the pro-
nursing functions into a meaningful whole and provides
cess of anticipating and planning for needs after dis-
a central source of client information. Figure 23.7 illus-
charge, is a crucial part of comprehensive health care and
trates the various documents that may be included in a
should be addressed in each client’s care plan. Because
nursing care plan.
the average stay of clients in acute care hospitals has
become shorter, people are often discharged still needing STANDARDIZED APPROACHES TO CARE PLAN-
care. Although many clients are discharged to other agen- NING Most health care agencies have a variety of pre-
cies (e.g., nursing homes), such care is increasingly being printed, standardized guides for providing essential
delivered in the home. (See Chapters 12 to 14.) nursing care to specified groups of clients who have cer-
tain needs in common (e.g., all clients with pneumonia).
Standards of care, standardized care plans, protocols,
Developing Nursing Care Plans policies, and procedures are developed to (a) ensure that
Nursing care planning involves a formal or informal plan minimally acceptable standards of care are provided and
of care. An informal care plan is a plan of action that (b) promote efficient use of nurses’ time by removing the
exists in the nurse’s mind. For example, the nurse may need to handwrite common activities that are done over
think, “Mrs. Phan is very tired. I will need to reinforce and over for many of the clients with common needs.
her teaching after she is rested.” A formal care plan is Standards of care describe nursing care for groups
a written guide that organizes information about the cli- of clients rather than for individuals, and they describe
ent’s care. The most obvious benefit of a formal written achievable, rather than ideal, nursing care. They define
care plan is that it facilitates continuity of care. the interventions for which nurses are held accountable;
Standardized care plans specify the nursing they do not contain medical orders. Standards of care
care for groups of clients with common needs (e.g., are usually agency records and not part of the client’s
all clients with myocardial infarction). Individualized care plan, but they may be referred to in the plan (e.g.,
care plans are tailored to meet the unique needs of a nurse might write, “See standards of care for cardiac
a specific client—needs that are not addressed by stan- catheterization”). Standards of care may or may not be
dardized plans. It is important that all nursing caregivers organized according to problems or nursing diagnoses.
use a consistent approach with a client. Nurses also use Standardized care plans are also preplanned, preprinted
the written care plan for direction about what needs to guides for the nursing care of groups of clients with
M23_KOZI2703_04_SE_C23.indd 437 03/03/17 11:05 AM

Preprinted
Nursing Care
Plan
Problem
List Kardex Policies and
Procedures
1.
2. Protocols
3. Standards Critical Pathways

of Care
Outcomes Interventions
(b) Kardex cards for client
(a) Complete list of
profile, basic needs, and
client problems
collaborative plans
(c) Preprinted plans to (d) Critical Pathways

address client problems
Special Special
No. 3
Discharge Plan Teaching Plan
Nursing Nursing
Evaluation
Diagnosis Outcomes Interventions
No. 2
Nursing Nursing
Evaluation
(e) Addendum (f) Addendum
discharge plan teaching plan No. 1
Nursing Nursing
Evaluation
(g) Individualized nursing care plans

for nursing diagnoses
FIGURE 23.7 Documents that may be included in a complete client care plan.
Source: Wilkinson, J. M. (2012). Nursing process & critical thinking (5th ed., p. 452). Upper Saddle River, NJ: Prentice Hall. Adapted with permission.
common needs (e.g., a specific nursing diagnosis or all usually noted on the care plan (e.g., “Make social work
the nursing diagnoses associated with a particular medi- referral according to Unit Policy Manual”).
cal condition). However, they should not be confused A standing order is a written document about pol-
with standards of care. These care plans are generally icies, rules, regulations, or orders regarding client care.
included in a client’s chart. Standing orders give nurses the authority to carry out
Protocols are preprinted and preplanned to indi- specific actions under certain circumstances, often when
cate the actions commonly required for a particular a physician is not immediately available. In a hospital
group of clients. For example, an agency may have a critical care unit, a common example is the administra-
protocol for admitting a client to the intensive care unit tion of emergency antiarrhythmic medications when a
(ICU). Protocols may include both medical orders and client’s cardiac monitoring pattern changes. In a home
nursing interventions. care setting, a physician may write a standing order
Policies and procedures are developed to gov- for the administration of epinephrine for a client who
ern the handling of frequently occurring situations. For becomes excessively dyspneic (short of breath).
example, a hospital may have a policy specifying the Nursing care must be individualized to meet the
number of visitors a client may have. Some policies and unique needs of each client. In practice, a care plan
procedures are similar to protocols and specify what is usually consists of both preprinted and handwritten sec-
to be done, for example, in the case of cardiac arrest. If tions. The nurse uses standardized care plans for predict-
a policy covers a situation pertinent to client care, it is able, commonly occurring problems and handwrites an
M23_KOZI2703_04_SE_C23.indd 438 03/03/17 11:05 AM

individual plan for unusual problems or problems needing would be a common nursing diagnosis; therefore, Amanda
special attention. For example, a standardized care plan Aquilini’s nurse was able to obtain a standardized plan
for all “clients with a medical diagnosis of pneumonia” directing care commonly needed by clients with Deficient
would probably include a nursing diagnosis of Deficient Fluid Volume. (See Figure 23.3 on pages 423–424 and
Fluid Volume and direct the nurse to assess the client’s Figure 23.8.) However, the nursing diagnosis Risk for Inter-
hydration status. On a respiratory or medical unit, this rupted Family Processes would not be common to all clients
Standardized Care Plan for Nursing Diagnosis of DEFICIENT FLUID VOLUME
Related Factors Desired Outcomes Nursing Order (Identify Frequency)
__Decreased oral intake __Urinary output 1

__Monitor intake and output q____h
> 30 mL/hr
__Nausea __Weigh daily
__Urine specific gravity
__Depression 1.005 ±1.025 __Monitor serum electrolyte levels X 1 or
until normal
__Fatigue, weakness +
__Serum Na normal __Check skin turgor and mucous
8h
membranes q_______
__Difficulty swallowing __Mucous membranes
moist 4h
__Monitor temperature q_____
__Other:___________
__Skin turgor good __Administer prescribed IV therapy
__Excess fluid loss (Monitor according to protocol for
__Fever or increased __No weight loss intravenous therapy)
1000 mL D5 LR
metabolic rate __8-hour intake = 1
__Offer oral liquids q____h at 100 mL/hr
__Diaphoresis 400 mL oral
________________ clear, cold
Type_______________________
__Vomiting Other: __Instruct client regarding amount,
__Diarrhea type, and schedule of fluid intake
__Burns __Assess understanding of type of

fluid loss; teach accordingly
__Other___________
water
__Mouth care (prn) with___________
__Institute measures to reduce fever

Defining Characteristics (e.g., lower room temperature, remove
bed covers, offer cold liquids)
__Insufficient intake
Other Nursing Orders:_______________
__Negative balance of
Monitor urine specific gravity
___________________________________
intake and output
__Dry mucous q shift
___________________________________
membranes
__Poor skin turgor ___________________________________
__Concentrated urine ___________________________________

__Hypernatremia ___________________________________
__Rapid, weak pulse
___________________________________
__Falling blood pressure
__Weight loss
M. Medina RN 11-04-16
Plan Initiated by:__________________________________Date_________________
Plan/outcomes evaluated___________________________Date_________________
Plan/outcomes evaluated___________________________Date_________________
Client:____________________________________________
FIGURE 23.8 A standardized care plan for nursing diagnosis of Deficient Fluid Volume.
M23_KOZI2703_04_SE_C23.indd 439 03/03/17 11:05 AM

with pneumonia; it is specific to Amanda. Therefore, the A multidisciplinary care plan is a standardized
goals and nursing interventions for that diagnosis would plan that outlines the care required for clients with com-
need to be handwritten by the nurse. mon, predictable—usually medical—conditions. Such
plans, also referred to as collaborative care plans
and critical pathways, sequence the care that must
Types of Nursing Care Plans be given on each day during the projected length of stay
Although formats differ from agency to agency, the care for the specific type of condition. Like the traditional
plan is often organized into four sections: (a) problem/ nursing care plan, a multidisciplinary care plan can
nursing diagnoses, (b) goals/desired outcomes, (c) nursing specify outcomes and nursing interventions to address
interventions, and (d) evaluation. Some agencies use a three- client problems (including nursing diagnoses). However,
section plan in which evaluation is done with the goals or in it includes medical treatments to be performed by other
the nurses’ notes; others have five sections that add assess- health care providers as well.
ment data preceding the problem/nursing diagnosis. Critical pathways are used to plan and direct client
care. This multidisciplinary client-centred tool helps the
STUDENT CARE PLANS Because student care plans are health care team to deliver care according to the client
a learning activity as well as a plan of care, they may health outcomes. The document includes the expected
be more lengthy and detailed than care plans used by outcomes predicted by the client and the health care team
nurses. To help students learn to write care plans, educa- (nursing, physiotherapy, medicine, pharmacy, and social
tors may suggest a five-column format: (a) nursing diag- work, for instance) to develop and integrate a plan of care
nosis or hypotheses, (b) goals or desired health outcomes, as the client progresses through an illness. The plan is usu-
(c) interventions, (d) rationale, and (e) evaluation. A ally organized with a column for each day, listing the inter-
rationale is the scientific principle given as the reason ventions that should be carried out and the client outcomes
for selecting a particular nursing intervention. Students that should be achieved on that day. There are as many
may also be required to cite supporting literature for columns on the multidisciplinary care plan as the preset
their stated rationale. number of days allowed for the client’s diagnosis-related
group. For further information, see Chapter 9. Multidisci-
CONCEPT MAPS A concept map is a visual tool in
plinary care plans do not include detailed nursing activi-
which ideas or data are graphically depicted in circles or
ties. They should be drawn from, but do not replace,
boxes and relationships between these are indicated by
standards of care and standardized care plans.
connecting lines. Concept maps can encompass various
forms and categories of data, according to the creator’s
interpretation of the client or health condition. The con- The Planning Process
cept map for Amanda Aquilini (see page 435) is another
way of depicting her nursing care plan and includes In the process of developing client care plans, the nurse
unique boxes that enclose assessment, nursing diagnosis, engages in the following activities:
desired outcomes, and interventions. • Setting priorities
Concept maps are often used to depict complex rela-
• Establishing client goals or desired health outcomes
tionships among ideas, processes, actions, and so on. There
are numerous benefits to using concept maps. For example, • Selecting nursing interventions and activities
students can complete pathophysiology flowsheets or con- • Writing an individualized plan of care
cept maps to see the linkages among disease processes,
SETTING PRIORITIES Priority setting is the process
laboratory data, medications, signs and symptoms, risk
factors, and other relevant data. They can critically ana- of establishing a preferential order for nursing diagno-
lyze the “whole picture” of their clients, their conditions, ses, client health outcomes, and interventions. The nurse
and the connections between concerns, which promotes a and client begin planning by deciding which nursing
holistic approach to planning and evaluating care (Hicks- diagnosis requires attention first, which second, and
Moore, 2005; Hill, 2006). so on. Instead of rank-ordering diagnoses, nurses can
group them as having high, medium, or low priority.
COMPUTERIZED CARE PLANS Computers are increas- Life-threatening problems, such as loss of respiratory or
ingly being used to create and store nursing care plans. cardiac function, are designated as high priority. Health-
For an individualized plan, the nurse chooses the appro- threatening problems, such as acute illness and decreased
priate diagnoses from a menu suggested by the computer. coping ability, are assigned medium priority because they
The computer then lists possible goals and nursing inter- may result in delayed development or cause destructive
ventions for those diagnoses; the nurse chooses those physical or emotional changes. A low-priority problem is
appropriate for the client and types in any additional one that arises from normal developmental needs or that
goals and interventions or nursing actions not listed on requires only minimal nursing support.
the menu. The nurse can read the plan on the computer Nurses frequently use Maslow’s hierarchy of
screen or print out an updated working copy each day. needs when setting priorities. In Maslow’s hierarchy,
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physiological needs, such as air, food, and water, are address a high-priority diagnosis and then deal with a
basic to life and receive higher priority than the need for diagnosis of lower priority. Furthermore, because clients
security or activity. Growth needs, such as self-esteem, usually have several problems, the nurse often deals
are not perceived as “basic” in this framework. Thus, with more than one diagnosis at a time. See Table 23.8
such nursing diagnoses as Ineffective Airway Clearance and for priorities assigned to Amanda Aquilini’s nursing
Impaired Gas Exchange would take priority over such nurs- diagnoses.
ing diagnoses as Anxiety or Ineffective Coping. Priorities change as the client’s responses, problems,
It is not necessary to resolve all high-priority diag- and therapies change. The nurse must consider a variety
noses before addressing others. The nurse may partially of factors when assigning priorities:
TABLE 23.8 Assigning Priorities to Nursing Diagnoses for Amanda Aquilini
Nursing Diagnosis Priority Rationale

Ineffective Airway Clearance related High priority Loss of respiratory functioning is a life-threatening problem.
to (a) viscous secretions secondary The nurse’s primary concern must be to promote Amanda’s oxygen-
to deficient fluid volume, and ation by addressing the related factors.
(b) shallow chest expansion sec-
ondary to pain and fatigue
Deficient Fluid Volume related High priority Severe Deficient Fluid Volume is life threatening. Although not that
to intake insufficient to replace severe for Amanda, it is a high-priority problem because it is also
fluid loss secondary to fever and a contributing factor for Ineffective Airway Clearance. Collaborative
diaphoresis efforts to improve her hydration have already begun (intravenous
fluids). The nurse must immediately and continuously assess and
promote Amanda’s hydration.
Anxiety related to (a) difficulty breath- Medium Although Amanda is concerned about work and parenting roles, these
ing, and (b) concerns over work priority are not a threat to life. Also, treatment of her high-priority problem,
and parenting roles Ineffective Airway Clearance, will relieve one of the related factors
(dyspnea). Meanwhile, the nurse should provide symptomatic relief
of Amanda’s anxiety during periods of dyspnea because extreme
anxiety could further compromise her oxygenation by causing her
to breathe ineffectively and increasing the rate at which she uses
oxygen.
Risk for Interrupted Family Pro- Low priority Amanda’s child is currently being cared for. If Amanda’s husband
cesses related to illness and returns as planned, this risk diagnosis will not develop into an actual
temporary unavailability of father to diagnosis. No interventions are needed at present except for contin-
provide childcare ued assessment and support.
Imbalanced Nutrition: Less Than Low priority This problem is not currently health threatening, but it could be if it
Body Requirements related to persisted. It will almost certainly resolve in a day or two as the medi-
decreased appetite, nausea, and cal problem is treated. If the medical problem does not resolve
increased metabolism secondary to quickly, this will change to a medium priority.
disease process
Self-Care Deficit, Bathing/Hygiene Low priority This problem is caused by other, higher-priority problems; therefore, it
related to activity intolerance sec- will resolve as they resolve. Meanwhile, the nurse needs to assist
ondary to ineffective airway clear- Amanda with bathing and so on, to support and conserve her
ance and sleep pattern disturbance energy until she is strong enough to resume her own care.
Disturbed Sleep Pattern related to Low priority Lack of sleep is health threatening. But for the moment, the nurse does
cough, pain, orthopnea, fever, and not need to address this problem. Disturbed Sleep Pattern does
diaphoresis contribute to Amanda’s Ineffective Airway Clearance, but it is not the
main cause. Therefore, measures to promote sleep will be low prior-
ity at least until evening. After the nurse has attended to Amanda’s
oxygenation and hydration needs, this problem priority will change.
Pain (Chest) related to cough sec- Not on care The nurse did not write Pain as a problem on the care plan because
ondary to pneumonia plan Pain is to be addressed as the etiology of Disturbed Sleep Pattern
and Ineffective Airway Clearance. The related factors to pain (cough
and pneumonia) will be treated by medications (collaborative inter-
ventions). Independent nursing actions would address the problem
rather than the related factors and would be the same as the nursing
actions for Ineffective Airway Clearance.
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TABLE 23.9 Deriving Desired Client Health Outcomes from Nursing Diagnoses
Nursing Diagnosis Goals Desired Client Outcomes

Impaired Physical Mobility: Improved mobility Ambulate with crutches by end of the week
Inability to bear weight on left Able to bear weight on left leg Be able to stand without assistance by end of the month
leg related to inflammation of
knee joint
Ineffective Airway Clearance Effective airway clearance Lungs will be clear to auscultation during entire postoperative
related to poor cough effort, period
secondary to incision pain No skin pallor or cyanosis by 12 hours following operation
and fear of damaging sutures Will demonstrate good cough effort within 24 hours after surgery
1. The client’s health values and beliefs: Values concerning through implementation of nursing interventions, hopes
health may be more important to the nurse than to the client will achieve. The terms goal and desired health
the client. For example, a client may believe being outcome are used interchangeably in this text. Some refer-
home for the children to be more urgent than a health ences also use the terms expected outcome, predicted outcome,
problem. However, in a life-threatening situation, the outcome criterion, and objective.
nurse usually must take the initiative. Some nursing literature differentiates the terms by
2. The client’s priorities: Involving the client in priori- defining goals as broad statements about the client’s status
tizing and care planning enhances collaboration. and desired health outcomes as the more specific, observable
Sometimes, however, the client’s perception of what criteria used to evaluate whether the goals have been met.
is important conflicts with the nurse’s knowledge of For example:
potential problems or complications. For example, Goal (broad): Improve nutritional status
the client may not regard turning and repositioning Desired health outcome (specific): Gain 2.5 kg by April 25
in bed as important, preferring not to be disturbed.
When goals are stated broadly, as in this example,
However, the nurse, who is aware of the potential
the care plan must include both goals and desired health
complications of prolonged bed rest (e.g., muscle
outcomes. They are sometimes combined into one state-
weakness and decubitus ulcers), needs to inform the
ment linked by the words “as evidenced by,” as follows:
client and gain the client’s agreement to carry out the
“Improve nutritional status as evidenced by weight gain
necessary interventions.
of 2.5 kg by April 25.”
3. The resources available to the nurse and client: If money, Writing the broad, general goal first can help students
equipment, or personnel resources are scarce in a think of the specific outcomes that are needed, but the
health care agency, then the nurse must use critical broad goal is just a starting point for planning. It is the spe-
thinking, clinical reasoning, and creative measures to cific, observable outcomes that must be written on the care
address the nursing diagnoses. plan and used to evaluate client progress. Table 23.9 shows
4. The urgency of the health problem: Regardless of the both broad goals and desired health outcomes.
framework used, life-threatening situations require Purpose of Goals or Desired Health Outcomes Goals
that the nurse assign them high priority. For example, or desired health outcomes serve the following purposes:
in Table 23.8, although Amanda Aquilini is anxious
about childcare, her Ineffective Airway Clearance has 1. They provide direction for planning nursing interventions. Ideas
for interventions come more easily if the desired health
higher priority (see the Concept Map on Ineffective
outcomes state clearly and specifically what the nurse
Airway Clearance on page 435).
plans for the client to achieve.
5. The medical treatment plan: The priorities for treating
2. They serve as criteria for evaluating client progress. Although
health problems must be congruent with treatment by
developed in the planning step of the nursing process,
other health care professionals. For example, a high
desired health outcomes serve as the criteria for judg-
priority for the client might be to become ambulatory;
ing nursing interventions and client progress in the
however, if the physician’s therapeutic regimen calls
evaluation step.
for extended bed rest, then ambulation must assume a
lower priority in the nursing care plan. 3. They enable the client and nurse to determine when the problem
has been resolved.
ESTABLISHING CLIENT GOALS OR DESIRED HEALTH 4. They help motivate the client and nurse to achieve other
OUTCOMES After establishing priorities, the nurse and health goals. As goals are met, both client and nurse
client set goals for each nursing diagnosis. On a care can see that their efforts have been worthwhile.
plan, the goals or desired health outcomes describe, This provides motivation to continue following
in terms of observable client responses, what the nurse, the plan.
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Long-Term and Short-Term Goals Goals may be BOX 23.9 EXAMPLES OF ACTION VERBS
for the short term or the long term. A short-term goal
might be “Client will raise right arm to shoulder height Apply Explain Share
by Friday.” In the same context, a long-term goal might Assemble Help Sit
be “Client will regain full use of right arm in 6 weeks.” Breathe Identify Sleep
Short-term goals are useful (a) for clients who require
Choose Inject State
health care for a short time and (b) for those who are
frustrated by long-term goals that seem difficult to attain Compare List Talk
and need the satisfaction of achieving a short-term goal. Define Move Transfer
In an acute care setting, much of the nurse’s time is Demonstrate Name Turn
spent on meeting the client’s immediate needs, so most Describe Prepare Verbalize
goals are short-term goals. However, long-term goals Differentiate Report
are also needed for clients in acute care settings to guide
Discuss Select
planning for their discharge to long-term agencies or
home care. Long-term goals are often used for clients Drink
who live at home and have chronic health problems and
for clients in nursing homes, extended care facilities, and
rehabilitation centres.
Standardized nursing language is required if nursing client’s pulse or urinary output. The subject is often
data are to be included in computerized databases that omitted in goals; it is assumed that the subject is the
are analyzed and used in nursing decisions. Researchers client unless indicated otherwise.
have developed a taxonomy, the Nursing Outcomes
2. Verb. The verb specifies an action the client is to per-
Classification (NOC), for describing client outcomes
form, for example, what the client is to do, learn, or
that respond to nursing interventions. An NOC is simi-
experience. Verbs that denote directly observable
lar to a broadly stated goal and may be used in health
behaviours, such as administer, demonstrate, show, or walk,
organizations that use the NANDA nursing diagnoses
must be used. See Box 23.9 for some examples.
(Moorhead, Johnson, Maas, & Swanson, 2013).
3. Conditions or modifiers. Conditions or modifiers may be
Relationship of Goals or Desired Health Outcomes added to the verb to explain the circumstances under
to Nursing Diagnoses or Problem Statements Goals which the behaviour is to be performed. They explain
are derived from and relate to the client’s nursing diag- what, where, when, or how. For example,
noses. For example, if the nursing diagnosis is Risk for
Deficient Fluid Volume related to diarrhea and inadequate • Walks with the help of a walker (how)
intake secondary to nausea, the essential goal statement • Lists signs and symptoms of diabetes after attending
might be “Maintain fluid balance as evidenced by uri- two group diabetes classes (when)
nary and stool output in balance with fluid intake, nor-
• Weight will remain at existing level when at home
mal skin turgor, and moist mucous membranes.”
(where)
For every nursing diagnosis or problem statement,
the nurse must write at least one desired health outcome • Discusses Canada’s Food Guide’s recommended daily serv-
that, when achieved, directly demonstrates resolution of ings (what)
the problem. When developing goals/desired outcomes, Conditions need not be included if the criterion of
ask the following questions: performance clearly indicates what is expected.
1. What is the client’s problem? 4. Criterion of desired performance. The criterion indicates the
2. What is the opposite, healthy response? standard by which a performance is evaluated or the
3. How will the client look or behave if the healthy response level at which the client will perform the specified behav-
is achieved? (What will I be able to see, hear, measure, iour. These criteria may specify time or speed, accuracy,
palpate, smell, or otherwise observe with my senses?) distance, and quality. To establish a time-achievement
criterion, the nurse needs to ask, “How long?” To estab-
4. What must the client do and how well must the client do
lish an accuracy criterion, the nurse asks, “How well?”
it to demonstrate problem resolution or to demonstrate
Similarly, the nurse asks, “How far?” and “What is the
the capability of resolving the problem?
expected standard?” to establish distance and quality
criteria, respectively. Examples are as follows:
Components of Goal or Desired Health Outcome
Statements Goal or desired health outcome statements • Weighs 75 kg by April (time)
usually have the following four components: • Lists five out of six signs of diabetes (accuracy)
1. Subject. The subject, a noun, is the client, any part of • Walks one block per day (time and distance)
the client, or some attribute of the client, such as the • Administers insulin using aseptic technique (quality)
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Table 23.10 lists desired outcomes that were devel- 1. Write goals and outcomes in terms of client responses, not nurse
oped for Amanda Aquilini. activities. Beginning each goal statement with “The
client will” can help focus it on client behaviours and
Guidelines for Writing Goals or Desired Health Out-
responses. Avoid statements that start with enable, facil-
comes The following guidelines can help nurses write
itate, allow, let, permit, or similar verbs followed by the
useful goals and desired health outcomes:
TABLE 23.10 Desired Outcomes for Amanda Aquilini
Nursing Diagnosis* Goal Statements/Desired Outcomes
Ineffective Airway Clearance related to viscous Respiratory status: Gas exchange, as evidenced by the following:
secretions and shallow chest expansion • Absence of pallor and cyanosis (skin and mucous membranes)
secondary to fluid volume deficit, pain, and • Use of correct breathing/coughing technique after instruction
fatigue • Productive cough
• Symmetrical chest excursion of at least 4 cm
Within 48–72 hours:
• Lungs clear to auscultation
• Respirations 12–22/min, pulse less than 100 beats/min
• Inhales normal volume of air on incentive spirometer
Deficient Fluid Volume: intake insufficient to Fluid balance, as evidenced by the following:
replace fluid loss related to vomiting, fever, • Urine output greater than 30 mL/h
and diaphoresis • Urine specific gravity 1.005–1.025
• Good skin turgor
• Moist mucous membranes
• Stating the need for oral fluid intake
Anxiety related to difficulty breathing and con- Anxiety control, as evidenced by the following:
cerns about work and parenting roles • Listening to and following instructions for correct breathing and coughing
technique, even during periods of dyspnea
• Verbalizing understanding of condition, diagnostic tests, and treatments
(by end of day)
• Decrease in reports of fear and anxiety; none within 12 hours
• Voice steady, not shaky
• Respiratory rate of 12–22/min
• Freely expressing concerns and possible solutions about work and
parenting roles
Risk for Interrupted Family Processes related to Family coping, as evidenced by the following:
mother’s illness and temporary unavailability • Report of satisfactory childcare arrangements having been made
of father to provide childcare • Client and husband communicating effectively and working together to
solve problems
• Family members expressing feelings and providing mutual support
Imbalanced Nutrition: Less Than Body Require- Nutritional status: Nutrient intake, as evidenced by the following:
ments related to decreased appetite, nausea, • Eating at least 85% of each meal
and increased metabolism secondary to dis- • Maintaining present weight
ease process • Verbalizing importance of adequate nutrition
• Verbalizing improved appetite
Bathing/Hygiene Self-Care Deficit related to Self-care: Activities of daily living, as evidenced by the following:
activity intolerance secondary to airway clear- • Ambulates to bathroom without dyspnea, fatigue, ineffective breathing, or
ance and sleep pattern disturbance shortness of breath
• Within 24 hours, bathes with assistance in bed; within 48 hours, bathes
with assistance at sink; within 72 hours, bathes in shower without
dyspnea
• Reports satisfaction and comfort with hygiene needs
Disturbed Sleep Pattern related to cough, pain, Sleep, as evidenced by the following:
orthopnea, and diaphoresis • Observed sleeping at night rounds
• Reports feeling rested
• Does not experience orthopnea
*The nursing diagnoses are listed in the order of priority.
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word client. These verbs indicate what the nurse hopes Correct identification of the main related factors
to accomplish, not what the client will do. during the diagnosing phase provides the framework for
choosing successful nursing interventions. For example,
Correct: Client will drink 100 mL of water per hour
the diagnostic label Activity Intolerance may have sev-
(client behaviour).
eral related factors: pain, weakness, sedentary lifestyle,
Incorrect: Maintain client hydration (nursing action).
anxiety, or cardiac arrhythmias. Interventions will vary
2. Be sure that desired health outcomes are realistic for the client’s according to the cause of the problem.
capabilities, limitations, and designated time span, if indi-
cated. Limitations refer to finances, equipment, family Types of Nursing Interventions Nursing interventions
support, social services, physical and mental condi- are identified during the planning phase of the nursing
tion, and time. For example, the outcome “Measures process; however, they are actually performed during the
insulin accurately” may be unrealistic for a client who implementation phase. Nursing interventions include
has poor vision caused by cataract. both direct and indirect care, as well as nurse-initiated,
physician-initiated, and other provider–initiated treat-
3. Ensure that the goals and desired health outcomes are compat-
ments. Direct care is an intervention performed through
ible with the therapies of other professionals. For example,
interaction with the client. Indirect care is an intervention
the outcome “Will increase the time spent out of bed
performed away from, but on behalf of, the client, such
by 15 minutes each day” is not compatible with a phy-
as interdisciplinary collaboration or management of the
sician’s prescribed therapy of bed rest.
care environment. Some indirect care may be planned
4. Make sure that each goal is derived from only one nursing diag- for by the nurse but provided by other caregivers, such
nosis. For example, the goal “The client will increase as unregulated care providers.
the amount of nutrients ingested and show progress Independent interventions are those activities
in the ability to feed self ” is derived from two nurs- that nurses are licensed to initiate on the basis of their
ing diagnoses: Self-Care Deficit: Feeding and Imbalanced knowledge and skills. They include physical care, ongo-
Nutrition: Less Than Body Requirements. Keeping the goal ing assessment, emotional support and comfort, teaching,
statement related to only one diagnosis facilitates eval- counselling, environmental management, and making
uation of care by ensuring that planned nursing inter- referrals to other health care professionals. In perform-
ventions are clearly related to the diagnosis. ing an autonomous activity, the nurse determines that
5. Use observable, measurable terms for outcomes. Avoid words the client requires certain nursing interventions, either
that are vague and require interpretation or judgment carries these out or delegates them to other nursing per-
by the observer. For example, phrases such as “increase sonnel, and is accountable or answerable for the decision
daily exercise” and “improve knowledge of nutrition” and the actions. An example of an independent action
can mean different things to different people. is planning and providing special mouth care for a client
6. Make sure the client considers the goals or desired health out- after diagnosing Impaired Oral Mucous Membranes.
comes important and values them. Some outcomes, such as Dependent interventions are activities car-
those for problems related to self-esteem, parenting, and ried out under the physician’s orders or supervision,
communication, involve choices that are best made or according to specified routines. Physicians’ orders
by the client or in collaboration with the client. Some commonly include orders for medications, intravenous
clients may know what they want to accomplish with therapy, diagnostic tests, treatments, diet, and activity.
regard to their health problems; others may not know all The nurse is responsible for explaining, assessing the
the outcome possibilities. Clients are usually motivated need for, and administering the medical orders. Nursing
and expend the necessary energy to reach goals they interventions may be written to individualize the medi-
consider important. cal order based on the client’s status. For example, for a
medical order of “Progressive ambulation, as tolerated,”
SELECTING NURSING INTERVENTIONS AND ACTIVI- a nurse might write the following nursing interventions:
TIES Nursing interventions and activities are the actions 1. Have client dangle legs for 5 min, 12 h postop.
that a nurse performs to achieve client goals. The specific 2. Have client stand at bedside 24 h postop; observe for
strategies chosen should focus on eliminating or reducing pallor, dizziness, and weakness.
the health problem or the factors contributing to it.
When it is not possible to change the factors related 3. Check client’s pulse before and after client ambulates.
to the health problem, the nurse chooses interventions Do not allow client to continue if pulse >110.
to treat the signs and symptoms. Examples of this situa- Collaborative interventions are actions the
tion would be Pain related to surgical incision and Anxiety nurse carries out in collaboration with other health
related to unknown etiology. care team members, such as physical therapists, social
Nursing diagnoses/problem statements related to workers, dietitians, and physicians. Collaborative nurs-
interventions for risk reduction should focus on measures ing activities reflect the overlapping responsibilities of,
to reduce the client’s risk factors. and collegial relationships among, health care personnel.
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For example, the physician might order physical therapy

to teach the client crutch walking. The nurse would be EVIDENCE-INFORMED PRACTICE
responsible for informing the physical therapy depart-
ment and for coordinating the client’s care to include the What Enhances the Self-Efficacy
physical therapy sessions. When the client returns to the
nursing unit, the nurse would assist with crutch walking
of First-Time Mothers Who Are
and collaborate with the physical therapist to evaluate Breast-Feeding?
the client’s progress.
The Canadian Paediatric Society and Health Canada advocate
Considering the Consequences of Each Strategy Usu- that mothers exclusively breast-feed their infants for the first
ally, several possible interventions can be identified for 6 months of life. Current evidence demonstrates that about
50% of Canadian mothers are still breast-feeding at 6 months,
each nursing diagnosis. The nurse’s task is to choose those
with fewer than 20% breast-feeding exclusively. An interven-
that are most likely to achieve the desired client outcomes. tion consisting of exploration of past experience, observa-
The nurse begins by considering the risks and benefits of tion of others, encouragement, and physiological cues was
each activity. An intervention may have more than one presented. Based on the initial assessments of the women,
consequence. For example, the strategy “Provide accurate through a randomized controlled trial (RCT) with 150 primipa-
information” could result in several client behaviours. rous (first-time) mothers, one group received the intervention
Determining the consequences of each strategy and the other group received the standardized postpartum
teaching over the course of three interactions: two in hospi-
requires nursing knowledge and experience in client
tal and one through telephone after discharge. More of the
assessment. For example, the nurse’s experience may intervention group continued to breast-feed exclusively at 4
suggest that providing information the night before the and 8 weeks and reported higher breast-feeding self-efficacy.
client’s surgery may increase the client’s worry and ten-
NURSING IMPLICATIONS: Enhancing the first-time
sion, whereas maintaining the usual rituals before sleep is
mother’s sense of self-efficacy through patient teach-
more effective. The nurse might then consider providing ing and supportive interactions after delivery, both in
information several days before surgery. person and via the telephone, is effective in maintaining
Criteria for Choosing Nursing Strategies After breast-feeding in primiparous mothers. This preliminary
evidence supports those interventions that focus on
considering the consequences of the alternative nursing
counselling new mothers, enhancing their sense of self-
strategies, the nurse chooses one or more that are likely efficacy, and providing information on physiological cues
to be most effective. Although the nurse bases this deci- that enhance breast-feeding. The importance of initially
sion on knowledge and experience, the client’s input is assessing the participants and providing an interven-
important. (See the Evidence-Informed Practice box on tion that addressed their areas of lack of confidence or
what enhances the self-efficacy of first-time mothers who knowledge in breast-feeding was demonstrated.
are breast-feeding.) Source: Based on McQueen, K. A., Dennis, C. L., Stremler, R., & Norman, C. D.
The following criteria can help the nurse choose the (2011). A pilot randomized controlled trial of a breastfeeding self-efficacy interven-
tion with primiparous mothers. Journal of Obstretrical, Gynecological, and Neonatal
best nursing strategy: Nursing, 40(1), 35–46.
• The planned action must be safe and appropriate for

the individual’s age, health, and condition.
• The planned action must be achievable with the
resources available. For example, a home care nurse 1. Date and sign the plan. Recording the date the plan is
might want to include a nursing intervention for an written is essential for evaluation, review, and future
older adult client to “Check blood glucose daily”; but, planning. The nurse’s signature demonstrates account-
for that to occur, daily visits from a home care nurse ability to the client and to the nursing profession.
must be available. 2. Use category headings, such as Assessment Data, Nursing
• The planned action must be congruent with the cli- Assessment, Nursing Diagnoses/Problem Statements,
ent’s values, beliefs, and culture. Client Goals, Desired Health Outcomes, Nursing
Interventions, Selected Activities, and Evaluation.
• The planned action must be congruent with other
Include a date for the evaluation of each goal.
therapies.
3. Where permitted, use accepted medical abbreviations and
• It must be based on evidence from research or expert
symbols and key words. See Table 24.4 on page 473
opinion.
for a list of commonly used medical abbreviations
• It must be within established standards of care as and Table 24.4 on page 473 for commonly used
determined by government regulations and profes- abbreviations and symbols.
sional associations and the policies of the agency.
4. Refer to procedure books or other sources of information, rather
WRITING AN INDIVIDUALIZED PLAN OF CARE The than including all the details on a written plan.
nurse uses the following guidelines when writing a nurs- 5. Tailor the plan to the unique characteristics of the client by
ing plan of care: ensuring that the client’s choices, such as preferences
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about the times of care and the methods used, are 9. Include plans for the client’s discharge and home care needs. It is
included. This reinforces the client’s individuality and often necessary to consult and make arrangements with
sense of control. the community health nurse, the social worker, and spe-
cific agencies that supply client information and needed
6. Ensure that the nursing plan incorporates preventive and health
equipment.
maintenance aspects as well as restorative ones. For exam-
ple, carrying out the order “Provide active-assistance See the Sample Care Plan box for Amanda Aquilini.
ROM (range-of-motion) exercises to affected limbs
q2h” prevents joint contractures and maintains mus-
cle strength and joint mobility. The Nursing Interventions Classification
7. Ensure that the plan contains orders for ongoing assessment of The Iowa Intervention Project has developed a taxon-
the client (e.g., “Inspect incision q8h”). omy of nursing interventions, referred to as the Nursing
8. Include collaborative and coordination activities in the plan. Interventions Classification (NIC). The NIC provide
For example, the nurse may write orders to ask a nurses with a standardized language to describe and com-
nutritionist or physical therapist about specific aspects municate their interventions to other nurses and providers
of the client’s care. and to compare outcomes. More than 514 interventions
Sample Care Plan for Amanda Aquilini

Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion
Goals/Desired Outcomes Nursing Interventions Rationale
Demonstrate adequate air exchange Monitor respiratory status q4h: rate, This helps identify progress toward or
(goal), as evidenced by the following: depth, effort, skin colour, mucous mem- deviations from goal. Ineffective Airway
branes, amount and colour of sputum. Clearance leads to poor oxygenation,
• Absence of pallor and cyanosis
Monitor results of blood gases, chest evidenced by pallor, cyanosis, lethargy,
(skin and mucous membranes)
radiography studies, and incentive spi- and drowsiness.
• Use of correct breathing/coughing
rometer volume, as available. Inadequate oxygenation causes
technique after instruction
Monitor level of consciousness. increased pulse rate. Respiratory
• Productive cough rate may be decreased by narcotic
Auscultate lungs q4h.
• Symmetrical chest expansion of analgesics.
Take vital signs q4h (temperature, pulse,
at least 4 cm
respiration [TPR], blood pressure [BP],
pulse oximetry, pain).
Within 48–72 hours Instruct in breathing and coughing This enables the client to cough
techniques. Remind to perform, and up secretions. The client may need
• Lungs clear to auscultation
assist q3h. encouragement and support because
• Respirations 12–22/min, pulse of fatigue and pain.
Administer prescribed expectorant;
<100 beats/min
schedule for maximum effectiveness. This helps loosen secretions so they
• Inhaling normal volume of air on Maintain Fowler’s or semi-Fowler’s can be coughed up and expelled.
incentive spirometer position. Gravity allows for fuller lung expansion
Administer prescribed analgesics. Notify by decreasing pressure of abdomen on
physician if the pain is not relieved. diaphragm.
Administer oxygen by nasal can- This controls pleuritic pain by blocking
nula, as prescribed. Provide portable pain pathways and altering percep-
oxygen if client goes off unit (e.g., for tion of pain, enabling client to increase
radiography). thoracic expansion. Unrelieved pain
Assist with postural drainage daily may signal impending complication.
at 0930. Supplemental oxygen makes more oxy-
Administer the prescribed antibiotic to gen available to the cells, even though
maintain constant blood level. Observe less air is being moved by the client,
for rash and gastrointestinal or other thereby reducing the work of breathing.
side effects. Gravity facilitates movement of secre-
tions upward through the respiratory
passage.
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Sample Care Plan for Amanda Aquilini (continued)

Nursing Diagnosis: Deficient Fluid Volume related to intake insufficient to replace fluid loss
(See standardized care plan for Deficient Fluid Volume, Figure 23.8, p. 439.)
Nursing Diagnosis: Anxiety related to difficulty breathing and concerns over work and parenting roles
Goals/Desired Outcomes Nursing Interventions Rationale
Demonstrate decreased anxiety, as evi- When the client is dyspneic, stay with Presence of a competent caregiver
denced by the following: her; reassure her you will stay and reduces fear of being unable to breathe.
remain calm and confident. Focusing on breathing may help client
• Listening to and following instruc-
tions for correct breathing and Encourage client to do slow, deep feel in control and decrease anxiety.
coughing technique, even during breathing. Control of anxiety will help the client
periods of dyspnea When client is dyspneic, give brief maintain an effective breathing pattern.
• Verbalizing understanding of con- explanations of treatments and Information increases client’s under-
dition, diagnostic tests, and treat- procedures. standing and reassurance of what to
ments (by end of day) When the acute episode is over, give expect.
detailed information about nature of Anxiety and pain interfere with learn-
• Decrease in reports of fear and
condition, treatments, and tests. ing. Knowing what to expect reduces
anxiety; none within 12 hours
Encourage to express and expand on anxiety.
• Voice steady, not shaky
her concerns about her child and her Awareness of source of anxiety enables
• Respiratory rate of 12–22/min work. Explore alternatives as needed. the client to gain control over it.
• Freely expressing concerns about Note whether the husband returns as Husband’s continued absence would
work and parenting roles, but scheduled. If not, institute care plan for constitute a defining characteristic for
placing them in perspective in actual Interrupted Family Processes. this nursing diagnosis.
view of her illness
are grouped into seven domains and 30 classes of inter- sacrum or when emptying a catheter bag, the nurse
ventions within the taxonomy (Bulechek, Dochterman, measures 200 mL of strong-smelling, brown urine. Each
Butcher, & Wagner, 2013). All NIC interventions are linked requires new nursing action.
to the NANDA nursing diagnostic labels.
Implementing Skills
To implement the care plan successfully, nurses need
Implementing good cognitive, interpersonal, and technical skills. The
skills are distinct from one another; in practice, how-
The nursing process is action oriented, client centred, ever, nurses use them in various combinations and
and goal directed. Implementing is the phase in which with different emphasis depending on the activity. For
the nurse puts the nursing care plan into action. Imple- instance, when inserting a urinary catheter, the nurse
menting consists of doing, delegating, and recording. needs cognitive knowledge of the principles and steps of
After developing a plan of care based on the assessing the procedure, technical skill in draping the client and
and diagnosing phases, the nurse puts the plan into effect manipulating the equipment, and interpersonal skills to
and evaluates the results. On the basis of this evaluation, inform and reassure the client.
the plan of care is continued, modified, or terminated. The cognitive skills (intellectual skills) include
The nurse concludes the implementing step by recording problem solving, decision making, critical thinking, and
nursing activities and the resulting client responses. As in creative thinking (see Chapter 21). They are crucial to
all phases of the nursing process, clients and support per- safe, intelligent nursing care.
sons are encouraged to participate as much as possible. Interpersonal skills are necessary for all nursing
Ongoing assessment occurs simultaneously with activities: caring, comforting, referring, counselling, and
implementation. While implementing the nursing inter- supporting are just a few. The skills include conveying
ventions, the nurse continues to reassess the client at knowledge, attitudes, feelings, interest, and appreciation
every contact, gathering data about the client’s responses of the client’s cultural values and lifestyle. Before nurses
to the nursing actions and about any new problems that can be highly skilled in interpersonal relations, they
may develop. For example, while bathing an older adult must have self-awareness and sensitivity to others. (See
client, the nurse observes a reddened area on the client’s Chapters 12 and 22.)
M23_KOZI2703_04_SE_C23.indd 448 03/03/17 11:05 AM

diaphoresis (sweating). During rounds, the nurse discovers

that Amanda is sleeping and, therefore, defers the cooling
back rub that had been planned as an intervention.
New data may indicate a need to change the pri-
Assessing
orities of care or the nursing strategies. For example, a
Diagnosing nurse begins to teach Ms. Eves, who has diabetes, how
to give herself insulin injections. Shortly after beginning
the teaching, the nurse realizes that Ms. Eves is not con-
centrating on the lesson. Subsequent discussion reveals
that she is worried about her eyesight and fears she is
Evaluating going blind. Realizing that the client’s level of stress is
interfering with her learning, the nurse ends the les-
Planning son and makes arrangements for the nurse practitioner
Implementing from the diabetes clinic to meet with her. The nurse also
• Reassessing the client
provides supportive communication to help alleviate the
• Determining the nurse’s
need for assistance client’s stress.
• Implementing the nursing
interventions DETERMINING THE NURSE’S NEED FOR ASSIS-
• Supervising the delegated TANCE When implementing some nursing strategies,
care
• Communicating nursing
the nurse may require assistance for one of the following
activities reasons:
• The nurse is unable to safely implement the nursing
strategies alone (e.g., turning a heavy client in bed).
FIGURE 23.9 Implementing: The fourth phase of the nursing • Assistance would reduce stress on the client (e.g., turn-
process, in which the nurse implements the nursing intervening a person who experiences acute pain when moved).
tions and documents the care provided. • The nurse lacks the knowledge or skills to implement
a particular nursing activity (e.g., a nurse who is not
Technical skills are hands-on skills, such as familiar with a particular model of oxygen mask).
manipulating equipment, giving injections, and ban-
daging, moving, lifting, and repositioning clients. These IMPLEMENTING NURSING INTERVENTIONS It is
activities are also called procedures or psychomotor skills. The important to explain to the client what will be done,
term psychomotor includes the interpersonal component, what sensations to expect, and what the client is expected
for example, the need to communicate with the client. to do. For many nursing actions, it is also important to
Technical skills require knowledge and, frequently, man- ensure the client’s privacy, for example, by closing doors,
ual dexterity. The number of technical skills expected of a pulling curtains, or draping the client. The number and
nurse has greatly increased in recent years because of the kind of nursing activities is almost unlimited. Some
increased use of technology, especially in acute care hospitals. examples are caring, communicating, helping, teaching,
counselling, acting as a client advocate, leading, and
managing. Nurses also coordinate client care. This activ-
Process of Implementing ity involves scheduling client contacts with other health
care professionals (e.g., laboratory and radiology techni-
The process of implementing (Figure 23.9) normally cians, physical and respiratory therapists), departments,
includes the following: or agencies and serving as a liaison among the members
• Reassessing the client of the health care team.
• Determining the nurse’s need for assistance When implementing interventions, nurses should
• Implementing the nursing interventions follow these guidelines:
• Delegating and supervising • Base nursing interventions on scientific knowledge, nursing
• Communicating the nursing actions research, evidence-informed practice, and professional standards
of care when these exist. The nurse must be aware of the
REASSESSING THE CLIENT Just before implementing scientific rationale, as well as possible side effects or
an order, the nurse must reassess the client to make sure complications, of all interventions (Canadian Nurses
the intervention is still needed. Even though an order is Association [CNA], 2015). For example, a client pre-
written on the care plan, the client’s condition may have fers to take an oral medication after meals; however,
changed. For example, Amanda Aquilini had a nursing this medication is not absorbed well in the presence
diagnosis of Disturbed Sleep Pattern related to cough, pain, of food. Therefore, the nurse will need to explain why
orthopnea (trouble breathing when lying down), fever, and this preference cannot be accommodated.
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• Clearly understand the interventions to be implemented and ques- make their own decisions are ways of respecting dig-
tion any that are not understood. The nurse is responsible nity and enhancing self-esteem.
for intelligent implementation of medical and nursing • Encourage clients to participate actively in implementing the
plans of care. This requires knowledge of each inter- nursing interventions. Active participation enhances the
vention, its purpose in the client’s plan of care, any client’s sense of independence and control. However,
contraindications (e.g., allergies), and changes in the clients vary in the degree of participation they desire.
client’s condition that may affect the order. Some want total involvement in their care, whereas
• Adapt activities to the individual client. A client’s beliefs, others prefer little involvement or have limited capac-
values, age, health status, and environment are fac- ity for self-care. The amount of desired involvement
tors that can affect the success of a nursing action. may be related to the severity of the illness; the client’s
For example, the nurse determines that a client chokes culture; or the client’s fear, understanding of the ill-
when swallowing pills and so consults with the phy- ness, and understanding of the intervention.
sician to change the order to a liquid form of the
medication; or the nurse recognizes that many Asian SUPERVISING DELEGATED CARE While developing and
persons prefer to drink hot water rather than cold writing nursing interventions on the client’s care plan,
water and, after confirming it with a specific client, the nurse must also determine who should actually per-
supplies this at the bedside. form the activity. The ability to delegate client care and
assign tasks is a vital skill for registered nurses (RNs)
• Implement safe care. For example, when changing a ster-
ile dressing, the nurse practises sterile technique to and licensed or registered practical nurses (LPNs/RPNs)
prevent infection; when giving a medication, the nurse because many health care agencies have assistive person-
administers the correct dosage by the ordered route. nel to perform tasks previously done only by these nurses.
To delegate appropriately, the nurse must match the
• Provide teaching, support, and comfort. See Chapter 26. The needs of the client and family with the skills, knowledge,
nurse should always explain the purpose of the inter- and scope of practice of the available caregivers. This
vention, what the client will experience, and how the requires knowing the background, experience, knowl-
client can participate. The client must have sufficient edge, skills, and strengths of each person and understand-
knowledge to agree to the plan of care and to be able ing which tasks are within their legal scope of practice.
to assume responsibility for as much self-care as possi- Canadian RNs provide leadership while caring for
ble. These independent nursing activities enhance the clients requiring complex care, and they collaborate
effectiveness of nursing care plans (see Figure 23.10). with other professionals to set standards of client care
• Use a holistic approach. The nurse must always view the while ensuring quality client care. Unregulated health
client as a whole and consider the client’s responses in care providers are increasingly evident in Canadian
that context. For example, whenever possible, the nurse health care settings. RNs are involved in making key
honours the client’s expressed preference that interven- decisions that determine the initial and ongoing use of
tions be planned for times that fit with the client’s usual unregulated health care providers. Unregulated health
schedule of visitors, work, sleep, or eating. care provider standards vary, as they are identified by
• Respect the dignity of the client and enhance the client’s self- individual health care agencies across the provinces and
esteem. Providing privacy and encouraging clients to territories (CNA, 2012; CNA & Canadian Federation of
Nurses Unions [CFNU], 2015).
COMMUNICATING THE NURSING ACTIONS After carry-
ing out the nursing interventions, the nurse completes
the implementing phase by reporting and recording the
nursing activities and client responses in the client record
in a timely fashion. When a client’s health is changing
rapidly, the charge nurse and/or the primary care pro-
vider may want to be kept up to date with verbal reports.
Nurses also report client status at a change of shift and on
a client’s discharge to another unit or health care agency
in person, via a voice recording, or in writing. For infor-
mation on documenting and reporting, see Chapter 24.
Evaluating
FIGURE 23.10 Amanda agrees to practise deep-breathing To evaluate is to judge or to appraise. Evaluating is the last
exercises every 3 hours during the day. In addition, she verbal-
izes awareness of the need to increase her fluid intake. phase of the nursing process. In this context, evaluation
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is a planned, ongoing, purposeful activity in which clients

and health care professionals determine (a) the client’s
progress toward goal achievement and (b) the effective-
ness of the nursing care plan. Evaluation is an important
aspect of the nursing process because conclusions drawn Assessing
from the evaluation determine whether the nursing inter- Evaluating Diagnosing
ventions should be terminated, continued, or changed. • Collecting data related
to outcomes
Evaluation completed immediately after implement- • Comparing data with
ing a nursing action enables the nurse to make on- desired outcomes
• Relating nursing activities
the-spot modifications in an intervention. Evaluation to outcomes
performed at specified intervals (e.g., once a week for the • Drawing conclusions
about problem status
home care client) shows the extent of progress toward • Continuing, modifying, or Planning
goal achievement and enables the nurse to correct any terminating the nursing
care plan
deficiencies and modify the care plan, as needed. Evalu-
Implementing
ation performed at discharge allows the nurse to measure
the degree of goal achievement and the client’s self-care
abilities with regard to follow-up care. Most agencies
have a special discharge record for the terminal evalua-
tion. Through evaluating, nurses accept responsibility for
their actions, indicate interest in the results of the nurs- FIGURE 23.11 Evaluating: The final phase of the nursing
process, in which the nurse and the client determine the
ing actions, and demonstrate a desire not to perpetuate client’s progress toward goal achievement and the effective-
ineffective actions but to adopt more effective ones. ness of the plan of care. The plan may be continued,
modified, or terminated.
Relationship of Evaluating to the Other

The evaluation process (see Figure 23.11) has five
Phases of the Nursing Process components:
Successful evaluation depends on the effectiveness of the 1. Collecting data related to the desired client health
steps that precede it. Assessment data must be accurate outcomes
and complete so that the nurse can formulate appropri-
ate nursing diagnoses and desired health outcomes. The 2. Comparing the data with the desired health outcomes
desired health outcomes must be stated concretely in 3. Relating nursing actions to client goals and desired
behavioural terms if they are to be useful for evaluat- health outcomes
ing client responses. Without the implementing phase in 4. Drawing conclusions about problem status
which the plan is put into action, there would be nothing 5. Continuing, modifying, or terminating the client’s
to evaluate. care plan
The evaluating and assessing phases overlap. As
previously stated, assessment (data collection) is ongoing
COLLECTING DATA Using the clearly stated, precise,
and continuous at every client contact. However, data
and measurable desired health outcomes as a guide, the
are collected for different purposes at different points
nurse collects data so that conclusions can be drawn
in the nursing process. During the assessing phase, the
about whether goals have been met. It is usually neces-
nurse collects data for the purpose of making diagnoses.
sary to collect both objective and subjective data.
During the evaluating step, the nurse collects data for the
Some data may require interpretation. Examples of
purpose of comparing them with preselected goals and
objective data requiring interpretation are the degree
judging the effectiveness of the nursing care. The act of
of tissue turgor of a dehydrated client or the degree of
assessing (data collection) is the same; the differences lie
restlessness of a client with pain. When objective data
in (a) when the data are collected and (b) how the data
need interpretation and the nurse has not worked with
are used.
the client recently, the nurse may obtain the views of
other nurses to substantiate whether any change has
occurred. Examples of subjective data needing inter-
Process of Evaluating Client Responses pretation include complaints of nausea or pain by the
In the planning step, the nurse identifies the desired out- client. When interpreting subjective data, the nurse must
comes (indicators) that will be used to measure (evaluate) rely on either (a) the client’s statements (e.g., “My pain is
client goal achievement. Desired outcomes serve two worse now than it was after breakfast”) or (b) objective
purposes: (a) They establish the kind of evaluative data indicators of the subjective data, even though these indi-
that need to be collected; and (b) they provide a standard cators may require further interpretation (e.g., decreased
against which the data are evaluated. restlessness, decreased pulse and respiratory rates, and
M23_KOZI2703_04_SE_C23.indd 451 03/03/17 11:05 AM

relaxed facial muscles as indicators of pain relief). Data effective. However, it is important to collect more data
must be recorded concisely and accurately to facilitate before drawing that conclusion. On questioning the
the next part of the evaluation process. client, the nurse might find any of the following: (a) the
client planned a 1000-calorie diet and prepared and ate
COMPARING DATA WITH OUTCOMES If the first two the food; (b) the client planned a 1000-calorie diet but
parts of the evaluation process have been carried out did not prepare the correct food; (c) the client did not
effectively, it is relatively simple to determine whether understand how to plan a 1000-calorie diet, so she did
a desired health outcome has been met. Both the nurse not bother with it.
and the client play an active role in comparing the If the first possibility is found to be true, the nurse
client’s actual responses with the desired health outcomes. can safely conclude that the nursing strategy “Explain
Did the client drink 3000 mL of fluid in 24 hours? Did how to plan and prepare a 1000-calorie diet” was effec-
the client walk unassisted the specified distance per day? tive in helping the client gain knowledge and lose weight.
When determining whether a goal has been achieved, the However, if the nurse learns that either the second
nurse can draw one of three possible conclusions: or third possibility actually happened, then it must be
1. The goal was met; that is, the client response is the assumed that the nursing strategy did not affect the
same as the desired health outcome. outcome. The next step for the nurse is to collect data
about what the client actually did to lose weight. It is
2. The goal was partially met; that is, either a short-term important to establish the relationship (or lack thereof)
goal was achieved but the long-term goal was not, or the of the nursing actions to the client responses.
desired health outcome was only partially attained.
DRAWING CONCLUSIONS ABOUT THE STATUS OF
3. The goal was not met.
THE PROBLEM The nurse judges if goals are achieved
After determining whether a goal has been met, the by determining whether the care plan was effective
nurse writes an evaluative statement (either on the care in resolving, reducing, or preventing client problems.
plan or in the nurse’s notes). An evaluative statement When goals have been met, the nurse can draw one of
consists of two parts: (a) a conclusion and (b) support- the following conclusions about the status of the client’s
ing data. The conclusion is a statement that the goal or problem:
desired health outcome was met, partially met, or not
• The actual problem stated in the nursing diagno-
met. The supporting data are the list of client responses
sis has been resolved; or the potential nursing prob-
that support the conclusion, for example:
lem is being prevented and the risk factors no longer
oal Met: Oral intake 300 mL more than out-
G exist. In these instances, the nurse documents that the
put; skin turgor good; mucous membranes moist. goals have been met and discontinues the care for the
problem.
If the goal has not been met, alterations in interven-
tions are necessary, and more time is needed for achieve- • The potential problem stated in the nursing diagnosis is
ment of the goal. See the Sample Care Plan for Amanda being prevented, but the risk factors are still present. In
Aquilini: Modified Following Implementation and Evalua- this case, the nurse keeps the problem on the care plan.
tion (p. 453) for evaluative statements for Amanda Aquilini. • The actual problem still exists even though some goals
Data in this table represent Ms. Aquilini’s responses to care are being met. For example, a desired health outcome on
as observed by the night nurse on the morning after her a client’s care plan is “Will ingest 3000 mL of fluid daily.”
admission to the unit. In practice, care plans usually do not Even though the data may show that this outcome has
have a column for evaluative statements; rather, evaluative been achieved, other data (dry oral mucous membranes)
statements are recorded in the nurses’ notes. may indicate that the client still has a Deficient Fluid
Volume. Therefore, the nursing interventions must be
RELATING NURSING ACTIONS TO CLIENT GOALS OR continued, even though this one goal was met.
OUTCOMES The third aspect of the evaluating process
When goals have been partially met, or when goals
is determining the relationship of the nursing actions to
have not been met, one of two conclusions can be drawn:
the outcomes. It should never be assumed that a nursing
action was the only factor in meeting or not meeting a 1. The care plan may need to be revised since the prob-
goal; clients’ response must be considered. lem is only partially resolved. The revisions may need
For example, Mrs. Sophi Ringdale was obese and to occur during assessing, diagnosing, or planning
needed to lose 14 kg. When the nurse and client drew phases, as well as implementing.
up a care plan, one goal was “Lose 1.4 kg in 4 weeks.” 2. The care plan does not need revision because the
A nursing strategy in the care plan was “Explain how client merely needs more time to achieve the previously
to plan and prepare a 1000-calorie diet.” Four weeks established goals. To make this decision, the nurse must
later, the client weighed herself and found that she had assess why the goals are being only partially achieved,
lost 1.8 kg. The goal had been met—in fact, exceeded. including whether the evaluation was conducted too
It is easy to assume that the nursing strategy was highly soon (see Figure 23.12).
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Sample Care Plan for Amanda Aquilini:

Modified Following Implementation and Evaluation
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion;
Desired Outcomes/ Explanation for Continuing or
Indicators Evaluation Statements Nursing Interventions Modifying Nursing Interventions
Respiratory status: gas

exchange, as evidenced
by the following:
• Absence of pal- Partially met. Skin and Monitor respiratory status q4h; rate, Retain nursing interventions to con-
lor and cyanosis mucous membranes not depth, effort, skin colour, mucous tinue to identify progress. Goal status
(skin and mucous cyanotic, but still pale membranes, and amount and indicates problem has not been
membranes) colour of sputum. resolved.
• Use of correct Partially met. Uses cor- Monitor the results of blood gases,
breathing/cough- rect technique when pain chest radiography studies, pulse
ing technique well controlled by oximetry, and incentive spirometer
after instruction narcotic analgesics volume, as available.
• Productive cough Met. Cough productive Monitor level of consciousness.

of moderate amounts of
thick, yellow, pink-tinged
sputum
• Symmetrical Not met. Chest Auscultate lungs q4h.

chest excursion excursion = 3 cm
of at least 4 cm
• Lungs clear to Not met. Scattered Monitor vital signs q4h (TPR, BP, Client does not need to be rein-
auscultation inspiratory crackles aus- pulse oximetry, pain). structed as she demonstrates correct
within 48–72 h cultated throughout right techniques; she may still need sup-
anterior and posterior port and encouragement because of
chest fatigue and pain of breathing.
• Respirations Partially met. Respira- Instruct the client in breathing and

12–22/min, tions 26/min, pulse 96 coughing techniques. Remind her
pulse, less than to perform the task, and assist q3h.
100 beats/min Support and encourage. (11/04/17,
JW)
• Inhaling normal Not met. Tidal volume Administer prescribed expectorant; As soon as client is hydrated and
volume of air only 350 mL (Evaluated schedule for maximum effective- fever is controlled, she will probably
on incentive 11/04/17, JW) ness. Have the client maintain be discharged to self-care at home.
spirometer Fowler’s or semi-Fowler’s position.
Administer prescribed analgesics.
Notify the primary care provider if
the pain not relieved. Administer
oxygen via nasal cannula, as pre-
scribed. Provide portable oxygen if
the client goes off the unit (e.g., for
radiography). Assist with postural
drainage daily at 0930 h. On 4/17,
teach to continue prn at home.
(11/04/17, JW)
Administer prescribed antibiotic
to maintain constant blood level.
Observe for rash and gastrointestinal
or other side effects.
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CONTINUING, MODIFYING, OR TERMINATING THE

NURSING CARE PLAN After drawing conclusions about
the status of the client’s problems, the nurse modifies
the care plan by indicating “discontinued,” “goal met,”
or “problem resolved” and the date, per agency policy.
Whether or not goals were met, a number of decisions
must be made about continuing, modifying, or terminat-
ing nursing care for each problem. Before making indi-
vidual modifications, the nurse must first determine why
the plan as a whole was not completely effective. This

requires a review of the entire care plan and a critique
of the nursing process steps involved in its development.
See Table 23.11 for a checklist to use when reviewing a
care plan.
FIGURE 23.12 Upon assessment of respiratory excursion,
Mary detects failure of the client to achieve maximum ventila-
Assessing An incomplete or incorrect database influ-
tion. Mary and Amanda re-evaluate the care plan and modify it ences all subsequent steps of the nursing process and
to increase coughing and deep-breathing exercises to q2h. care plan. If data are incomplete, the nurse needs to
TABLE 23.11 Evaluation Checklist
Assessing Diagnosing Planning Implementing

Are the data com- Are the nursing diagnoses Desired Health Outcomes Was client input obtained
plete, accurate, and relevant and accurate? Do the new nursing diag- at each step of the nursing
validated? Are the nursing diagnoses noses require new goals? process?
Do the new data supported by the data? Are the goals realistic? Were the goals and nursing
require changes in the Has the problem status interventions acceptable to the
Was enough time allowed
care plan? changed (i.e., potential, actual, client?
for goal achievement?
risk)? Did the caregivers have the
Do the goals address all
Are the diagnoses stated knowledge and skill to perform
aspects of the problem?
clearly and in the correct the interventions correctly?
Does the client still concur
format? Were explanations given to
with the goals?
Have any nursing diagno- the client prior to implementing?
Have client priorities
ses been resolved?
changed?
Nursing Interventions
Do nursing interventions
need to be written for new nurs-
ing diagnoses or new goals?
Are the nursing interven-
tions related to the stated
goals?
Is there a rationale to justify
each nursing intervention?
Are the nursing inter-
ventions clear, specific, and
detailed?
Are the new resources
available?
Do the nursing interven-
tions address all aspects of the
client’s goals?
Were all nursing interven-
tions clearly effective?
M23_KOZI2703_04_SE_C23.indd 454 03/03/17 11:05 AM

reassess the client and record the new data. In some are also involved in evaluating and modifying the overall
instances, new data may indicate the need for new nurs- quality of care given to groups of clients.
ing diagnoses, new goals, and new nursing interventions.
Quality Assurance A quality assurance (QA) program is an
Diagnosing/Analyzing If the database is incomplete, ongoing, systematic process designed to evaluate and
new diagnostic or problem statements may be required. promote excellence in the health care provided to clients.
If the database is complete, the nurse needs to ana- Quality assurance frequently refers to evaluation of
lyze whether the problems were identified correctly and the level of care provided in a health care agency; it may
whether the nursing diagnoses/analyses are relevant to also include the evaluation of care provided on one nurs-
that database. After making judgments about the status of ing unit in an agency, within a health region, or even in
the problem, the nurse revises or adds new diagnoses or a province or territory. QA activities are generally man-
statements as needed to reflect the most recent client data. aged by the nursing unit administration, but all nurses
participate in the process.
Planning: Desired Health Outcomes If a nursing
Quality assurance requires evaluation of three com-
diagnosis or problem statement is inaccurate, the goal
ponents of care: (a) structure, (b) process, and (c) out-
statement will need revision. If the nursing diagnosis/
come. Each type of evaluation requires different criteria
statement is appropriate, the nurse then checks to find
and methods, and each has a different focus.
out if the goals are realistic and attainable. Unrealistic
Structure evaluation focuses on the setting in
goals require correction. The nurse should also deter-
which care is given. It answers the question, What effect
mine whether priorities have changed and whether the
does the setting have on the quality of care? Structural
client still agrees with the priorities. Goals must also be
standards describe desirable environmental and orga-
written for any new nursing diagnoses.
nizational characteristics that influence care, such as
Planning: Nursing Interventions The nurse inves- equipment and staffing.
tigates whether the nursing strategies were related to Process evaluation focuses on how the care was
goal achievement and whether the best nursing strate- given. It answers questions such as Is the care relevant to
gies were selected. Even when diagnoses and goals are the client’s needs? Is the care appropriate, complete, and
appropriate, the nursing strategies selected may not timely? Process standards focus on the manner in which
have been the best ones to achieve the goal. New nurs- the nurse uses the nursing process and meets care stan-
ing interventions may reflect changes in the amount of dards. Some examples of process criteria are “Checks
nursing care the client needs, scheduling changes, or client’s identification band before giving medication”
rearrangement of nursing activities to group similar and “Performs and records chest assessment, including
activities or to permit longer rest or activity periods for auscultation, once per shift.”
the client. If new nursing diagnoses or problem state- Outcome evaluation focuses on demonstrable
ments have been written, then new nursing interven- changes in the client’s health status as a result of nurs-
tions will also be necessary. ing care. Outcome criteria are written in terms of client
responses or health states, just as they are for evaluation
Implementing Even if all sections of the care plan within the nursing process. For example, “How many
appear to be satisfactory, the manner in which the plan clients develop pneumonia after undergoing hip repair?”
was implemented may have interfered with goal achieve- or “How many clients who have a colostomy experience
ment. Before selecting new interventions, the nurse an infection that delays discharge?”
should check whether they were carried out. Other per-
sonnel may not have carried them out, either because the Quality Improvement In Canada, the Canadian Council on
orders were unclear or because they were unreasonable Health Services Accreditation (CCHSA), the Canadian
in terms of external constraints, such as money, staff, Patient Safety Institute, and nurse educators, practitio-
time, and equipment. ners, and researchers promote quality health care, iden-
After making the necessary modifications to the care tifying and measuring nursing-sensitive desired health
plan, the nurse implements the modified plan and begins outcomes and exploring various factors that affect cli-
the nursing process cycle again. Refer to Nursing Care ent safety and best practices (Armstrong, Laschinger,
Plan for Amanda Aquilini: Modified Following Imple- & Wong, 2009; Kingston-Riechers, Ospina, Jonsson,
mentation and Evaluation on page 453 to see how the Childs, Mcleod, & Maxted, 2010). Governments also
plan for Amanda Aquilini was modified after evaluation play a role by requiring health care organizations to
of goal achievement and review of the nursing process. provide excellent care and to increase public awareness
Additions to the care plan are shown in italics. of their rights to safe and quality care. An example can
be seen in the passing of the Excellence Care for All Act,
Evaluating the Quality of Nursing Care In addition to 2010 in Ontario (Ontario Ministry of Health and Long-
evaluating goal achievement for individual clients, nurses Term Care, 2011).
M23_KOZI2703_04_SE_C23.indd 455 03/03/17 11:05 AM

Unlike quality assurance, quality improvement bodies promote and require peer evaluation as a means
(QI) monitors client care rather than organizational of supporting continuing professional competence, an
structure, focuses on processes rather than individuals, essential element of professional accountability.
and uses a systematic approach with the intention of
improving the quality of care rather than ensuring the qual-
ity of care. QI studies focus on identifying and correcting
a system’s problems, such as duplication of services in a Nursing Process
hospital. QI is also known as continuous quality improvement
(CQI), total quality management (TQM), performance improve- Summarized
ment (PI), or persistent quality improvement (PQI).
The nursing process is foundational to nursing practice.
Nursing Audit An audit involves the examination or review
Its basic structure can be modified for the split-second
of records. A retrospective audit is the evaluation of
decision making sometimes necessary in critical care
a client’s record after discharge from an agency. Retro-
environments or the complex, long-range planning and
spective means “relating to past events.” A concurrent
evaluation necessary for community health-promotion
audit is the evaluation of a client’s health care while
programs. It is characterized as being the following:
the client is still receiving care from the agency. These
evaluations use interviews, direct observation of nursing • Open and flexible to meet the unique needs of clients,
care, and review of clinical records to determine whether families, communities, and whole populations
specific evaluative criteria have been met. • Cyclical and dynamic, with a built-in plan for evalua-
Peer Review Another type of evaluation of care is the tion, reassessment, and modification
peer review. In nurse peer review, nurses functioning • Client centred and individualized
in the same capacity (i.e., peers) appraise the quality of • Interpersonal and collaborative as a process and as a
care or practice performed by other equally qualified means of communication
nurses. The peer review is based on established stan-
• Planned and goal directed
dards or criteria. The individual peer review focuses on the
performance of an individual nurse and is intended to • Creative
support professional growth. The nursing regulatory • Universally applicable
Case Study 23
Ms. Sharon Noble is a 55-year-old woman who lives with her rates her pain (heaviness) as 8/10 using the numeric rating
partner, Marielle Symes, in a condominium they own in Barrie, scale.
Ontario. They have no children, but they do have a close network 5. Client concerns: Sharon is very worried about her own
of friends. Sharon has a business degree and is a self-employed health. In addition, she is worried about
proprietor of Novel-Novels Book Shoppe. She is an agnostic. Her Marielle. Marielle just had cataract sur-
medical care in hospital is covered by the Ontario Health Insur- gery, and Sharon has been looking after
ance Plan (OHIP). She arrives at the hospital alone. her, instilling the eye drops, shopping,
1. Presenting symptoms: Chest pain and shortness of breath and preparing foods.
× 3 hours.
2. Vital signs: Temperature: 36.4°C; pulse: 140/min; respira-
tion: 28/min at rest. BP: 150/97 mm Hg, cloxacillin allergy. CRITICAL THINKING QUESTIONS
3. Assessment: Visibly short of breath (SOB) at rest, skin cold
and clammy, capillary oxygen level is low in blood (saturation
90%) on room air. Chest auscultation: Air entry throughout 1. What questions run through your mind when analyzing
with medium coarse wet crackles mid to lower lobes. Apical Sharon’s subjective data?
heart rate very rapid. O2 via 5 L nasal prongs commenced. 2. What questions run through your mind when analyzing
IV of normal saline at 20 mL/h initiated by RN. She reports Sharon’s objective data?
a cloxacillin allergy. 3. Considering the above symptoms, explain why Sharon’s
4. Client statement: “I have a heaviness that won’t let up in the current condition is a medical emergency.
middle of my chest. I feel as if I could be sick to my stom-
4. What are your nursing priorities when assessing and
ach.” Chest pain started after Sharon unloaded five heavy
caring for Sharon?
boxes of books sent from a publisher. She thought that once
she stopped working, it would go away but the intensity of
the pressure kept mounting and has lasted 3 hours. She Visit MyNursingLab for answers and explanations.
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KEY TERM S
actual nursing diagnostic labels p. 430 multidisciplinary protocols p. 438
diagnosis/problem directive care plan p. 440 quality assurance
statement p. 429 interview p. 420 neutral question p. 420 p. 455
assessing p. 412 discharge planning nondirective quality improvement
audit p. 456 p. 437 interview p. 420 (QI) p. 456
client health etiology p. 430 norm p. 431 rapport p. 420
outcomes p. 429 evaluation p. 450 nursing diagnosis rationale p. 440
closed questions p. 420 evaluative statement p. 429 related factors p. 430
cognitive skills p. 448 p. 452 Nursing Interventions retrospective audit
collaborative focused assessment Classification p. 456
care plans p. 440 p. 422 (NIC) p. 447 risk factors p. 429
collaborative formal care plan Nursing Outcomes risk nursing
interventions p. 445 p. 437 Classification diagnosis/problem
concept map p. 440 goals p. 442 (NOC) p. 443 statement p. 429
concurrent audit p. 456 independent nursing process p. 411 screening
constant data p. 418 functions p. 431 objective data p. 418 examination p. 422
critical pathways p. 440 independent open-ended standard p. 431
cues p. 427 interventions p. 445 questions p. 420 standardized
database p. 417 individualized outcome evaluation care plans p. 437
data collection p. 415 care plans p. 437 p. 455 standing order p. 438
defining inferences p. 427 peer review p. 456 structure
characteristics informal care plan policies p. 438 evaluation p. 455
p. 430 p. 437 potential nursing subjective data p. 418
dependent functions interpersonal skills diagnosis/problem technical skills p. 449
p. 431 p. 448 statement p. 429 validation p. 427
dependent interview p. 420 priority setting p. 440 variable data p. 418
interventions p. 445 leading question p. 420 procedures p. 438 wellness nursing
desired health medical process evaluation diagnosis/problem
outcomes p. 442 diagnoses p. 430 p. 455 statement p. 429

• The nursing process is a systematic, client-centred • Assessment involves mutual participation by client and
method for structuring the delivery of nursing care. At nurse in obtaining subjective and objective data about the
every stage of the process, the nurse works closely with client’s health status and assessing the social determinants
the client to tailor care and build a relationship of mutual of health affecting individual, family, group, and commu-
regard and trust. nity clients.
• The goals of the nursing process are to identify a client’s • The client is the primary source of data. Secondary
actual or potential health care needs as well as his or her sources are family, significant others, health care team
strengths, to establish plans to meet the identified needs, members, the health record, and pertinent literature.
and to deliver and evaluate specific nursing interventions • Subjective data are the client’s personal perceptions, often
to meet those needs. gathered during the nursing health history.
• The nursing process is organized into five interrelated, • Objective data (e.g., data observed and collected during
interdependent phases: assessing, diagnosing, planning, the physical examination) are detectable by the observer.
implementing, and evaluating.
• Some data must be validated. Objective data can be used
• Assessing involves collecting, organizing, validating, and to validate subjective data, and vice versa. Primary and
documenting data. secondary data can also be used to validate each other.
M23_KOZI2703_04_SE_C23.indd 457 03/03/17 11:05 AM

• Both nursing and non-nursing models provide frame- • Planning involves the nurse, the client, support persons,
works for collecting and organizing client data. and other caregivers.
• In the assessment phase, nurses need to listen carefully to • Planning involves setting priorities, establishing client
client stories to gain an understanding of the health con- goals or desired health outcomes, selecting nursing inter-
cerns of each individual. In the diagnosis phase, nurses ventions, and writing a plan of care.
use their clinical reasoning to develop a plan of care that • Desired health outcomes describe specific and measure-
acknowledges the uniqueness and diversity of each indi- able client responses and help the nurse evaluate the
vidual client. effectiveness of the nursing interventions.
• Diagnosing, or making a nursing diagnosis/analysis, is the • Nurses initiate and tailor nursing care plans that opera-
process of making a clinical judgment (nursing diagnosis tionalize critical pathways and concept maps.
or hypothesis) about a client’s potential or actual health • Standardized care plans should be tailored to meet indi-
problems and strengths, and identifying desired health vidual, family, group, and community needs.
outcomes.
• Implementation is carrying out or delegating the nursing
• Nursing diagnoses or client problems can be catego- interventions in collaboration with clients. It incorporates
rized into four types: actual, possible, risk, and wellness all the activities performed to promote health, prevent
diagnoses. complications, treat symptom problems, and facilitate the
• Critical thinking skills used in diagnosing include analysis, client’s coping with chronic alterations in health status.
synthesis, inductive reasoning, and decision making. • Evaluating is the process of comparing client responses to
• Three phases of the diagnostic/analytic process are data preselected outcomes to determine whether goals have been
analysis; identification of client’s health problems, health met. It includes renegotiating and modifying unmet goals
risks, and strengths; and formulation of diagnostic state- and re-identifying client health outcomes of the plan of care.
ments, including desired health outcomes. • Nursing interventions and actions promote desired health
• It is important to identify client strengths as well as problems. outcomes.
N CLEX- ST YL E PRACTICE QUI Z

1. A client has undergone a cesarean section. She and 4. Which of the following behaviours is most representa-
her baby have just been brought to the recovery room. tive of the nursing diagnosis (nursing analysis) phase of
What is the nurse’s initial action? the nursing process?
a. Perform a newborn assessment a. Identifying major problems or needs
b. Inspect the client’s dressing and lochia b. Organizing data in the client’s family history
c. Assess the client’s level of pain c. Establishing short-term and long-term goals
d. Ask the client if she would like to feed her baby d. Administering an antibiotic
2. The nurse records the client’s breakfast intake as “tea 5. Which of the following behaviours would indicate that
240 mL, milk 125 mL, 1 egg, 2 slices of toast.” The the nurse was using the assessment phase of the nursing
nurse knows that the documentation is part of which process as part of nursing care?
phase of the nursing process? a. Proposing hypotheses
a. Assessment b. Generating desired health outcomes
b. Diagnosis c. Reviewing results of laboratory tests
c. Planning d. Documenting care
d. Evaluation
6. What is a benefit of using a conceptual or theoretical
framework for collecting and organizing assessment data?
3. A nursing care plan includes the desired health outcome
of “quality of life” for a client with a chronic degenera- a. Correlation of the data with other members of the
tive illness who is likely to live for many more years. health care team
Which of the following is one example that would indi- b. Demonstration of cost-effective care
cate the outcome has been met?
c. Use of creativity and intuition in creating a plan
a. The client demonstrates financial resources to pay of care
for health care for many years. d. Collection of all necessary information for a thor-
b. The client spends the majority of his or her time in ough appraisal
spiritual reflection.
7. The client with a fractured pelvis requests that family
c. The client has no signs or symptoms of preventative members be allowed to stay overnight in the hospital
complications of the illness. room. Which of the following should the nurse consult
d. The client verbalizes satisfaction with current rela- before determining whether or not this request can be
tionships with other persons. honoured?
M23_KOZI2703_04_SE_C23.indd 458 03/03/17 11:05 AM

a. Hospital policies 9. Which of the following steps should the nurse perform
b. Standardized care plans first when initiating the implementation phase of the
nursing process?
c. Orthopedic protocols
a. Carrying out nursing interventions
d. Standards of care
b. Determining the need for assistance
8. The nurse selects the nursing diagnosis “risk for c. Reassessing the client
impaired skin integrity,” related to immobility, dry skin, d. Documenting interventions
and surgical incision. Which of the following represents 10. A client comes into the doctor’s office for re-evaluation of
a properly stated outcome or goal? his diabetes. The nurse collects the client’s recent blood
a. The client will turn in bed every 2 hours. sugar values, which the client has been recording daily at
b. The client will report the importance of applying home. What type of assessment is the nurse performing?
lotion to skin daily. a. Initial assessment
c. The client will have intact skin during b. Problem-focused assessment
hospitalization. c. Emergency assessment
d. The client will use a pressure-reducing mattress. d. Time-lapsed assessment
REFERENCES
Alfaro-Lefevre, R. (2013). Critical thinking, clinical reasoning, and clini- Hicks-Moore, S. L. (2005). Clinical concept maps in nursing educa-
cal judgement: A practical approach (5th ed.). St. Louis, MO: Elsevier tion: An effective way to link theory and practice. Nurse Education in
Saunders. Practice, 5, 348–352.
Armstrong, K., Laschinger, H., & Wong, C. (2009). Workplace Johnson, D. E. (1959). A philosophy of nursing. Nursing Outlook, 7,
empowerment and magnet hospital characteristics as predictors of 198–200.
patient safety climate. Journal of Nursing Care Quality, 24(1), 55–62. Kingston-Riechers, J., Ospina, M., Jonsson, E., Childs, P., McLeod,
Bulechek, G. M., Dochterman, J. C., Butcher, H. K., & Wagner, L., & Maxted, J. (2010). Patient safety in primary care. Edmonton,
C. M. (2013). Nursing intervention classification (NIC) (6th ed.). AB: Canadian Patient Safety Institute and BC Patient Safety &
St. Louis, MO: Mosby Elsevier. Quality Council.
Canadian Hypertension Education Program. (2012). CHEP 2012 McQueen, K. A., Dennis, C. L., Stremler, R., & Norman, C. D.
recommendations. Retrieved from http://www.hypertension.ca/ (2011). A pilot randomized controlled trial of a breastfeeding
chep-recommendations. self-efficacy intervention with primiparous mothers. Journal of
Canadian Nurses Association. (2012). Position statement: Staff mix deci- Obstretrical, Gynecological, and Neonatal Nursing, 40(1), 35–46.
sion making framework for quality nursing care. Retrieved from Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013).
https://www.cna-aiic.ca/en/on-the-issues/better-care/ Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO:
staffing-patient-outcomes/staff-mix-framework. Elsevier Mosby.
Canadian Nurses Association. (2015). Framework for the practice of North American Nursing Diagnosis Association (NANDA)
registered nurses in Canada. Retrieved from International. (2015). Nursing diagnoses: Definitions and
https://cna-aiic.ca/becoming-an-rn/the-practice-of-nursing. classification 2015–2017. Oxford, UK: Wiley-Blackwell.
Canadian Nurses Association & Canadian Federation of Nurses Ontario Ministry of Health and Long-Term Care. (2011). Excellence
Unions [CNA/CFNU]. (2015). Position statement: Practice environ- Care for All Act, 2010. Retrieved from http://www.health.gov.
ments: Maximizing outcomes for clients, nurses and organizations. Retrieved on.ca/en/legislation/excellent_care.
from https://www.cna-aiic.ca/en/on-the-issues/better-care. Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis,
Canadian Nurses Association, Canadian Medical Association, & MO: Mosby.
Health Action Lobby. (2013). Integration: A new direction for Canadian Orlando, I. (1961). The dynamic nurse–patient relationship. New York,
health care. Retrieved from https://www.cna-aiic.ca/en/on-the- NY: Putnam.
issues/better-care/transformation-to-integrated-care. Pehler, S., Markwardt, M., & Hibbard, D. (2015). Nursing diagnosis
Carpenito, L. J. (2013). Nursing care plans: Transitional patient and family development of longing: Content validation with nursing experts.
centered care (Nursing care plans and documentation). Philadelphia, PA: International Journal of Nursing Knowledge, 26(3), 121–126.
Lippincott, Williams & Wilkins. Roy, C. (2008). The Roy adaptation model (3rd ed.). Upper Saddle
Garbulo, D. C., de Carvalho, E. C., & Napoloao, A. A. (2015). River, NJ: Prentice Hall.
Concept analysis and content validation of risk of injury to the Stewart, C. J., & Cash, W. B., Jr. (2011). Interviewing: Principles and
urinary tract: Nursing diagnosis. International Journal of Nursing practices (13th ed.). Boston, MA: McGraw-Hill.
Knowledge, 26(4), 170–177. Wiedenbach, E. (1963). The helping art of nursing. American Journal
Gordon, M. (2016). Manual of nursing diagnosis (13th ed.). Boston, of Nursing, 63(11), 54–57.
MA: Jones & Bartlett. Wilkinson, J. M. (2012). Nursing process and critical thinking (5th ed.).
Hill, C. M. (2006). Integrating clinical experiences into the concept Upper Saddle River, NJ: Prentice Hall.
mapping process. Nurse Educator, 31(1), 36–39.
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Chapter 24
Documenting and
Reporting
Updated by
Vicki Foley, RN, PhD
School of Nursing, University of Prince Edward Island
E
LEARNING OUTCOMES
After studying this chapter, you will be able to ffective communication
1. Discuss ethical and legal considerations of documentation in client among the health care
records. team is vital to the qual-
2. Discuss the purposes of client records and documentation. ity of client care. Generally, members
of the health care team communicate
3. Compare and contrast different documentation systems.
through discussion, reports, and
4. Explain how various forms in the client record are used to
records. A discussion is an infor-
document the steps of the nursing process.
mal oral consideration of a subject
5. Compare and contrast the documentation needed for clients in
by two or more persons to identify
acute care, long-term care, and home care settings.
a problem or establish strategies to
6. Discuss guidelines for effective documentation that meet legal and
resolve a problem. A report is oral,
ethical standards.
written, or computer-based commu-
7. Identify prohibited abbreviations, acronyms, and symbols that
nication intended to convey informa-
cannot be used in any form of clinical documentation.
tion to others. For instance, nurses
8. Identify essential guidelines for reporting client data.
report on a client’s progress at the
end of a hospital work shift.
A record, also called a chart
or client record, is a formal, legal
document that provides evidence
of a client’s care and can be hand
written or computer based. Although
health care organizations use dif-
ferent systems and forms for docu-
mentation, all client records contain
similar information. The process of
making an entry on a client record is
called documenting, recording, or
charting.
M24_KOZI2703_04_SE_C24.indd 460 17/03/17 11:34 AM

Chapter 24 Documenting and Reporting 461
Ethical and Legal personal information. In addition, provinces and territories

apply an additional act to protect the public’s privacy. For
Considerations example, Manitobans are protected by the Freedom of
Information and Protection of Privacy Act, 1997, amended
2011 (Manitoba Government, 2011), and Ontarians are
The Canadian Nurses Association’s (CNA) Code of Ethics
protected by the Personal Health Information Protection
for Registered Nurses outlines values for practice, including
Act, 2004, amended 2010 (Service Ontario, 2010).
safe, competent, ethical, accountable, and confidential
care (CNA, 2008). Documenting and reporting are critical
nursing activities guided by the Code of Ethics. The client’s
record is the cornerstone of communication among sev- Ensuring Confidentiality
eral disciplines involved in the care of the client. Nurses of Digital Health Information
are responsible and accountable for documenting and
reporting client care and for implementing competent care Digital health records have become a reality for Canadian
that meets the standards for professional nursing practice nurses. The Canada Health Infoway (CHI), a nonprofit
(Canadian Nurses Protective Society [CNPS], 2007). organization with a mandate to improve the health of
The client’s record is a legal document and can be Canadians, collaborates with its partners to accelerate the
entered as evidence in a court of law. Nurses need to be development, adoption, and effective use of digital health
aware of and follow the legal and ethical standards of solutions across Canada. Health facilities in many prov-
documentation. Documentation must be clear, concise, inces are making significant progress in the transition to
accurate, relevant, and completed in a timely manner. Sub- digital health records. Notably, in 2014, the pan-Canadian
jective opinions must be avoided, and objective language average for electronic health record (EHR) availability was
should be used when documenting or reporting client care. 89% (CHI, 2014). A study commissioned by the CHI and
Statements made by clients or family members must be the CNA revealed that 83% of nurses are comfortable
quoted to ensure accuracy. Diverse cultural perspectives using digital tools in their practice (Harris/Decima, 2014).
need to be taken into consideration and clarified when Because of the increased use of digital client infor-
documenting subjective data. Detailed descriptions of mation, health care agencies have implemented policies
what was observed and changes to a client’s health status and procedures to ensure the privacy and confidential-
need to be documented. If care is not documented, then it ity of client information. Regardless of the system of
is considered not completed (Cartwright-Vanzant, 2010). record-keeping used, the general principles for docu-
Nurses can be called to court to testify several years menting and recording apply. Health care agencies are
after a case has started. A nurse’s memory may fade; ultimately responsible for the digital information system
therefore, accurate, timely, objective documentation will selected and the overall security of the network. See the
allow recollection of what occurred and give credible Clinical Alert box on faxing and/or e-mailing confiden-
evidence of the care provided. A well-constructed record tial information.
will allow nurses to impart their testimony as docu- Nurses are accountable for the integrity and security
mented in the client’s chart. All aspects of the record, of client records during use and must adhere to set poli-
including flowsheets, graphic records, progress notes, cies and procedures. The following are some suggestions
nurses’ notes, late entries, and incident reports, will for ensuring confidentiality of computerized records:
provide a complete picture of events for the court. Jury 1. A personal password is required to enter and sign out
decisions in the Canadian court system are influenced by from computer files. The password should not be shared
the overall quality of a client’s health records. A careless with anyone, including other health care team members.
entry, poor spelling, and poor grammar tend to preju-
dice the entire client record, leaving everything suspect
of being of poor quality or incompetent and, therefore,
possibly inaccurate (Cartwright-Vanzant, 2010). CLINICAL ALERT
As a legal record, most client records are retained Take safety measures, and ensure you are following agency
by the health care institution or held for a minimum of policy before faxing and/or e-mailing confidential information. Consent
10 years by a health care professional responsible for the is needed from the client to fax or e-mail information. A fax cover sheet
client’s care. If the individual is under 18 years, then the should contain instructions that the faxed material is to be given only to
record is held for 10 years after the client turns 18 years the named recipient, and e-mails should include a line indicating that
the message is intended only for the use of the individual to whom it is
old (College of Nurses of Ontario [CNO], 2009a). The addressed and may contain information that is confidential and privileged.
public has the legal right to request access to their Make sure that personally identifiable information (e.g., client name,
personal health records. social insurance number) has been removed, or consider use of a unique
In Canada, federal privacy legislation, the Personal identifier or code. If needed, confirm that the material is being sent to a
Information Protection and Electronic Documents Act (S.C. 2000, confidential fax number, or call ahead to ensure the person is present to
receive the fax. Check that the fax number or e-mail address is correct
c. 5) (Department of Justice, 2011), applies to provin- before pressing the “send” button.
cial and territorial organizations collecting and holding
M24_KOZI2703_04_SE_C24.indd 461 02/03/17 4:49 PM

2. After logging on, never leave a computer terminal Accountability

unattended.
Nurses are mandated to follow the institution’s policies
3. Do not leave client information displayed on the mon-
and procedures as well as the standards set out by the
itor screen visible for others to read.
regulatory body in each province or territory related
4. Follow agency policies and procedures for document- to documentation legal liability (Austin, 2011). Their
ing sensitive material, such as medical diagnoses. documentation must be accurate, relevant, timely, and
5. Exit the client record, and log off the system when complete (CNO, 2009a).
work is completed.
6. Information technology (IT) personnel must install a
firewall to protect the server from unauthorized access.
Auditing for Quality Assurance
7. Inform the appropriate health facility managers when a An audit is a review of records. Client records are
security breach has occurred. regularly audited for quality assurance to evaluate the
health care facility and the care provided by all health
care providers. Accrediting agencies, such as Accredita-
Purposes of Client tion Canada, may audit client records to determine if

a particular health agency is meeting the stated agency
Records and standards (see the section “Evaluating the Quality of
Nursing Care” in Chapter 23).
Documentation
Client records are kept for a number of purposes, includ-
Education and Research
ing communication, accountability, planning client care, Most agencies allow nursing students and health care
auditing health care agencies, research, and education. providers to have access to client records. Nursing stu-
dents or health care providers are bound by a strict
ethical code and legal responsibility to hold all informa-
Communication tion in confidence and to protect clients’ privacy and
The client record is the primary communication vehicle anonymity by not using identifiable data (CNO, 2009b).
for members of the health care team. Each health care Client records contain valuable information for
provider contributes to the care of the client in various research and education. Client records provide a com-
ways and uses the client record to access, communicate, prehensive view of the client, including nursing and
and document information. Clear, concise, relevant, and medical diagnoses, signs and symptoms of the condition,
accurate documentation provides continuity of care and diagnostic findings, behaviours, effective treatment strat-
increases the probability of quality health care and posi- egies, and factors that affect outcomes. Information from
tive patient outcomes. As nurses work within interprofes- client records can assist health care planners to identify
sional teams, documentation is used as a key vehicle to service needs and client outcomes. Using data from client
communicate and facilitate the type of care needed for records, research can be conducted to determine themes
clients. Collaborative efforts should be used to develop and patterns, which can be further analyzed to deter-
documentation of client care with common assessment mine effective health care interventions.
criteria (e.g., pain assessment scale in palliative clients).
The use of EHRs could also bring experts from a dis-
tance, if needed, to engage in interprofessional team
care planning. Interprofessional collaboration and appropriate
Documentation Systems
technology, two of the key principles of primary health A number of documentation systems are currently used:
care (see Chapter 25), can enhance the nurse’s ability to (a) source-oriented record; (b) problem-oriented medical
assist clients to access the needed care for optimal health. record; (c) the assessment, problems, interventions, evalua-
tion (APIE) model; (d) focus charting; (e) charting by excep-
tion (CBE); (f) computerized documentation; and (g) case
Planning Client Care management. These documentation systems can be imple-
Each health professional uses data from the client’s mented using the traditional paper forms or with EHRs.
record to plan care for that client. A primary care pro-
vider, for example, may order a specific antibiotic after
establishing that the client’s temperature is steadily rising
Source-Oriented Record
and that laboratory tests reveal the presence of a certain The traditional client record is a source-oriented
microorganism. Nurses use baseline and ongoing data to record. Each health care professional or department
evaluate the effectiveness of the nursing care plan. makes notations in a separate section or sections of the
M24_KOZI2703_04_SE_C24.indd 462 02/03/17 4:49 PM

client’s chart. For example, the admissions department Many agencies combine narrative charting with
completes an admission sheet; nurses document the ini- another system. For example, an agency using a charting-
tial nursing assessment and provide interdisciplinary by-exception system (discussed later) may use narrative chart-
notes; the physician records on a physician’s order sheet ing when describing findings of abnormalities. When
and a physician’s history sheet; all disciplines record using narrative charting, it is important to organize the
on interdisciplinary notes; and other departments or information in a clear, coherent manner. Using the nurs-
personnel may have their own documentation forms. In ing process as a framework is one way to organize the
this type of documentation, information about a par- information. (See Box 24.1.)
ticular problem is distributed throughout the record. For Source-oriented records are convenient because
example, if a client had right hemiplegia (paralysis of health care providers from each discipline can easily
the left side of the body), data about this problem might locate the forms on which to record data, and it is easy
be found in the initial nursing assessment, physician’s to trace the information to a specific discipline. The dis-
history sheet, on the physician’s order sheet, and in the advantage is that information about a particular client
interdisciplinary notes. See Table 24.1 for the compo- problem is scattered throughout the chart, so it is difficult
nents of a source-oriented record. to find chronological information on a client’s problem
Narrative charting is a traditional part of the and his or her progress.
source-oriented record (see Figure 24.1). It consists of
written notes that include routine care, normal findings,
and client problems. The information has no right or
wrong order, although a chronological order is recom-
Problem-Oriented Medical Record
mended and frequently used. Narrative documentation In the problem-oriented medical record (POMR),
is being replaced by other systems, such as charting by or problem-oriented record (POR), data are
exception and focus charting. arranged according to the problem the client has, rather
TABLE 24.1 Components of the Source-Oriented Record
Form Information
Admission (face) sheet Legal name, birth date, age
Social insurance number, health card number, other health insurance information
Address
Marital status; closest relatives or person to notify in case of emergency
Date, time, and admitting diagnosis
Food or drug allergies
Name of admitting (attending) primary care provider
Initial nursing assessment Findings from the initial nursing history and physical health assessment
Graphic record Body temperature, pulse rate, respiratory rate, blood pressure, daily weight, and special mea-
surements, such as fluid intake and output and oxygen saturation
Daily care record Activity, diet, bathing, and elimination records
Special flowsheets Examples: fluid balance record, skin assessment
Medication record Name, dosage, route, time, date of regularly administered medications
Name or initials of person administering the medication
Nurses’ notes Pertinent assessment of client
Specific nursing care, including teaching, and client’s responses
Client’s complaints and how client is coping
Medical history and physical Past and family medical history, present medical problems, differential or current diagnoses,
examination findings of physical examination by the primary care provider
Physician’s order form Medical orders for medications, treatments, and so on
Physician’s progress notes Medical observations, treatments, client progress, and so on
Consultation records Reports by medical and clinical specialists
Diagnostic reports Examples: laboratory reports, radiography reports, computed tomography (CT) reports
Consultation reports Reports by medical and clinical specialists
Client discharge plan and Started on admission and completed on discharge; includes nursing problems, general
referral summary information, and referral data
M24_KOZI2703_04_SE_C24.indd 463 02/03/17 4:49 PM

FIGURE 24.1 A narrative note in an EHR.

“Narrative notes” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
BOX 24.1 EXAMPLE OF ORGANIZING (b) it takes constant vigilance to maintain an up-to-date
NARRATIVE CHARTING problem list; and (c) it is repetitive because assessments
and interventions that apply to more than one problem
Situation: Client is on day 2 after abdominal surgery. must be repeated.
Questions to ask yourself are The POR has four basic components:
• What assessment data are relevant?
• What nursing interventions have I completed? 1. Database
• What is my evaluation of the result of the interventions, 2. Problem list
and/or what is the client’s response to the interventions?
3. Plan of care
4. Progress notes
EXAMPLE
1000h: Diminished breath sounds in all lung fields with DATABASE The database consists of all information
crackles in the lower left lobe (LLL). Not using incen- known about the client when the client first enters the
tive spirometer (IS). Stated he is “not sure how to use it.”
health care agency. It includes the nursing assessment,
Temperature 39°C. Instructed how to use IS. Discussed the
the physician’s history, social and family data, the results
importance of deep breathing and coughing after s urgery.
Administered analgesic for c/o abdominal pain rating of
of the physical examination, and baseline diagnostic
5/10. After pain relief (1/10), able to demonstrate correct tests. Data are constantly updated as the client’s health
use of IS. status changes.
S. Martin, RN
1400h: Using IS each hour. Lungs less diminished with PROBLEM LIST The problem list (Figure 24.2) is derived
fewer LLL crackles. Temperature 38°C. from the database. It is usually kept at the front of the
S. Martin, RN chart and serves as an index to the numbered entries
in the progress notes. Problems are listed in the order
in which they are identified, and the list is continu-
than according to the source of the information. Mem- ally updated as new problems are identified and others
bers of the health care team contribute to the problem resolved. All health care providers can contribute to the
list, plan of care, and progress notes. Plans for each problem list, which includes the client’s physiological,
active or potential problem are drawn up and progress psychological, social, cultural, spiritual, developmen-
notes are recorded for each problem. tal, and environmental needs. Nurses write problems
The advantages of POR are (a) it encourages col- as nursing diagnoses, and physicians write problems as
laboration and (b) the problem list is at the top of the medical diagnoses, surgical procedures, or symptoms.
chart, which alerts health care providers to the client’s As the client’s condition changes or more data are
needs and makes it easier to track the status of each obtained, it may be necessary to redefine problems.
problem. The disadvantages are (a) health care providers Figure 24.2 illustrates how this has been done for prob-
differ in their ability to use the required charting format; lems listed. When a problem is resolved, a line is drawn
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FIGURE 24.2 An example of a problem list in the POMR in an EHR. In this record the nurse clicks on the problem to obtain more
information. The lower screen allows the nurse or other health care provider to add problems to the problem list.
“POMR” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
through it, and the number is not used again for that See Chapter 23 for examples of subjective and
client. objective data.
PLAN OF CARE The initial list of orders or plan of care A: Assessment is the interpretation or conclu-
is made with reference to the current or active problems. sions drawn about the subjective and objective
Care plans are generated by the health care provider data. The problem list is created from the data-
who lists the problems. Nurses write nursing care plans, base; the “A” entry should be a statement of the
and physicians write physician’s orders or medical care problem. In all subsequent SOAP notes for that
plans. The written plan in the record is listed under each problem, the “A” should describe the client’s con-
problem in the progress notes and is not isolated as a dition and level of progress rather than merely
separate list of orders. restating the diagnosis or problem.
PROGRESS NOTES A progress note in the PORM P: Plan refers to the plan of care designed to
is a chart entry made by all health care professionals resolve the stated problem. The initial plan is
involved in a client’s care; they all use the same type of written by the health care provider who enters
sheet for their notes. Progress notes are numbered to cor- the problem into the record. All subsequent
respond to the problems on the problem list and may be plans, including revisions, are entered into the
lettered for the type of data. For example, SOAP is an progress notes.
acronym for subjective data, objective data, assessment,
and planning. Over the years, the SOAP format has been modified.
The acronyms SOAPIE and SOAPIER refer to formats
S: Subjective data are obtained from what the
that add interventions, evaluation, and revision.
client says. They describe the client’s percep-
tions and experience of the problem. When
I: Interventions refer to the specific interventions
possible, the nurse quotes the client’s words;
that have actually been performed by the health
otherwise, they are summarized. Subjective data
care provider.
are included only when it is important and rel-
evant to the problem. It is important for nurses E: Evaluation includes client responses to nursing
to acknowledge cultural considerations when interventions and medical treatments. This is
recording subjective data to ensure accuracy and primarily reassessment of client data.
relevancy in their documentation.
R: Revision reflects care plan modifications that
O: Objective data consist of information that is arose from the evaluation. Changes may be
measured or observed by use of the senses (e.g., made in desired outcomes, interventions, or tar-
vital signs, laboratory and radiography results). get dates.
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SOAP Format SOAPIER Format APIE Format

6/6/12 #5 Generalized pruritus 6/6/12 #5 Generalized pruritus 6/6/12 A— Generalized pruritus r/t unknown cause
1400 S— “My skin is itchy on my 1400 S— “My skin is itchy on my 1400 States, “My skin is itchy on my
back and arms, and it's been back and arms, and it's been back and arms, and it's been like
like this for a week.” like this for a week.” this for a week.” Skin appears clear.
O— Skin appears clear—no rash O— Skin appears clear—no rash No rash or irritations noted. Marks
or irritation noted. Marks where or irritation noted. Marks where where client has scratched noted
client has scratched noted on client has scratched noted on on left and right forearms. Allergic
left and right forearms. Allergic left and right forearms. Allergic to elastoplast but has not been in
to elastoplast but has not been to elastoplast but has not been contact. No previous history of
in contact. No previous history in contact. No previous history pruritus.
of pruritus. of pruritus. P— Instruct to not scratch skin.
A— Altered comfort (pruritus): cause A— Altered comfort (pruritus): cause — Apply calamine lotion,
unknown. unknown. as necessary.
P— Instructed not to scratch skin. P— Instruct to not scratch skin. — Cut nails to avoid scratches.
— Applied calamine lotion to back — Apply calamine lotion, — Assess further to determine
and arms at 1430 h. as necessary. whether recurrence associated
— Cut fingernails. — Cut nails to avoid scratches. with specific drugs or foods.
— Assess further to determine — Assess further to determine — Refer to physician and
whether recurrence associated whether recurrence associated pharmacist for assessment.
with specific drugs or foods. with specific drugs or foods. I — Instructed not to scratch skin.
— Refer to physician and — Refer to physician and Applied calamine lotion to back
pharmacist for assessment. pharmacist for assessment. and arms at 1430 h.
T. Ritchie, RN I — Instructed not to scratch skin. Assisted to cut fingernails.
Applied calamine lotion to back Notified physician and pharmacist
and arms at 1430 h. of problem.
Assisted to cut fingernails. E— States, “I'm still itchy. That
Notified physician and lotion didn't help.”
pharmacist of problem. T. Ritchie, RN
1600 E— States, “I'm still itchy. That
lotion didn't help.”
R— Remove calamine lotion, and
apply hydrocortisone cream, as
ordered. T. Ritchie, RN
FIGURE 24.3 Examples of nursing progress notes that use the SOAP, SOAPIER, and APIE formats.
See Figure 24.3 for an example of progress notes (e.g., P #5). The interventions employed to manage the
that use the SOAP, SOAPIER, and APIE formats. problem are labelled “I” and numbered according to the
problem (e.g., I #5). The evaluation of the effectiveness of
the interventions is also labelled and numbered accord-
APIE ing to the problem (e.g., E #5).
The APIE documentation model is similar to SOAPIER

charting. APIE is an acronym for assessments, problems,
interventions, and evaluation of nursing care. This sys-
Focus Charting
tem consists of a client care assessment flowsheet and Focus charting is intended to make the client’s con-
progress notes. The flowsheet uses specific assessment cerns and strengths the focus of care. Three columns
criteria in a particular format, such as human needs or for documenting are usually used: (a) date and time,
functional health patterns. The time parameters for a (b) focus, and (c) progress notes (see the example at the
flowsheet can vary from minutes to months. In a hospital end of this section). The focus can be a condition, a nurs-
intensive care unit, for example, a client’s blood pressure ing diagnosis, a behaviour, a sign or symptom, an acute
may be monitored by the minute, whereas in an ambula- change in the client’s condition, or a client strength. The
tory clinic a client’s blood glucose level may be recorded progress notes are organized into data (D), action (A),
once a month. and response (R), referred to as DAR or DARP, where (P)
After the assessment, the nurse establishes and docu- stands for plans for future actions or future interventions.
ments specific problems on the progress notes. The prob- The data category consists of observations of client
lem statement is labelled “P” and referred to by number status and behaviours, including data from flowsheets
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(e.g., vital signs, pupil reactivity). The nurse records both 1. Flowsheets that highlight significant findings and define assess-
subjective and objective data in this section. The action ment parameters and findings. Examples of flowsheets
category includes immediate and future nursing actions. include a graphic record (see Figure 24.4), fluid bal-
It can also include any changes to the plan of care. The ance record, daily nursing assessments record (see
response category describes the client’s response to any nurs- Figure 24.5), client teaching record, client discharge
ing and medical care. record, and skin assessment record.
Focus charting systems provide a holistic perspective 2. Standards of nursing care. Printed standardized docu-
of the client and the client’s needs. This documentation mentation of nursing care eliminates much of the
system also provides a framework for the progress notes repetitive charting of routine care. An agency using
(DAR). The three components do not need to be docu- CBE must develop its own specific standards of nurs-
mented in order, and each note does not need to have all ing practice that identify the minimum criteria unique
three categories. Flowsheets and checklists are frequently to the type of client and care. For example, “The
used in the client’s chart to document routine nursing nurse must ensure that the unconscious client has oral
tasks and assessment data. care at least q2h (every 2 hours).” Documentation of
care according to these specified standards involves
Date/Hour Focus Progress Notes
only a check mark in the routine standard box on the
13/12/25 Pain D: G
uarding abdominal incision. Facial graphic record. All exceptions to the standards are
grimacing. Rates pain at “8” on scale
fully described in narrative form on the nurses’ notes.
of 0–10.
0900 A: Administered morphine sulphate 4 mg IV. 3. Bedside access to chart forms. All flowsheets are kept at the
client’s bedside to allow for immediate documentation
0930 R: R ates pain at “1.” States willing to
ambulate.
and to eliminate the need to transcribe data from the
nurse’s worksheet to the permanent record.
Charting by Exception
Charting by exception (CBE) is a documentation
Computerized Documentation
system in which only significant findings or exceptions to EHRs are used to manage the huge volume of informa-
norms are recorded by using flowsheets as much as pos- tion required in contemporary health care. That is, the
sible. CBE incorporates three key components: clinical EHR can integrate all pertinent client information into
observations, nursing interventions, and client response one record. Nurses use computers to store the client’s
to nursing care (Guido, 2010). database, add new data, create and revise care plans,
FIGURE 24.4 Table of vital signs and SpO2.

“Vital signs and SpO2” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
M24_KOZI2703_04_SE_C24.indd 467 02/03/17 4:49 PM

FIGURE 24.5 Sample of a head and face assessment on a daily nursing CBE assessment form in an EHR.
“Head and Face Assessment” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
and document client progress (see Figure 24.6). Some

institutions have a computer terminal at each client’s
bedside, or nurses carry a small handheld device, which
enables the nurse to document care immediately after it
is given. Multiple flowsheets are not needed in comput-
erized record systems because information can be easily
Rick Brady/Pearson Education, Inc.
retrieved in a variety of formats. For example, the nurse

can obtain results of a client’s blood test, a schedule of
all clients on the unit who are to have surgery during
the day, a suggested list of interventions for a nursing
diagnosis, a graphic chart of a client’s vital signs, or a
printout of all progress notes for a client. Many systems
can generate a work list for the shift, with a list of all
treatments, procedures, and medications needed by the
client. FIGURE 24.6 A bedside computer.
M24_KOZI2703_04_SE_C24.indd 468 02/03/17 5:34 PM

BOX 24.2 SELECTED PROS AND CONS OF alert and aware of others who might hear the dictation
COMPUTER DOCUMENTATION to ensure client confidentiality.
EHRs can improve communication between health
PROS care providers and authorized clinicians and have made
it possible to securely transmit integrated client informa-
• Nurses can use their time more efficiently.
tion from one health care organization to another within
• The system links various sources of client information. the health care system. (See the section “Computer
• Client information, requests, and results are sent and Technology and Informatics in Nursing” in Chapter 25
received quickly. Communication between providers is
for additional information.) Selected pros and cons of
enhanced.
computer documentation are shown in Box 24.2.
• Links to monitors improve accuracy of documentation.
• Bedside terminals can synthesize information from moni-
toring equipment.
• Bedside terminals eliminate the need to take notes on a Case Management
worksheet before recording.
• Bedside terminals permit the nurse to check an order The case management model emphasizes high-quality,
immediately before administering a treatment or cost-effective care delivered within an established length
medication. of stay. This model uses a multidisciplinary approach to
• Information is legible. planning and documenting client care by using critical
• The system incorporates and reinforces standards of care. pathways. These forms identify the outcomes that certain
• Standard terminology improves communication. groups of clients are expected to achieve on each day of
care, along with the interventions necessary for each day.
CONS The case management model also incorporates
graphics and flowsheets. Progress notes typically use some
• Client’s privacy may be infringed on if security measures type of CBE. For example, if goals are met, no further
are not used. charting is required. Goals that are not met are called
• Breakdowns make information temporarily unavailable. variances. They are deviations from what is planned on
• The system is expensive. the critical pathway—unexpected occurrences that affect
• Extended training periods may be required when a new the planned care or the client’s responses to care. When
or updated system is installed. a variance occurs, the nurse writes a note documenting
the unexpected event, the cause, and the actions taken to
correct the situation or justify the actions taken.
Computers can make planning care and documenta- Critical pathways work best for clients with one or
tion relatively easy. To record nursing actions and client two diagnoses and few individualized needs. Data from
responses, the nurse either chooses from standardized clients with multiple diagnoses (e.g., a client with a hip
lists of terms or types narrative information into the fracture, pneumonia, diabetes, and a pressure sore) or
computer. Automated speech-recognition technology those with an unpredictable course of symptoms (e.g., a
allows nurses to enter data by voice for conversion to client with neurological problems and seizures) are dif-
written documentation. If the spoken word is used to ficult to document on a critical path. See Table 24.2 for
create personal health information, the nurse must be an example of how a variance might be documented.
TABLE 24.2 Example of Variance Documentation (Critical Pathway)
A client has had a below-the-knee amputation. On the third postoperative day, he has a temperature of 38.8°C. Lung sounds
are clear, and he is not coughing. The nurse notices redness and skin breakdown over the client’s sacrum. The critical pathway
outcomes specified for day 3 are “Oral temperature 37.7°C” and “Skin intact over bony prominences.” The nurse should chart the
following variances:
Date/Time Variation Cause Action Taken/Plans

12/4/16 0900 Elevated temperature (38.8°C) Possible sepsis 4/16—Blood cultures × 3 per order
• Monitor temperature q1h.
• Monitor intake and output (I&O), hydration, and
mental status.
12/4/16 1130 Impaired skin integrity: stage 1 Client does not move 4/16—Positioned on L (left) side
redness, 5 cm circular area about in bed unless • Turn client side-to-side q2h while awake.
on sacrum reminded • On every client contact, remind client to move
about in bed.
• Apply Duoderm after bath.
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TABLE 24.3 Documentation for the Nursing Process Kardexes

Step Documentation Forms The Kardex is a concise method of organizing and
recording data about a client. It consists of a series of
Assessment Initial assessment form, various
flowsheets cards kept in a portable index file or in a computer-
generated form. The Kardex may or may not become a
Nursing diagnosis Nursing care plan, Kardex, critical
path, interdisciplinary notes,
part of the client’s permanent record. In some organiza-
problem list tions, it is a temporary worksheet written in pencil for
ease in recording frequent changes in details of a client’s
Planning Nursing care plan, critical
path care. Nurses need to ensure the pencil-written informa-
tion is accurately transcribed from the original medical
Intervention Interdisciplinary notes,
flowsheets
order. The information on Kardexes may be organized
into various sections. For example,
Evaluation Interdisciplinary notes
• Pertinent information about the client, such as name,
room number, age, religion, marital status, admission
Documenting Nursing date, physician’s name, diagnosis, type of surgery and

date, occupation, and next of kin
Activities • Allergies and list of medications, including date of
order and times of administration
Client records should describe the client’s perceptions • List of intravenous fluids, with dates of infusions
and ongoing health status and reflect the nursing pro- • List of daily treatments and procedures, such as irri-
cess. Regardless of the records system used in the organi- gations, dressing changes, postural drainage, or mea-
zation, nurses should document evidence of the nursing surement of vital signs
process using a variety of forms throughout the client’s • List of diagnostic procedures ordered, such as radiog-
record (see Table 24.3). raphy or laboratory tests
• Specific data on how the client’s physical needs are to
be met, such as type of diet, assistance needed with
Admission Nursing Assessment feeding, elimination devices, activity, hygienic needs,
and safety precautions (e.g., one-person assist)
A comprehensive admission assessment, also referred
• A problem list, stated goals, and nursing interventions
to as an initial database, comprehensive head-to-toe assessment,
to meet the goals
nursing history, or nursing assessment, is completed when the
client is admitted to the nursing unit. As discussed in Information on the Kardex may be updated by the
Chapter 23, these forms may be organized according to nurse or a delegate (e.g., the nursing unit clerk) to keep
health patterns, body systems, functional abilities, health the data current. Whether the Kardex is a paper docu-
problems and risks, nursing model, or type of health ment or a computer file, it is important to have a place
care setting. on it to record dates and the initials of the person review-
ing or revising it.
Nursing Care Plans Flowsheets

There are two types of nursing care plans: (a) traditional Flowsheets enable nurses to document nursing data
and (b) standardized. The traditional care plan is written quickly and concisely and provide an easy-to-read record
for each client. The form varies from agency to agency, of the client’s condition over time.
according to the needs of the client and the department.
GRAPHIC RECORD This record typically indicates body
Most forms have three columns: (a) nursing diagnoses,
temperature, pulse, respiratory rate, blood pressure,
(b) expected outcomes, and (c) nursing interventions.
weight, and, in some agencies, other significant clinical
(See the section “Developing Nursing Care Plans” in
data, such as admission or postoperative day, treatments,
Chapter 23 for additional information.)
protective measures, diagnostic studies, bowel move-
Standardized care plans have been developed to save
ments, diet, appetite, hygiene, and activity.
documentation time. These plans can be based on an
institution’s standards of practice, thereby helping to INTAKE AND OUTPUT RECORD All routes of fluid
provide high-quality nursing care. Standardized care intake and all routes of fluid loss or output are measured
plans must be individualized by the nurse, critically ana- and documented on this form. Information about ways
lyzing the client using the nursing process to competently to measure and record specific amounts of fluid intake
address individual client needs. and output are described in Chapter 40.
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MEDICATION ADMINISTRATION RECORD (MAR) Med- medications, specialized care or treatments, and
ication administration records usually include desig- follow-up appointments
nated areas for the date the medication was ordered, the • Discharge destination (e.g., home, nursing home) and
expiration date, the medication name, dose, frequency, mode of discharge (e.g., walking, wheelchair, ambulance)
route, time of administration, and the nurse’s signature.
• Referral services (e.g., home health nurse, social worker)
Some records also include a place to document the
client’s allergies. (A sample medication record is shown
in Figure 33.5 on page 805.)
Long-Term Care Documentation
Requirements for documentation in long-term care set-
Progress Notes tings are based on professional standards, federal and
Progress notes made by nurses provide information provincial regulations, and policies of the health care
about the progress a client is making toward achieving agency.
desired outcomes. In addition to assessment and reas- Nurses need to familiarize themselves with regula-
sessment data, progress notes include information about tions influencing the type and frequency of documen-
client problems and nursing interventions. tation required in long-term care facilities. The nurse
usually completes a nursing care summary at least once
a week for clients requiring skilled care and every 2 to
Nursing Discharge 4 weeks for those requiring intermediate care. Summa-
ries should address the following:
and Referral Summaries
• Specific problems expressed by clients and/or families
A discharge note and referral summary are completed
when the client is being discharged and transferred to • Mental health status
another institution or to a home setting in which a visit • Activities of daily living (ADLs)
by a community health nurse is required (see the section • Hydration and nutrition status
“Continuity of Care” in Chapter 14). Some records
• Elimination status
combine the discharge plan, including instructions for
care, follow-up appointments, and the final progress • Safety measures needed
note. Regardless of format, discharge and referral sum- • Medications
maries usually include some or all of the following: • Treatments
• Description of the client’s physical, mental, and emo- • Preventive measures
tional status at discharge or transfer
See Box 24.3 for more specific guidelines for long-
• Resolved health problems term care documentation.
• Unresolved continuing health problems and continu-
ing care needs, which may include a review-of-systems
checklist that considers integumentary, respiratory, BOX 24.3 GUIDELINES FOR LONG-TERM
cardiovascular, neurological, musculoskeletal, gastro- CARE DOCUMENTATION
intestinal, elimination, and reproductive problems
Long-term care facilities require nurses to follow specific
• Treatments that are to be continued (e.g., wound care,
guidelines:
oxygen therapy)
• Complete the assessment and screening forms and plan
• Current medications of care within the period specified by agency policy.
• Restrictions that relate to (a) activity, such as lifting, • Document and report any change in the client’s condition
stair climbing, walking, driving, or work; (b) diet; and to the physician and the client’s family within 24 hours.
(c) bathing, such as sponge bath, tub, or shower • Document all measures implemented in response to a
change in the client’s condition.
• Functional and self-care abilities in terms of vision,
hearing, speech, mobility with or without aids, meal • Document nursing summaries and progress notes that
comply with the frequency and standards required by
preparation and eating, and preparation and adminis- agency policy, using the nursing process as a guideline.
tration of medications
• Ensure that progress notes address the client’s progress
• Comfort level in relation to the goals or outcomes defined in the plan
of care.
• Support networks, including family, significant others,
spiritual adviser, community self-help groups, home • Review and revise the plan of care according to agency
policies or whenever the client’s health status changes.
care, and other community agencies available
• Keep a record of any visits and phone calls from family,
• Client education provided in relation to the dis- friends, and others regarding the client.
ease process, activities and exercise, special diet,
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BOX 24.4 GUIDELINES FOR HOME HEALTH

CARE DOCUMENTATION EVIDENCE-INFORMED PRACTICE
Home care nurses must follow these documentation
guidelines:
What Do Nursing Students Think about
• Complete a comprehensive nursing assessment, and Incidents and Incident Reporting?
develop a plan of care.
A qualitative study was conducted among 10 fourth-year
• Write a progress note during each client visit, noting
nursing students from an urban baccalaureate program in
any changes in the client’s condition, nursing interven-
Canada to examine their perceptions of incidents and inci-
tions performed (including education and instructional
brochures and materials provided to the client and home dent reporting. Five scenarios were presented, each portray-
caregiver), client responses to nursing care, and vital ing a situation that varied in terms of the potential for patient
signs, as indicated. harm and the clinical team members involved. Of the 50
events (10 participants × 5 scenarios), participants identified
• Keep a copy of the care plan in the client’s home, and
37 events as incidents, yet their rationales for identifying an
update it as the client’s condition changes.
incident varied, as did their decisions to report and how to
• Report changes in the plan of care to the appropriate report the incident.
member of the health care team, and document that
these were reported. NURSING IMPLICATIONS: Findings revealed that the
• Encourage the client or home caregiver to record data, students believed reporting incidents could harm other
when appropriate. health care professionals and also reflect badly on
• Write a discharge summary, including the client’s health themselves. The findings suggest there is a need for
status at discharge, outcomes achieved, and recommen- more emphasis in nursing programs regarding what
dations for further care. constitutes an incident, as well as how and when to
report incidents.
Source: Based on Espin, S., & Meikle, D. (2014). Fourth-year nursing student percep-
tions of incidents and incident reporting. Journal of Nursing Education, 53(4), 238–243.
Home Care Documentation

Home care is one of the fastest growing areas in health
nurses are responsible to report the incident. Effective
care in Canada because of an increasing older popula-
communication and documentation regarding the care
tion and shorter hospitalizations. Health care providers
provided to the client, the client’s progress, and continu-
often document in client-held records that remain at the
ity of care will decrease the risk for errors and may help
residence. (See Box 24.4 for guidelines for home health
identify problems that could prevent similar occurrences
care documentation.) Health care providers may access
in the future. It is important to promote a culture of
critical information through the use of voicemail, wire-
safety and to remember that incident reports are not to
less devices, and laptops, which enhances their ability to
blame an individual; instead, the purpose is to improve
care for their clients and maintain accurate and current
the quality of client care (Casey & Wallis, 2011).
records. In addition, telehealth technologies allow the
sharing of professional expertise in urban areas with
health care providers practising in homes and communi-
ties in rural and remote locations. General Guidelines for
Documentation
Incident Reports
Because the client’s record is a legal document and
An incident report is a form completed by the nurse, if the may be used to provide evidence in court, many factors
nurse was directly or indirectly involved or witnessed are considered in recording. Health care professionals
an error that adversely affected the client. Incident must not only maintain the confidentiality of the client’s
reports, also known as event or occurrence reports, are record, but also meet legal standards in the process of
completed when the care provided is not consistent with documenting or recording.
standard practice, causing injury, harm, or loss to the
client, and negatively affecting the quality of client care
(Dunn, 2010). Near-misses, no-harm events, adverse
events, medication or human errors, and miscommu- Date and Time
nication causing errors are instances when an incident The date and time of each documentation entry is
report would be completed. (See the Evidence-Informed required for legal reasons and for client safety. Record
Practice box on incident reports.) the time according to the 24-hour clock to avoid con-
Nurses are accountable to provide safe and compe- fusion about whether the time was a.m. or p.m. (see
tent care to clients. When errors occur in nursing care, Figure 24.7).
M24_KOZI2703_04_SE_C24.indd 472 02/03/17 4:49 PM

p.m. Legibility
2400 All entries must be legible and easy to read to pre-
2300 12 1300 vent interpretation errors. Printing or easily understood
11 1200 1 handwriting is usually permissible.
1100 a.m. 0100
2200 1400
10
0200
2 Permanence
1000
All entries on the client’s record are made in dark ink,
according to agency policies, so that the record is perma-
2100 9 0900 0300 3 1500 nent and changes can be identified. Dark ink reproduces
well on microfilm and in duplication processes. In rela-
tion to EHRs, nurses must follow agency policy when
0800 0400 recording information and when correcting or revising
8 4 information that was entered previously.
2000 1600
0700 0500
0600
7 5 Accepted Terminology and Abbreviations
1900 6 1700
1800
Use only commonly accepted abbreviations, symbols, and
terms that are specified by the agency. Many abbrevia-
tions are standard and used universally. When in doubt
FIGURE 24.7 The 24-hour clock. about whether to use an abbreviation, write the term out
in full until certain about the abbreviation. Abbreviations
that are not official can lead to misunderstandings. For
example, D/C may mean “discharge” or “discontinue”;
Timing od could mean “once a day” or “right eye.” Refer to
Follow the health care institution’s policy about the fre- Table 24.4 and Table 24.5 for the commonly used abbre-
quency of documentation, and adjust the frequency as a viations and those that are not to be used. Use the metric
client’s condition indicates. For example, a client whose system to document measurements (e.g., height, weight,
blood pressure is fluctuating requires more frequent doc- volume).
umentation than a client whose blood pressure is con-
stant. Documenting should be done as soon as possible
after an assessment or intervention. No documentation
Correct Spelling
should be completed before providing nursing care. Blan- Correct spelling is essential for accuracy in documen-
ket charting (i.e., charting all events occurring within an tation. Two decidedly different medications may have
extended period of time) should be avoided. almost similar spellings, for example, digitoxin and
TABLE 24.4 Commonly Used Abbreviations*
Abbreviation Term Abbreviation Term

abd abdomen BRP bathroom privileges
ABO the main blood group system c with
ac before meals (ante cibum) C Celsius (centigrade)
ADL activities of daily living CBC complete blood count
ad lib as desired (ad libitum) CBR complete bed rest
adm admitted or admission CDA Canadian Diabetes Association
a.m. morning (ante meridiem) Cl client
amb ambulatory cm centimetre
amt amount c/o complains of
approx approximately (about) DAT diet as tolerated
BM (bm) bowel movement drsg dressing
BP blood pressure Dx diagnosis
BR bed rest ECG (EKG) electrocardiogram
(continued)
M24_KOZI2703_04_SE_C24.indd 473 02/03/17 4:49 PM

TABLE 24.4 Commonly Used Abbreviations* (continued)
Abbreviation Term Abbreviation Term

fld fluid PE (PX) physical examination
g gram per by or through
GI gastrointestinal p.m. afternoon (post meridiem)
GP general practitioner PO by mouth (per ora)
gtt drops (guttae) postop postoperative(ly)
h hour (hora) preop preoperative(ly)
H2O water prep preparation
I&O intake and output prn when necessary (pro re nata)
j joule pt patient
IV intravenous q every (quaque)
kg kilogram qh (q1h) every hour (quaque hora)
kJ kilojoule q2h, q3h, and so on every 2 hours, 3 hours, and so on
L litre qid four times a day (quarter in die)
Lab laboratory req requisition
liq liquid Rt (rt, R) right
LMP last menstrual period S (S) without (sine)
lt (L) left SI Systeme International d’unites (metric system)
m metre spec specimen
meds medications STAT at once, immediately (statim)
mg milligram tid three times a day (ter in die)
mL millilitre TL team leader
mod moderate TLC tender loving care
neg negative TO telephone order
NPO nothing by mouth (nil per os) TPR temperature, pulse, respirations
NS normal saline VO verbal order
O2 oxygen VS vital signs
OOB out of bed WNL within normal limits
pc after meals (post cibum) wt weight
*Institutions may elect to include some of these abbreviations on their “do-not-use” list. Check your agency’s policy.
TABLE 24.5 Official “Do Not Use” List*
Do Not Use Potential Problem Use Instead

U, u (unit) Mistaken for “0” (zero), the number “4” Write “unit”
(four), or cc
IU (for International Unit) Mistaken for IV (intravenous) or the Write “International Unit”
number 10 (ten)
Q.D. QD, q.d., qd (daily) Mistaken for each other Write “daily” and “every other day”
Q.O.D., QOD, q.o.d., qod (every other day) Period after the Q mistaken for “I” and
“O” mistaken for “I”
Trailing zero (X.0 mg)** Decimal point is missed. Write X mg
Lack of leading zero (.X mg) Write 0.X mg
MS Can mean morphine sulfate or magne- Write “morphine sulfate” or “magnesium
MSO4 and MGSO4 sium sulfate. sulfate”
Confused for one another
*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.
**A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size
of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
From Facts About the Official “Do Not Use” List, by The Joint Commission, 2010. Retrieved from http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf. © The Joint Commis-
sion, 2010. Reprinted with permission.
M24_KOZI2703_04_SE_C24.indd 474 02/03/17 4:49 PM

digoxin. Errors in spelling can negatively affect your considered a professional misconduct. When using com-
credibility as a nurse (Cartwright-Vanzant, 2010). puterized charting, the nurse needs to be aware of the
agency’s policy and process for correcting documenta-
tion mistakes.
Signature
Sample Recording
Each recording should be signed by the nurse who per-
Date: 2013/12/10 Time: 0100h
formed the care provided. The signature includes the
name and title, for example, “Susan J. Green, RN.” The entry mistake AJR
following title abbreviations are often used; however, Pulse 180 beats per min 108 beats per min
nurses need to follow the institution’s policy about how Abby J. Roberts, NS
to sign their name:
Write on every line but never between lines. If a blank
RN = registered nurse appears in a notation, draw a line through the blank space
RNA = registered nurse assistant so that no additional information can be recorded at any
LPN = licensed practical nurse (outside Ontario) other time or by any other person, and sign the notation.
RPN = registered practical nurse (Ontario only)
RPN = registered psychiatric nurse (Western provinces)
NA = nursing assistant
NS = nursing student
Sequence
RA = resident attendant Document events in the chronological order in which they
SN = student nurse occur. For example, record assessments, then the nursing
interventions, and then the client’s responses. Update
or revise problems, as needed. Events documented out
Accuracy of sequence must be clearly identified as a late entry,
The client’s name and identifying information should be according to agency policy. If alterations are made to the
stamped or written on each page of the clinical record. sequence of events, explain that you are making a late note
Before making an entry, check that the chart is the cor- entry and include the actual time you are making the note
rect one. Do not identify charts by room number only; in the client record (Cartwright-Vanzant, 2010).
check the client’s name. Special care is needed when
caring for clients with the same last name. Health care
facilities may use a brightly coloured warning sticker on Appropriateness
the health care record and information shared by clients Document only information that is significant to the
with similar names. client’s health problems and care. Any other personal
Documentation must be accurate, clear, relevant, and information that the client conveys is inappropriate for
concise. Accurate documentation consists of facts or obser- the record. Documenting irrelevant information can be
vations rather than opinions or interpretations. It is more considered an invasion of the client’s privacy or subject
accurate, for example, to write that the client “refused to legal action from the client. A client’s disclosure that
medication” (fact) than to write that the client “was unco- she had a heroin addiction 20 years ago, for example,
operative” (opinion) or to write that a client “was crying” would not be recorded on the client’s medical record
(observation) than to write that the client “was depressed” unless it had a direct bearing on the client’s health.
(interpretation). Similarly, when a client expresses worry
about the diagnosis or problem, this should be quoted
directly on the record: “Stated: ‘I’m worried about my
leg.’” When describing a situation, avoid general words,
Completeness
such as large, good, or normal, which can be interpreted dif- Document only information that is helpful to the client
ferently. For example, chart specific data, such as “2 × 3 and the health care providers. Nurses’ notes need to
cm bruise,” rather than “large bruise.” reflect the nursing process. Document all assessments,
When a recording mistake is made, draw one line nursing diagnoses, plans, nursing interventions, and cli-
through it (leave the mistake readable), and correct the ent comments and responses to interventions and tests,
error, according to agency policy. For example, write the progress toward goals, and communication with other
words entry mistake above it with your initials or name health care providers.
(depending on agency policy) and the date and time Care that is omitted because of the client’s condition
of correction. Do not erase, blot out, or use correc- or refusal of treatment must also be documented. It is
tion fluid. Do not recopy a chart page or remove chart vitally important to clearly document the events of what
pages because an error occurred. The original entry happened and why a component of care was omitted.
must remain visible. Correcting or modifying another Ensure that the details are specific, and state who was
health care provider’s documentation is illegal and is notified and the outcomes of these actions.
M24_KOZI2703_04_SE_C24.indd 475 02/03/17 4:49 PM

Legal Prudence BOX 24.5 KEY ELEMENTS OF A CHANGE-

OF-SHIFT REPORT
Accurate, complete documentation should enhance legal
protection for the nurse. The client’s chart is admissible The following guidelines are important to follow in shift-
in court as a legal document. The nurse’s documenta- change reports:
tion should present an accurate, complete representation • Follow a particular order (e.g., room numbers in a
of the quality of care given. Incompleteness or omission hospital).
seriously undermines the strength of the evidence, com- • Provide basic identifying information for each client
petency of the nurse, and questions if care was actually (e.g., name, room number, bed designation).
provided. Failing to maintain a client’s record or falsifying • For newly admitted clients, provide the reason for admis-
information within the client’s record is considered a pro- sion or medical diagnosis (or diagnoses), age, general con-
dition, surgery (date), diagnostic tests, plan of therapy, and
fessional misconduct under the nurses’ legislation of most significant information about the client’s support people.
jurisdictions. The nurse must adhere to professional stan- • Include significant changes in the client’s condition and
dards of nursing care and follow the institution’s policies present information in order (i.e., assessment, nursing
and procedures for intervention and documentation in all diagnoses, interventions, outcomes, and evaluation).
situations—especially in high-risk situations. For example, For example, “Mr. Ronald Oakes said he had an aching
pain in his left calf at 1400 hours. Inspection revealed
2013/12/9 1100h—Client stated “feeling dizzy.” no other signs. Calf pain is related to altered blood
Raised side rails. Instructed to stay in bed and ring circulation. Rest and elevation of his legs on a footstool
call bell if requiring assistance. for 30 minutes provided relief.”
RS Chartrand, RN • Provide exact information, such as “Ms. Jessie Jones
received Demerol 100 mg intramuscularly at 2000 hours,”
2013/12/9 1130h—Found beside table on the floor. Client
not “Ms. Jessie Jones received some Demerol during the
said, “I climbed over these rails all by myself.” When asked evening.”
about pain, replied, “I feel fine but a little dizzy.” Helped
client into bed. BP 100/60, P90, R24, Dr. RJ Naden notified. • Report the client’s need for special emotional support.
For example, a client who has just learned that his biopsy
RS Chartrand, RN
results revealed malignancy and who is now scheduled
for a laryngectomy needs time to discuss his feelings
before preoperative teaching starts.
Reporting • Include current nurse interventions/plans/care and

physician-prescribed orders.
• Report clients that have been transferred or discharged
Reports can be either verbal or written. The purpose from the unit.
of reporting is to communicate specific information to • Clearly state priorities of care and care that is due after
a person or group of people, for example, at change- the shift begins. For example, in a 0700h report, the nurse
of-shift or when transferring a client. A report should might say, “Mr. Li’s vital signs are due at 0730, and his
be concise, including only pertinent information and no IV bag will need to be replaced by 0800.” Give this
information at the end of that client’s report, as people
extraneous details. remember best the first and last information given.
• Be concise. Do not elaborate on background data or rou-
tine care. For example, do not report “Vital signs at 0800
Change-of-Shift Reports and 1200” when that is the unit standard. Do not report
coming and going of visitors unless there is a problem or
A change-of-shift report is a report usually given to concern or if the visitors are involved in teaching and care.
nurses starting the next shift. The purpose is to provide Social support and visits are considered the norm.
continuity of care for clients by providing the subsequent • Incorporate a verification process (e.g. opportunity to ask
health care provider with a quick summary of the client and respond) to ensure that information is both received
needs and details of care to be given. and understood.
Change-of-shift reports can be written or given ver-
bally, either in person or by audiotape recording. The
face-to-face report permits the listener to ask questions
during the report; written and tape-recorded reports are maintain effective communication among the health care
often brief and less time consuming. Reports are some- team members when discussing a client’s condition and
times given at the bedside, and clients as well as nurses can progress. Implementation of the SBAR tool can increase
participate in the exchange of information. See Box 24.5 quality care and client safety by decreasing miscommu-
for key elements of a change-of-shift report and nication, which will help to prevent errors, such as near-
Box 24.6 for a sample change-of-shift report. misses (Boaro, Fancott, Baker, Velji, & Andreoli, 2010).
The SBAR tool can also be used during transition of care,
SITUATION-BACKGROUND-ASSESSMENT-RECOMMEN- for debriefing, and for conflict resolution (Andreoli et al.,
DATION (SBAR) The SBAR is a communication tool com- 2010). (See Box 24.7 and the Weblinks section online the
monly used during change-of-shift reports to promote and chapter for SBAR tools.)
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BOX 24.6 SAMPLE CHANGE-OF-SHIFT REPORT BOX 24.7 SAMPLE SBAR COMMUNICATION
TOOL
The following sample of a shift-change report uses the key
elements listed in Box 24.5: S = Situation
• State your name, unit, and client name.
ROOM 201—C.W.
• Briefly state the problem.
Admitted last night for pneumonia B = Background
Allergic to penicillin • State client admission diagnosis and date of admission.
DNR • State pertinent medical history.
IV of D5/0.45 NS infusing at 100 mL/h in (L) forearm • Provide brief summary of treatment to date.
Need sputum specimen for C&S • Client code status (if appropriate).
Temperature 39.1. Tylenol 325 mg, 2 tablets given at 0600h A = Assessment
Lung sounds diminished in lower lobes • Vital signs
• Pain scale
ROOM 202—G. H.
• Is there a change from prior assessments?
Admitted for left total knee arthroplasty on 2016/09/14. R = Recommendation
Has discharge orders to go to rehab today • State what you would like to see done, or specify that
Dressing clean, dry, and intact the appropriate health care provider needs to come
Regular diet. Taking fluids well. and assess the client.
Had BM yesterday • Ask if the health care provider wants to order any tests
or medications.
Pain rating of 4/10—last medicated with oxycodone 2.5 mg
with acetaminophen 325 mg, 1 tablet, given at 0400h • Ask the health care provider if she or he wants to be
notified for any reason.
• In case of no improvement, ask the health care pro-
vider when you should call again.
Telephone Reports
Health care providers frequently provide reports on After reporting, the nurse should document the date,
clients by telephone. For example, nurses inform physi- time, and content of the call. For example,
cians about a change in a client’s condition; a radiologist
reports the results of a radiographic study; a nurse may 2015/09/14, 1200h. Admitted from ED. c/o burning
confer with a nurse on another unit about a transferred upper right quadrant abdominal pain. Rates pain at
client. The nurse receiving a telephone report should 6/10. BP 115/80, P100, R15. Demerol 100 mg given
IM per order.
document the date and time, the name of the person
giving the information, and the information received and
2015/09/14, 1300h. BP 100/40, P115, R30. Pain
should sign the documentation. For example: unchanged. Color pale and diaphoretic. Reported by
telephone to Dr. Burns at 1305.
2013/06/06 1035h. GL Messina, laboratory technician,
reported by telephone that Mrs. Sara Ames’s hematocrit TS Jones, RN
was 39%. Barbara Ireland, RN
If any doubt exists about the information given

over the telephone, the person receiving the information
Telephone Orders
should repeat it back to the sender to ensure accuracy. Health care providers often order a therapy or medica-
The nurse needs to provide concise, accurate, and tion for a client by telephone. Most agencies have specific
relevant information when giving a telephone report policies about telephone orders. While the primary care
to another health care provider. Begin with your name provider gives the order, write the complete order down, and
and relationship to the client. For example, “This is Jana read it back to the primary care provider to ensure accuracy.
Gomez; I’m calling from xxx Hospital, Unit xxx, about Question the primary care provider about any order that is
your client, Dorothy Mendes. I’m her registered nurse ambiguous, unusual (e.g., an abnormally high dosage of a
on the 0700h to 1900h shift.” Telephone reports usually medication), or contraindicated by the client’s condition.
include the client’s name and medical diagnosis, changes Have the primary care provider verbally acknowledge the
in nursing assessment, vital signs related to baseline vital read-back of the verbal/telephone order. Then, indicate on
signs, significant laboratory data, and related nursing the physician’s order form that it is a verbal order (VO) or a
interventions. The nurse should have the client’s chart telephone order (TO). See Box 24.8 for selected guidelines.
ready to provide any further information. Implement- Once the order is transcribed on the physician’s
ing the SBAR tool can assist the nurse to communicate order sheet, the order must be countersigned by the pri-
important information regarding the client. mary care provider within a period described by agency
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BOX 24.8 GUIDELINES FOR TELEPHONE AND Nursing Care Conference

VERBAL ORDERS
A nursing care conference is a meeting of a group
With telephone and verbal orders, it is especially important of nurses to discuss possible solutions to certain prob-
to carefully follow these guidelines: lems of a client. The nursing care conference allows
1. Know the agency policy for telephone and verbal orders. each nurse an opportunity to offer possible solutions to
2. Do not accept an order from a prescriber you do not the problem (e.g., lack of progress toward goal attain-
know. ment). Other health care providers may be invited to
3. Ask the prescriber to speak slowly and clearly. attend the conference to offer their expertise. For exam-
4. Ask the prescriber to spell out the medication if you are ple, a social worker may discuss the family problems of
not familiar with it. a severely burned child, or a dietitian may discuss the
5. Question the drug, dosage, or changes if they seem dietary problems of a client who has diabetes. Nursing
inappropriate for this client. care conferences are most effective when members on
6. Write down the order, or enter it into a computer. the team will accept and respect each person’s contribu-
7. Read the order back to the prescriber at the end. Use tions and listen with an open mind to what others are
words for abbreviations (e.g., three times a day for tid). saying.
8. When writing a dosage, always put a number before a
decimal (e.g., 0.3 mL) but never put a zero after a deci-
mal (e.g., 6 mg).
9. Write out “units” (e.g., 20 units of insulin, not 20 u of Nursing Rounds
insulin).
Nursing rounds are procedures in which a group of
10. Follow agency policy on the prescriber protocol for
signing telephone orders (e.g., within 24 hours). nurses visit selected clients’ bedsides to do the following:
11. Never follow a voicemail order. Call the prescriber back • Obtain information that will help plan nursing care
for a verbal order. Write it down, and read it back for
confirmation. • Provide clients the opportunity to discuss their care
• Evaluate the nursing care the client has received
• Identify alternative nursing possibilities from evidence-
policy. Many acute care facilities require that this be based practice and experienced nurses
done within 24 hours. Most agencies require a Regis-
During nursing rounds, the nurse assigned to the
tered Nurse to take verbal orders.
client provides a brief summary of the client’s needs and
the interventions being implemented. Nursing rounds
Conferring offer advantages to both clients and nurses. Clients can

participate in the discussions and nurses can meet the
client and assess the client’s environment (e.g., view the
Nurses often confer with colleagues and other health equipment being used). To facilitate client participation
care providers for advice, information, ideas, or instruc- in nursing rounds, nurses need to use terms that the cli-
tions about the client situation to plan nursing care. Two ent can understand. Medical terminology can exclude
ways nurses share information are through (a) a nursing the client from the discussion.
care conference and (b) nursing rounds.
Case Study 24
Mr. Anderson, an 80-year-old man from Prince Edward Island, 12—Refused lunch
was admitted for back pain. He has a past medical history of 2—Client fell out of bed
hypertension. He told the admitting nurse that he has lost inter-
est in many of his normal activities because of the constant pain.
You read the following documentation entry by the nurse who
previously provided care: CRITICAL THINKING QUESTIONS
8—Client is a complainer. I listened to him for 15 minutes,
with no resolution of his concerns 1. What guidelines were not used in this documentation?
BP 210/90 and 180/70, P 72, R 18 2. The nursing diagnosis for Mr. Anderson is Acute Pain.
What would you expect to document?
M24_KOZI2703_04_SE_C24.indd 478 02/03/17 4:49 PM

3. Using the following pieces of data for Mr. Anderson, sort h. BP 210/90, P 72, R 18
them into a SOAPIER note: i. Add to plan of care to offer analgesic around the clock
a. “I didn’t sleep last night.” q4h versus prn
b. Positioned on side with pillows behind back j. 2013/6/6 #1 pain
c. Continues to need analgesic medication to progress k. “Sharp, stabbing pain in lower back that radiates to
toward goal of pain relief left leg.”
d. States pain is 8 out of 10 l. Medicated with ordered analgesic
e. “I feel better.” (after interventions) 4. Use the same data, and sort them into a DAR note.
f. Last medicated 5 hours previously
g. Heating pad applied to lower back
KEY TERM S
APIE p. 466 documenting p. 460 nursing rounds p. 478 record p. 460
change-of-shift flowsheets p. 470 problem-oriented recording p. 460
report p. 476 focus charting p. 466 medical record report p. 460
chart p. 460 incident reports p. 472 (POMR) p. 463 SBAR p. 476
charting p. 460 Kardex p. 470 problem-oriented SOAP p. 465
charting by exception narrative charting record (POR) source-oriented
p. 467 p. 463 p. 463 record p. 462
client record p. 460 nursing care progress note variances p. 469
discussion p. 460 conference p. 478 p. 465

• Client records are legal documents that provide evidence • The Kardex record is used for quick access to current
of a client’s care. data about clients.
• The nurse has a legal and ethical duty to maintain confi- • The content of progress notes should be accurate,
dentiality of the client’s record; this includes special mea- sequential, appropriate, complete, concise, legally pru-
sures to protect client information that is digitally stored. dent, relevant, and ethical.
• Client records are kept for a number of purposes, includ- • The general principles of documentation for long-term
ing communication, planning client care, auditing health care are the same as those for acute care; however,
care agencies, research, and education. documentation in long-term care (a) is less frequent
• In source-oriented records, recording is organized around and (b) focuses more on daily functioning, preventive
the source of the information. measures, and restorative care.
• In problem-oriented records, recording is organized • Documentation needs to follow professional, regulatory,
around client problems. and accreditation standards and agency policies.
• Other examples of documentation systems include APIE • The case management model emphasizes high-quality,
(assessment, planning, interventions, evaluation), focus cost-effective care delivered within an established length
charting, charting by exception, computer documenta- of stay.
tion, and case management. • Document data as soon as possible after nursing assess-
• The use of computer terminals at the bedside allows for ments, interventions, and evaluations.
immediate documentation of nursing actions. • The purpose of reporting is to communicate specific
• The case management model focuses on standardized information for the goal of improving or maintaining
interventions given within a defined time frame. quality of care.
• The case management record for a client incorporates • A change-of-shift report and a telephone report are con-
graphics and flowsheets along with critical pathways that sidered handoff communications.
serve as both an abbreviated care plan and a documenta-
tion form.
M24_KOZI2703_04_SE_C24.indd 479 02/03/17 4:49 PM


1. The Cameron family is caring for their father at home 6. Which of the following charting samples correctly
in the final stage of his life. The family has decided that illustrates the “R” in focus charting?
they will all participate in providing care to minimize a. 50 mg of dimenhydrinate given intravenously for
the caregiver burden for Mrs. Cameron. How should nausea
the home care nurse document this situation?
b. 400 cc of dark green vomitus
a. “The agency’s standardized palliative care plan will
be implemented.” c. An antiemetic every 6 hours to manage nausea
b. “Each family member has agreed to spend one day d. Client states “nausea has decreased”
per week caring for Mr. Cameron.” 7. A nurse receives a telephone call during the evening
c. “Mrs. Cameron is unable to cope with the care of shift on a psychiatric unit in a large urban facility. The
her husband without assistance.” caller identifies himself as the husband of one of the
d. “A care plan has been developed and presented to clients and would like to know how his wife is doing.
the Cameron family.” The nurse is unable to verify the caller’s identity. What
is the nurse’s best response?
2. A client frequently refuses his daily medication. The a. “Agency policy prevents me from providing confiden-
nurse is finishing the narrative charting in the client tial client information.”
record and writes the subjective client statement, “Don’t
come near me with that pill. I hate it…. Go away, and b. “Confidential information can’t be provided without
stop bothering me.” Which of the following is the best client permission.”
comment that the nurse could include in the narrative c. “If you want client information, call back in the
recording? morning.”
a. “Client uncooperative again.” d. “I don’t know who you are, so I can’t give you any
b. “Client remains negative about treatment.” information.”
c. “Client still very angry with nurse.” 8. Which statement best exemplifies the guidelines on how
d. “Client refuses scheduled medication.” nurses resolve a problem with a chart entry?
a. Erase all errors as thoroughly as possible, and write
3. Which of the following guide nursing documentation the correction in the same spot
and reporting?
b. Draw a pencil line through the wrong entry and
a. Canadian Nurses Association, International Council write entry mistake above it
of Nurses, health facility policies
c. Write mistaken entry above the entry with the nurse’s
b. Canadian Council of Health Standards Associa- initial or name
tion, health facility policies, International Council of
Nursing d. Write error above the entry with the nurse’s position
or title
c. Canadian Nurses Association, health care policies,
provincial or territorial nurses’ unions 9. Which of the following is a legal comment frequently
d. Canadian Nurses Association, Canadian Council of used to describe nursing care?
Health Standards Association, health care policies a. Nurses are too busy to chart effectively.
4. While doing the final medication check at a client’s b. Nurses are often sued for malpractice.
bedside, the nurse realized an error in the medication c. Nurses’ routine care that is not documented is
dose. The nurse immediately returned to the medication assumed to be done.
room to obtain the correct dosage. Shortly thereafter, d. Nurses’ routine care that is not documented is
the appropriate dose of medication was administered. assumed to not be done.
Where should the nurse document this situation?
a. Make an additional notation on the medication record 10. Maria Dubois, a registered nurse, works on a surgical
unit, and recently she has been visiting her son, Roberto
b. In the narrative notes (age 18 years), who is receiving treatment on a medical
c. Complete an incident report unit in the same facility. The nurse assigned to care for
d. On the shift change report Roberto finds Nurse Dubois reading her son’s chart.
What is the best response by the medical unit nurse in
5. Which of the following abbreviations, if used in a client this situation?
record, could contribute to an unsafe client outcome? a. “Maria, what you are doing is illegal.”
(Select all that apply.)
b. “Maria, please read the chart in a private place.”
a. OD
c. “Maria, as a nurse you should know the chart is
b. NPO confidential.”
c. WNL d. “Maria put that chart back; you have no business
d. D/C reading it.”
M24_KOZI2703_04_SE_C24.indd 480 02/03/17 4:49 PM

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1394–1401. Department of Justice. (2011). Personal information protection and
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Canadian Nurses Association. (2008). Code of ethics for registered nurses Saddle River, NJ: Prentice Hall.
(Centennial ed.). Ottawa, ON: Author. Harris/Decima. (2014). Final report: National survey of Canadian nurses:
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Your best defence. Infolaw, 1(1). Ottawa, ON: Author. Users/Default.sid18931/Downloads/hd-2014_nurses_survey-
Cartwright-Vanzant, R. (2010). Medical record documentation: infoway_release_june2014%20(1).pdf.
Legal aspects in neonatal nursing. Newborn & Infant Nursing Reviews, Manitoba Government. (1997, amended 2011). Freedom of
10(3), 134–137. information and protection of privacy act. Winnipeg, MB: Manitoba
Casey, A., & Wallis, A. (2011). Effective communication: Principle Government.
of nursing practice. Nursing Standard, 25(32), 35–37. Service Ontario. (2004, amended 2010). Personal health information
College of Nurses of Ontario. (2009a). Documentation, revised 2008. protection act. Toronto, ON: Government of Ontario. Retrieved
Pub No. 41001. Retrieved from http://www.cno.org/Global/docs/ from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_
prac/41001_documentation.pdf. statutes_04p03_e.htm.
M24_KOZI2703_04_SE_C24.indd 481 02/03/17 4:49 PM

Chapter 25
Nursing Informatics
and Technology
Updated by
Lorie Donelle, RN, PhD
Western University
Richard Booth, RN, PhD
University of Toronto
A
LEARNING OUTCOMES
After studying this chapter, you will be able to dvances in technology,
1. Define the concepts of nursing informatics. the growth of scientific

knowledge, the increase
2. Outline the current conceptualizations of technology by nurses.
in chronic disease burden, and a sub-
3. Discuss some of the modern information and computer technology
stantial proportion of aging Canadi-
(ICT) used within clinical practice.
ans underscores the need for health
4. Explain how nurses are using core technology in different areas of
information that is reliable, accurate,
practice (e.g., research, administration, practice, education).
and accessible to clients and health
5. Outline evidence-informed nursing practice in the presence of ICT.
care providers. Nurses are the larg-
6. Explain sociotechnical perspectives as related to the use of ICT in est provider group with the greatest
practice (e.g., workflow, human-technology relationships).
interaction with information technol-
7. Describe the process of clinical informatics implementation. ogy (IT) and client health care (Deese
8. Describe consumers’ participation in health informatics. & Stein, 2004). Information and com-
9. Identify different nursing-specific informatics organizations in puter technologies (ICTs) are foun-
Canada. dational to nursing and health care
10. Discuss issues of professional practice within a technologically practice. Included in this chapter are
mediated health care environment. basic definitions, conceptualizations,
technologies, roles, and a historical
overview of the health informatics
within nursing. Social media, mobile
health, evidence-informed practice,
and professionalism are discussed in
relation to ICT and nursing practice.
There is widespread consen-
sus that the Internet and IT are
revolutionizing health care prac-
tices (D’Alessandro & Dosa, 2001; c
M25_KOZI2703_04_SE_C25.indd 482 17/03/17 11:34 AM

Chapter 25 Nursing Informatics and Technology 483
c Ferguson, 2000; Kassirer, 2003). Not surprisingly, the nursing profession and Canadians in general
are increasingly relying on the Internet and IT as tools for improved access to health information and
health care (Canadian Home Care Association, 2008; Underhill & McKeown, 2008). The Health Council
of Canada has made the development of information and computer technology to all Canadians a
priority (Health Council of Canada [HCC], 2005).
Definition of Nursing 2011), the Canadian Nurses Association (CNA) released

the e-Nursing Strategy for Canada report, asserting that “ICT
Informatics is no longer an add-on to traditional methods of health
care but, rather, an integrated, integral part of practice”
The term nursing informatics was coined roughly (CNA, 2006, p. 10). The report positions nursing educa-
35 years ago by Scholes and Barber (1980) to describe tion and nurse educators as pivotal players in advanc-
“the application of computer technology to all fields of ing nursing knowledge and skill through the planned
nursing—nursing services, nurse education, and nurse incorporation of ICT competencies within undergradu-
research” (p. 73). From Scholes and Barber’s (1980) origi- ate and graduate education programs (CNA, 2006). In
nal definition, there has been significant evolution of the response, the CASN and the Infoway called on nurse
term over the past three decades. In 2012, the Canadian educators, researchers, and clinicians with informatics
Association of Schools of Nursing (CASN) with Canada expertise to develop a nursing informatics educational
Health Infoway (Infoway) jointly released the “Nursing resource (CASN, 2013) and informatics competencies
Informatics Entry-to-Practice Competencies for Regis- needed for entry-to-practice (CASN/Infoway, 2012).
tered Nurses.” Within the CASN report, nursing infor- By the early 2000s, the term eHealth (electronic
matics was defined as a “science and practice [which] health) was commonly used as a catch-all term within the
integrates nursing, its information and knowledge, and informatics disciplines. The term eHealth was adopted by
their management, with information and communica- a number of health care organizations and is a popular
tion technologies to promote the health of people, fami- term within the Canadian health care system. Currently,
lies and communities worldwide” (International Medical eHealth is used synonymously with such terms as informat-
Informatics Association [IMIA], 2009). What is constant ics, health informatics, and digital health within the Canadian
across all definitions of nursing informatics is the under- context. Within this chapter, the term informatics will be
standing that information, science, knowledge, and prac- used to describe the evolving science of information,
tice intersect (see Figure 25.1). technology, and nursing practice.
As the topic of “informatics” became recognized as As well, the term technology will be used in reference to
a unique discipline within health care (Saba & Westra, computerized (or microprocessor) systems that are used
Figure 25.1 A word-cloud of aggregated published definitions of “nursing informatics” as listed by Thede (2010) on her website.
The size of the text denotes the frequency with which the specific word was used in the definitions. Connecting words such as “and”
and “the” have been removed from the cloud. Thede’s listing of nursing informatics definitions encompasses a period from 1980 to
2008. Words such as “information,” “science,” “practice,” and “knowledge” appear to be common threads between different nursing
informatics definitions.
Source: Data for the word cloud based on Thede, L. (2010). Nursing informatics definitions. Retrieved from http://dlthede.net/Informatics/Chap01Overview/NIDefinitions.html.
M25_KOZI2703_04_SE_C25.indd 483 27/02/17 1:07 PM

in the practice, delivery, or management of patient care. risk of cardiovascular disease. Knowledge requires syn-
Another common term within the health care literature thesis of information to identify relationships that pro-
is information and computer technology (ICT). vide fuller understanding of an issue or subject (see
Historically, this term has been used to describe various Figure 25.2). For example, the development of client
informatics devices, software, hardware, or systems. care maps (concept maps) are generated from the syn-
For instance, a handheld blood pressure machine may thesis of information derived from client assessment and
be referred to as an ICT device. Similarly, an electronic the nursing research literature to inform evidence-based
medical record (EMR) may also be referred to as an ICT decision making for effective patient care.
device. Given the common use of such terms as technology These concepts—data, information, and knowl-
and ICT, within this chapter ICT will refer to computer- edge—can be influenced by nursing informatics applica-
ized technology that is used by nurses in their practice. tions (e.g., electronic health record [EHR]). Raw data
(e.g., patient data) can be collected and stored by using
computer systems. Electronic monitoring of vital signs
Informatics Fundamentals: and electrocardiography (ECG) in intensive care units
can be recorded directly in the EMR. Integration of data
Data, Information, to provide useful information is demonstrated by the use
of aggregated or combined patient data. For example,
and Knowledge information on the prevalence of immunizations for a
specific disease across communities or the frequency of
To better understand nursing informatics, an explanation falls across a given organization can be calculated from
of the interrelationships among data, information, and incident records embedded into electronic documenta-
knowledge is required. Data are raw observations that tion. Knowledge can be enhanced through integration
have not been interpreted, such as age, weight, blood of care maps or decision-support systems (e.g.,
pressure, number of admissions, and number of work- medication administration decision support), which ana-
load units. Information results when data are inter- lyze raw data and nursing assessments to suggest nurs-
preted, organized, or structured in a meaningful way. ing diagnoses and recommended interventions. Beyond
For example, data regarding gender, age, weight, height, clinical nursing practice, nursing informatics applica-
laboratory values, and blood pressure (e.g., BP = 120/80 tions also support data, information, and knowledge
mm Hg) can be interpreted to provide information about integration for education, administration, and research.
Figure 25.2 Both data and information are presented in this screenshot of the assessments section of a patient’s electronic medi-
cal record (EMR). Knowledge is required on behalf of the nurse to interpret the various data and information contained in this record
in order to determine appropriate nursing interventions and actions.
Source: Courtesy of Royal Victoria Regional Health Centre, Barrie, Ontario.
M25_KOZI2703_04_SE_C25.indd 484 27/02/17 1:07 PM

Standardized Languages almost instantaneously across geographical distances.

According to the Internet World Statistics (2014), over
2 billion people use the Internet globally (1.1 billion
To utilize information and knowledge, a common language Internet users in 2007 and 2 billion in 2011).
(e.g., for use in documenting patient care) is required to In the past, accessing the Internet was possible only
communicate effectively. Within nursing informatics, the through hardwired connections (e.g., telephone line,
term standardized language refers to the use of a broadband cable connection). Over the past decade,
body of terms that has been agreed upon by an over- access to the Internet via mobile devices has become
arching authority or by general consent (McGonigle & prevalent worldwide. It is now possible in many loca-
Mastrian, 2012). The International Classification for Nurs- tions to access the Internet through handheld mobile
ing Practice (ICNP) is a set of nursing diagnoses, interven- devices via cellular or satellite reception. The increased
tions, and outcomes that has been endorsed by the CNA access and immediacy of the Internet has stimulated new
since 2006. In 2010, a new agreement was struck between areas of opportunity for nursing informatics. Yet, access
the International Council of Nurses (ICNP’s authoring concerns remain (provincially and within the northern
body) and the International Healthcare Terminology Stan- Canadian territories) with regard to situations where
dards Development Organisation (IHTSDO) to harmo- Internet access is limited or nonexistent because of a
nize standardized languages for use in health information lack of IT infrastructure or the topography of the area.
systems. The agreement between the IHTSDO and the
International Council of Nurses will help ensure that
informatics systems will contain nursing terms and facili- Social Media
tate nursing’s involvement in the future development of
The first iterations of the World Wide Web (WWW)
standardized languages used in health care.
consisted of mostly static webpages that did not offer
For example, consider the use of standardized ter-
any real interactive capability. The rise of Web 2.0 in
minology to describe a pressure ulcer. A “pressure ulcer”
the early 2000s enabled users to create and generate
might be referred to as a “bed sore” or “decubitus
content, share ideas, and collaborate with others. The
ulcer.” If a standardized language is not developed and
emergence of collaborative web platforms, such as blogs,
used to ensure all pressure ulcers are named “pressure
wikis, video-sharing sites, and other social networking
ulcers,” various ICT systems will be limited in tracking
sites, has ushered in a new phase in the Internet’s history;
all instances of the condition. Therefore, standardized
with these platforms, users not only access information
nursing languages, such as ICNP, are extremely impor-
from Internet sources but also share their content with
tant to ensure the consistency of classification of nursing
others. As online participation and interaction increased,
interventions, outcomes, and phenomena.
this novel use of the Internet was given the term social
media. Social media expand the functionality of the
Computer Technology Internet through the use of mobile and web-based com-
munication technologies to generate an interactive and
and Informatics in Nursing user-centric platform for information sharing and social
networking. All elements of nursing practice (and par-
ticularly educational practice settings) are influenced
All informatics systems use some sort of computerized by the Internet and related social media technologies.
technology and are typically interlinked with other com- It is important to discuss the significance (and potential
puterized devices to form larger networks. Since nurses impact) of this new communication modality within the
work in a variety of contexts, the types of computer tech- context of nursing informatics. (See Box 25.1.)
nology used by nurses range significantly. For instance,
within acute care environments, it is common to find
workstations on wheels (WOWs), which are mobile carts Box 25.1 Social Media in Nursing
normally outfitted with a computer terminal, screen, and To explore how social media technologies can be used safely
other peripherals, such as barcode scanners, that can and effectively by nurses, Fraser (2011) developed a com-
be used to enable provider order entry capabilities and prehensive book to explore the topic. Fraser’s work explores
point-of-care documentation into an EMR. Although how these sorts of technologies can be safely and effectively
computerized technology has existed within the nursing embedded into a nurses’ practice to assist in building net-
role for decades, it is now becoming smaller and more works, obtaining knowledge, and creating quality content for
streamlined into a nurse’s work life and clinical delivery others. Key thematic topics related to social media and nurs-
than ever before. ing practice discussed in this work include the following:
• Building a professional profile, reputation, and network
• Participating in online communities
Internet • Managing the risks and benefits of social media
As a global network of interconnected computers, the • Sharing interests, knowledge, and expertise with others
Internet allows people to send and receive information
M25_KOZI2703_04_SE_C25.indd 485 27/02/17 1:07 PM

Along with impacting nursing, social media have also Canada the EHR, defined by Canada Health Infoway
afforded clients and consumers new ways and opportu- (Infoway), is:
nities to seek health information and connection with
others. Currently, there are a number of online services … client and provider demographics, diagnostic images,
that clients can use to seek advice, connect with others profiles of dispensed drugs, laboratory test results and
to discuss health concerns, and, in some cases, interact clinical reports or immunizations. This information con-
with clinicians to address specific health-related issues. stitutes the essence of an electronic health record (EHR)—
Although social media have afforded new opportunities the secure and lifetime record of a person’s health and
to health care services, allowing consumers and clini- health care history—that’s available to authorized health
cians to share information, because of the strict health care providers and to the individual (Canada Health
privacy laws with regard to personal health information, Infoway, 2016a, p. 7). (See Figure 25.3.).
the use of social media in formalized health care services
is still very new. Given the rise in the consumer space of Other commonly used terms for the electronic record
technology such as social media, it is expected that social include electronic medical record (EMR) or elec-
media will have impacts on various elements of health tronic patient record (EPR). Unlike the complete
care as we move into the next decade. health record of the EHR, an EMR is a computer-based
patient record specific to a single clinical practice, such as
a family health team or group practice (Canada Health
Electronic Health Records Infoway, 2016b, para 1). In essence, the EHR is considered
a comprehensive record of information of an individual,
Electronic health record (EHR) systems permit elec- drawn from various EMR systems. (See Box 25.2.)
tronic data retrieval by caregivers, administrators, and Generally, EMRs can be found within various clini-
other persons who require the data and have authorized cal and organizational settings. For instance, a nurse
access. In November 2002, the Romanow Commission practitioner–led clinic may use an EMR to help record and
issued the report titled Building on Values: The Future of document patient interactions. Similarly, a large hospital
Health Care in Canada, which emphasized the importance organization might also operate an EMR to document all
of EHR systems as “one of the keys to modernizing medical and nursing care delivered to a patient. Until the
Canada’s health care system and improving access and EMR replaces paper-based charting and documentation of
outcomes for Canadians” (Romanow, 2002, p. 77). The care delivery, a “hybrid” solution (i.e., the simultaneous use
EHR has been defined as an individual’s health record of both paper charts and electronic records) may be used.
that is accessible online from many separate, interoper- Canada Health Infoway is a national, not-for-profit
able, automated systems within an electronic network. organization that was established in 2001. Infoway’s
Simply put, the health information collected within the purpose is to “realize the vision of healthier Canadians
EHR would be accessible (with proper authorization) by through innovative digital health solutions” (Canada
many diverse health care providers, using different EHR Health Infoway, 2016c). Infoway is funded by the Gov-
systems within Canada. Although the use of the term ernment of Canada to strategically invest in EHR-
electronic health record tends to vary between countries, in related initiatives across the provinces and territories.
Health User Interface Digital Health Workflow Communication Health

Information & Experience Services Across the Care Across the Care Analytics
Continuum Continuum
Interoperable functionality… across (and between) care organizations, settings and disciplines
Figure 25.3 The categories of digital health functionality that are considered in Canada Health Infoway’s Digital Health Blueprint.
Source: Canada Health Infoway, 2016d. Digital Health Blueprint: Enabling Coordinated and Collaborative Health Care. Available from https://www.infowayinforoute. ca/en/component/
edocman/resources/technical-documents/architecture/2944-digital-healthblueprint-enabling-coordinated-collaborative-health-care?Itemid=101, p. 42
M25_KOZI2703_04_SE_C25.indd 486 27/02/17 6:16 PM

Box 25.2 Common Electronic Medical CPOE systems have the potential to reduce medication
Record Functionality errors caused by illegible handwriting and have been
found to assist in decreasing certain prescribing and
Electronic medical record (EMR) systems usually consist medication errors. However, Koppel Metlay, Cohen,
of (but are not limited to) the following (Registered Nurses Abaluck, Localio, Kimmel, and Strom (2005) demon-
Association of Ontario [RNAO], 2011):
strated that such a system also brought to light new types
• Client demographics of potential medication errors. Another example of an
• Medical history application software system that integrates with
• Allergy and immunization status an EMR is a picture and archiving communica-
• Laboratory results and trending tion system (PACS). PACS allows digital images to be
• Pharmacy and medication records (including side effects securely transferred and accessed by multiple health care
and contraindications) providers. Previously, all medical imaging was physically
• Advanced directives transferred and interpreted on film. Interpretation of
• Diagnostic tests and reports medical imagery can now occur remotely from the ori-
• Images gin of the image, thus reducing time required between
• Clinical records, both historic and current assessment and diagnosis.
Care documentation is also supported with the use
of EMRs. Documentation electronically is commonly
referred to as electronic documentation, or electronic
charting. This catch-all term is used to describe how
In 2006 and updated in 2016, Canada Health Info- nurses and other health care providers capture, tran-
way released a “blueprint” document outlining the scribe, and add information to a patient’s electronic
components necessary for the interoperable EHR and record. As stated by the RNAO (2011), the term electronic
describing how the components will work together. documentation is a misnomer—the principles of documen-
According to Infoway, the creation of a pan-Canadian tation completed electronically are the same as those of
EHR will attempt to ensure that the various compo- documentation on paper (see Chapter 24). In advanced
nents of the EHR system are developed using consis- EMR systems, documentation can take on a number of
tent standards, to allow information and knowledge to different activities from narrative charting, to vital signs
flow across jurisdictions (e.g., health information cap- trending (e.g., graphical representation of vital sign fluc-
tured in a rural hospital will be easily accessible in an tuation over a period), to other standardized outcome
urban health care setting with the proper security and assessments of client functioning (e.g., Resident Assess-
privacy permissions). ment Index, or C-HOBIC).
Infoway’s interest in the effective use of EHR sys- Finally, patients can undergo diagnostic procedures
tems by health care professionals aligns with its man- in which ICT can play a significant role. Computed
date to accelerate the adoption of those systems within tomography (CT), magnetic resonance imaging (MRI),
Canada (Canada Health Infoway, 2016a). Infoway and positron emission tomography (PET) use computers
and the CASN have partnered to develop tools and to perform tests and analyze findings. Blood gas analyz-
resources for faculty and students related to the devel- ers, pulmonary function test machines, and intracranial
opment of skill in nursing informatics for students and pressure monitors can sometimes be linked to store data
practising nurses (Canada Health Infoway, 2012). In in the EMR.
addition, health professional practice associations state
that providers should be competent in the use of infor-
matics within practice (CNA, 2006; Health Council of
Telehealth
Canada, 2006). The goal of the CASN/Infoway initia- Telehealth refers to the use of ICT to support health
tive is to develop competencies, educational resources, care, services, and expertise over any geographical dis-
and mentorship for nursing faculty to ensure that gradu- tance. For instance, in Ontario, the Ontario Telemedi-
ates develop competencies in informatics. Other health cine Network (OTN) operates a province-wide two-way
care technologies also work in conjunction with the EMR videoconferencing telehealth network that connects
and are used to collect, organize, or manage different over 1175 sites across the province (OTN, 2014). As
types of health information. For instance, a computer- one of the largest telehealth networks in the world,
ized provider order entry (CPOE) system allows a OTN delivers over 200,000 clinical “visits” per year
clinician or provider to enter treatment and medication (OTN, 2014). Patient assessments, educational work-
orders electronically. Orders that are entered electroni- shops, and other consultations can be conducted via the
cally are received at their respective destinations (e.g., OTN, thus saving patients and their families the finan-
pharmacy for medication orders) within the health care cial and logistical burden of travel over large geographi-
organization (e.g., hospital) for processing and delivery. cal distances to obtain health care. For example, using
M25_KOZI2703_04_SE_C25.indd 487 27/02/17 1:07 PM

synchronizing a Bluetooth-enabled home blood pressure

monitor with a cellular phone. Blood pressure readings
from the monitor were automatically sent to a data
centre for processing by a case manager caring for the
specific client. Active and passive RM can increase client
confidence in their self-health care and in their ability
to live independently at home. RM is especially helpful
in tracking behaviours of older adults with cognitive
decline (e.g., forgetting to take medications).
Point of Care Technology

Point of care (POC) technology and devices can assist
USDA
nurses in collecting and documenting data at or near

FIGURE 25.4 Consumers and clinicians are able to consult
the location of care. For instance, computer tablets and
using telehealth technology in the form of a video conference. mobile technologies are commonly used in home care
to assist nurses in documenting or recording patient
information at patients’ homes. Similarly, within hospital
videoconferencing, an interprofessional team can exam- settings, POC technologies can include various devices,
ine and consult from kilometres away, especially in rural such as digital or tympanic thermometers; digital scales;
or remote areas where resources and expertise are scarce pulse oximetry; ECG; telemetry; hemodynamic monitor-
(see Figure 25.4). Telehealth can be used in (a) telecon- ing; apnea monitors; fetal heart monitors; blood glucose
sultation, teleimaging, teledermatology, teleopthamol- analyzers; ventilators; and intravenous (IV) pumps. Some
ogy, and telepsychiatry, (b) education and training in of these devices can transmit data to more sophisti-
health disciplines, such as telelearning and telemen- cated systems (e.g., EMR) or interact with the user via
toring, (c) health information transfer for health care digital displays. Most POC technologies include error
providers, and (d) health care information for clients. detection, warnings that the instrument is malfunction-
(See Box 25.3 for more benefits.) ing or that the assessed value is outside predetermined
REMOTE MONITORING Telehealth technologies can
parameters. These devices can act to extend the nurse’s
also support various types of remote monitoring (RM) observations and supply reliable health status–related
of patients in their households. Active and passive RM data. To avoid cross-contamination, medical asepsis is
technologies support the care of Canadians in their necessary in using these devices with numerous clients in
homes. Active monitoring applications require individ- acute care settings.
ual participation, such as pushing a button, whereas pas-
sive RM technologies (e.g., bed sensors) do not require
any action by the individual for the system to work. Portals
Stand-alone devices (e.g., blood pressure monitor, glu-
cometer, weight scale, etc.) can be connected to either a Portals are websites that allow a user to view informa-
telephone line, mobile network, or the Internet to trans- tion that is personalized and/or relevant to their role,
mit data to authorized specialists or clinicians managing such as the NurseONE portal of the CNA (http://
the patient’s care. In the study by Logan et al. (2007), nurseone-inf-fusion.ca/). For instance, the social net-
RM of patients’ blood pressure was accomplished by working site Facebook is a type of Internet portal—upon
authenticating, Facebook users are able to personalize
their online presence with various feeds, friends, and
BOX 25.3 BENEFITS OF TELEHEALTH images. Health care portals are similar in many respects.
Patient portals allow an individual patient (or sometimes
Telehealth can offer new ways to assist in improving health the family) to log in to a hospital information system
care of patients living in remote locations. For instance,
(HIS) to view select elements of his or her treatment or
telehealth can do the following:
care (i.e., obtain laboratory values, rebook appointments)
• Help ensure continuity of client care
(McGonigle & Mastrian, 2012). Similarly, portals can
• Reduce geographical barriers to care also act as a technology link, connecting two or more
• Allow for collaboration among health care team members various ICT systems together. Portal technology can
• Potentially increase client involvement in care enable a user to securely access information from two or
• Act as a distance education tool more discrete sources (i.e., two different EMR systems)
(see Box 25.4).
M25_KOZI2703_04_SE_C25.indd 488 02/03/17 3:51 PM

BOX 25.4 PATIENT PORTAL AT SUNNYBROOK nursing curricula, as opposed to being taught in a stand-
HEALTH SCIENCES CENTRE alone course. A functional understanding of informatics
across the educational spectrum is important in order to
Sunnybrook Health Sciences Centre in Toronto uses a remain competent within the profession. As mentioned
patient portal to provide patients with access to elements of above, with support from Infoway/CASN, a national team
their medical records. Currently, the portal provides patients
of nursing informatics experts developed a set of entry-
with the ability to grant specific access to family caregiv-
to-practice nursing informatics competencies related to
ers or other related health care organizations and agencies
(e.g., family physician, pharmacists). Patients using the the domains of information and knowledge management,
portal are able to access select elements surrounding their professional and regulatory accountability, and informa-
health records, including laboratory results, clinic notes, and tion and communication technologies (CASN, 2012).
other personalized health information. Similarly, patients are Each competency has a list of indicators that articulates
also able to electronically submit appointment requests, the entry-to-practice informatics knowledge and skills
make medication refill requests, and send electronic needed by newly registered RNs to effectively practise in
messages to clinicians involved in their ongoing care. As technology-enabled health care settings (CASN, 2012).
of 2015, the patient portal at Sunnybrook Health Sciences The CASN nursing informatics competencies are intended
Centre has over 50 000 users and continues to grow daily to guide curriculum development within undergraduate
(Sunnybrook Health Sciences Centre, 2015).
schools of nursing. A number of integration points for
nursing informatics that exist within nursing education
have been explored over the years. High-fidelity simula-
tion mannequins, handheld devices within clinical practi-
mHealth and Mobile Technology cum, virtual nursing environments, and Internet-enabled
Recently, there has been a rise in the use of mobile tech- technologies are just a few examples of commonly used
nology and mobile health (mHealth) within health care. informatics technologies within education. With support
The World Health Organization defines mobile health from Infoway and the CASN, a nursing informatics edu-
(mHealth) as an area of eHealth whereby health services cational toolkit was created to support the integration
and information are provided using mobile technologies of informatics competencies within nursing education
such as mobile phones and personal digital assis- curriculum and to facilitate the development of nurs-
tants (PDAs) (www.who.int/goe/mobile_health/en/). ing informatics knowledge and skills among faculty. This
For example, within Ontario, the eShift Model of collaboration has resulted in the development of several
Homecare utilizes technology-trained registered nurses other educational resources related to technology-enabled
(RNs), unregulated care providers (UCPs), and mobile nursing practice. (See Digital Health in Nursing Education
technology to provide palliative care to clients who wish Resources, available at http://www.casn.ca/education/
to die at home. Different from the traditional home care digital-healthnursing-informatics-casn-infoway-nurses-
model reliant on one RN making intermittent home visits, training-project/.)
in the eShift Model an RN, situated remotely from the Over the past decade the use of computer-
client, cares for several clients and their families in collabo- conferencing systems (e.g., WebCT, Blackboard, Moodle)
ration with a UCP who provides care to one client in the has become commonplace within the education sec-
client’s home. The UCP uses electronic standardized care tor. Similarly, e-mail and the use of electronic scholarly
forms supported by a wireless handheld device (i.e., smart- resources (e.g., electronic journal articles, e-books) have
phone) and communicates in real time with the remotely become standard in schools around Canada. Many uni-
located RN. A physician/nurse practitioner (NP) portal versities and colleges offer distance education courses
allows care team members to review client care documen- mediated through computer conferencing and other
tation and to communicate directly with each other. videoconferencing platforms. For instance, the Ontario
Primary Health Care Nurse Practitioner consortium
(consisting of nine universities in Ontario) delivers online
classes to over 150 nurse practitioner students on various
How Nurses Are Currently topics by using the web-conferencing system Elluminate.
The professor leading the class is able to present a slide-
Using Technology show, complete with voice narration, and has the ability
to send and receive text messages from students.
Education
As outlined in this chapter, nursing informatics is a
Research
core competency within nursing practice. Nagle (2007), Nursing research has been heavily influenced by infor-
a champion of nursing informatics within Canada, matics over the past few decades. From data analysis
advocates for informatics embedded in undergraduate software packages to assist researchers in analyzing
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quantitative and qualitative data (e.g., SPSS, NVivo) to Box 25.5 Informatics Administration:
new methods of data collection via electronically aggre- Wait Times Now Available Online in
gated data, informatics within the research realm has Some Provinces
significant potential to improve patient care and prac-
tice. Research databases, such as the Cumulative Index Many provinces now publish wait time listings for various
for Nursing and Allied Health Literature (CINAHL), common medical procedures online. From these websites,
consumers and patients can view up-to-date wait times for
provide nurses with ease of access to research informa-
various services at specific hospitals and organizations.
tion to guide practice. Similarly, the Cochrane Col-
See, for example, the following sites:
laboration and other evidence-informed databases have
• Ontario: http://www.health.gov.on.ca/en/public/
reduced access and geographical barriers for nurses seek- programs/waittimes/
ing research evidence.
• Alberta: http://waittimes.alberta.ca
With the increased use of Internet and related tech-
• British Columbia: https://swt.hlth.gov.bc.ca/
nologies, new areas of research have begun to arise within
• New Brunswick: http://www1.gnb.ca/0217/
health care. The use of socially generated or aggregated
surgicalwaittimes/index-e.aspx
knowledge has generated an interesting approach to
examining public health issues. For instance, Chew and
Eysenbach (2010) discovered that the microblogging sys-
tem Twitter supported health information delivery during (e.g., Resource Matching and Referrals Project, eHealth
the 2009 H1N1 flu pandemic outbreak. In their study, Ontario). Interoperable informatics systems can assist
they found that messages posted via Twitter could be used clinicians and administration in terms of matching
to disseminate health-related information from credible patients to appropriate resources in the community. Sim-
sources. Similarly, the authors indicated that Twitter may ilarly, wait times for various procedures can be captured
be useful in assisting public health personnel in tracking in real time, allowing administration and leadership to
real-time developments associated with extraordinary make decisions regarding resource allocation (e.g., staff,
situations, as pandemics or natural disasters. There is finances, human resources, etc.). (See Box 25.5.)
growing interest in the use of social media technologies
within all health care sectors, particularly within public
health, to engage with clients, for health education and Practice
communication, and as a means for individuals to share
The clinical application of informatics in the direct provi-
information and support. A social media toolkit was cre-
sion of care includes the use of EMRs, CPOE, decision
ated by Public Health Ontario to support the integration,
support, reporting systems, e-mail, Internet, phones, and
use, and evaluation of social media technologies within
fax machines that act in support of clinical decision mak-
public health in Canada (Davies, Dhaliwal, Brankley,
ing. Handheld, point-of-care devices and other devices,
McColl, Mai, & Williams, 2014). Currently, Toronto Pub-
such as laptops, computer terminals, and monitoring
lic Health uses Twitter to broadcast information related
systems, will collect raw data, which are eventually fed
to health to its 20 000 followers (as of May 2015).
into a clinical informatics system. Nurses play a key role
The Health Outcomes for Better Information and
in and are vital to ensuring the collection, input, and
Care (HOBIC) is an initiative originally developed by
validation of data entered into clinical informatics sys-
the Ontario Ministry of Health and Long-Term Care to
tems. Some informatics systems will capture individual
collect nursing-sensitive outcomes related to patient care.
patients’ data and aggregate or combine them to form
As of 2007, HOBIC became a national initiative, called
unit- or organizational-level information on health trends
Canadian HOBIC (C-HOBIC). C-HOBIC allows nurses
among patients or to assess if there has been an increase
to collect information related to the impact nurses make
in preventable situations, such as falls or medication
on patients suffering from pain, fatigue, dyspnea, and nau-
errors. See Box 25.6 for an example of how a health care
sea. Other outcomes measured in the HOBIC initiative
agency uses handheld devices to improve client care.
include those related to pressure ulcers, falls, continence,
activities of daily living, and readiness for discharge.
For more information, visit http://www2.cna-aiic.ca/ Box 25.6 How One Home care Agency
c-hobic/about/default_e.aspx. Uses Handheld Devices
Saint Elizabeth Health Care, a home care agency in
Canada, recently implemented 5000 mobile tablet devices
Administration to its clinicians to enable staff to use these “devices and a
range of apps to connect the circle of care in new ways,
Informatics applied to an administration setting can from scheduling appointments to more efficiently planning
streamline processes that were once difficult and time and navigating routes to electronically recording patient
consuming. For instance, streamlining patient refer- data” (Saint Elizabeth, 2015).
ral processes is a significant issue in parts of Canada
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Using Evidence-Informed the mass media: television, radio, newspapers and maga-
zines, and (increasingly) the Internet. A media-literate
Nursing Practice in ICT person can evaluate, analyze, and produce both print
and electronic media (Aufderheide & Firestone, 1993).
Within contemporary health care, information (digital)
Clinical Knowledge Translation literacy involves the development of a critical approach
Chapter 3 outlines the significance of research evi- to accessing (e.g., distinguishing between information and
dence in support of evidence-informed nursing practice. In knowledge; searching for content beyond the first six
evidence-informed nursing practice, the nurse considers “hits” of an online search; managing the “multimedia
the available research literature in determining best care flow”), assessing (e.g., assessing the usefulness, timeliness,
practices within the life context of the client. In addition accuracy, and integrity of information; questioning/
to the research literature, consideration is given to the checking answers provided by technology tools; judg-
availability of fiscal, material, or human resources and ing validity and completeness of material referenced by
to personal clinical expertise. Clinical decision making hypertext links), and using information (Bawden, 2001;
regarding client care constitutes an intersection of mul- Eysenbach, 2008; Canadian Public Health Association
tiple information sources (e.g., clinical expertise, patient [CPHA], 2015).
preference for alternative forms of care, clinical research Experts have expressed concern that Internet use
evidence, and available resources). DiCenso, Cullum, and access to information is inequitable, that is, Internet
and Cilisko (1998) illustrated the intersection of these use and information access are not fairly balanced in
information sources in considering, for example, clinical relation to gender, age, income, and education. (See
expertise in determining a client’s status to tolerate an the Lifespan Considerations box on youth and adults.)
intervention supported by research evidence and the cli- Older individuals with lower education and limited
ent’s preference to accept or decline treatment, mitigated income tend to have less skill in accessing and assessing
by the resources available. online information. This situation becomes particularly
Nurses working today are expected to deal with troubling given that government, business or corpo-
overwhelming sources and amounts of information to rate, and public information is increasingly accessible
provide “evidence-informed” health care. Foundational via the Internet (Balka, Rodje, & Bush, 2007). Beyond
to the evidence-informed clinical decision-making pro- the skill limitations described above, many Canadians
cesses are information literacy skills. Information remain limited in their ability to access online informa-
(digital) literacy is a term that captures the proficien- tion if living in rural and remote areas or have limited
cies of knowing, identifying, finding and organizing, bandwidth.
evaluating, and using information (e.g., critical evalua- Bandwidth refers to the amount of informa-
tion of and production of new knowledge) that advances tion that can be transmitted and is an important vari-
research skills and critical thinking (Mackey & Ho, 2005). able in determining access to online information. The
Information literacy has become an important topic for Broadband Canada Program brings broadband access
nurses in providing evidence-informed care. For nurses, to an estimated 218 000 rural and remote households
this involves critical thinking, an awareness of personal within some of Canada’s most remote communities
and professional ethics, information evaluation, con- (e.g., Aboriginal communities). Connectivity projects
ceptualizing information needs that address the existing were targeted for Aboriginal communities in Nunavut
context of health care (e.g., clinical expertise, access to (one project), British Columbia (three projects), Mani-
resources, research evidence, client preference), organiz- toba (two projects), Ontario (four projects), and Quebec
ing information, and interacting with other information (three projects) to provide high-speed Internet access to
professionals (Bruce, 1999). Aboriginal communities (Aboriginal Affairs and North-
Digital transition is a phrase that refers to the ern Development Canada, 2012). Nurses practising in
movement of significant professional and scholarly infor- rural and remote Canadian communities tend to have
mation from paper to digital form (Bawden & Robinson, fewer clinical resources and geographically distant rela-
2009). Increasingly, greater availability of online infor- tionships with colleagues (MacLeod, Kulig, Stewart,
mation has highlighted the need for media, computer, Pitblado, & Knock, 2004).
and digital literacies (information literacy components)
that allow nurses to access and evaluate web-based mate-
rials (Mackey & Ho, 2005). Nurses currently practise
in complex information environments characterized by Roles in Nursing Informatics
greater amounts of available information, in a variety of
formats, and accessible through diverse media and com- All nurses function in an informatics role in some capac-
munication channels. ity. Nurses hold instrumental positions within the health
Media literacy is defined as the application of care system to develop and improve ICT used in clinical
critical thinking in assessing information gained from delivery. Specialized roles within the nursing and health
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Lifespan Considerations Box 25.7 List of Canadian Nursing

Informatics Organizations
Youth and Adults Below is a list of Canadian nursing informatics organizations:
Computer and Internet-based programs are increasingly
Canadian Nursing Informatics http://cnia.ca
available for children and adults to learn everything—from a
Association (CNIA)
foreign language to algebra. There are many issues of con-
cern related to frequent and extended use of computers by all Saskatchewan Nursing http://cnia.ca/SNIA.html
ages. In particular, repetitive motion injuries (especially of the Informatics Group (SNIA)
hand) can occur with extensive typing and use of the com- Manitoba Nursing Informatics http://www.mnia.ca
puter mouse; eye strain can occur from computer monitor Association (MNIA)
viewing; and musculoskeletal damage is related to inadequate
Ontario Nursing Informatics http://www.onig.on.ca
ergonomic arrangement of chairs, desk surface height, and
monitor placement. Students and adults who use computers Group (ONIG)
daily should be thoroughly evaluated and instructed in the pre- Quebec—Association http://cnia.ca/AQIISTI.html
vention of these conditions. Parents need to be reminded of québécoise des infirmières
potential risks to children from Internet contact with strangers et infirmiers en systèmes et
and adult-only websites. They also need to monitor school- technologies de l’information
children’s use of computers to ensure they are not being side- (AQIISTI)
tracked from homework into playing computer games and
New Brunswick Nursing http://www.nbnig-giinb.ca
messaging. The unprecedented prevalence of overweight
Informatics Group (NBNIG)
and obese children and adolescents within Canada has been
associated with technology use. In fact, the Canadian Society Nova Scotia Nursing http://www.nsnig.ca
for Exercise Physiology (2011) recommends that children ages Informatics Group (NSNIG)
5 to 17 years limit their recreational screen time (e.g., televi-
sion, computer, electronic games) to no more than 2 hours per
day, and for children under 2 years, screen time is entirely dis-
couraged. All persons should be wary about protecting their
financial and personal information when conducting business care professions have evolved over the past 2 decades
via the computer. Similarly, there has been an increase in the in order to ensure the advancement of the informatics
prevalence of online bullying or “cyber bullying” among youth discipline within health care. Nurse informaticians
(i.e., using electronic media, such as the Internet, e-mail, and (also known as informatics nurses) are nurses who have
social networking sites, to harass, threaten, or embarrass oth-
specialized knowledge and skills within the informat-
ers) (Mishna, Saini, & Solomon, 2009). It has been reported by
Mitchell, Ybarra, and Finkelhor (2007) that a large majority of ics discipline (McGonigle & Mastrian, 2012). Box 25.7
youth who are victimized by cyber bullying do not disclose the lists nursing informatics organizations in Canada. Many
experiences to their parents. nurse informaticians undertake graduate preparation
in management, leadership, informatics, and practice
Older Adults
elements to prepare for the complexity of their roles.
Computer skills and competency classes are being taught Within many health care organizations and hospitals, a
to increasing numbers of older adults. Use of the computer
clinical informatics department will typically include a
and access to the Internet can provide older adults with an
avenue of communication and exposure to a vast amount of
number of nurse informaticians working to develop and
health care information. Although nurses have little control maintain ICT components housed within their health
over which Internet sites will be accessed, it is important to care setting. Current educational avenues within Canada
teach clients and the general public to evaluate information to obtain specialized knowledge in health informatics
from the site and to be aware that misinformation can also be include self-directed courses, college diplomas, under-
presented on the Internet. Important guidelines that increase graduate specialization, and graduate preparation.
the validity of an online resource are as follows:
• The article or information lists the author and credentials
and/or the institution from which the information came.
• A date is provided, indicating when the information was
updated.
How Technology Influences
• If health care information is presented, a disclaimer
should be included. The disclaimer presents the limita-
Humans and How Humans
tions of the information and should state that it does not
substitute medical advice.
Influence Technology
Computer and Internet resources can be very effective Discussions of nursing informatics tend to focus heavily
teaching aids for older adults. They may provide audiovisual
on the technology. Technology is sometimes described
instruction and may even be interactive. They are useful for
teaching about medical conditions and medications and for
as a panacea or a “cure-all” within health care. It is not
providing information about procedures and surgeries to be uncommon to hear statements such as “The technology
performed. will solve our issues” or “The computers will improve
how nurses perform their roles.” This is an example
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of technological determinism—a perspective that 1. Having access to the medication from a centralized
identifies technology as the primary actor in social changes medication cart
(Croteau & Hoynes, 2003). In many respects, a bal- 2. Performing the “Ten Rights of Medication Admin-
anced approach is required when examining how the istration” while cross-comparing with the written
social elements of nursing mix with the technological orders on the medication Kardex
elements of informatics. A sociotechnical perspective
3. Walking to the client’s room with the medications in a
entertains a dynamic relationship between how humans
small plastic basket
and technology interact within an environment (Berg,
Aarts, & Vander Lei, 2003). Rather than viewing and 4. Obtaining a cup of water prior to entering the client’s
evaluating an informatics or ICT system as an isolated room
entity, a sociotechnical perspective would evaluate the 5. Checking the identity of the client on his or her
ICT performance within the context in which it oper- attached ID band around the wrist and ensuring again
ates. ICT can be understood only within the larger that the “Ten Rights of Medication Administration”
environment that includes nurses, consumers, health are followed
care professionals, and support staff, leading to a more 6. Asking the client if he or she has any questions regard-
holistic (and accurate) understanding of how informatics ing the prescribed medications
functions. Understanding and appreciating how humans
and technology work together is an important consid- 7. Observing the client taking the medications
eration within the nursing informatician role. Without 8. Mobilizing to the nursing station and documenting the
this understanding, clinical technology can be developed medication administration in the client’s chart
that is sometimes ill suited to support the nursing role or
care delivery. As seen in the example above, much of what the
nurse “does” to complete the action of administering
medications to the client is often accomplished without
conscious thought. This type of knowledge, also known
Workflow or Nursing as tacit knowledge, is extremely difficult to evaluate or
make explicit. When informatics and ICT systems are
Practice Process implemented into a practice area that has not previously
used these innovations, issues can arise as a result of
Nowhere is the understanding of process and change the “changes” that occur in the pre-established nursing
management as vitally important as in the issue of work- workflow processes.
flow. Workflow is a term used to describe a process of Let us review a situation in which a computerized
interconnected steps that depict an action or behaviour. provider order entry (CPOE) system was implemented
For instance, an example of workflow within nursing in a clinical environment to automate the ordering and
might include a nurse distributing medications to his or delivering of medications (Cheng, Goldstein, Geller,
her patients. The workflow process of this action would & Levitt, 2003) (see Figure 25.5). The developers of
include the following: the CPOE system conceptualized the workflow of
A. CPOE conceptualization of workflow
Physician Pharmacist Unit Clerk Nurse

writes order verifies order delivers order administers order
B. Actual Physician
workflow writes order Pharmacist Unit Clerk
verifies order delivers order
Nurse
initiates order
Nurse
administers order
Figure 25.5 A demonstration of how workflow can be altered by the implementation of ICT can be observed in this example.
Source: From “The effects of CPOE on ICU workflow: an observational study,” by C.H. Cheng, et al., AMIA Annu Symp Proc. 2003, p. 150–154.
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medication administration as a linear process (i.e., physi- technology use. Limited household income continues to
cian S pharmacist S unit clerk S nurse). Not surpris- be the reason for restricted access to technology or the
ingly, the actual workflow of medication administration Internet. A survey of health information and the Internet
did not subscribe to a linear pathway; rather, the actual reported that more than one-third of Canadian adults
workflow was much more nurse dependent than origi- used the Internet to search for health information in 2005
nally thought (see “Actual Workflow” in Figure 25.5). (Underhill & McKeown, 2008). Almost 6 out of every 10
Subsequently, the conceptualized CPOE workflow pro- (58%) home Internet users went online at some point in
cesses needed to be altered, as it quickly became appar- 2005 to search for health information. A relatively high
ent that physicians were rarely the primary initiator of proportion of these “health users” were women, with
medication orders on this particular unit. higher levels of education and income.
Therefore, it is important that nurses be involved The use of the Internet to search for health informa-
in the planning, development, and implementation of tion appears to be unevenly distributed among Cana-
ICT used in practice. As clearly outlined in the example dians. Searching for health information online is an
above, the practice realities of nursing were not consid- example of what has been described as a second-level digital
ered in the original conceptualization of the medication divide among Internet users. Canadians with the lowest
administration process. Operationalizing nurses’ clinical health-literacy skills were found to be more than 2.5 times
knowledge and possessing an understanding of informat- as likely to describe their health as fair or poor relative to
ics may assist in developing better and more functional Canadians with excellent literacy skills (Canadian Coun-
ICT to support client care. cil on Learning [CCL], 2008). Similarly, individuals with
lower health-literacy skills were also more than 2.5 times
as likely to be receiving income support (CCL, 2008).
Consumers’ Health Hirji (2004) has noted that barriers to accessing health
information and services are associated with low literacy
Informatics and levels and limited technological skills, particularly among
older adults. These systemic barriers mean that certain
Online Information Access Canadians cannot access online health or other resources
related to important determinants of health (e.g., educa-
According to Statistics Canada (2011), in 2010, nearly tion and employment) (Middleton & Sorensen, 2006).
80% of Canadian households had access to the Inter- Currently, contemporary models of health care advo-
net, and many used multiple devices to go online. North cate for a client-centred model that places increased respon-
Americans increasingly use the Internet as a tool for sibility for self–health care with the individual. Health
improved access to health information and health care. education, a component of client-centred care, requires a
In fact, the widespread availability of the Internet has skill set that enables access to and comprehension of health
dramatically opened public access to health and medical educational material. However, many Canadians do not
information that was previously the domain of expert have the necessary literacy skills—reading, writing, speak-
knowledge (Anderson, Rainey, & Eysenbach, 2003). This ing, and other forms of communication— to meaning-
rise in online information seeking is not unexpected, fully participate in these important health care discussions
given the increased prevalence and popularity of tablets, (Statistics Canada, 2003). General literacy skills include
smartphones, laptops, and other Internet-capable devices, prose, document, and numeric literacy. According to the
which are becoming commonplace in Canada. Regard- most recent International Adult Literacy and Life Skills
less, as outlined by Ferguson and Risling (2016), despite Survey (Statistics Canada, 2013), almost half the Cana-
the availability of the Internet, nurses should not assume dian adults do not have the prose or numeric literacy skills
that everyone has access to or is willing to use the Internet needed for daily functioning, and nearly 20% cannot per-
to access information and/or services. The Canadian form simple mathematical tasks. Older adults have even
Radio-television and Telecommunications Commission poorer skills: 27% of individuals aged 56 to 65 years and
(CRTC) forecasted that by the end of 2015 all Canadians 52% of those aged 66 years and older have difficulty with
would have broadband Internet access (including those basic reading.
living in rural and remote areas but this goal is not yet Fundamental to effective use of health informa-
reached). Despite promised access based on technology tion is literacy and health literacy skill (Nutbeam, 2000;
infrastructure, the 2010 Canadian Internet Use Survey Calgary Charter on Health Literacy, 2008). Health
reported that of the one-fifth (21%) of households without literacy is defined as the degree to which a person
home Internet access, over one-half (56%) reported they has the capacity to obtain, interpret, and understand
had no need for or interest in it. Other reasons for lack basic health-related information and to make appro-
of Internet access included the cost of Internet service or priate health care decisions (Nutbeam, 2000; Calgary
computer equipment (20%) or the lack of a device, such Charter on Health Literacy, 2008). Low levels of literacy
as a computer (15%). About 12% of households reported constitute a major barrier to accessing and using health
they lacked the confidence, knowledge, or skills to support information to make informed health decisions. Canada
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Although informatics provides immense opportunities

Evidence-Informed Practice for collaboration, sharing, and exchange, care must be
taken to ensure the anonymity of patients and their
Do Online Communities of Practice information.
Professionalism within a digitally connected world is
Facilitate Knowledge Exchange? essentially no different from that in a noncomputerized
In this study, it was found that community health nurses world. That said, the context in which professionalism
(CHNs) working with vulnerable homeless populations were operates within nursing and health care has changed.
able to use an online community for knowledge exchange. Unlike a decade ago, mobile devices, high-speed wireless
The researchers in the study developed an online community Internet, and digital cameras were not prevalent within
of practice (CoP) that would provide CHNs with a secure online nursing populations. Currently, many of these mobile
space to create discussion threads, collaborate on best prac-
tices, and connect geographically dispersed members. Using
and Internet-connected devices are readily available
Q-methodology, the authors were able to identify two different within clinical environments or are personally owned by
thematically related user groups—(a) tacit knowledge warriors nurses. Similarly, with the increased use of social media
and (b) tacit knowledge communicators. Warriors believed the technologies, the blurring of personal and professional
CoP could be used for such purposes as political awareness roles has become a salient topic within nursing practice.
and for the validation of nursing practice considerations. The In 2014, the International Nurse Regulator Col-
communicators were neutral regarding the emancipatory ele- laborative (INRC) released a position statement regard-
ments espoused by the warriors, stating that they wished the
CoP was more interactive in regards to having their questions
ing social media use within the nursing profession. The
promptly answered, enabled by a discussion facilitator. All par- INRC stated that “while social media is a beneficial tool,
ticipants agreed that the CoP would be a valuable tool to share there are principles that nurses need to pay attention to in
information, knowledge, and experiences with other CHNs. order to reduce risks to members of the public” (INRC,
Nursing Implications: The study examined not only
2014, para 2). They recommend that all nurses follow the
the functionality of the technology but also other vari- six key tenets when using social media: professional, posi-
ous sociotechnical responses by CHNs (i.e., warriors, tive, patient/person-free, protect yourself, privacy, and
communicators) emerging through their participation pause before you post.
and use of the online CoP. This deeper-level examina- Therefore, it is important that nurses uphold the
tion of a health ICT system reinforces the need to con- same professional standards of practice in the online
sider the ongoing and evolving relationship between world as in the physical realm. In some respects, the
humans and technology—not all users of technology
will react or “use” the ICT in the same fashion, as evi-
blurring between nurses’ online presence (e.g., on Face-
denced in this study. book, Twitter, LinkedIn) and their physical represen-
tation is quickly making them “one and the same.”
Source: Based on Valaitis, R. K., Akhtar-Danesh, N., Brooks, F., Binks, S., &
Semogas, D. (2011). Online communities of practice as a communication resource
Therefore, any online activity by nurses may be scruti-
for community health nurses working with homeless persons. Journal of Advanced nized if deemed to violate professional standards of the
Nursing, 67(6), 1273– 1284.
province or territory.
Although there are many horror stories revolving
around inappropriate use of social media technologies
has a significant percentage of adults (60%) who lack within the profession (see Box 25.8), significant benefits
the skills to manage their health literacy needs, with the can come from having a functional and robust online
most vulnerable being seniors (ages 66 years and older); presence. The use of professional networking sites can
immigrants, especially those who do not speak either assist nurses in terms of finding employment, connect-
French or English; and people who are not employed ing with others, sharing information or resources, and
(CCL, 2008). Without adequate health literacy skills, ill- expanding a nurse’s professional network (Fraser, 2011).
informed decisions may be made, health conditions may
go undetected or worsen, and people may get lost in the
health care system (CCL, 2008). Given the increasing
role of the Internet as a primary source of informa- Box 25.8 Violation of Professionalism
tion about health and medical topics (see the Evidence- Online
Informed Practice box), health literacy constitutes a Recent Examples from the News Media
significant health care issue for nurses and clients.
1. Ex–Ty Hafan hospice nurse given six-month ban over
Facebook outbursts: http://www.bbc.com/news/
Professional Issues uk-wales-south-east-wales-23950614

2. Nurse firing highlights hazards of social media in
hospitals: http://abcnews.go.com/Health/nurse-
As society becomes connected through various ICT firing-highlights-hazards-social-media-hospitals/
and Internet-related technologies, nurses must be aware story?id=24454611
of the evolving professional practice responsibilities.
M25_KOZI2703_04_SE_C25.indd 495 27/02/17 1:07 PM

The use of social networking sites, such as LinkedIn remain abreast of developments in nursing informatics
and Twitter, can provide a competitive advantage for through involvement in professional organizations and
nurses who are seeking to demonstrate their knowledge reflective practice requirements.
or expertise in a specific nursing area or to build a net- The role of informatics within nursing will continue
work of colleagues to collaborate on various projects or to evolve and broaden over time. As outlined previously,
research studies. although there will be differing levels of engagement by
nurses in the informatics discipline, skills, knowledge,
and understanding of informatics in care delivery are
important for all clinicians. For instance, nurses must not
Conclusion only understand the underpinnings of nursing informat-
ics but also be ready to leverage and generate the future
Nursing informatics will continue to evolve as the impor- opportunities for informatics within practice. The com-
tance, accessibility, and understanding of informatics is ing decades promise many new innovations in health
realized within the profession. Since health care is an care technology—including nanotechnology, the ubiq-
information-rich environment, possessing the skills to use uitous Internet, and an increased prevalence of mobile
ICT to support patient care will be essential in the com- and wearable technologies. Therefore, without a critical
ing decades. Informatics can provide significant benefits mass of nurses engaged in the topic of informatics and
to the profession; regardless, sound clinical judgment of technology, the nursing profession will not be able to pro-
nurses must prevail when using technology to support vide the quality service that is expected by all Canadians
clinical practice. Therefore, it is important that nurses into the future.
Case Study 25
As a nurse working for a home care agency in a rural town, you
2. One of your clients has a complex leg wound, and you
want your clients to receive current and accu-
wish to obtain a consult from the covering wound care
rate health information. High-speed Internet
nurse. The wound care nurse is unable to physically see
access is available in your office, and many of
the client because of scheduling issues. What types of
the residents have computers in their homes
secured and approved ICTs could a home care nurse
with dial-up connections.
use to assist in completing this consult?
3. A client shares with you a website promising a cure for
the client’s illness. How would you respond?

1. You have a difficult clinical case and want to investigate
possible interventions. How can handheld or computer
technology assist in this endeavour?
Ke y Terms
application software electronic medical mobile technology portals p. 488
system p. 487 record (EMR) p. 486 p. 489 social media p. 485
bandwidth p. 491 electronic patient record nurse informaticians
software p. 484
computerized (EPR) p. 486 p. 492
standardized
provider order entry hardware p. 484 NurseONE portal p. 488
language p. 485
(CPOE) p. 487 health literacy p. 494 nursing informatics
data p. 484 information p. 484 p. 483 systems p. 484
decision-support information and personal digital tacit knowledge p. 493
systems p. 484 computer technology assistants (PDAs) technological
digital transition p. 491 (ICT) p. 484 p. 489 determinism p. 493
eHealth p. 483 information (digital) picture and archiving
telehealth p. 487
electronic literacy p. 491 communication
documentation p. 487 knowledge p. 484 system (PACS) p. 487 World Wide Web
electronic health record media literacy p. 491 point of care (POC) (WWW) p. 485
(EHR) p. 486 mHealth p. 489 p. 488 workflow p. 493
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C hapter Highlig hts

• Nursing informatics is the science of using computer monitors, blood glucose analyzers, ventilators, IV pumps,
information systems in the practice of nursing. CT, and MRI.
• A hospital information system (HIS) organizes data from • Telehealth and remote monitoring allows health care
various areas in the hospital such as admissions, medical professionals to provide care via electronic means of
records, clinical laboratory, pharmacy, order entry, and communication.
finance.
• Patient portals allow retrieval of client data and accounts.
• Concerns regarding privacy and confidentiality of health
Appointments can be scheduled using computers.
records have arisen as electronic databases and communi-
cations have proliferated. • Mobile technologies are used by home health nurses to
• Computers are used extensively to locate and access data record client data and to communicate with other care
through online databases and Internet searching. Many providers. Clients can also have computers in the home
nursing journals are electronic. that allow them to monitor their own health status and
send information about their condition to the nurse.
• Electronic health records (EHRs) enable data to be col-
lected on a client and made available to all health care • Specialized computer software programs enable case
providers who require it. managers to track clients’ needs, resources, and health
• Computer monitoring and diagnosing of client conditions care outcomes.
is widespread. Examples include digital or tympanic ther- • Each step of the nursing research process makes use of
mometers, digital scales, pulse oximetry, ECG, telemetry, computer technology. In particular, computers are used to
hemodynamic monitoring, apnea monitors, fetal heart access literature, analyze data, and report findings.
NCL EX- st yle pr acti c e qui z

1. Which of the following best defines nursing informatics? c. Disseminating the research findings
a. The compilation of information about nursing d. Designing the steps of the research plan
b. The use of computer information systems in the
practice of nursing 5. Which of the following is the most appropriate nursing
c. The results of research in nursing available online response when a client insists that the practitioner use a
treatment method discovered on an Internet site?
d. The ability to take nursing courses in an online format
a. “The treatment must be examined to see if it is
2. Which of the following presents the greatest challenge asso- appropriate.”
ciated with the use of an electronic client record system? b. “Most website treatments have not been studied or
researched.”
a. Cost
c. “Websites are like advertising; they are biased and
b. Accuracy may not be legitimate.”
c. Privacy d. “The person who established the website is the only
d. Accessibility one who can use it on clients.”
3. A public health nurse is developing a health and safety 6. Which of the following is a primary role of the nurse in
program for adolescents. The nurse wants to make telehealth practice?
this information as readily accessible as possible to this a. To inform the client’s health care provider of the call
population. Which strategy would be most effective at
reaching this population? b. To offer advice about the care being received by a client
a. Developing pamphlets and having high school coun- c. To evaluate a previous response received by a client
sellors distribute them via telehealth
b. Offering face-to-face 1-hour sessions over a 6-week d. To deliver health information, services, and expertise
period over any distance
c. Developing a Facebook page 7. How can the electronic health record improve client care?
d. Using a Twitter feed with a weekly hashtag a. It can be easily transported by the client and others.
conversation
b. It provides constant availability of client health
information.
4. Which of the following is the primary advantage of
using computers while conducting nursing research? c. It is understood and accepted by everyone
in health care.
a. Locating potential participants
d. It is easily accessed by any health care professional
b. Analyzing the quantitative data anywhere in the world.
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8. Which of the following organizations is funded by the c. Electronic health records (EHRs)
Government of Canada to invest in electronic health d. Mobile health (mHealth)
records–related (EHR-related) initiatives across Canada?
a. The Romanow Commission 10. A nurse in a community clinic has completed a health
b. Telehealth Canada assessment on a client. During the assessment process
c. Canada Health Infoway the nurse identified that the client needed teaching
about one of his medications and that he has limited
d. Canadian Nurses Association
health literacy skills. Which strategy should the nurse
use to best facilitate the teaching-learning process with
9. A nurse is involved in a pilot project called “Home this client?
Health Monitoring” to support clients remaining at
home and to improve heart health outcomes for these a. Provide the client with a handout on this medication
individuals. The clients enrolled in the program use to review at home
biometric capturing tools to submit clinical data to the b. Have a family member present during the teaching
nurse. The nurse provides education, interpretation of c. Verbally review the medication with the client
health data, and tracking of client progress, and facili- d. Use an iPad to show the client a video about this
tates improved client self-management skills. What is the medication
most accurate way to categorize this health program?
a. Telehealth
b. Health portal
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Chapter 26
Teaching and Learning
Updated by
C
LEARNING OUTCOMES
After studying this chapter, you will be able to lient education is a
1. Discuss the importance of the teaching role of the nurse. major aspect of nursing
practice and an impor-
2. Define andragogy, pedagogy, and geragogy.
tant independent nursing function.
3. Describe the three main categories of learning theories and their
Nursing regulators in Canada spec-
implications for teaching.
ify in their practice standards that
4. Discuss factors that facilitate or inhibit learning throughout the
teaching is a required competency
lifespan.
for nursing practice. Best practice
5. Discuss the identification of learning needs, teaching strategies,
guidelines for client-centred care
and expected learning outcomes.
also stress the importance of includ-
6. Discuss the nurse’s role in assisting clients to use health
ing teaching in client care. Teach-
information on the Internet.
ing needs should focus on providing
7. Describe essential aspects of effective teaching in clinical practice.
information on issues for which cli-
8. Discuss advantages and disadvantages of selected teaching ents have expressed needs in a man-
strategies.
ner that is meaningful and relevant to
9. Identify methods used to evaluate learning outcomes. them (Registered Nurses Association
of Ontario [RNAO], 2012). Legislation
related to nursing also includes client
teaching as a function of nursing,
thereby making teaching both a legal
and a professional responsibility.
Porter-O’Grady and Malloch
(2011) described nursing in the
twenty-first century as focusing on
team-based, relational, and inte-
grated functions that include activities
of accessing information, informing,
guiding, teaching, and counselling c
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Chapter 26 Teaching and Learning 501
c clients, with a focus on early client engagement and preventative interventions. Client education, a
key part of this role, is multifaceted, involving promoting, protecting, maintaining, and restoring health
and helping clients cope with illness or altered health status. Client education involves teaching about
reducing health risk factors, increasing a person’s level of wellness, taking specific protective health
measures, coping with diagnostic procedures and treatments, managing symptoms of illness, and
optimizing health status. All nurses are client educators, and most client interactions involve teaching.
See the Lifespan Considerations box in Chapter 8 (page 126) for examples of health-promotion teach-
ing topics for various age groups.
Teaching client’s home, and assisted-living and long-term care

facilities. Nurses also teach professional colleagues and
auxiliary health care personnel in academic institutions
Teaching is a system of activities intended to produce and health care facilities.
learning that facilitates enduring changes in behaviour
or ways of thinking. The teaching–learning process
is intentionally designed to produce specific learning
and involves dynamic interaction between teacher and Teaching Clients and Their Families
learner. Each participant in the process communicates Nurses may teach clients in one-to-one individualized
information, emotions, perceptions, and attitudes to the teaching sessions or in groups. For example, the nurse
other. The teaching process and the nursing process are may teach about wound care while changing a client’s
much alike. See Table 26.1. dressing or about diet, exercise, and other lifestyle behav-
Nurses teach clients and their families in a range iours that minimize the risk of a heart attack for a client
of settings, including hospital, primary health care clin- who has a cardiac problem. Clients are often taught
ics, community health centres, urgent care facilities, the in small groups in preparation for elective surgery in
preadmission clinics or in groups in the community,
Table 26.1 Comparison of the Teaching Process and the
addressing issues of healthy lifestyle. The nurse may also
Nursing Process be involved in teaching family members or other support
people who are caring for the client.
Step Teaching Process Nursing Process Because of the decreased length of hospital stays,
1 Collect data; analyze Collect data; analyze time constraints on client education can occur. Nurses
client’s learning client’s strengths and need to provide education that will ensure the client’s
strengths and deficits. safe transition from one level of care to another and
deficits. make appropriate plans for follow-up education in the
2 Make educational Make nursing diagnoses. home. Discharge plans must include both information
diagnoses. about what the client has been taught before transfer or
3 Prepare teaching Plan nursing goals or discharge and information about what remains for the
plan: desired outcomes, and client to learn to perform self-care in the home or other
select interventions. residence. (See the discussion of discharge planning in
• Write learning
outcomes. Chapter 14, page 254.)
• Select content
and time frame.
• Select teaching Teaching in the Community
strategies.
Nurses are often involved in community health educa-
• Select teaching
resources. tion programs. Such teaching activities may be part
of the nurse’s involvement in an organization, such as
4 Implement teaching Implement nursing
plan. strategies. seniors’ centres or Planned Parenthood, or with other
sectors in the community concerned with the well-being
5 Evaluate client Evaluate client outcomes
learning on the on the basis of achieve-
of citizens. Community teaching activities may be aimed
basis of achievement of goal criteria. at large groups of people who have an interest in some
ment of learning aspect of health, such as nutrition classes, cardiopulmo-
outcomes. nary resuscitation (CPR), cardiac risk factor reduction,
M26_KOZI2703_04_SE_C26.indd 501 27/02/17 5:38 PM

or bicycle or swimming safety programs. Community An important aspect of learning is the individual’s
education programs, such as childbirth preparation desire to learn and to act on the learning, referred to as
classes or family planning classes, are frequently offered. compliance. In the health care context, compliance is
the extent to which a person’s behaviour coincides with
medical or health advice. Since the term compliance may
Teaching Health Care Personnel imply that learners are not decision makers about their
own health, the term adherence is often used to reflect
Nurses are also involved in the instruction of professional the client’s engagement in the learning process and will-
colleagues through continuing education, in-service pro- ingness or ability to follow a recommended treatment
grams, and staff development. For example, experienced regimen. Adherence is best illustrated when the person
nurses can act as preceptors for students and new gradu- recognizes and accepts the need to learn and then
ate nurses. Nurses with specialized knowledge and expe- follows through with the appropriate behaviours that
rience can share that knowledge with nurses who are reflect the learning. For example, a person diagnosed as
new to that practice setting. Experienced nurses are often having diabetes willingly learns about the special diet
involved in the clinical teaching of nursing students. needed and then plans and follows the learned diet.
They may also teach specialized courses, such as critical Bastable (2014) explained both compliance and adher-
care nursing, perioperative nursing, and quality improve- ence as the client’s ability to maintain “health-promoting
ment or quality assurance processes. regimens, which are determined largely by a health care
Nurses can also be involved in teaching other health provider” (p. 219). Nurses should be cautious about
care professionals. They may participate in the educa- labelling clients as noncompliant. Clients may intend to
tion of medical students or allied health students. In this follow the treatment regimen but may be unable to do
capacity, the nurse educator clarifies the role of the nurse so for a number of reasons (e.g., no access to care or
for other health care professionals or how nurses can cannot afford the medicine).
work with them in caring for clients. Andragogy is the art and science of teaching with
a special focus on adults. Pedagogy is concerned with
all teaching and learning strategies regardless of age,
Learning although this Greek term refers to teaching children.
Geragogy is focused on the learning of older adults.
Nurses can use the following principles of adult learning
Clients have a variety of learning needs. A learning as a guide for client teaching (Bastable, 2014; Knowles,
need is a desire or a requirement to know something Holton, & Swanson, 2011):
that is presently unknown by the learner. Learning needs
include new knowledge but can also include a new skill • As people mature, they move from dependence to
or physical ability, a new understanding about an issue, independence.
new beliefs, or a way to change an ineffective behaviour. • An adult’s previous experiences can be used as a
Learning is a change in human disposition or capabil- resource for learning.
ity that persists and that cannot be accounted for solely • Learning is related to an immediate need, problem,
by growth. or deficit.
Learning is a cognitive activity that is represented
by a change in behaviour. Cognitive refers to the act of • An adult is more oriented to learning when the mate-
knowing or the development of knowledge. See Box 26.1 rial is useful immediately, not sometime in the future.
for attributes of learning. • Learning is reinforced by application and prompt
feedback and reflection.
Box 26.1 Attributes of Learning Learning Domains

Learning can take many forms that share the following Bloom (1956) identified three learning domains: (a) cog-
attributes: nitive, (b) affective, and (c) psychomotor. The cognitive
• An experience that occurs inside the learner domain includes six intellectual skills, from simple to
• The discovery of the personal meaning and relevance of complex, beginning with knowing, comprehending, and
ideas applying. The affective domain involves five major
• A consequence of experience learning categories: (a) feelings, (b) emotions, (c) interests,
• A collaborative and interactive process (d) attitudes, and (e) appreciations. The psychomotor
• An evolutionary process that builds on past learning and domain includes motor skills, such as giving an injec-
experiences tion, and also reflects a development hierarchy of skills,
• A process that is both intellectual and emotional reflecting increasing independence in performance of
the skill.
M26_KOZI2703_04_SE_C26.indd 502 27/02/17 5:38 PM

Nurses should include cognitive and affective Major cognitive theorists include Piaget, Lewin, and
domains in every teaching plan and all three domains Bloom (Bastable, 2014). As discussed in Chapter 17,
when teaching a skill. For example, teaching a client the Piaget’s (1966) five major phases of cognitive develop-
skill of how to irrigate a colostomy bag is in the psy- ment include the following phases: (a) sensorimotor, (b)
chomotor domain; understanding when the procedure preconceptual, (c) intuitive, (d) concrete operations, and
should be carried out is in the cognitive domain. Accept- (e) formal intuitive. Lewin (1951) viewed learning as
ing the colostomy bag as a part of the new body image involving four different types of change: changes in (a)
and maintaining self-esteem during the procedure is in cognitive structure, (b) motivation, (c) sense of belonging
the affective domain. to the group, and (d) voluntary muscle control.
Nurses applying cognitive theory will do the
following:
Learning Theories
• Provide a social, emotional, and physical environment
Three main theoretical constructs of learning theory conducive to learning
are (a) behaviourism, (b) cognitivism, and (c) humanism
• Encourage a positive teacher–learner relationship
(Bastable, 2014).
• Select multisensory teaching strategies
Behaviourism Edward Thorndike originally advanced
• Recognize that personal characteristics have an
behaviourism, a theory based on learning as reflected in
impact on learning
changes in behaviour. Other major behaviourist theo-
rists include Pavlov, Skinner, and Bandura (Bastable, • Develop teaching approaches to target different learn-
2014). In the behaviourist school of thought, an act is ing styles
called a response when it can be traced to the effects of a • Adapt teaching strategies to the learner’s developmen-
stimulus. Behaviourists closely observe responses and then tal level and readiness to learn
manipulate the environment (stimuli) to bring about the • Select teaching strategies that encompass the
intended behaviour change. cognitive, affective, and psychomotor domains of
Skinner also introduced the importance of positive learning
reinforcement in fostering repetition of an action.
Bandura (1971) claimed that most learning comes from Humanism Humanism, or humanistic learning the-
observational learning or instruction rather than from ory, focuses on both the cognitive and the affective quali-
trial-and-error behaviour. Bandura’s research focused ties of the learner. Prominent members of this school
on imitation, the process by which individuals copy or of thought include Maslow and Rogers. According to
reproduce what they have observed, and modelling, humanistic theory, learning is self-motivated, self-initiated,
the process by which a person learns by observing the and self-evaluated. Each individual is viewed as a unique
behaviours of others (Bastable, 2014). composite of biological, psychological, social, cultural,
Nurses applying behaviouristic theory will do the and spiritual factors. Learning focuses on self-development
following: and achieving full potential; it is best achieved when
it is relevant to the learner. Autonomy and self-determi-
• Provide time and opportunities for learners to solve nation are important; the learner is an active participant
problems by trial and error and takes responsibility for meeting his or her learning
• Select teaching strategies that evoke the desired needs.
behaviours Nurses applying humanistic theory will do the
• Praise the learner for correct behaviour and provide following:
positive feedback at intervals throughout the learning
experience • Recognize the importance of the nurse–client rela-
tionship on learning
• Provide role models of the desired behaviour
• Encourage learners to identify their own learning
needs and establish goals
Cognitivism Cognitivism, or cognitive theory,
depicts learning as a complex cognitive activity that • Encourage active learning by serving as a facilitator,
is largely a mental, intellectual, or thinking process. mentor, or resource for the learner
On the basis of their personal characteristics, experi- • Provide information or assist learners to access and
ence, and perceptions of their environments, cognitiv- evaluate new, relevant information
ists emphasize the importance of the social, emotional,
and physical contexts in which learning occurs. The
teacher–learner relationship and environment are con- Factors Affecting Learning
sidered important. Developmental readiness and indi-
vidual readiness and motivation are other key factors The nurse should be aware of the following factors that
with cognitive approaches. can facilitate or hinder optimal learning by a client.
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Age and Developmental Stage Three major fatigued, she is more likely to understand the need to
developmental stage factors associated with clients’ read- lose weight if she remembers having had more energy
iness to learn include physical, cognitive, and psychoso- when she weighed less. The nurse needs to validate the
cial maturation. Nurses need to consider these factors at relevance of learning with the client throughout the
each developmental period throughout the lifespan of learning process.
their clients (Bastable, 2014). (See Chapter 17.)
Feedback Feedback is information regarding a per-
Motivation Motivation to learn is the desire to learn. son’s performance in meeting a desired goal; it needs to
Motivation is generally greatest when a person experi- be meaningful and given in a timely manner. Feedback
ences a need and believes the need will be met through that accompanies the practice of psychomotor skills
learning. The nurse’s task is to help the client identify helps the person learn those skills. Support of desired
the need and to meet it. For instance, clients with heart behaviour through praise, positively worded corrections,
disease may need to know the harmful effects of smok- and suggestions for improvement are ways of providing
ing before they recognize the need to stop smoking; or positive feedback. Negative feedback, such as ridicule,
adolescents may need to know the consequences of an anger, or sarcasm, can lead people to withdraw from
untreated sexually transmitted infection before they see learning.
the need for treatment.
Nonjudgmental Support People learn best when
Readiness Readiness to learn refers to demon- they believe they are accepted and not being judged.
strated behaviours that reflect not only the client’s will- Once learners have succeeded in accomplishing a task
ingness to learn but also his or her ability to learn at a or understanding a concept, they gain self-confidence
specific time. For example, a client may want to learn in their ability to learn. This confidence reduces their
self-care during a dressing change, but when experi- anxiety about failure and can motivate further learning.
encing pain he may not be able or ready to learn. The Nonjudgmental support contributes to a positive and
nurse’s role relates to assessing the client’s readiness to safe climate for learning.
learn and creating the conditions that make it easier for
the client to learn. Simple To Complex Learning is facilitated by mate-
rial that is logically organized and proceeds from the simple
Active Involvement When the learner is actively
to the complex. Such organization enables the learner to
involved in the process of learning, learning becomes
comprehend new information, assimilate it with previ-
more meaningful and faster, and retention is better
ous learning, and form new understandings. Simple and
(Figure 26.1). Active learning promotes more effective
complex are relative terms depending on the level at which
problem solving and application of learning to the cli-
the person is learning. What is simple for one person may
ents’ own situations. For example, clients who are actively
be complex for another.
involved in learning about their therapeutic diets may be
more able to apply the principles being taught to their Repetition Repetition of key concepts and facts facili-
cultural food preferences and their usual eating habits. tates retention of newly learned material. When the
Relevance The client can learn more easily if he or same information is provided in several formats, includ-
she can connect or relate the new knowledge or skills to ing visual and verbal formats, and in examples, such
what he or she already knows. For example, if a client repetition can reinforce learning. Practice of psycho-
is diagnosed with hypertension, is overweight, and is motor skills, particularly with feedback from the nurse,
improves performance of those skills and facilitates skill
transfer to another setting.
Timing People retain information and psychomotor

skills best when the time between learning and active
use of the learning is short; the longer the time interval,
the higher the chances of the learning being forgotten.
Immediate application facilitates learning. For example,
a person who is only shown literature and videotapes

about self-administering insulin and is not permitted to
self-administer the insulin until discharge from the hos-
pital is unlikely to remember what was learned. Learning
will be enhanced, however, if the person can self-administer
injections while still in hospital.
Environment An optimal learning environment with

reduced distractions facilitates learning. Noise can dis-
Figure 26.1 Learning is facilitated when the client is tract the learner and interfere with listening and think-
interested and actively involved. ing. To facilitate optimal learning, nurses choose a time
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Table 26.2 Common Barriers to Learning
Barrier Explanation Nursing Implications

Acute illness The client requires all resources and Defer teaching until the client is less ill. Focus teaching on
energy to cope with illness. coping with symptoms.
Pain Pain decreases a client’s ability to Assess and control pain before teaching.
concentrate.
Prognosis The client can be preoccupied with Defer teaching to a better time. Focus the teaching on
illness and unable to concentrate coping strategies.
on new information.
Biorhythms Mental and physical performances Adapt the time of teaching to suit the client.
have a circadian rhythm.
Emotions (e.g., anxiety, Emotions deplete energy and distract Deal with emotional responses to learning and possible
denial, depression, grief) from learning. misinformation first. Provide repetition of content.
Language The client may not be fluent in the Obtain the services of an interpreter or a nurse with
nurse’s language. appropriate language skills. Increase teaching time.
Age
• Older adults Vision, hearing, and motor control can Consider sensory and motor deficits in the teaching plan.
be impaired in older adults.
• Children Children have a shorter attention span Plan shorter and more active learning episodes.
and vocabulary limitations.
Culture or religion There may be cultural or religious Assess the client’s cultural or religious needs when plan-
restrictions with regard to acquir- ning learning activities.
ing certain types of knowledge, for
example, birth control information.
Physical disability Visual, hearing, sensory, or motor Plan teaching activities appropriate to learner’s physical
impairments may interfere with a abilities. For example, provide audio learning tools for
client’s ability to learn. the client who is blind, or large-print materials for the
client whose vision is impaired.
Mental disability Impaired cognitive ability may affect Assess client’s capacity for learning and plan teaching
the client’s capacity for learning. activities to complement the client’s ability. Plan more
complex learning for the client’s caregivers.
or location in which distractions in the environment are Cultural Barriers Cultural barriers to learning
limited and interruptions are unlikely. include language, beliefs, and values. Western medicine
Privacy is essential for some learning. For example, may conflict with cultural healing beliefs and practices.
when a client is learning to irrigate a colostomy bag, the Nurses need to be competent in providing culturally safe
presence of others can be embarrassing and, thus, inter- and sensitive care; otherwise, the client may be partially
fere with learning. However, when a client is particularly or totally noncompliant with recommended treatments.
anxious, having a support person present can give the Another impediment to learning is differing values held
client confidence. Some of the most common barriers to by clients and their health care providers. For example,
learning are described in Table 26.2. clients who come from a culture that does not value
slimness may have difficulty learning about a weight-
Emotions Emotions, such as high anxiety, fear, anger,
reducing diet. The nurse and the client therefore should
and depression, can impede learning. Clients or fami-
together determine an acceptable weight and develop
lies who are experiencing extreme emotional states
a plan for achieving that weight (Purnell & Paulanka,
may retain only part of the communication. Emotional
2008).
responses, such as fear and anxiety, may be relieved by
information that relieves uncertainty. Psychomotor Ability Nurses must be aware of
a client’s psychomotor skills when planning teaching.
Physiological Events Physiological events, such as
Motor abilities can be affected by health status. For
a critical illness, pain, or sensory deficits, inhibit learning.
example, an older adult who has severe osteoarthritis
Certain drugs and treatments can interfere with the cli-
of the hands may not be able to put on a bandage. The
ent’s ability to concentrate and apply energy to learning,
following physical abilities are important for learning
and the learning itself is impaired. The nurse should try
psychomotor skills:
to reduce the physiological barriers to learning as much
as possible before teaching. Some clients, however, may 1. Muscle strength. For example, an older client who can-
find it helpful to have analgesics and rest before learning. not rise from a chair because of insufficient leg and
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muscle strength cannot be expected to learn to lift knowledge, the change process, learning theories, and
herself out of a bathtub without assistance. the nursing and teaching processes when teaching clients
2. Motor coordination. Gross and fine motor coordination and their families.
are required for many skills. For example, a client who
lacks hand coordination will probably find it difficult Assessing
to self-administer an injection. A comprehensive assessment of learning needs incor-
3. Energy. Energy is required for most psychomotor skills porates data from the nursing history and physical
and learning these skills uses more energy. People who assessment and addresses the client’s support system. It
have limited energy may be taught skills during the also considers client characteristics that can influence
times when their energy levels are highest. the learning process: for example, readiness to learn,
4. Sensory acuity. Sight is used for most learning. Clients who motivation to learn, and reading and comprehension
are visually impaired often need the assistance of a sup- level. Learning needs change as the client’s health status
port person to learn some tasks. changes, so nurses must constantly reassess them.
Nursing History Several elements in the nursing
history provide clues to learning needs as well as client
Nurse as Educator strengths and limitations. These elements include the
client’s (a) age, (b) understanding and perceptions of the
Being an educator is a primary role for the nurse. Cli- health problem, (c) health beliefs and cultural practices,
ents and families have the right to health information (d) economic factors, (e) learning style, and (f) support
to make informed decisions about their health and ill- systems. Examples of open-ended interview questions
ness. The nurse’s role is to promote healthy lifestyles or to elicit this information are shown in the Assessment:
better health status through the application of health Interview box.
Learning Needs and Characteristics

The use of opened-ended questions can help nurses find evidence of clients’ learning needs.
Primary Health Problem • Does your current doctor know about these medications?
• Tell me what you know about your current health problem. • What health professional’s advice or treatments conflicted
What do you think caused it? with your values or beliefs?
• What concerns do you have about it? • When a conflict arose, what did you do?
• How has the problem affected what you can or cannot do
during your usual activities? Learning Style
• What do you or did you do at home to relieve the prob- • What is your highest level of formal education?
lem? How helpful was it? • Do you like to read?
• How have the treatments you have started helped your • Where do you obtain health information (e.g., physician,
problem? nurse, magazines, books, pharmacist, Internet, and so on)?
• What, if any, difficulties have the treatments caused you? • How do you best learn new things?
• Tell me what you know about the tests (surgery, treat-
ments) you are going to have. a. By reading about them
b. By asking questions and discussing them
Health Beliefs c. By watching a demonstration
• How would you describe your health generally? d. By using Internet-based resources
• What things do you usually do to keep healthy? e. By listening to the teacher
• What health problems do you think you may be at risk for f. By first being shown how something works and then
because of family history or lifestyle? doing it
• What changes would you be willing to make to decrease g. By working on your own or in a group
your risk for these problems or to improve your health? h. By reflecting on what was learned
Cultural Factors Client Support System

• What language do you use most often when speaking and • Would you like a family member or friend to help you
writing? learn about the things that you need to do to take care of
• Do you seek the advice of another health care practitioner? yourself?
• Do you currently use any herbs, treatments, or remedies • Who do you think would be interested in learning with
commonly used in your cultural group? you?
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Age Age provides information on the person’s develop- concern may indicate knowledge deficits or misinfor-
mental status that may indicate the need for distinctive mation. In addition, the effects of the problem on the
health teaching content or teaching approaches. Simple client’s usual activities can alert the nurse to other areas
questions to school-age children and adolescents will requiring instruction. For example, people who cannot
elicit information on what they know. Observing younger manage self-care at home often need information about
children at play provides information about their motor community resources and services.
and intellectual development as well as their relation-
Health Beliefs and Cultural Practices The client’s
ships with other children. For older people, questioning
health beliefs and practices must be considered in any
may reveal slow recall or limited motor abilities, sensory
teaching plan. The health belief model described in
deficits, or learning difficulties. (See the Lifespan Con-
Chapter 7 provides a predictor of preventive health
siderations box.)
behaviour. Many cultural groups have their own beliefs
Client’s Understanding of the Health Problem A and practices, a number of them related to diet, health,
client’s perception of a current health problem and illness, and lifestyle. Nurses need to know how the
• If noncompliance is a problem, investigate the cause. It

Special Teaching Considerations could be a result of lack of finances, lack of understanding,
OLDER ADULTS transportation problems, and so on.
Older adults may have chronic illnesses that require multiple Older adults come with a lifetime of experiences and knowl-
treatments or medications. Health teaching will focus on health edge of their own. Respect this, and always have them use their
and wellness promotion and prevention of illness and accidents, strengths to work through any problems. Positive reinforcement
as with other age groups. Older adults’ greatest need is in learn- and ongoing evaluation of what has been taught are important
ing to manage their own lives and to maintain optimal health factors in effective health teaching with older adults.
and functioning as they live with their chronic health conditions.
CHILDREN
For older adults to be motivated to learn, the material must be
practical and have meaning for them individually, especially if the The parent is a child’s first and most important teacher. Every
information is new to them. Special considerations in teaching interaction between a child and a parent (or others) is a moment
older adults include the following: in which teaching and learning occurs, often unconsciously.
Children learn by observation and interaction and pick up
• Health promotion is a priority need and should include
these areas: information, values, and skills from the world around them.
Nurses can assist parents to teach their children about health
• Exercise
promotion, disease prevention, and care and procedures, using
• Nutrition knowledge of the child’s developmental level. Considerations in
• Safety habits teaching children include the following:
• Regular health checkups
Preschool Age (3–5 Years)
• Understanding of medications
• Children at this stage are concerned about fear of pain
• Set achievable goals—involve the client and family in doing this.
and bodily harm. Reassure them and allow them to tell you
• If developing written materials, about these fears. Use words carefully. For example, use
• Use large, black print (e.g., at least 14-point font) in bul- “fix” instead of “cut”; “bandage” instead of “dressing.”
leted format. • Allow the child to play with replicas or dolls to learn about
• Use buff-coloured paper (which avoids the glare from body parts.
white paper). • Give praise and approval to motivate learning.
• Present information at the Grade 6 reading level.
Middle and Late Childhood (6–11 Years)
• Increase time for teaching and allow for rest periods as pro-
cessing of information is slower. • At this age, children are able to think logically, but abstract
• Ensure that verbal presentation of material is well organized thought is limited.
and that there is minimal distraction. • They like to be actively involved in the learning process.
• Repeat information, as necessary. • Teaching for health promotion often occurs through the
• Use return demonstrations with psychomotor skills, such as school nurse.
self-administering insulin injections.
• Determine where clients obtain most of their health informa- Adolescence (12–19 Years)
tion (e.g., newspapers, Internet, magazines, television). • Adolescents have a strong need to belong to a group,
• Use examples that clients can relate to in their daily lives. develop friendships, and maintain peer support.
• Be aware of sensory deficits, such as hearing and vision • Nurses need to develop a mutually respectful and trusting
difficulties. relationship with them.
• Use the setting with which the individual is most comfortable—
either a group setting or a one-on-one setting.
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practices and values held by clients will likely affect their The nurse assesses for these readiness characteristics:
learning needs. Folk beliefs of certain groups can also
• Physical readiness: Is the client able to focus on things
affect learning. Although the client may readily under-
other than physical status? Is the client experiencing
stand the health care information being taught, this
pain, fatigue, or nausea?
learning may not be implemented in the home where
folk health practices prevail. (See the “Health Beliefs and • Emotional readiness: Is the client emotionally ready to
Practices” section in Chapter 11 and the “Transcultural learn self-care activities? Clients who are extremely
Teaching” section later in this chapter.) anxious, depressed, or grieving over their health status
are not ready.
Learning Style Individuals have preferences about how
• Cognitive readiness: Can the client think clearly at this
they like to learn. Some people are visual learners and
point? Is the client taking any medications that may
learn best by watching; others learn by manipulating
affect his or her level of consciousness?
equipment and discovering how it works. Other people
can learn well from reading material presented in an Nurses can promote readiness to learn by providing
orderly fashion, whereas others learn best in groups physical and emotional support during the critical stage
where they can discuss the content. For many, stressing of recovery. As the client stabilizes physically and emo-
the emotional aspects promotes learning. tionally, the nurse can provide opportunities to learn.
A client’s learning style may be based on his or her
cultural background. For example, clients from cultures Motivation As discussed earlier, motivation relates to
that have a strong oral tradition may prefer educational whether the client wants to learn, and it is usually greatest
videos presented in their own language. when the client is ready, the learning need is recognized,
The nurse may not have the time to assess each and the information being offered is meaningful to the
learner’s particular learning style and then adapt teach- client. Nurses can increase a client’s motivation in several
ing accordingly; what the nurse can do, however, is to ask ways:
clients how they like to learn. Many people know what • By relating the learning to something the client values
helps them learn, and the nurse can use this information and helping the client see the benefits of learning
in planning teaching. In teaching a group, the nurse can
• By helping the client make the learning situation
use a variety of teaching techniques and vary activities to
pleasant and nonthreatening
meet all clients’ preferred ways of learning, thus address-
ing different learning styles. One learning situation will • By encouraging self-direction and independence
be effective for some clients in the group, whereas other • By demonstrating a positive attitude about the client’s
approaches may be preferable for other clients. ability to learn
Client Support System The nurse explores the cli- • By offering continuing support and encouragement as
ent’s support system to determine the extent to which the client attempts to learn (i.e., positive reinforcement)
others can enhance learning and offer support. Family • By creating a learning situation in which the client is
members or a close friend may help the client perform likely to succeed, as motivation for continued learning
required skills at home and maintain required lifestyle
changes. Health Literacy Health literacy is “the ability to
access, comprehend, evaluate and communicate infor-
Physical Examination The visual inspection part of
mation as a way to promote, maintain and improve
the physical examination provides useful clues to clients’
health in a variety of settings across the life-course”
learning abilities, such as mental status, energy level,
(Public Health Agency of Canada, 2015). It includes the
and nutritional status, as well as their physical limita-
ability to read, understand, and act on health informa-
tions to learning or to perform self-care activities. For
tion, including such tasks as comprehending prescription
example, visual ability, hearing ability, and muscle coor-
labels and nutrition labels, interpreting appointment
dination affect the selection of content and approaches
slips, completing health insurance forms, and follow-
to teaching.
ing instructions for diagnostic tests (Bastable, 2014;
Readiness To Learn A client who is ready may search Weiss et al., 2005).
out information by asking questions, reading books or Limited health literacy skills are often more preva-
articles, talking to others, and generally showing interest. lent among certain groups: older adults, people of lim-
The person who is not ready to learn is more likely to ited education, people from low-income groups, prison
avoid the subject or situation. In addition, the unready inmates, and immigrant populations with limited English
client may change the subject when it is brought up by proficiency.
the nurse. For example, the nurse might say, “I was won- Low health literacy skills are associated with poor
dering about a good time to show you how to change health outcomes and higher health care costs, and low
your dressing,” and the client responds, “Oh, my wife literacy has direct and indirect effects on almost all
will take care of everything.” aspects of health. Clients with low literacy skills have less
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information about health promotion and management

of a disease process for themselves and their families.
Teaching Clinical
They may be unable to read the educational materials
or miss the opportunity for employment where literacy Teaching Clients
is involved. with Low Literacy Levels
It is a challenge for the nurse to teach clients with
low or no reading and writing skills. However, such Nurses can use several methods to improve their success in
teaching clients with low or no reading and writing skills:
teaching is vitally important because clients with low
literacy skills need learning opportunities to improve • Use multiple teaching methods: Show pictures.
Read out important information. Lead a small group
their health practices. (See the Teaching: Clinical boxes discussion. Role play. Demonstrate a skill. Provide
on developing written teaching aids and teaching clients hands-on practice.
with low literacy levels.) • Emphasize key points in simple terms, and provide
examples.
Reading Level The nurse should not assume that
• Limit the amount of information in a single teaching
a client’s reading level is equal to the highest grade or session by providing short and frequent sessions.
level of formal education the client has completed. Most • Associate new information with something the client
word-processing programs have a readability feature, already knows or associates with his or her job or
e.g., for the Microsoft Word program, under File S lifestyle.
Options S Proofing, one can calculate the readability • Reinforce information through repetition.
of the written material. Written health education mate- • Involve the client actively in the learning.
rials should be written for lower reading levels, such as • Obtain feedback: Ask the client specific questions
the Grade 5 or Grade 6 level (Bastable, 2014; Mayer & about the information presented, or ask the client to
repeat it in his or her own words.
Villaire, 2007). People with good reading skills are not
• Avoid handouts with many pages or a classroom lec-
offended by simple reading material and prefer easy- ture format with a large group.
to-read information (see the Teaching: Clinical box on
• Explain acronyms (i.e., HDL [high-density lipoprotein],
developing written teaching aids). COPD [chronic obstructive pulmonary disease]).
Box 26.2 describes assessment data clusters and
teaching plans for two clients, Mr. Steinberg and
Mr. Evans.
Diagnosing/Analyzing
Nursing diagnoses/analyses for clients with learning needs
Teaching Clinical can be designated in two ways: (a) as the client’s primary
concern or problem, either stated by the client or identi-
Developing Written Teaching Aids fied by the nurse, or (b) as a diagnosis/problem statement
related to the learning need. As the culmination of assess-
When developing any written teaching aids, nurses should
ment, and in consultation with the client, the nurse may
consider the following guidelines:
conclude that the client’s main concern relates to a lack of
• Keep reading level at or below the Grade 6 level.
knowledge or skill in a particular area. It is important to
• Write abbreviations out in full, and define technical
terms.
target client teaching to the aspects of an issue regarding
• Use active voice, not passive voice.
which the client is lacking knowledge. The nurse’s diagno-
sis would relate to the client’s need for information on the
• Use easy, common words of one or two syllables
(e.g., use instead of utilize, or give instead of admin- diet and its application to her or his life. It is important,
ister). therefore, to identify what the client already knows or
• Use the second person (you) rather than the third is able to do, clarify any inaccuracies, and then provide
person (the client). teaching to build on existing knowledge or skills. The pro-
• Use a large type size (14 to 16 point), especially for cess of diagnosis requires critical thought and consultation
older adults. with clients and families to accurately determine the need
• Write short sentences. and the nurse’s teaching activities.
• Avoid writing something in all capital letters. NANDA International (2014) includes the following
• Place priority information first, and repeat it more diagnostic labels that could be used in learning situa-
than once.
tions: Deficient Knowledge, where clients have a need for
• Use bold font for emphasis. knowledge as a result of a change in their health status,
• Use simple pictures, drawings, or cartoons, if appro- or Readiness for Enhanced Knowledge as persons seek infor-
priate.
mation to move toward higher levels of health. Each
• Leave plenty of white space on the page to create an
easy-to-read and uncluttered appearance. of these diagnoses requires specification of the area of
learning needed. An example of this type of diagnosis
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Box 26.2 Identifying Nursing Diagnoses/aNAlyses, Outcomes, and Interventions: Clients

Requiring Teaching
Data Cluster: The nurse brings Mr. Steinberg the first dose of a new medication ordered by his physician. The nurse asks
Mr. Steinberg if he understands what this medication is and why he is taking it. He says no.
Diagnosis Desired Outcomes/ Selected Teaching

of Learning Need Long-Term Goal Evaluation Criteria Content Interventions
Lack of knowledge Client takes pre- Client conveys • Identification of • Inform the client of both
about newly prescribed medications understanding about correct medication the generic name and
scribed medication safely and monitors the safe use of name the brand name of the
self for their effects. medication. • Description of medication.
medication • Instruct the client on the
• Description of side purpose and action of the
effects of medication medication.
• Description of medica- • Instruct the client on the
tion precautions dosage, route, and dura-
tion of the medication.
• Instruct the client on
specific precautions to
observe when taking the
medication (e.g., no driv-
ing), as appropriate.
Data Cluster: George Evans is a 45-year-old man who has come to the clinic for his annual physical examination. He expresses
concern about his family history of heart disease and requests information about activities to decrease his risk of heart disease.
Expressed need The client initiates Client initiates action • Asks health-related • Assist the client in iden-
for information for change to achieve to promote well- questions, when tifying target behaviours
enhanced health personally important ness, recovery, and indicated that need to change
goals. rehabilitation. • Seeks health-related to achieve the desired
information from a vari- goal.
ety of sources • Assist the client in iden-
• Uses strategies to tifying a specific goal for
eliminate unhealthy change.
behaviours • Assess the client’s present
knowledge and skill level in
relationship to the desired
change.
• Explore with the client
potential barriers to chang-
ing behaviour.
would be Knowledge Deficit: Low-cholesterol diet for a client due to client motivation to learn. Nurses usually have the
who has a low-cholesterol diet recommended to treat his elevated knowledge to provide the requested information without
cholesterol level. The goal for the learning situation would relate formal planning and may use pen and paper illustrations
to the client’s ability to accurately describe his diet modifications or graphics on their personal digital assistants (PDAs)
(Wilkinson & Ahern, 2008). to enhance their explanations. The nurse may need to
Clinical applications of these kinds of diagnoses using access specific knowledge to appropriately inform the
the assessment data are shown in Box 26.2. client but can do so spontaneously.
Formal Planning If the client’s need to learn requires
a more extensive learning process, a formalized process
Planning or a plan for teaching will be developed. On some nurs-
Informal Teaching Clients frequently ask ques- ing units, formalized and standardized teaching plans are
tions during the course of their care. Informal teach- developed to address frequent client learning needs (Dalby,
ing is often initiated in response to these questions or Nesbitt, Frechette, Kennerly, & Lacoursiere, 2013). Devel-
other indicators of readiness to learn. These “teaching oping a teaching plan is accomplished in a series of steps.
moments” may be brief but are usually highly effective Involving the client in the process promotes the formation
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Teaching Clinical
Sample Teaching Plan: Wound Care

Assessment of Learner: A 24-year-old male university student iii. Wound care equipment
suffered a 7-cm laceration on the lower anterior part of the a. Cleansing solution
left leg during a hockey game. The laceration was cleaned, b. Dressing materials
sutured, and bandaged. The client was given an appointment
iv. Demonstration of wound cleansing and bandaging on the
to return to the health clinic in 7 days for suture removal. client’s wound
Client states that he lives in the university dormitory and is
v. Resources available for client’s questions
able to care for the wound if given instructions. Client is able
to understand and read English. vi. Follow-up treatment plan
• Nursing diagnosis: Lack of knowledge of wound and Teaching Methods
suture care
• Long-term goals: Client’s wound will heal completely 1. Describe normal wound healing with the use of
without infection or other complications. audiovisuals.
• Intermediate goal: At clinic appointment, client’s wound 2. Discuss the mechanism of wound infection. Use audiovi-
will be healing without signs of infection, loss of func- suals to demonstrate infected wound appearance.
tion, or other complication.
3. Demonstrate the equipment needed for cleansing and
• Short-term goals: Client will (a) correctly list three signs bandaging wound.
and symptoms of wound infection and (b) correctly
perform a return demonstration of wound cleansing 4. Demonstrate wound cleansing and bandaging on the
and bandaging. client’s wound.
Behavioural Outcomes 5. Discuss available resources.
On completion of the instructional session, the client will do 6. Provide a handout of the procedure and frequently asked
the following: questions (FAQs)
1. Describe normal wound healing Evaluation

2. Describe signs and symptoms of wound infection The client will do the following:
3. Demonstrate wound cleansing and bandaging
1. Correctly describe normal wound healing and signs and
symptoms of wound infection
Content Outline
2. Return demonstration of wound cleansing and bandaging
i. Normal wound healing
3. State contact person and telephone number to obtain
ii. Infection
assistance
a. Signs and symptoms
b. Signs of systemic infection. 4. State date, time, and location of follow-up appointment
of a meaningful plan and stimulates client motivation to Like client outcomes, learning outcomes should do the
achieve the desired outcomes. (See the Teaching: Clinical following:
box for a sample teaching plan for wound care.)
• State the client (learner) behaviour or performance,
Determining Teaching Priorities The client’s learning not the nurse behaviour. For example, “Identify per-
needs must be ranked according to priority. The client sonal risk factors for heart disease” (client behaviour),
and the nurse should do this together, with the client’s not “Teach the client about cardiac risk factors” (nurse
priorities always being considered. Once a client’s pri- behaviour).
orities have been addressed, the client is generally more
• Reflect an observable, measurable activity. The perfor-
motivated to concentrate on other identified learning
mance may be visible (e.g., walking) or invisible (e.g.,
needs. For example, a man who wants to know all about
adding a column of figures). However, it is necessary to
coronary artery disease may not be ready to learn how to
be able to deduce whether an unobservable activity has
change his lifestyle until he meets his own need to learn
been mastered from some performance that represents
more about the disease. Nurses can also use theoretical
the activity. Therefore, the performance of an out-
frameworks, such as Maslow’s hierarchy of needs, to
come might be written as “selects low-fat foods from
establish priorities. (See the section “Needs Theories” in
a menu” (observable), not “understands low-fat diet”
Chapter 12.)
(unobservable). Selected measurable verbs used for
Setting Learning Outcomes Learning outcomes can learning outcomes are shown in Box 26.3. Avoid using
be considered the same as desired outcomes for other such words as knows, understands, believes, and appreciates;
nursing diagnoses. They are written in the same way. these are neither observable nor measurable.
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Box 26.3 Examples of Measurable Verbs

for Writing Learning Outcomes Evidence-Informed Practice
Cognitive Affective Psychomotor Adolescents’ Drug Use While Driving:

Domain Domain Domain
Evidence for Nurses’ Interventions
Compares Accepts Assembles
with High-School Youth
Describes Attends Calculates
Evaluates Chooses Changes A study of 3655 senior high school students in Atlantic
Canada explored risk factors associated with driving while
Explains Discusses Demonstrates under the influence of opioids, alcohol, and cannabis.
Identifies Displays Measures Approximately 32% of participants reported opioid use in
Labels Initiates Moves the previous year. Logistical regression was used to identify
factors correlated with driving while under the influence of
Lists Joins Organizes drugs. Factors identified included medical opioid prescrip-
Names Participates Shows tion and recreational drug use, higher socioeconomic status,
Plans Shares higher sensation seeking, lower parental attachment, and
risky driving behaviours.
Selects Uses
Nursing Implications: Driving while under the
States
effects of opioids and other drugs is a serious concern
Writes for both adolescent well-being and society as a whole.
On the basis of this research, nurses can provide edu-
cational programming for youth in schools to identify
the risks associated with the use of these drugs and
impairment while driving.
• Use modifiers as required to clarify what, where,
when, or how the behaviour will be performed. Exam- Source: Based on Asbridge, M., Cartwright, J., & Langille, D. (2015). Driving
under the influence of opioids among high school students in Atlantic Canada:
ples are “demonstrates four-point crutch gait correctly” Prevalence, correlates, and the role of medical versus recreational consumption.
(modifier), “irrigates his colostomy bag independently Accident Analysis and Prevention, 75, 184–191. doi: 10.1016/j.aap.2014.12.001
(modifier) as taught,” or “states three (modifier) factors

that affect blood glucose level.”
• Include criteria specifying the time by which learning insulin injection” means that the nurse must include con-
should have occurred. For example, “The client will tent about the body sites suitable for insulin injections.
state three things that affect blood glucose level by end Nurses can select among many sources of information,
of second class on diabetes.” including books, nursing journals, and other nurses and
Learning outcomes can reflect mastery of concepts, health care professionals. Regardless of the sources the
moving from the simple to the complex. For example, nurse chooses, content should be as follows:
the learning outcome “The client will list cardiac risk • Accurate and current
factors” is a low-level knowledge outcome that simply
• Based on learning outcomes
requires the learner to identify cardiac risk factors; it
does not suggest application of the knowledge to the • Adjusted for the learner’s age, developmental stage,
learner’s own situation. The learning outcome “The cli- culture, and ability
ent will describe personal cardiac risk factors” requires the • Selected with consideration of the time and resources
learner to not only describe the cardiac risk factors but available for teaching
also identify his personal behaviours that increase his risk
for cardiac disease. Selecting Teaching Strategies The method of teaching
In writing learning outcomes, the nurse must be that the nurse chooses should be suited to the individual
specific about the necessary behaviours and knowledge and to the material to be learned (Figure 26.2). For
(cognitive, psychomotor, and affective) of the learner to example, the person who cannot read needs material
be able to positively influence his or her health state. In presented in other ways; a one-to-one demonstration
most cases, the learning needs are more complex than with questions and answers is usually the best strategy
simple acquisition of knowledge and include the applica- for teaching a client a skill, and group discussion is a
tion of that knowledge to the learner (refer to Box 26.2 useful way of discussing effective coping strategies. See
on page 510). The Evidence-Informed Practice box illus- Table 26.3 for selected teaching strategies.
trates this complexity and the necessary learning.
Teaching Tools The right tools facilitate teaching.
Choosing Content What is to be taught, the content, Tools can include handouts, equipment and supplies,
is determined by learning outcomes. For instance, the photo albums, overhead transparencies, flip charts, bul-
stated learning outcome “Identify appropriate sites for letin boards, models of the human body, audiotapes
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and videotapes, closed-circuit television, and computer

programs. Tools need to be carefully selected for the
individual client on the basis of the nurse’s assessment.
Organizing Learning Experiences To save nurses’ time
in constructing their own teaching guides, some health
agencies have developed teaching guides for common
teaching sessions. These guides standardize content and
teaching methods and make it easier for the nurse to
implement client teaching. Standardized teaching plans
also facilitate consistency of content for learners, thereby
decreasing the risk of confusion if different content is

taught. For example, when teaching infant bathing, the
nurses on the unit should be consistent about which soaps
are appropriate for the infant’s bath. Whether the nurse
is implementing a plan devised by another or developing
FIGURE 26.2 Teaching materials and strategies should be
an individualized teaching plan, some guidelines can
suited to the client’s age and learning abilities. help the nurse organize the learning experience:
TABLE 26.3 Selected Teaching Strategies
Strategy Major Type of Learning Characteristics

Explanation or description Cognitive • Teacher controls content and pace.
(e.g., lecture) • Learner is passive and, therefore, retains less information than
when actively participating.
• Feedback is determined by teacher.
• Can be given to individual or group.
One-to-one discussion Affective, cognitive • Encourages participation by learner.
• Permits reinforcement and repetition at learner’s level.
• Permits introduction of sensitive subjects.
Answering questions Cognitive • Learner guides content taught.
• Learner may need to overcome cultural perception that asking
questions is impolite.
• Can be used with individuals and groups.
Demonstration Psychomotor • Can be used with individuals and small or large groups.
• Does not permit use of equipment by learners; learner is
passive.
Discovery Cognitive, affective • Teacher guides problem-solving situation.
• Learner is active participant.
• Retention of information is high.
Group discussions Affective, cognitive • Learner can obtain assistance from supportive group.
• Group members learn from one another.
• Teacher needs to keep the discussion focused.
Practice Psychomotor • Allows repetition and immediate feedback.
• Permits hands-on experience.
Printed and audiovisual Cognitive • Forms include books, pamphlets, films, programmed
materials instruction, and computer learning.
• Learners can proceed at their own speed.
• Nurse can act as resource person.
• Learner can learn independently.
(continued)
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TABLE 26.3 Selected Teaching Strategies (continued)
Strategy Major Type of Learning Characteristics

Role playing Affective, cognitive • Permits expression of attitudes, values, and emotions.
• Can assist in development of communication skills.
• Teacher must create supportive, safe environment for learners.
Modelling Affective, psychomotor Nurse sets example by attitude and psychomotor skill.
Computer-assisted learning All types of learning • Learner is active.
programs • Learner controls pace.
• Provides immediate reinforcement and review.
• Use with individuals or groups.
• Start with something the learner is concerned about; Learning what needs to be done to change behaviour and
for example, before learning how to self-administer acting on that knowledge are two different processes. The
insulin, an adolescent wants to know how to adjust his stages of change, the person’s willingness and perceived
or her lifestyle and continue to play sports. need to change, and barriers to change are important ele-
• Review what the learner knows, and then proceed to ments to reflect on when implementing a teaching plan.
the unknown. This approach gives the learner confi- (See the section “The Transtheoretical Model: Stages of
dence. Sometimes, you will need to elicit this informa- Health Behaviour Change” in Chapter 8.)
tion, either by asking questions or by having the client When implementing a teaching plan, the nurse may
fill out a questionnaire. find the following guidelines helpful:
• Early in the teaching session, address any area that is 1. Assess the characteristics of the learners, and iden-
causing the client anxiety. A high level of anxiety can tify factors that will affect their learning.
impair concentration in other areas. For example, a 2. Determine the outcomes jointly with the client
woman highly anxious about turning her husband in (learner). Reassess learning activities and change
bed might not be able to learn about bathing him until them if they are ineffective. Active learner involve-
she has successfully learned to turn him in bed. ment can enhance learning.
• Teach the basics before proceeding to the variations or
3. The optimal time for each session depends on the
adjustments. It is confusing to learners to have to con-
learner. Whenever possible, ask the client for help in
sider possible adjustments and variations before they
choosing the best time for learning.
master the basic concepts. For example, when teach-
ing a female client how to insert a retention catheter, 4. The nurse should take time to establish rapport
it is best to teach the basic procedure. Once the skill before teaching. A relationship between client and
is mastered, the nurse could address trouble-shooting nurse that is respectful, constructive, and focused on
or adaptations. client needs will facilitate learning.
• Schedule time for review of content and to answer 5. Be sensitive to any signs that the pace is too fast or
questions learners may have. too slow. A client who appears confused or does
not comprehend material when questioned may be
finding the pace too fast. When the client appears
Implementing bored and loses interest, the pace may be too slow,
The nurse must be flexible in implementing any teach- the learning period may be too long, or the client
ing plan and revise the plan, as needed. The client’s may be tired.
needs may change, or external factors may intervene. 6. Build on the client’s previous learning, and encourage
For instance, the nurse and the client, Mr. Brown, have the client to learn and develop new skills. For example,
planned to learn how to irrigate his colostomy bag at the spouse of a person with diabetes may already have
1000h, but when the time comes, Mr. Brown wants addi- some knowledge about diabetes that the nurse can
tional information before actually doing it himself. In build on.
this case, the nurse alters the teaching plan and discusses 7. Communicate clearly and concisely. The words
the desired information, provides written information, used need to have the same meaning to the learner
and defers teaching the psychomotor skill until the next as to the teacher. Using a layperson’s vocabulary
day. Refer to Table 26.2 on page 505 for a list of barriers enhances communication. Even such words as urine
to learning. or feces may be unfamiliar to some clients, and abbre-
GUIDELINES FOR TEACHING Knowledge alone is viations, such as RR (recovery room) or PAR (post-
not enough to motivate a person to change behaviour. anesthesia room), are often misunderstood.
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Teaching Clinical
Elena Dorfman/Addison Wesley/Pearson Education, Inc.

Teaching Tools for Children
The use of the following teaching aids can help focus chil-
dren’s attention:
• Visits. Visiting the hospital and treatment rooms;
seeing people dressed in uniforms, scrub suits, pro-
tective gear
• Dress-up. Touching and dressing up in the clothing
they will see and wear
• Colouring books. Using colouring books to prepare
for treatments, surgery, or hospitalization; shows
what rooms, people, and equipment will look like
• Storybooks. Storybooks describe how the child will
Figure 26.3 Teaching activities may need to include hands-
feel, what will be done, and what the place will look
on client participation.
like. Parents can read these stories to children sev-
eral times before the experience. Younger children
like this repetition.
outcomes, (b) by giving feedback, and (c) by helping
• Dolls. Practising procedures that children will later
experience on dolls or teddy bears gives a sense of
the learner derive satisfaction from learning. Teach-
mastery of the situation. Custom dolls are often avail- ing activities may need to be replaced or supple-
able for inserting tubes and giving injections. mented to attain learning outcomes. Figure 26.3
• Puppet play. Puppets can be used in role-play situ- illustrates that actual handling of the syringe may be
ations to provide information and show the child more effective than explanation alone.
what the experience will be like; they help the child
express emotions. 13. Use repetition to reinforce learning. Summariz-
• Health fairs. Health fairs can educate children about ing content, rephrasing (using other words), and
their bodies and ways to stay healthy. Fairs can teaching the material in another way are means of
focus on high-risk problems that children face, such repeating and clarifying content. For instance, after
as accidents and poisoning.
discussing the kinds of foods that can be included in
a diet, the nurse describes the foods again but in the
context of the three meals eaten during one day.
8. Use teaching aids that can help focus a learner’s 14. The use of advance organizers to structure the con-
attention. To facilitate transfer of learning, the nurse tent facilitates retention of information. Use such
should use the type of supplies or equipment the cli- statements as “There are three signs of inflamma-
ent will use. Before the teaching session, the nurse tion that I am going to discuss with you.”
needs to assemble all equipment and visual aids and
15. Assessment of learner outcomes must always be
ensure that all audiovisual equipment is functioning
based on reasonable behavioural changes for the cli-
effectively. (See the Teaching: Clinical box on teaching
ent to enact.
tools for children.)
9. Create an environment conducive to learning. If pos- Special Teaching Strategies Nurses can choose
sible, the client should be out of bed for learning activ- from a number of special teaching strategies that are
ities. Being seated facilitates alertness, but the nurse appropriate for the learner and the learning outcomes.
needs to be attentive to signs of fatigue in the client. Client Contracting Client contracting involves estab-
10. Use multiple senses in teaching to enhance learning. lishing a learning contract with a client that specifies
For example, when teaching about changing a surgi- certain outcomes and when they are to be met. Here is
cal dressing, the nurse can tell the client about the an example of a self-contract:
procedure (hearing), show how to change the dress-
I, Amy Martin, will exercise strenuously for 20 minutes
ing (sight), and let the client manipulate the equip-
three times per week for a period of 2 weeks and will then
ment (touch).
buy myself six yellow roses.
11. Provide a context for learning. For example, learning
to select low-sodium foods can be done very effec- Amy Martin
tively in a tour of a grocery store or through food July 30, 2013
selection from a restaurant menu. The contract, drawn up and signed by the client
12. Provide opportunities for clients to explore the con- and the nurse, can specify the learning outcomes, the
tent themselves. Ways to increase learning include responsibilities of the client and the nurse, and the
stimulating motivation and self-direction, for exam- methods of follow-up and evaluation. The contract
ple, (a) by providing specific, realistic, achievable can be changed in two ways: (a) if the client meets the
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contract outcomes and wants to negotiate new learning referred to as anticipatory problem solving. For example, the
outcomes, and (b) if the client decides that it is not pos- nurse might ask parents with a newborn and a 2-year-old
sible to meet the existing learning outcomes and wants at home to identify ways of addressing issues of sibling
to revise them (Bastable, 2014). A learning contract rivalry with the toddler.
allows for freedom, mutual respect, and mutual respon-
Behaviour Modification The behaviour modification
sibility and encourages clients to accept responsibility
system for changing behaviour has as its basic assump-
for learning.
tions the following: (a) that human behaviours are
Group Teaching Group instruction is economical and learned and can be selectively strengthened, weak-
provides members with an opportunity to share with and ened, eliminated, or replaced and (b) that a person’s
learn from others. A small group allows for discussion in behaviour is under conscious control. Under this sys-
which everyone can participate. A large group often neces- tem, desirable behaviour is rewarded and undesirable
sitates a lecture technique or use of films, videos, or slides behaviour is ignored. The client’s response is the key
by teachers. It is important that all members involved in to behaviour change. For example, clients trying to
group instruction have a learning need in common (e.g., quit smoking are not criticized when they smoke, but
prenatal health or preoperative instruction). they are praised or rewarded when they go without a
cigarette for a certain period. A learning contract may
Internet Learning Resources The Internet has become
also be used to support this learning. Similarly, children
a part of the lives of many Canadians, allowing them
are motivated to healthy behaviours, such as handwash-
to communicate and obtain information quickly. The
ing, through provision of rewards, such as gold stars or
Internet has also become an important source of health
special experiences.
information, screening tools, health services, and sup-
port groups; and many individuals are now accessing Transcultural Teaching The nurse and clients of differ-
the Internet before consulting health care profession- ent cultural and ethnic backgrounds have additional bar-
als about their health issues. Statistics Canada (2010) riers to overcome in the teaching–learning process. These
reported that 69.9% of Canadians searched the Inter- barriers can include language and communication prob-
net for medical or health information in 2009. These lems, differing concepts of time, conflicting cultural heal-
searches focused on specific diseases, healthy lifestyles, ing practices, beliefs that may negatively affect learning,
symptoms, drugs or medications, and alternative ther- or unique high-risk or high-frequency health problems
apies. The fastest growing group of people learning that can be addressed with health-promotion instruction.
to use the Internet is those age 55 years and older Nurses should consider the following guidelines when
(Mauk, 2010). More than 48% used the Internet first, teaching clients from various ethnic backgrounds:
prior to consulting with a physician. Nurses, therefore,
• Obtain teaching materials, pamphlets, and instructions in lan-
need to be aware of such technology and be competent
guages used by clients. Nurses who are unable to read the
in integrating it into their teaching..
foreign language material for themselves can have the
Online Health Information Computer-assisted interpreter read the material to clients.
instruction (CAI) can be used to teach new information, • Use visual aids, such as pictures, charts, or diagrams, to com-
provide opportunities for the application of information, municate meaning. Audiovisual material can be helpful
or support the development of complex problem-solving if English is spoken clearly and slowly. Even if under-
skills, often for continuing education of health care standing the verbal message is a problem for the cli-
professionals. The learners are able to set the pace that ent, seeing a skill or procedure may be helpful. In
meets their learning needs. some instances, an interpreter can be asked to clarify
Computer simulations are becoming a common the visual aid.
teaching strategy in student learning situations, such as
• Use concrete words rather than abstract words. Use simple
nursing labs. Simulations provide not only a safe environ-
language (short sentences, short words), and present
ment but also a realistic scenario for student learning,
only one idea at a time.
without jeopardizing the safety of a real client. Simula-
tions can also standardize teaching and evaluation. • Allow sufficient time for learners to ask questions, and clarify
any misconceptions resulting from differences in language
Discovery or Problem Solving In using the discovery or culture.
or problem-solving technique, the nurse presents some
initial information and then a situation related to the • Avoid the use of medical terminology or health care language,
information. The learner applies the new information such as “taking your vital signs” or “apical pulse.”
to the situation and decides what to do. Learners can Rather, nurses should say they are going to take a
work alone or in groups. The nurse guides the learners blood pressure reading or listen to the client’s heart.
through the thinking process necessary to reach the best • If understanding another’s pronunciation is a problem, validate
action to take in the situation. This method may also be information in writing or with handouts.
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• Use humour very cautiously. Meaning can change in the • Oral questioning (e.g., asking the client to restate
translation process. information or provide correct verbal responses to
• Do not use slang words or colloquialisms. These may be questions)
interpreted literally. • Self-reports and self-monitoring, which can be useful
• Do not assume that a client who nods, uses eye contact, or smiles during follow-up phone calls and home visits
is indicating understanding of what is being taught. These • Online self-assessment or self-screening tools, and
responses may simply be the client’s way of indicating post-learning questionnaires
respect.
The acquisition of psychomotor skills is best evaluated
• Invite and encourage questions during teaching. Urge clients by observing how well the client carries out a procedure,
to ask questions to clarify information. such as changing a dressing or self-administering an
• When explaining procedures or functioning related to injection.
personal areas of the body, it may be appropriate to have Affective learning is more difficult to evaluate. Whether
the teaching done by a nurse (and interpreter, if needed) of the attitudes or values have been learned can be inferred
same sex. by listening to the client’s responses to questions, not-
• Include the family in planning and teaching. This approach ing how the client speaks about relevant subjects, and
promotes trust and mutual respect. Ask the client to observing the client’s behaviour that expresses feelings
identify the appropriate family member and incor- and values. For example, do clients who state that they
porate that person into the planning and teaching to value health actually report use of condoms every time
promote adherence and support of health teaching. they have sex with a new partner?
Following evaluation, the nurse may find it necessary
• Consider the client’s time orientation. The client may be more to modify or repeat the teaching plan if the outcomes
oriented to the present than to the future, so teaching have not been met or only partially met. For the hospital-
preventive health behaviours may be difficult. ized client, follow-up teaching in the home or by phone
• Identify cultural health practices and beliefs. Noncompliance may be needed.
with health teaching may be related to conflict with Behaviour change does not always take place
folk medicine beliefs, lack of understanding, or con- immediately after learning. Often, individuals accept
flict with cultural beliefs. To encourage compliance, change intellectually first and then change their behav-
the nurse needs to learn to the client’s explanation of iour inconsistently (e.g., Mrs. Green, who knows that
why the illness developed and how it might be treated. she must lose weight but diets and exercises only peri-
odically). The nurse can assist clients with behaviour
change by allowing for client vacillation and by providing
Evaluating encouragement.
Evaluating is both an ongoing and a final process in Evaluating Teaching It is important for nurses to
which the client, the nurse, and often the support people evaluate their own teaching and the content of the teach-
determine what has been learned. ing program. Evaluation should include a consideration
of all factors: the timing, the teaching strategies, the
Evaluating Learning The process of evaluation of
amount of information, whether the teaching was help-
learning is the same as evaluating client achievement of ful, and so on. The RNAO (2012) has published practice
desired outcomes for other nursing diagnoses. Learning recommendations for client-centred teaching (see Box 26.4),
is measured against the predetermined learning out- which can be used as the standard against which one
comes selected in the planning phase of the teaching evaluates one’s teaching with clients. The nurse may find,
process. Thus, the outcomes serve not only to direct the for example, that the client was overwhelmed with too
teaching plan but also to provide outcome criteria for much information, was bored, or was motivated to learn
evaluation. For example, the outcome “Selects foods that more. Both the client and the nurse should evaluate the
are low in carbohydrates” can be evaluated by asking the learning experience. The client can tell the nurse what
client to name such foods or to select low-carbohydrate was helpful as well as those teaching strategies that were
foods from a list. not useful. Feedback questionnaires and videotapes of the
The best method of evaluation depends on the type learning sessions can also be useful.
of learning. In cognitive learning, the client demonstrates The nurse should not feel ineffective as a teacher
acquisition of knowledge. Examples of the evaluation if the client forgets some of what is taught. Forgetting
tools for cognitive learning include the following: is normal and should be anticipated. Having the client
• Direct observation of behaviour (e.g., observing the write down information, repeating it during teaching,
client selecting the solution to a problem by using the giving handouts on the information, and involving the cli-
new knowledge) ent actively in the learning process all promote retention.
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Box 26.4 RNAO (2012) Practice outcomes to other health care professionals. If teaching is
Recommendations not documented, then, legally, it did not occur.
for Client-Centred Teaching It is also important to document the responses of
the client and support people to teaching activities. What
1. Create a safe, shame-free and blame-free environment to did the client or support person say or do to indicate
assess client learning. that learning had occurred? Has the client demonstrated
2. Use a universal precautions approach for health literacy mastery of a skill or the acquisition of knowledge? The
to create a safe, shame-free and blame-free environment. nurse records this evidence of learning in the client’s
3. Assess the learning needs of the client. chart. (See Chapter 24.)
4. Tailor your approach and educational design by collabo- Many agencies have multiple-copy client teaching
rating with the client and the interprofessional team. forms that include medical and nursing diagnoses, the
5. Engage in more structured and intentional approaches treatment plan, and the client education. After the teach-
when facilitating client-centred learning. ing session is completed, the client and the nurse sign the
6. Use plain language, pictures, and illustrations to promote form, and a copy of the form is given to the client as a
health literacy. record of teaching and as reinforcement of the content
7. Use a combination of educational strategies for effective taught. A second copy of the completed and signed form
learning: is placed in the client’s chart. The parts of the teaching
a. Printed materials process that should be documented in the client’s chart
b. Telephone include the following:
c. Audiotapes
d. Video • Diagnosed learning needs
e. Computer-based and multimedia presentations • Learning outcomes
8. Assess client learning. • Topics taught
9. Communicate client-centred learning effectively with: • Client outcomes
a. The client
• Need for additional teaching
b. The interprofessional team
• Resources provided
Source: Registered Nurses’ Association of Ontario. (2012). Facilitating client centred
learning. Toronto, ON: Registered Nurses’ Association of Ontario. The written teaching plan that the nurse uses as
a resource to guide future teaching sessions might also
include these elements:
Documenting • Actual information and skills taught

• Teaching strategies used
Documentation the teaching process is essential because
it provides a legal record that the teaching took place • Time framework and content for each class
and communicates the teaching strategies and learning • Teaching outcomes and methods of evaluation
Case Study 26
Mrs. Marcos, 59 years old, is the vice-president of a bank frequently nods her head, but she also seems preoccupied
and is heavily relied on by her employer and coworkers. She and is readily distracted.
moved to Canada from the Philippines 5 years ago. Three
days ago, she was admitted to the hospital with complaints of
shortness of breath and mild chest pain. A diagnostic evalua-
tion indicated that she has significant coronary artery disease
but has not yet suffered a heart attack. Her physician has indi-
cated that Mrs. Marcos will need to make significant lifestyle
changes to reduce her risk of a heart attack. As her nurse,
you recognize Mrs. Marcos’s need to learn about her disease
process, diet, exercise, and stress reduction. As you begin 1. How would you evaluate Mrs. Marcos’s readiness to
teaching Mrs. Marcos, you note that she is very pleasant and learn?
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2. Mrs. Marcos is a well-educated client. What would be the 5. How might your teaching differ if you were teaching
benefit of a learning needs assessment? Mrs. Marcos at home, rather than in a hospital or acute
3. You recognize that you have a great deal of information to care setting?
provide to Mrs. Marcos, and you are concerned that you
will not be able to teach everything. What can you do to Visit MyNursingLab for answers and explanations.
help Mrs. Marcos and still accomplish your teaching goals?
4. How will you know if your teaching is effective?
Key Term s
adherence p. 502 cognitive theory p. 503 learning p. 502 positive
affective domain p. 502 compliance p. 502 learning need p. 502 reinforcement p. 503
andragogy p. 502 geragogy p. 502 modelling p. 503 psychomotor
client education p. 500 health literacy p. 508 motivation p. 504 domain p. 502
cognitive p. 502 humanism p. 503 pedagogy p. 502 readiness to learn p. 504
cognitive domain p. 502 imitation p. 503 teaching p. 501

• Teaching clients and families about their health needs is plan, evaluating learning outcomes and teaching effec-
a major nursing task. Nurses also teach colleagues, other tiveness, and documenting instructional activities.
health care professionals, auxiliary personnel, nursing • Learning outcomes guide the content of the teach-
and other health care students, and groups in community ing plan and are written in terms of client or learner
education programs. behaviour.
• Learning is represented by a change in behaviour or a • Teaching strategies should be suited to the client, the mate-
different way of thinking. rial to be learned, and the teacher. They should be adjusted
• Three main theories of learning are behaviourism, cogni- to the client’s developmental level and health status.
tivism, and humanism. • A teaching plan is a written plan consisting of learning
• Bloom has identified three learning domains: cognitive, outcomes, content to teach, a time frame for teaching,
affective, and psychomotor. and strategies to use in teaching the content. The plan
• A number of factors facilitate learning: motivation, readi- must be revised when the client’s needs change or the
ness, active involvement, relevance, feedback, nonjudg- teaching strategies prove ineffective.
mental support, the progression from simple to complex • Adaptations in teaching will facilitate learning for clients
concepts, repetition, timing, and environment. who have low or no reading skills, who are older, or who
• Such factors as emotions, certain physiological events, are from different cultural backgrounds.
cultural barriers, and psychomotor deficits can impede • Evaluation of the teaching–learning process is both an
learning. ongoing and a final process.
• The teaching process, like the nursing process, consists • Documentation of client teaching is essential to commu-
of six activities: assessing the learner, diagnosing learn- nicate the teaching to other health care professionals and
ing needs, developing a teaching plan, implementing the to provide a record for legal and accreditation purposes.
N cl ex- St yl e Practic e Qui z

1. A community health nurse is giving a presentation to a c. Asking the group to complete a feedback
group of parents. Which of the following actions would questionnaire
provide the nurse with the best initial feedback on the d. Administering a quiz on the content of the
nurse’s teaching skills? presentation
a. Eliciting the group’s feelings about the presentation
2. Which of the following activities would be classified as
b. Observing the group’s nonverbal behaviour learning in the affective domain of Bloom’s taxonomy?
M26_KOZI2703_04_SE_C26.indd 519 27/02/17 5:39 PM

a. Learning how to calculate an appropriate drug 7. A nurse is talking with a client who is scheduled to have
dosage a diagnostic procedure. Which comment by the client
b. Learning to accept the loss of a limb indicates a teachable moment?
c. Learning how to insert a catheter a. “I’ve had this procedure done before.”
d. Reading handout material on the symptoms of con- b. “Will this procedure hurt?”
gestive heart failure c. “I’m trying not to think about it.”
3. Which of the following is the best way to help a cli- d. “I have an appointment with another person right
ent newly diagnosed with diabetes to learn the dietary now.”
requirements associated with the disease? 8. A client needs to learn to self-administer insulin injec-
a. Providing a videotape that addresses the dietary tions. Which statement may reflect low literacy skills?
requirements associated with the disease a. “I will read the information later. I’m too tired right
b. Asking a nutritionist to visit the client to present now.”
information and handouts about the diabetic diet b. “I’ve watched my brother give his own shots. I know
c. Assisting the client to determine how to work favou- how to do it.”
rite foods into the diabetic diet c. “I’m afraid of injections. Do I have to give my own
d. Having the client attend a group meeting for diabetic shots?”
clients to discuss adapting to this chronic health d. “Do you have a video showing how I should give
condition myself the shot?”
4. A nurse is scheduling a teaching situation. Which of the 9. A nurse has been working with a client on healthy eat-
following clients is most likely ready to learn? ing. The client has a learning outcome of “to use cred-
a. A 45-year-old man whose doctor just informed him ible online health information to support health eating.”
that he has cancer Which of the following statements reflects that the client
b. A 3-year-old child whose parents have read her a sto- has met this learning outcome?
rybook about going to the hospital a. “I’m reading a weekly healthy eating food blog.”
c. A 60-year-old woman who received medication b. “I’ve joined a fitness and wellness chat room.”
5 minutes ago for relief of abdominal pain c. “I found a website produced by the Dietitians of
d. A 70-year-old man who is recovering from a stroke Canada.”
and has returned from physical therapy d. “I’ve accessed a local weight loss centre’s online
recipe site.”
5. How can the nurse best assess a client’s style of
learning? 10. A client’s learning outcome is “Client will state medi-
cation name, purpose, and appropriate precautions.”
a. Ask the client how he or she learns best Which of the following documented statements reflects
b. Use a variety of teaching strategies evidence of learning?
c. Observe the client’s interactions with others a. Taught name, purpose, and precautions for the new
d. Ask family members how the client learns cardiac medication; client seemed to understand.
b. Written information about the medication provided
6. A 74-year-old client who takes multiple medications tells and reviewed; correct responses were given to follow-
the nurse, “I have no idea what that little yellow pill is up questions.
for.” What is the best nursing diagnosis for this client? c. Written information read to client; stated he would
a. Knowledge Deficient: Medication Information read it when he got home.
b. Readiness for Enhanced Knowledge: Disease Information d. The client provides accurate information about the
c. Lack of Knowledge: Self-Care Measures medication when questioned.
d. Noncompliance: Medication Self-Administration
Re f erenc es
Bandura, A. (1971). Analysis of modelling processes. In A. Bandura teaching to improve care. Clinical Journal of Oncology Nursing, 17(5),
(Ed.), Psychological modelling: Conflicting theories (pp. 1–62). New York: 472–475.
NY: Aldione-Atherton. Knowles, M., Holton, E. F., & Swanson, R. A. (2011). The adult
Bastable, S. (2014). Nurse as educator: Principles of teaching and learning for learner: The definitive classic in adult education and human resource develop-
nursing practice (4th ed.). Boston, MA: Jones & Bartlett. ment (7th ed.). Burlington, MA: Elsevier.
Bloom, B. S. (Ed.). (1956). Taxonomy of educational objectives. Book 1, Lewin, K. (1951). Field theory in social science. New York, NY: Harper
Cognitive domain. New York, NY: Longman. and Row.
Dalby, C. K., Nesbitt, M., Frechette, C. A., Kennerley, K., & Mauk, K. L. (2010). Gerontological nursing: Competencies for care
Lacoursiere, L. (2013). Standardization of initial chemotherapy (2nd ed.). Boston, MA: Jones & Bartlett.
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Mayer, G. G., & Villaire, M. (2007). Health literacy in primary care: A Registered Nurses’ Association of Ontario [RNAO]. (2012).
clinician’s guide. New York, NY: Springer. Facilitating client-centred learning. Toronto, ON: Author.
NANDA International. (2014). NANDA International Nursing Diagnoses: Statistics Canada. (2010). Internet use by individuals, by type of activity.
Definitions and classification 2015–2017. Oxford, UK: Wiley- CANSIM Table 358-0130. Retrieved from http://www40.statcan.
Blackwell. gc.ca/l01/cst01/comm29a-eng.htm?sdi=internet.
Piaget, J. (1966). Origins of intelligence in children. New York, NY: Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt,
Norton. D. A., Pignone, M. P., … Hale, F. (2005). Quick assessment of
Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: literacy in primary care: The newest vital sign. Annals of Family
Advancing innovation, transforming health care (3rd ed.). Sudbury, MA: Medicine, 3(6), 514–522.
Jones & Bartlett Learning. Wilkinson, J. M., & Ahern, N. R. (2008). Nursing diagnosis handbook
Public Health Agency of Canada (PHAC). (2015). Health literacy. with NIC interventions and NOC outcomes (9th ed.). Upper Saddle
Retrieved from http://www.phac-aspc.gc.ca/. River, NJ: Prentice Hall Health.
Purnell, L. D., & Paulanka, B. J. (2008). Transcultural health care: A cul-
turally competent approach (3rd ed.). Philadelphia, PA: F. A. Davis.
M26_KOZI2703_04_SE_C26.indd 521 27/02/17 5:39 PM

Chapter 27
Leading, Managing,
and Delegating
Updated by
Aroha Page, RN, PhD
Associate Professor, School of Nursing, Nipissing University
A
LEARNING OUTCOMES
After studying this chapter, you will be able to ccording to the Cana-
1. Describe the nurse’s clinical leadership role in patient care. dian Nurses Association
(CNA, 2009b), by 2020,
2. Compare and contrast leadership and management.
we will see a different Canadian health
3. Differentiate formal from informal leaders.
care system. Many of these changes
4. Compare and contrast different leadership styles. will have been driven by advances in
5. Identify the characteristics of an effective leader. knowledge and technology, as well
6. Compare and contrast the levels of management. as changes in global, national, and
regional dynamics. In Toward 2020:
7. Describe the skills and competencies needed by a nurse manager.
Visions for Nursing (Villeneuve &
8. Describe the functions of management.
MacDonald, 2006), the CNA envi-
9. Describe change management theories and the impact of change sioned nurses as working with a
on leadership decisions.
team of multidisciplinary health care
10. Discuss the roles and functions of nurse leaders in planning for providers. The CNA stressed that
and implementing change.
nurse leaders “must focus on health
and the health system, not [just] on
nurses and nursing…. Nurses will be
expected to be strong advocates for
patients, facilities, communities, and
social issues” (p. 84). Nurses must
work efficiently and effectively to
meet public expectations and to be
effective leaders and change agents
within interprofessional teams in the
health care system.
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Chapter 27 Leading, Managing, and Delegating 523
Nurse as Leader 5. Communicating patient needs to other team

members
Leadership, management, and delegation are integral 6. Role modelling the appropriate standards and
aspects of the nursing role. A nurse may function as a man- patient preferences for care
ager and a change agent in some situations or as a leader 7. Delegating care to others within their scopes for safe
delegating aspects of care to others. The professional nurse patient care
may assume a formal role of leader and manager or func- 8. Educating unregulated workers to the expected stan-
tion in a leadership and management role in nursing care. dards of care, where needed
Both roles are linked but differ in their focus. 9. Supporting other nursing and interprofessional team
A leader essentially influences others to work members in their provision of care
together to accomplish a specific goal. Leaders are often
visionaries; they are informed, articulate, confident, and 10. Representing nursing scope of practice within the
self aware. Leaders must have excellent interpersonal interprofessional team, committee work, and the
skills and be astute communicators. Most importantly, larger organization
leaders have the ability to innovate, change, motivate, 11. Accessing needed resources for improved client care
facilitate, mentor, and inspire others. Within their orga- 12. Analyzing and influencing public policy and program
nizations, nurse leaders engage and lead teams that development related to health.
implement evidence-based practice, assess the effective-
ness of care, engage in quality assurance processes, and A manager is an employee of an organization
construct process improvement strategies. Nurses also who is given the authority, power, and responsibility
work in multiple roles in teams for interprofessional and for planning, organizing, coordinating, and directing
intersectoral collaboration for improved health care. the work of others and for establishing and evaluating
Every nurse providing care to patients and clients standards. Managers understand organizational struc-
is deemed to have clinical leadership responsibilities ture and culture. They control human, financial, and
(Canadian Association of Schools of Nursing, 2014; material resources. Managers set goals, make decisions,
CNA, 2009a, 2009b; Swanwick & McKimm, 2011). With solve operational problems, and initiate and implement
experience and knowledge, this leadership role becomes change. These nurses are often referred to as nurse manag-
embedded in one’s practice. These responsibilities include ers, nursing unit managers, or nursing unit coordinators.
the following: Managers are also responsible for (a) contributing
to the accomplishment of the goals of the organization,
1. Coordinating health care teams, including delega- (b) efficiently using the organization’s resources, (c) ensuring
tion, performance evaluation, and facilitation of effective patient, client, or resident care, and (d) ensuring
continuity of care compliance with institutional, professional, regulatory, and
2. Setting directions for nursing care governmental standards. Managers concentrate on activi-
ties to increase the organization’s productivity, whereas
3. Influencing others to provide care to professional leaders focus on motivation, developing a vision, and build-
standards through collaboration and support ing trusting relationships. Table 27.1 compares the roles
4. Advocating for patients within the interprofessional of the leader and the manager. Figure 27.1 provides some
team and the organization examples of leader and manager roles.
Table 27.1 Comparison of Leader and Manager Roles
Leaders Managers
May or may not be officially appointed to the position Are appointed officially to the position
Have power and authority to enforce decisions as decided Have power and authority to enforce decisions
by followers
Influence others toward goal setting, either formally or Carry out predetermined policies, rules, and regulations
informally
Are interested in risk taking and exploring new ideas Maintain an orderly, controlled, rational, and equitable structure
Relate to people personally in an authentic and Relate to people according to their roles
empathetic manner
Feel rewarded by personal achievements Feel rewarded when fulfilling organizational mission or goals
May or may not be successful as managers Are managers as long as the appointment holds
Manage relationships Manage resources
Focus on people Focus on systems
M27_KOZI2703_04_SE_C27.indd 523 27/02/17 1:10 PM


B

A
Figure 27.1 Nurses as leaders and managers. A: The nurse manager discusses work assignments during the change-of-shift
report. B: The nurse delegates basic client care activities to other care providers. C: The nurse consults the social worker during
discharge planning.
Leadership Autocratic (authoritarian, directive) lead-

ers make decisions for the group. The leader believes
Leadership may be either formal or informal. The that the individuals in the group are incapable of
formal leader is selected by an organization and independent decision making. The autocratic leader
given official authority to make decisions and act. An determines policies and gives orders to the group. The
informal leader is not officially appointed to direct group members may feel secure because procedures are
activities of others but is acknowledged as a leader well defined. However, the group’s needs for creativ-
because of such attributes as seniority, expert knowl- ity, autonomy, and self-motivation are not met, and
edge, mentorship, special abilities, experience, or a openness and trust between the leader and the group
charismatic personality. Leaders perform an important members are minimal. Members may feel dissatisfied
role in influencing colleagues to achieve goals. with this type of leadership; however, sometimes an
autocratic style is effective. When urgent decisions are
necessary (e.g., during a cardiac arrest, a unit fire, or
Leadership Theory a mass casualty event), one person must assume the
Classic Leadership Theories The trait theorists responsibility to make decisions without being chal-
found that leaders often possess specific traits and abili- lenged. This style can also be effective when a project
ties, including good judgment, decisiveness, knowledge, must be completed quickly and efficiently.
adaptability, integrity, tact, popularity, nonconformity, Democratic (participative, consultative)
and cooperativeness (what leaders are). The behaviourists leaders encourage group discussion and decision mak-
believed that through education, training, and life expe- ing. This type of leader assumes individuals are capable
riences, effective leaders develop a particular style of of making decisions and value independence. Group
leadership (what leaders do). These leadership styles productivity and satisfaction are high as members con-
have been characterized as autocratic, democratic, tribute to the effort. The democratic leader acts as a
laissez-faire, and bureaucratic. facilitator, actively guiding the group toward achieving
M27_KOZI2703_04_SE_C27.indd 524 27/02/17 1:10 PM

goals, providing constructive criticism, offering informa- The transactional leader focuses on the pro-
tion, making suggestions, and asking questions. This cess, not the future. The main activities are supervision,
type of leadership demands that leaders have faith in organization, and monitoring of staff performance. The
the group members to accomplish their tasks. Although leader promotes compliance by using rewards and pun-
democratic leadership has been shown to be less efficient ishments. Rewards may be in the form of job promotion,
than authoritarian leadership, it allows for more self- preferred shifts, and special privileges or more benefits.
motivation, creativity, and cooperation among group Punishments may be in the form of suspension, demo-
members. This style of leadership can be beneficial in tion, or job loss.
the health care setting. The transformational leader fosters creativity,
The laissez-faire (nondirective, permissive, risk taking, commitment, and collaboration by empower-
ultra-liberal) leader presupposes the group is self- ing the group to share in the organization’s vision. The
motivated, autonomous, and self-regulating. This leader leader inspires others with a clear, attractive, and attain-
allows group members to act independently, which may able goal and enlists members to participate in attaining
result in a lack of coordination. Members may perceive the goal. The Registered Nurses’ Association of Ontario
a lack of direction from the leader. A laissez-faire style (RNAO, 2013) stresses the need for nurse leaders to be
is most effective for groups whose members have both aware of the personal attributes they bring to their role.
personal and professional maturity. The best practice guidelines include the following attri-
The bureaucratic leader does not trust self or butes for transformational leadership:
others to make decisions. Instead, the bureaucrat relies
1. Strong professional nursing identity
on the organization’s rules, policies, and procedures to
direct the group’s efforts. Group members may be dissat- 2. Reflection on, and commitment to, developing one’s
isfied with the leader’s inflexibility and use of judgment. leadership attributes
Table 27.2 compares the autocratic, democratic, laissez- 3. Responsibility for the development of one’s own lead-
faire, and bureaucratic leadership styles. ership expertise
Situational leaders consider the situation and
4. Willingness to mentor others
determine an appropriate leadership style for the indi-
vidual or group to perform the task in that particular sit- 5. Cultivation of professional and personal supports for
uation. This leadership style is adaptive to the group and members
the task undertaken. Situational leaders may incorporate In addition, transformational nurse leaders work to
all types of leadership style, depending on the task and create an environment of empowerment, support others
the skills, attitudes, and decision-making capabilities of to develop and integrate knowledge, and understand the
the followers. impact of change.
Contemporary Leadership Theories Contempo- One subtype of the transformational leader is a
rary theorists have described charismatic leaders, trans- servant leader, and this type of leadership is based
actional leaders, transformational leaders, and shared on the concept that leaders serve the best interests of
leadership. their followers (Irving & Longbotham, 2007) and cre-
A charismatic leader is characterized by an emo- ate a work environment of mutual respect, trust, and
tional relationship between the leader and the group collaboration (Sturm, 2009). In nursing, this concept
members. The engaging personality of the leader evokes is internally consistent with a focus on caring where
strong feelings of commitment to the leader and the the leader aspires to assist those they are leading to
leader’s cause and beliefs. The followers of a charismatic become more autonomous, empathetic, and healing.
leader often overcome extreme hardship to achieve the Strengths-based nursing leadership (SBNL) (Gottlieb,
group’s goals because of their faith in the leader. Gottlieb, & Shamian, 2012) builds on the theory of
Table 27.2 Comparison of Autocratic, Democratic, Laissez-Faire, and Bureaucratic Leadership Styles
Autocratic Democratic Laissez-Faire Bureaucratic

Degree of control Makes decisions alone Collaborative No control Strict reliance on policy
Leader activity level High High Minimal High
Assumption of responsibility Leader Shared Group Leader
Output of the group High quantity, Creative, high quality Variable Predictable quality
good quality
Efficiency Very efficient Less efficient than Inefficient Efficient
autocratic
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strengths-based care (SBC). (See Chapter 4 for a discus- Box 27.1 Characteristics
sion of SBC.) SBNL is about recognizing, mobilizing, of Effective Leaders
capitalizing, and developing people’s strengths, creating
conditions that enable them to lead. SBNL is based on Effective leaders
the principles that leadership (a) works with the whole • Are able to function autonomously
while appreciating the interrelationships among its parts, • Use a leadership style that is natural to them
(b) recognizes the uniqueness of staff, nurse leaders, • Use a leadership style appropriate to the task and
and the organization, (c) creates work environments the members
that promote nurses’ health and facilitate their learning • Assess the effects of their behaviour on others and the
and development, (d) understands the significance of effects of others’ behaviour on themselves
subjective reality and created meaning, (e) values self- • Are sensitive to the forces acting for and against
determination, (f) recognizes that nurses function best change
in those environments that capitalize on their strengths, • Express an optimistic view about human nature
and (g) invests in collaborative partnerships. • Are energetic
In the current context of complexity and chaos • Are open and encourage openness so that trust is
within the health care system, the concept of quantum developed
leadership has emerged to incorporate concepts of • Facilitate personal relationships
systems and complexity theory (Porter-O’Grady & • Plan and organize activities of the group
Malloch, 2011). • Are consistent in behaviour toward group members
Shared leadership recognizes that a professional • Delegate tasks and responsibilities to develop members’
workforce is made up of many leaders. No one person abilities
is considered to have knowledge or ability beyond that • Involve members in most decisions
of other members. Appropriate leadership is thought to • Value and use group members’ contributions
emerge in relationship to whatever challenges confront • Encourage creativity
the group. Shared governance refers to the process • Encourage feedback about their leadership style
where people participate in the planning and decision- • Assess for and promote the use of current
making processes while holding one another accountable technology
for the outcomes of the actions.
Effective Leadership
Leadership is a learned process. An effective leader people or command resources. Personal power is
needs to apply the principles of effective leadership, associated with being admired by others, and this admi-
which include vision, influence, and power to effect posi- ration is the result of the person having such attributes
tive change. This skill set encompasses an understand- as strength of character, passion, inspiration, or wisdom.
ing of motivational factors, such as needs, goals, and Task power is the ability to influence the person who
rewards; knowledge of leadership skills and of group is able to help with a process or task. Relationship
dynamics; and possession of effective communication power pertains to the respect others have for an indi-
and interpersonal skills to influence others. Statements vidual’s personal abilities, knowledge, or skills. Expert
about effective leaders are listed in Box 27.1. power is based on the person’s expertise or knowledge
Vision is a mental image of a possible and desir- (Sullivan & Decker, 2009).
able future state. Leaders transform visions that reflect
their values and beliefs into realistic goals and com-
municate their visions to others, who accept them as
their own. Nurse as Manager
Influence is an informal strategy used to gain
the cooperation of others without exercising formal New nurses manage patient care but generally will not
authority. Influence is exercised through persuasion and assume formal management roles early in their profes-
excellent communication skills; it is based on a trusting sional careers. However, nurses need an understanding
relationship with the followers. of the roles and functions of the nurse manager. The
Power is the capacity to act or to influence oth- manager’s job is to accomplish the work of the organiza-
ers to act to achieve something. There are five sources tion. To this end, managers perform a number of roles
of power: (a) position power, (b) personal power, (c) and functions that vary with the type of organization
task power, (d) relationship power, and (e) expert power. and the level of management. Managers are not neces-
Position power is related to the authority associated sarily leaders, but if they are, they are much more effec-
with a role or title and includes the power to manage tive in their roles.
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Levels of Management Organizing Organizing involves determining respon-

sibilities, communicating expectations, and establishing the
Traditional management is divided into three levels of chain of command for authority and communication.
responsibility. First-level managers (e.g., program or
unit managers, supervisors, charge nurses, head nurses, Directing Directing is the process of getting the
or nurse managers) are responsible for managing the organization’s work accomplished. Directing involves
work and day-to-day activities of a specific work group assigning and communicating expectations. It could also
or groups. Their primary responsibility is to imple- include providing instruction and guidance and mak-
ment the organization’s goals. This level of manager ing decisions on an ongoing basis. For example, charge
represents staff and reports to a middle-level manager. nurses direct shift work by assigning clients and schedul-
Nurses providing direct care or service will report to ing meal and break times. Staff nurses direct the care of
their immediate supervisors, usually a nursing manager, clients by ordering nursing care, communicating care in
and need a clear picture of the roles and responsibilities written care plans and shift reports, and supervising care
of these managers in order to work effectively in the that is given by others.
setting. Coordinating Coordinating is the process of
Middle-level managers (e.g., program directors ensuring that plans are carried out and evaluating out-
or department directors) supervise a number of first- comes. At times, the manager may include other health
level managers and are responsible for the activities in professionals and ensure that each provides care in a
the departments they supervise. Middle-level managers coordinated manner. The manager measures results or
serve as liaisons between first-level managers and upper- actions against standards or desired outcomes and then
level managers. reinforces effective actions.
Upper-level managers, for example, senior
administrators such as the executive directors (EDs),
vice-presidents (VPs), or chief executive officers (CEOs), Principles of Management
are primarily responsible for instilling organizational
changes by establishing goals and developing strategic A manager exercises authority, accountability, and
plans. Nurse managers at this level (e.g., chief nursing responsibility, as described below.
officer, nursing practice leader) are responsible for lead- Authority is the official power to act; it is the legiti-
ing the management team to work collaboratively to mate right to direct the work of others and an integral
achieve the organization’s vision and goals with a view component of managing. Authority is always associated
to achieving an excellent standard of patient services. with responsibility and accountability. The manager must
exercise the authority that comes with the role but cannot
act outside of the specified authority of the position.
Accountability is a person’s ability and willing-
Management Functions ness to assume responsibility for one’s own actions and
Four management functions that help achieve the goal to accept the consequences of one’s behaviour. At the
of quality client care are (a) planning, (b) organizing, individual level, accountability is reflected in the nurse’s
(c) directing, and (d) coordinating. ethical integrity. At the institutional level, it is reflected in
the statement of philosophy and objectives of the nurs-
Planning Planning is an ongoing process that involves ing department and nursing policies. At the professional
(a) assessing a situation, (b) establishing goals and objec- level, it is reflected in standards of practice developed by
tives based on assessment of a situation or future trends, national and provincial or territorial nursing associations.
and (c) developing a plan of action that identifies pri- Responsibility is an obligation to complete a task.
orities, delineates who is responsible for implementation, Managers are responsible for all operations under their
determines deadlines, and describes how the intended authority, including the utilization of resources, commu-
outcome is to be achieved and evaluated. In short, it nication to subordinates, and implementation of organi-
involves deciding what to do; when, where, and how to zational goals.
do it; who will do it; and what resources will be used.
For example, when planning for the introduction of a
falls-prevention program, the upper-level manager devel- Skills and Competencies
ops the goals, approves the financial commitment, and
directs the middle manager to implement the program.
of Nurse Managers
The middle manager communicates and directs the To be effective managers, nurses need to be able to
implementation of the falls-prevention program to the think critically, communicate well, manage resources
first-level manager. The first-level manager is responsible effectively, enhance employee performance, build and
for directing the actual implementation of the program manage teams, manage conflict, manage time effectively,
with staff. delegate effectively, and initiate and manage change.
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Critical Thinking Critical thinking is a cognitive are extremely hard working and have been the driving
process that includes creativity, problem solving, and force of much of the progress in nursing in the past
decision making. The nurse manager reasons with logic, 20 years.
exploring the assumptions, the alternatives, and the con- • Generation X (1965–1978): Nurses of this genera-
sequences of actions. See Chapter 21 for a discussion of tion are independent, resilient, and confident, and
critical thinking and decision making. they place their colleagues and clients before their
Communicating Good communication is essential to employers. They like to share their expertise with their
effective interpersonal skills and often determines the colleagues and clients. Their care tends to be guided
manager’s success as a leader. Managers use both verbal more by their clients’ desire than by rules and policies
and written communication. Effective managers com- in the organization.
municate assertively, clearly, accurately, and honestly. • Millennial Generation, or Generation Y (1979–
Managers use networking, a process of establishing 2000): Nurses of this generation grew up with tech-
professional links through which people share ideas, nologies and are at ease with computers, video games,
knowledge, and information; offer support and direction and cell phones. They can multitask and strive for self-
to one another; and facilitate accomplishment of profes- fulfillment; they can also establish rapport easily with
sional goals. team members, patients, and families.
Managing Resources Managers allocate resources Enhancing Employee Performance Managers

for care. One of managers’ greatest responsibilities is are responsible for enhancing employee performance
their accountability for human, fiscal, and material by providing appropriate learning opportunities, such
resources. Budgeting and managing variances between as in-service education or professional workshops, or
the actual and the budgeted expenses are crucial skills by encouraging achievement of advanced educational
for any manager. qualifications. Nurse managers who provide support
to enhance their staff performance will find that their
Human Resources Determining the correct staff mix
employees have greater commitment to the institution,
of registered nurses (RNs), licensed practical nurses
are more effective in their roles, have increased self-
(LPNs) or registered practical nurses (RPNs), and unreg-
esteem, and are better able to meet their goals.
ulated workers in a practice setting can directly influence
Nursing personnel provide care within a community
client outcomes. Teamwork by all levels of nurses and
of practice on their nursing units. Managers facilitate a
unregulated workers is essential to provide the best care
learning environment by encouraging staff to be men-
to patients. Delegation between nurses must be accom-
tors or preceptors. Mentors nurture new nurses by
plished on the basis of the knowledge of other nurses’
teaching, guiding, assisting, counselling and support-
scope of practice; client factors, such as complexity of
ing them in their practice, often informally (Marriner
care, predictability of care outcomes, and risk of nega-
Tomey, 2009). Preceptors are experienced nurses who
tive consequences to care; and practice environmental
assist new nurses in understanding routines, policies, and
factors, such as access to resources and supports for
procedures of the unit, and in improving clinical nursing
nurses and policies and procedures needed for decision
skills and judgment.
making (CNA, Canadian Council for Practical Nurse
Regulators, & Registered Psychiatric Nurses of Canada, Building and Managing Teams Managers are
2014; College of Nurses of Ontario [CNO], 2014). responsible for building and managing the work team. Famil-
Intergenerational Workers Currently, four generations iarity with group processes and the roles that group
of nurses are working in the health care system. Today’s members play facilitates the manager’s ability to lead the
nurses can be categorized into the Silent Generation, Baby work group. Groups develop in stages, during which roles
Boomers, Generation X, and the Millennial Generation (Sudheimer, and relationships are established (Detailed information
2009). Managers need to be aware that the different work about group stages and roles is provided in the section
ethics, values, and strengths of intergenerational nurses “Group Communication” in Chapter 22.)
can contribute to productivity but also create stress in the Evaluating the group’s work is another responsibility of
workplace. The characteristics of each generation are the manager. Effectiveness, efficiency, and productivity
described below (birth year ranges are in parentheses): are three outcome measures that are frequently used. In
nursing, effectiveness is a measure of the quality or
• Silent Generation (1933–1944): Nurses of this gen- quantity of services provided. Efficiency is a measure
eration have a traditional work ethic and excellent of the resources used in the provision of nursing services.
critical thinking skills. They are disciplined and loyal Productivity is a performance measure of both the
team players. They share their knowledge and exper- effectiveness and the efficiency of nursing care. Produc-
tise readily with their colleagues. tivity is frequently measured in the amount of nursing
• Baby Boomers (1945–1964): Nurses of this genera- resources used for each client or in terms of required
tion make up the majority of the nursing staff. They versus actual hours of care provided.
M27_KOZI2703_04_SE_C27.indd 528 27/02/17 1:10 PM

Managing Conflict Nurse managers are frequently collaboration. Basic principles for all types of conflict
required to manage conflict. Conflict can arise from dif- management include demonstrating respect for all par-
fering values, philosophies, or approaches, or competi- ties, avoiding blaming others, allowing full discussion,
tion for limited resources, and is not always a negative using ground rules during meetings to promote fair-
experience. Conflict that is addressed can lead to more ness, encouraging active listening, identifying the themes
holistic and inclusive approaches in the health care set- in the discussion, and exploring alternative solutions
ting. When conflict among nurses is left unresolved, it (Sullivan & Decker, 2009).
can lead to lack of trust among nurses and the resulting
workplace incivility (bullying and inappropriate conduct Managing Time Effective nurse managers use time effec-
and behaviours) and can have serious consequences for tively and assist others to do the same. Many factors
patient care (CNO, 2009). All nurses are expected to inhibit good use of time, such as personal preferences,
demonstrate effective conflict-resolution skills. (See the emergencies or crises that divert the nurse’s attention,
Evidence-Informed Practice box.) Communication strat- and unrealistic demands from others. Strategies that can
egies, such as active listening, being aware of nonverbal be employed to use time well involve setting goals and
behaviours, and addressing behaviours in a nonjudg- priorities, delegating appropriately, examining how time
mental manner, all contribute to promoting respect and is used, minimizing paperwork (automating, whenever
collegiality among team members. Conflict-resolution possible), and using regular schedules that avoid inter-
strategies include compromise, negotiation, and col- ruptions and set time limits on activities (Sullivan &
laboration, based on a full discussion of the issue and Decker, 2009).
exploring alternative solutions (Sullivan & Decker, 2009).
However, these strategies are only the first step in resolv-
ing the conflict. Nurses need to explore and understand
the root cause of conflict. Nurse as Delegator
There are many methods to manage conflict, and
each has its advantages and disadvantages. Among Delegation is the transference of responsibility and
the most common are compromise, negotiation, and authority for the performance of an activity to a com-
petent individual. The delegator retains accountability
for the outcome. Managers use delegation so that they
can devote more time to tasks that cannot be delegated.
Delegation builds self-esteem, promotes morale, and
Evidence-Informed
enhances teamwork and organizational goal attainment.
Practice
In nursing, delegation refers to care that is provided by
someone else and supervised by the nurse. The delegat-
Creating a Positive Nursing Workplace ing nurse defines the task, determines who can perform
Culture to Reduce Incivility the task, describes the expectation, seeks agreement,
meets timelines, monitors performance, and provides
An interprovincial team of nursing researchers explored the
work life of nurses across Canada, using a questionnaire to
feedback to the delegated worker regarding performance
identify the nurses’ perceptions of their immediate supervi- and outcomes of the assigned task (CNA, Canadian
sor’s leadership style and their sense of empowerment in Council for Practical Nurse Regulators [CCPNR], &
the workplace, personal workplace incivility experiences, Registered Psychiatric Nurses of Canada [RPNC], 2012;
and current state of emotional burnout. The findings of CNO, 2013).
the survey indicated that nurse managers who used a As a result of the increasing complexity of the
resonant leadership style incorporating self-awareness, health care work environment, RNs are delegating
self-management, sociopolitical awareness, and effective
management of relationships with others created positive
components of nursing care more and more to unreg-
workplace environments for the nurses on their units. Such ulated care providers (UCPs), such as commu-
workplaces strongly correlated with greater work satisfaction nity health workers, health care aides, home support
and productivity, and reduced incivility. workers, personal support workers (PSWs), visiting
Nursing Implications: Nurse managers and leaders
housekeepers, palliative care workers, and unit or ward
who nurture relationships in the workplace and focus aides. Many unregulated health care providers have
on creating positive workplace environments through educational programs of varying length and complex-
their leadership style ultimately contribute to improved ity but are not held to specific standards of practice.
patient care. Nurses’ increased job satisfaction and Practices of these workers vary across Canada. An RN
sense of empowerment are beneficial to patient care who delegates a task is accountable for selecting an
and outcomes. appropriately skilled caregiver who has the appropriate
Source: Laschinger, H. K. S., Wong, C., Cummings, G. G., & Grau, A. L. (2014). scope of practice and for continued evaluation of the
Resonant leadership and workplace empowerment: The value of positive organiza-
tional cultures in reducing workplace incivility. Nursing Economics, 32(1), 5–15, 44.
care provided to the patient. The actual performance
of the task is, however, the responsibility of the UCP.
M27_KOZI2703_04_SE_C27.indd 529 27/02/17 1:10 PM

Box 27.2 Examples of Tasks That Can Box 27.3 Principles Used by the Nurse
and Cannot Be Delegated to Unregulated to Determine Delegation to Unregulated
Care Providers Care Providers
The following principles should inform every decision to
Tasks That Can Be Delegated to Unregulated delegate:
Care Providers:
1. The nurse must assess the individual patient before
• Taking and reporting vital signs delegating tasks.
• Measuring and recording intake and output 2. The patient must be medically stable.
• Client transfers and ambulation 3. The care provider must have the requisite knowledge
and skills.
• Bathing
• Feeding The task must have the following characteristics:
• Attending to safety 1. Be considered routine for this client.
• Weighing 2. Not require a substantial amount of scientific knowledge
• Performing simple dressing changes or technical skill.
• Performing basic life support (cardiopulmonary 3. Be considered safe for this client.
resuscitation [CPR]) 4. Have a predictable outcome.
The nurse must ensure the following:

Tasks That Cannot Be Delegated to
Unregulated Care Providers: 1. Know the agency’s procedures and policies about
delegation.
• Assessment 2. Know the scope of practice and job description for
• Interpreting data each health care discipline on the team.
• Identifying care and service issues for patients 3. Be aware of individual variations in work
• Creating a plan for nursing care abilities.
• Evaluating care effectiveness 4. Teach the task using demonstration and return
demonstration, as needed.
• Care of invasive intravenous lines and
apparatus 5. Clarify reporting expectations to ensure the task is
accomplished.
• Administering medications
6. Ensure that patient safety is of paramount importance
• Inserting nasogastric tubes for all care providers.
• Patient education
• Performing triage
• Giving advice via the telephone
The CNO (2013) noted that a specific task that

can be delegated to one UCP may not be appropriate
for a different UCP, as it depends on each UCP’s edu-
Guidelines for delegating nursing tasks and procedures cational preparation and experience. Also, a task that
are given in Box 27.2. is appropriate for the UCP to perform with one client
Tasks that can be delegated to UCPs vary provin- (who is in a stable condition) may not be appropriate
cially and must be considered by the delegating RN. with a different client or the same client under altered
Principles guiding the nurse’s decision to delegate that circumstances.
ensure the safety and quality of outcomes are listed in It is important to note that the nurse is not held
Box 27.3. The UCP cannot delegate tasks to another legally responsible for the acts of the UCP but is account-
person. able for the quality of the act of delegation and has the
A nurse who delegates a task must communicate ultimate responsibility for ensuring that proper care is
clearly to ensure the UCP understands the following: provided. The nurse must know specific scopes of prac-
tice to delegate effectively and to ensure that proper care
• The specific tasks to be completed for each client
is provided.
• The timing of the task
• The expected outcomes for each task, including
parameters outside of which the UCP must immedi-
ately report to the nurse Clinical Alert
• Resources available to the UCP Nurses are responsible for their own actions. Any nurse
who feels unqualified to perform a delegated task must decline to
• When and in what format (written or verbal) a report perform it.
on the task is expected
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Change • Invest in relationships with employees, clients, and key

partners
Change is the process of making something different • Reinforce the organization’s vision, mission, and values
from what it was (Sullivan & Decker, 2009). Change can • Encourage and support behaviours that align with
involve gaining new knowledge or skills or adapting what strategic planning
is currently known in light of new information. Change • Remove barriers that hinder strategic actions
can involve individual clients, families, communities,
organizations, nursing as a profession, and the entire Change can also be considered covert or overt. A
health care delivery system. Change is an integral aspect covert change is hidden or occurs without the individual’s
of nursing, and nurses are often change agents, that awareness. For example, the resources available for
is, individuals who initiate, motivate, and implement a specific patient service are reduced. Overt change is
change. It is essential for managers to understand the change a person is aware of. Examples are the develop-
impact of change on employees and to develop strategies ment of policies related to visiting hours. People who
of support. Change often produces feelings of anxiety experience overt change may also experience anxiety.
among those affected and requires a manager to have Overt change may necessitate behavioural changes
additional understanding of the impact change may that are at variance with the person’s values, needs,
have on employees’ lives. Change agents have the follow- or goals.
ing characteristics:
• Excellent communication and interpersonal skills
Models of Change
• Knowledge of available resources
The following section describe the contemporary change
• Skill in problem solving
models commonly used in practice. Refer to Prochaska’s
• Skill in teaching model of change described in Chapter 8 of this book.
• Respect of those involved in the change Stefancyk, Hancock, and Meadows (2013) suggested
• Ability to encourage and nurture those going through that change is a normal part of nursing and health care
change and proposed the term change coach as opposed to
change agent, noting the managers’ role of coaching and
• Self-confidence, ability to take risks and inspire trust
mentoring staff to negotiate complex changes. Further,
in self and others
they noted that nurse managers need to be conversant
• Ability to make decisions with change models and theories and have skill sets in
• A broad base of knowledge the coaching behaviours of guidance, facilitation, and
• A good sense of timing motivation.
Lewin’s Theory of Change In his classic work,
Lewin (1951) described that change involves three stages:
Types of Change (a) unfreezing, (b) moving, and (c) refreezing. He also
Unplanned change is an alteration imposed by exter- stated that it requires a change agent to implement any
nal events or persons. It occurs when unexpected events planned change. During the unfreezing stage, the change
force a reaction. Drift is a type of unplanned change, in agent will identify the desired change and the related
which change occurs without effort on anyone’s part. driving and restraining forces, generate alternative solu-
Situational change, or natural change, can also be considered tions, and motivate the participants to change. In the
unplanned and occurs without any control by the person second stage, the moving stage, the change agent helps
or group affected. An example is the change that occurs the participants to see that the status quo is undesirable,
because of a war or a natural disaster. Not all situational and together they carry out actions to implement the
changes are negative, as with the government’s focus on change. In the final stage, refreezing, the change agent will
primary health care and its implication for professional facilitate integration and stabilization of the change. See
practice. an example in Figure 27.2.
Planned change is an intended attempt to achieve
RogerS’ Theory of Diffusion of Innovation
desired change. These changes may be specific to
Rogers (2003) defined diffusion as the process by which
the organization (e.g., visiting schedule policies), cross-
an innovation is communicated through certain channels
institutional (e.g., merging of linen services), or system-
over time among members of a social system (p. 35).
wide (e.g., restructuring of health care services). To
Diffusion is a special type of communication con-
facilitate organizational changes, nurse leaders must do
cerned with the spread of messages that are perceived
the following:
as new ideas. During the communication phase, infor-
• Understand that change does not necessarily occur in mation is discussed for a mutual understanding. Early
a linear fashion adopters of the innovation often become champions
M27_KOZI2703_04_SE_C27.indd 531 27/02/17 1:10 PM

Unfreezing Moving Refreezing
Preparing staff for Staff accepts the Change is

change (e.g., a new need for change evident and
reporting system) and engages in the becomes the
change process new norm
FIGURE 27.2 An example using Lewin’s Theory of Change Model.

Source: Based on work from Lewin, K. (1951). Field theory in social science: Selected theoretical papers. New York, NY: Harper & Row.
to support the change. This diffusion process can be 6. Produce short-term wins. Create some visible successes.
construed as risk taking and can incur uncertainty, as it 7. Don’t let up. Institute the change tirelessly until the vision
moves members out of their traditional comfort zones. is achieved.
APPRECIATIVE INQUIRY Appreciative inquiry (AI)
is an approach to organizational change, where one would Make It Stick
focus on what is positive (appreciative), examine the chal- 8. Create a new culture. Foster the new ways of behaving
lenges, and explore what is working well (Cooperrider, and help the group to develop it into a part of their
Whitney, Stavros, & Fry, 2008). AI adopts a positive culture.
approach to individual and organizational change. It
encourages the participants to visualize where they want An important aspect of planning change is deter-
to be in the future, set goals, and act toward achieving mining the criteria by which that acceptance can be
their destiny. AI focuses on building strengths rather than identified. Accepting change often takes time, particu-
on problems. AI is an effective approach to changing larly when it does not fit into a person’s attitudinal
organizational culture, to planning for organizational framework. The course of acceptance is easier for people
strategic directions, and to mentoring programs. if they are involved in the process. If possible, change
should be instituted on a small scale before full imple-
KOTTER’S EIGHT-STEP CHANGE PROCESS Kotter mentation (pilot project). To facilitate acceptance of the
and Rathgeber’s (2006) perspective on transformational change, the change agent also needs to identify common
change involves creating a vision to help direct the change driving and restraining forces (see Box 27.4). Guidelines
effort and encouraging risk taking and nontraditional for dealing with resistance are listed in Box 27.5.
ideas, activities, and actions. These are two critical actions
of leading changes in organizations. To combat common
organization behaviours and resistance to change, Kotter BOX 27.4 COMMON DRIVING AND
and Rathgeber (2006) provided the following eight steps to RESTRAINING FORCES FOR CHANGE
guide leaders and managers in leading change successfully: Identifying driving and restraining forces can help the
change agent make acceptance of the change possible.
Set the Stage
1. Create a sense of urgency. Help others see the need for DRIVING FORCES
change and the importance of acting immediately.
• Perception that the change is challenging
2. Pull together the guiding team. Form a group to guide the • Economic gain
change. • Perception that the change will improve the situation
Decide What to Do • Visualization of the future impact of change
• Potential for self-growth, recognition, achievement, and
3. Develop the change vision and strategy. Allow everyone to improved relationships
share his or her vision regarding how to transform the
past into a reality for the future.
RESTRAINING FORCES
Make It Happen • Fear that something of personal value will be lost
4. Communicate for understanding and buy-in. Ensure as many • Misunderstanding of the change and its implications
people as possible will understand and accept the pro- • Low tolerance for change
posed vision and the strategy. • Perception that the change will not achieve goals
5. Empower others to act. Facilitate the process to achieve • Lack of time or energy
the vision by removing barriers and providing the • Perceived loss of freedom
needed resources and support.
M27_KOZI2703_04_SE_C27.indd 532 03/03/17 4:18 PM

Box 27.5 Guidelines for Dealing with A Vision for Change

Resistance to Change
As nurses work at the forefront of the health care system,
The following guidelines are useful for dealing with resistance they are constantly affected by change. Knowledgeable
to change: nurses make rational plans to deal with opportunities
1. Determine the reasons for the opposition to both to initiate and to guide the needed change as they
the change. embrace and respond to change.
2. Provide accurate and complete information. One of the visions for the year 2020 is to have at
3. Be open to revisions, but keep the goal in mind. least 20% of nursing leaders drawn from the Aborigi-
4. Present the negative consequences of failing nal and visible minority populations, and at least 10%
to change. nursing leaders be male. Nursing curriculum must fos-
5. Emphasize the positive consequences of ter opportunities to develop skills required for nursing
the change leadership (Canadian Association of Schools of Nursing
6. Recognize that resistance is often an emotional [CASN], 2014; Villeneuve & MacDonald, 2006). Nurses
response. can learn to be leaders by doing the following:
7. Keep resisters involved in contact with supporters. • Seize opportunities created by change
8. Maintain a climate of trust, support, and
confidence.
• Enable others to influence change
9. To access optimal power, use the following • Support each other, especially younger nurses
strategies: • Practise personal accountability
• Know the formal lines of authority in the
• Ensure that the Code of Ethics for Registered Nurses is
organization. followed at work every day
• Identify key persons who will be affected by the • Apply research; participate in research
change. • Embrace lifelong learning
• Try to understand the issues for key people affected • Build strategic relationships
by the change.
• Cultivate flexibility and innovation
• Build a coalition of supporters of the change to
facilitate implementation. • Advocate for improved client care
• Follow the organizational chain of command in Now, more than ever, we need the knowledge, exper-
communicating with administrators. tise, and capacity of nurses to bring solutions to our
Source: Sullivan, Eleanor J., Effective Leadership and Management in Nursing, 7th Ed., health care challenges. Nurses are, and will continue to
©2009. Reprinted and Electronically reproduced by permission of Pearson Education,
Inc., New York, NY.
be, at the heart of the system’s transformation, driving
and managing change (CNA, 2009a).
Case Study 27
You recently attended interviews for two nursing positions and
are trying to decide which opportunity to pursue. During your first
2. Think about the managers you have admired. What
characteristics did they have that you would like to
interview, the nurse manager, Mr. Caruso, was cheerful, spoke
integrate into your own management style?
highly of his current staff, complimented them on their abilities,
listened to your ideas, and explored ways that you could contrib- 3. Both nurse managers in the case study spoke of
ute to his team’s effectiveness. The second nurse manager, Mrs. changes that were taking place in their facilities.
Turner, was also cheerful and talkative. She provided you with a As a nurse, how can you assist your peers who
job description as a primary nurse caregiver, explained what is seem to resist change?
expected of new employees, and spoke of the new programs 4. What factors should you consider before making
she was attempting to implement. Both nurse a decision about accepting a position in a team
managers talked about changes taking place nursing environment as opposed to a primary nursing
in their facilities and the need for employees environment?
to remain flexible.
Critical Thinking Questions Visit MyNursingLab for answers and explanations.
1. On the basis of the brief data provided, speculate about

the leadership style of each of these nurse managers.
M27_KOZI2703_04_SE_C27.indd 533 27/02/17 5:43 PM

Ke y Terms
accountability p. 527 democratic (participa- mentors p. 528 shared
appreciative inquiry tive, consultative) middle-level governance p. 526
(AI) p. 532 leaders p. 524 managers p. 527 shared leadership p. 526
authority p. 527 directing p. 527 Millennial Generation, Silent Generation p. 528
autocratic effectiveness p. 528 or Generation Y p. 528 situational
(authoritarian, efficiency p. 528 networking p. 528 leaders p. 525
directive) expert power p. 526 organizing p. 527 strengths-based nursing
leaders p. 524 first-level personal power p. 526 leadership p. 525
Baby Boomers p. 528 managers p. 527 planned change p. 531 task power p. 526
bureaucratic formal leader p. 524 planning p. 527 transactional
leader p. 525 Generation X p. 528 position power p. 526 leader p. 525
change p. 531 influence p. 526 power p. 526 transformational
change agents p. 531 informal leader p. 524 preceptors p. 528 leader p. 525
change coach p. 531 laissez-faire (nondi- productivity p. 528 unplanned change p. 531
charismatic rective, permis- quantum unregulated care
leader p. 525 sive, ultra-liberal) leadership p. 526 providers
clinical leadership p. 523 leader p. 525 relationship (UCPs) p. 529
coordinating p. 527 leader p. 523 power p. 526 upper-level
critical thinking p. 528 leadership style p. 524 responsibility p. 527 managers p. 527
delegation p. 529 manager p. 523 servant leaders p. 525 vision p. 526

• The professional nurse frequently assumes the roles of • Networking is the establishment of professional link-
leader and manager. Leaders influence others to accom- ages to obtain information, share ideas, and facilitate the
plish a specific goal, whereas managers are employees of accomplishment of professional goals.
an organization with responsibility and accountability for • Delegation is a management tool that a manager can use
accomplishing the tasks of the organization. to improve productivity. The manager transfers responsi-
• Several leadership styles have been described: autocratic, bility and authority to another but retains accountability
democratic, laissez-faire, and bureaucratic. Leadership for the task.
styles vary and are often blended to fit the situation. • Organizational changes include unplanned changes and
Nurses need to know which style is their most authentic planned changes.
and learn to incorporate aspects of other styles into
their practice. • Planned changes require problem-solving skills, decision-
making skills, and interpersonal competence. Nurse
• Descriptions of leadership, such as charismatic, transac- leaders and managers must be able to understand the
tional, transformational, connective, and shared, reflect driving and restraining forces and engage their staff in
the traits and behaviours of leaders and the relation- the change process.
ships between leaders and followers.
• Lewin’s change theory addressed the unfreezing, mov-
• Four major management functions are discussed: plan- ing, and freezing stages. Kotter described eight steps of
ning, organizing, directing, and coordinating. change from setting the stage to making it happen and
• Nurse managers work in the organizational framework of making it stick.
the employing agency. Principles of management include • Appreciative inquiry (AI) uses a positive approach to
authority, accountability, and responsibility. organization change. It encourages people to discover
• The skills and competencies required by nurse what works well, visualize their dreams, design action
managers are thinking critically, communicating, plans, and act to reach the destiny.
managing resources, enhancing employee performance, • Nurses function as change agents to initiate, motivate,
building and managing teams, managing conflict, and and implement change.
managing time.
M27_KOZI2703_04_SE_C27.indd 534 27/02/17 1:10 PM

N cl ex- St yl e Pr actic e Qui z

1. A nurse approaches the unit manager to complain b. Adherence to the agency policy on the use of the
about a colleague who always leaves the work area a Braden scale was 84%
mess for the oncoming shift. What is the best approach c. Braden scale compliance rates by the nursing
by the nurse manager to address this conflict? staff increased by 15% over the last audit results
a. Arrange to speak with the colleague about the to 84%
concerns expressed by the nurse d. Completion of the Braden scale by nursing staff was
b. Encourage the nurse to speak with the colleague highest on Wednesdays and lowest on Fridays
directly about the concerns
c. Call a staff meeting to have the nurses collectively 6. A nurse manager wants to develop a culture of inquiry
set rules for end of shift duties and learning on the unit. The manager has decided
d. Send an e-mail out to the unit staff reminding to implement the change by focusing on the strengths
everyone of the end of shift duties of the nursing staff, which include being strong clini-
cians and excellent teachers. During a staff meeting the
manager inquires how many staff would be interested
2. A registered nurse (RN) is deciding the client assign- in being involved in developing a New Graduate Nurse
ments during the intershift report. The RN must Mentorship Program. What type of change model is the
determine what aspects of care can be delegated to the nurse manager using to facilitate change to the organi-
unregulated care provider (UCP). Which task would be zational culture?
most appropriate to delegate to the UCP?
a. Lewin’s Theory of Change
a. Providing discharge teaching on the standard postop-
erative activity restrictions b. Appreciative Inquiry Theory
b. Assisting a client to ambulate the first time following c. Roger’s Theory of Innovation
a total hip replacement (THR) d. Kotter’s Eight-Step Change Process
c. Feeding a client with mild dysphagia as a result of a
cerebral vascular accident (CVA) 2 weeks ago 7. What should a staff nurse know before delegating tasks
d. Providing 1:1 care for a client with sepsis-induced to an unregulated care provider (UCP)?
acute delirium a. The worker should have practised each procedure
beforehand.
3. A code orange, mass casualty alert, has been acti- b. The worker’s level of knowledge must be verified
vated at a hospital. The unit manager on a medical before delegation.
unit takes charge and directs the nurses to determine c. Workers must be directly supervised in all aspects of
how many clients on each team can be immediately nursing care.
discharged. What leadership style is the nurse
manager using? d. Workers can perform procedures if they are guided
by a registered nurse.
a. Democratic
b. Laissez-faire 8. Which of the following approaches best illustrates trans-
c. Autocratic formational leadership?
d. Strength-based a. The leader stimulates group interest in establishing
unit goals that contribute to the agency’s mission.
4. A nurse is assigned a new role as a manager of an out- b. The leader forms subgroups or task forces that make
patient department where many issues have been identi- decisions about unit problems.
fied. Which of the following would be an important first c. The leader provides funding for continuing educa-
action to achieve? tion conferences to staff members who have not used
a. Working all of the unit shifts any sick leave.
b. Setting up a meeting with staff d. The leader adjusts his or her strategies to fit the cur-
c. Requesting feedback from the team rent situation.
d. Reviewing the unit budget
9. After taking the client’s history, the nurse recognizes
that the client is at risk of developing an infection.
5. The nurse manager is reviewing the results of a chart Which of the following should the nurse know about
audit, completed by the Quality Improvement team, to the problem?
evaluate whether the nurses are completing the Braden
scale on all clients according to the agency policy. What a. It is the responsibility of the client’s physician.
would be the best indicator that the nursing staff has b. It is a nursing diagnosis.
embraced this change? c. It is a collaborative problem.
a. When the nursing staff used the Braden scale it was d. It is a concern that should be left for the next
done well day shift.
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10. The nurse who is the stroke coordinator at a community b. Using information sessions to inform the audience,
care access centre explains that there will be a move gathering input, and recording questions from the
toward best practice guidelines in the management of attendees
stroke care and takes the time to facilitate information c. Introducing the changes, completing research, and
sessions regarding this change. Several physicians are using the information sessions to inform the audi-
resistant to the changes. Which strategy would help the ence about the change
nurse encourage change?
d. Applying a change theory to the process, completing
a. Requesting feedback from stakeholders, holding a current literature search, and using the information
information sessions to share the feedback, and sessions as a beginning step
determining which change theory to apply
Re f e r e nc e s
Canadian Association of Schools of Nursing (CASN). (2014). Kotter, J., & Rathgeber, H. (2006). Our icebergs are melting. New York,
National nursing education framework. Retrieved from http://www. NY: St. Martin’s Press.
casn.ca/education/national-nursing-education-framework. Lewin, K. (1951). Field theory in social science: Selected theoretical papers.
Canadian Nurses Association (CNA). (2009a). Position statement: New York, NY: Harper & Row.
Nursing leadership. Retrieved from https://www.cna-aiic.ca/en/ Marriner Tomey, A. M. (2009). Guide to nursing management and
download-buy/leadership. leadership (8th ed.). St. Louis, MO: Mosby.
Canadian Nurses Association. (2009b). The next decade: CNA’s vision for Porter-O’Grady, T., & Malloch, K. (2010). Quantum leadership:
nursing and health. Retrieved from http://www.cna-aiic.ca/CNA/ Advancing innovation, transforming health care (3rd ed). Burlington,
documents/pdf/publications/Next_Decade_2009_e.pdf. MA: Jones & Bartlett Learning.
Canadian Nurses Association, Canadian Council for Practical Registered Nurses Association of Ontario. (2013). Developing
Nurse Regulators, & Registered Psychiatric Nurses of Canada. and sustaining nursing leadership best practice guidelines
(2012). Joint position statement: Staff mix decision-making framework for (2nd ed.). Retrieved from http://rnao.ca/bpg/guidelines/
quality nursing care. Retrieved from https://www.cna-aiic.ca/en/ developing-and-sustaining-nursing-leadership.
search#q=nursing%20staff%20mix&f:cna-website-facet=[cna]. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York,
College of Nurses of Ontario (CNO). (2009). Practice guideline: NY: Simon & Schuster, Inc.
Conflict prevention and management. Toronto, ON: Author. Stefancyk, A., Hancock, B., & Meadows, M. (2013). The nurse
College of Nurses of Ontario. (2013). Practice guideline: manager: Change agent, change coach? Nursing Administration
Working with unregulated care providers. Retrieved from Quarterly, 37(1),13–17.
http://www.cno.org/en/learn-about-standards-guidelines/ Sturm, B. (2009). Principles of servant-leadership in community
standards-and-guidelines/. health nursing: Management issues and behaviors discovered in
College of Nurses of Ontario. (2014). Practice guideline: RN and RPN ethnographic research. Home Health Care Management and Practice,
practice: The client, the nurse and the environment. Toronto, ON: Author. 21, 82–89.
Cooperrider, D. L., Whitney, D., Stavros, J. M., & Fry, D. (2008). Sudheimer, E. E. (2009). Appreciating both sides of the generation
Appreciative inquiry handbook: For leaders of change (2nd ed.). Brunswick, gap: Baby boomer and Generation X nurses working together.
OH: Crown Custom Publishing Inc. Nursing Forum, 44, 57–63.
Gottlieb, L. N., Gottlieb, B., & Shamian, J. (2012). Principles of Sullivan, E. J., & Decker, P. J. (2009). Effective leadership and management
strengths-based nursing leadership for strengths-based nursing in nursing (7th ed.). Upper Saddle River, NJ: Pearson Prentice-Hall.
care: A new paradigm for nursing and healthcare for the Swanwick, T., & McKimm, J. (2011). What is clinical leadership …
21st century. Nursing Leadership, 25(2), 38–50. and why is it important? The Clinical Teacher, 8, 22–26.
Irving, J. A., & Longbotham, G. J. (2007). Team effectiveness and Villeneuve, M., & MacDonald, J. (2006). Toward 2020: Visions for
six essential servant leadership themes: A regression model based nursing. Ottawa, ON: Canadian Nurses Association. Retrieved
on items in the organizational leadership assessment. International from http://www.cna-nurses.ca/CNA/documents/pdf/
Journal of Leadership Studies, 2(2), 98–113. publications/Toward-2020-e.pdf.
M27_KOZI2703_04_SE_C27.indd 536 27/02/17 1:10 PM

UNIT 5
28
Nursing
Chapter Assessment and

Clinical Studies
Health Assessment
Madeleine Buck, BSc(N), MScA

Assistant Professor, Ingram School of Nursing, McGill University
A
LEARNING OUTCOMES
After studying this chapter, you will be able to ssessing a client’s health
1. Identify the purposes of the physical health assessment. status, which is a major
component of nursing
2. Explain the four methods of examination.
care, has two aspects: (a) nursing health
3. Identify expected findings during health assessment.
history, discussed in Chapter 23, and
4. Identify the steps in selected assessment procedures. (b) physical health assessment, which
5. Describe suggested sequencing to conduct a physical health is discussed in this chapter. A physical
assessment in an orderly manner. assessment can be any of three types:
6. Discuss variations in examination techniques appropriate for (a) a complete assessment (e.g., when
clients of different ages. a client is admitted to a health care
agency); (b) examination of a body sys-
tem (e.g., the cardiovascular system);
(c) examination of a body area (e.g.,
the lungs, when difficulty with breath-
ing is observed). Note: Some nurses
consider assessment to be the broad
term used in applying the nursing pro-
cess to health data and examination to
be the physical process used to gather
the data. In this text, the terms assess-
ment and examination are sometimes
used interchangeably, referring to both
a critical investigation and an evaluation
of client status.
M28_KOZI2703_04_SE_C28.indd 537 17/03/17 1:05 PM

538 UNIT FIVE Nursing Assessment and Clinical Studies
Physical Health Assessment health assessment is, therefore, conducted in a systematic

and efficient manner that requires the fewest position
changes for the client.
A physical health assessment can be done for many dif- The sequence of the assessment differs with children
ferent reasons: and adults. With children, always proceed from the least
• To obtain baseline data about the client’s functional invasive or uncomfortable to the more invasive. Exami-
abilities nation of the head and neck, heart, lungs, and range of
• To supplement, confirm, or refute data obtained in motion can be done early in the process, and the ears,
the nursing history mouth, abdomen, and genitals should be left for the end
of the examination.
• To obtain data that will help the nurse establish nurs- Frequently, nurses assess a specific body area instead
ing and client goals and a plan of care of the entire body. These focused assessments are made
• To evaluate the physiological outcomes of health in relation to client concerns, the nurse’s own observa-
care interventions and, thus, the progress of a client’s tion of problems, the client’s presenting problem, nurs-
health situation ing interventions provided, and medical therapies.
• To make clinical judgments about a client’s health Nurses use evidence-based practice guidelines and
status standards to focus health assessment on specific condi-
• To identify areas for health promotion and disease tions. For example, when screening for cancer, nurses
prevention should keep in mind the Canadian Cancer Society
screening guidelines (see Box 28.2). (See also Evidence-
A complete health assessment can be conducted Informed Practice box on prostate screening).
starting at the head and proceeding in a systematic
manner downward in what is referred to as a head-to-toe
assessment. However, the procedure can vary according
to the age of the individual, the severity of the ill-
Preparing the Client
ness, the preferences of the nurse, the location of the Before the assessment, the nurse should explain when
examination, and the clinical agency guidelines. The and where it will take place, why it is important, and
order of the standard head-to-toe assessment is given what will happen during the assessment. Often clients
in Box 28.1. Regardless of the procedure used, the cli- are anxious about what the nurse will find. They can
ent’s energy level and time need to be considered. The be reassured during the examination by explanations
BOX 28.1 HEAD-TO-TOE FRAMEWORK

• General survey • Upper extremities
• Vital signs • Skin and nails
• Head • Muscle strength and tone
• Hair, scalp, face • Joint range of motion
• Eyes and vision • Brachial and radial pulses
• Ears and hearing • Tendon reflexes
• Nose and sinuses • Sensation
• Mouth and oropharynx • Chest and back
• Neck • Skin
• Muscles • Thorax shape and size
• Lymph nodes • Lungs
• Trachea • Heart
• Thyroid gland • Spinal column
• Carotid arteries • Breasts and axillae
• Neck veins • Lower extremities
• Abdomen • Skin and toenails
• Skin • Gait and balance
• Abdominal sounds • Joint range of motion
• Specific organs (e.g., liver, bladder) • Femoral, popliteal, posterior tibial, and pedal pulses
• External genitals • Tendon and plantar reflexes
• Anus and rectum • Sensation
M28_KOZI2703_04_SE_C28.indd 538 03/03/17 11:13 AM

Chapter 28 Health Assessment 539
BOX 28.2 CANADIAN CANCER SOCIETY’S SELECTED EARLY DETECTION

AND SCREENING GUIDELINES FOR AVERAGE-RISK CANADIANS
Type of Cancer Early Detection and Screening* Possible Signs and Symptoms†
Prostate Cancer
The most common cancer in Prostate cancer can be detected early by Need to urinate often, especially at night
Canadian men using the prostate-specific antigen (PSA) Intense urge to urinate (urgency)
test to measure the antigen produced by the
Difficulty starting or stopping the urine flow
prostate gland and a digital rectal examina-
tion to palpate the prostate through the Inability to urinate
rectum. However, research does not clearly Weak, decreased, or interrupted urine stream
show if the benefits of testing for prostate A sense of incomplete emptying of the bladder
cancer outweigh the harms. Men who are
50 years or older should talk to their doctor Burning or pain during urination
about their risk of prostate cancer and about Blood in urine or semen
the benefits and harms of screening tests for Painful ejaculation
early detection.
Breast Cancer
The most common cancer in Women age 40–49 years should discuss the Painless lump in the breast or axilla
Canadian women; less than benefits and risks of mammography as well Changes in breast size or shape
1% of breast cancers occur as their risk of breast cancer.
Dimpling or puckering of the skin
in men Women age 50–69 years should have a
Redness, swelling, and increased warmth in
mammogram every 2 years.
the affected breast
Women age ≥70 years should speak with
Inverted nipple
their doctor about how often they should
be tested. Crusting or scaling on the nipple
Colorectal Cancer
The second leading cause Stool test (fecal occult blood test [FOBT] General discomfort in the abdomen (gas
of death from cancer in or fecal immunochemical test [FIT]) at least pains, bloating, fullness, or cramps); change
Canadians every 2 years in men and women age in bowel habits, such as persistent diarrhea
50 years and older or persistent constipation, for no appar-
ent reason; bright red or very dark blood in
stools; stools that are narrower than usual;
vomiting; feeling very tired; weight loss
Cervical Cancer
Rates are declining owing Papanicolaou (“Pap”) test required for sexually Abnormal bleeding from the vagina
to screening; introduction of active women every 1 to 3 years, depending Bleeding or spotting between regular menstrual
human papillomavirus (HPV) on previous test results, from the time they periods
vaccine may reduce the inci- are 21 years old
Bleeding after sexual intercourse
dence even further Continued Pap testing required even when
Menstrual periods that last longer and are
women are no longer sexually active
heavier than before
Continued Pap testing required in women
Bleeding after menopause
who have received the HPV vaccine
More discharge from the vagina than normal
Pain in the pelvis or lower back
Pain during sexual intercourse
Source: Summarized from the Canadian Cancer Society’s website

*Screening tests can find signs of cancer before symptoms develop, but further testing will be needed to confirm the presence of cancer.
†Note that the presence of any of the signs or symptoms can be indicative of a range of health problems other than cancer; Canadians should know what is normal for their bodies
so that they can report changes to how their bodies look or feel.
provided at each step. Inform the client that all informa- that are contraindicated for a particular client. The
tion gathered and documented during the assessment nurse helps the client, as needed, to undress and put
will be kept confidential. on a gown. Clients should empty their bladders before
Health assessments are usually painless; however, the examination. Doing so helps them feel more relaxed
it is important to determine in advance any positions and makes palpation of the abdomen and the pubic
M28_KOZI2703_04_SE_C28.indd 539 03/03/17 11:13 AM

Preparing the Environment

EVIDENCE-INFORMED PRACTICE It is important to prepare the environment before start-
ing the assessment. The time for the physical assessment
What Are the Best Screening should be convenient to both the client and the nurse.
Guidelines for Prostate Cancer? The environment should have a warm and comfortable
temperature and be well lit, and the equipment should
With prostate cancer representing 24% of all newly diag- be systematically arranged for the examination.
nosed cancer cases and 10% of all cancer deaths in Cana- It is important to provide the client with privacy.
dian men (Canadian Cancer Society, 2015), it is no wonder
that men in general as well as health care professionals are
Most people are embarrassed if their bodies are exposed
concerned about how this disease process is detected. or if others can overhear or view them during the assess-
The authors of this systematic review set out to determine ment. Family and friends should not be present unless
whether screening for prostate cancer reduces prostate the client specifically asks for someone to be present in
cancer-specific mortality or all-cause mortality and to assess the room. A client who is physically relaxed will usually
its impact on quality of life and adverse events. The research- experience little discomfort.
ers combined five randomized control trials and conducted
a meta-analysis of the findings. The studies combined had
341 342 participants in total, and the trials studied the effec-
tiveness of either one or more of the screening methods: Positioning
prostate-specific antigen (PSA) test (a blood test), digital
rectal examination (DRE), and transrectal ultrasound (TRUS)–
Several positions are frequently required during the
guided biopsy. After rigorous analysis of the data from physical assessment. It is important to consider the cli-
the studies, the authors concluded that “prostate cancer ent’s ability to assume a position. The client’s physical
screening did not significantly decrease prostate cancer- condition, energy level, and age should also be taken
specific mortality.” Bruising at the venipuncture site and mild into consideration. Some positions are embarrassing
anxiety during the screening were deemed as “minor” (no and uncomfortable and therefore should not be main-
study looked at the anxiety associated with DRE), and some
tained for long. The assessment is organized such that
of the major harms of screening included “overdiagnosis
and overtreatment, including infection, blood loss requiring
several body areas can be assessed in one position, thus
transfusion, pneumonia, erectile dysfunction, and inconti- minimizing the number of position changes needed (see
nence.” Complications from biopsies that were performed Table 28.1).
following false-positive screening result included infection,
bleeding, and pain. The authors concluded that “overdiag-
nosis and overtreatment are common, and are associated
with treatment-related harms. Men should be informed of
Draping
this and the demonstrated adverse effects when they are Drapes should be arranged so that the area to be assessed
deciding whether or not to undertake screening for prostate is exposed and other body areas are covered. Exposure
cancer. Any reduction in prostate cancer-specific mortality
of the body is frequently embarrassing to clients. Drapes
may take up to 10 years to accrue; therefore, men who have
a life expectancy less than 10 to 15 years should be informed provide not only a degree of privacy but also warmth.
that screening for prostate cancer is unlikely to be beneficial.” Drapes are made of paper, cloth, or bed linen.
NURSING IMPLICATIONS: Nurses play an important role
in helping Canadian men stay up to date and under-
stand the recommendations related to periodic health Instrumentation
assessment, such as prostate cancer screening. With
many men being concerned about prostate health and
All equipment required for the health assessment should
generally being told to “get screened early,” nurses can be clean, in good working order, and readily acces-
help these men understand that sometimes screening sible. Equipment is frequently set up on trays, ready for
can lead to negative outcomes, most importantly that use. Photographs of various instruments are shown in
screening can lead to false-positive results and unnec- Table 28.2.
essary interventions that come with major complica-
tions (e.g., incontinence, erectile dysfunction).
Source: Based on Ilic, D., Neuberger, M. M., Djulbegovic, M., Dahm, P. (2013). Methods of Examining
Screening for prostate cancer. Cochrane Database of Systematic Reviews 1,
CD004720. DOI: 10.1002/14651858.CD004720.pub3. Four primary techniques are used in the physical exami-
nation: (a) inspection, (b) palpation, (c) percussion, and
(d) auscultation. These techniques are discussed through-
area more comfortable. If a urinalysis is required, urine out this chapter as they apply to each body system.
should be collected at the time the client empties the
bladder. Since an empty rectum facilitates rectal exami- INSPECTION Inspection is a visual examination, that
nation, the client should be encouraged to defecate is, an assessment made by observing with the eyes. It
before a complete examination. should be deliberate, purposeful, and systematic. The
M28_KOZI2703_04_SE_C28.indd 540 03/03/17 11:13 AM

TABLE 28.1 Client Positions and Body Areas Assessed
Position Description Areas Assessed Cautions

Dorsal recumbent Back-lying position with Female genitals, rectum, May be contraindicated
knees flexed and hips and female reproductive for clients who have
externally rotated; small tract cardiopulmonary
pillow under the head; problems
soles of feet on the
surface
Supine (horizontal recumbent) Back-lying position with Head, neck, axillae, anterior Tolerated poorly by clients
legs extended; with or thorax, lungs, breasts, with cardiovascular or
without pillow under heart, vital signs, respiratory problems
the head abdomen, extremities,
peripheral pulses
Sitting A seated position, back Head, neck, posterior Older adults and weak
unsupported and legs and anterior thorax, clients may require
hanging freely lungs, breasts, axillae, support
heart, vital signs, upper
and lower extremities,
reflexes
Lithotomy Back-lying position with Female genitals, rectum, May be uncomfortable

feet supported in stir- and female reproductive and tiring for older
rups; the hips should tract adults and often
be in line with the edge embarrassing
of the Table
Sims’ Side-lying position with Rectum, vagina Difficult for older adults
lowermost arm behind and people with lim-
the body, uppermost ited joint movement
leg flexed at hip and
knee, upper arm flexed
at shoulder and elbow
Prone Lying on abdomen with Posterior thorax, hip joint Often not tolerated by
head turned to the movement older adults and
side, with or without a people with cardio-
small pillow vascular or respiratory
problems
nurse inspects with the naked eye and with the aid of or artificial light can be used. When using the auditory
a lighted instrument, such as an otoscope (used to view senses, it is important to have a quiet environment for
the ear). In addition to visual observations, olfactory accurate hearing. Observation can be combined with the
(smell) and auditory (hearing) cues are noted. Nurses fre- other assessment techniques.
quently use visual inspection to assess moisture, colour,
and texture of body surfaces, as well as shape, position, PALPATION Palpation is the examination of the body
size, colour, and symmetry of the body. Lighting must by using the sense of touch. The pads of the fingers
be sufficient for the nurse to see clearly; either natural are used because their concentration of nerve endings
M28_KOZI2703_04_SE_C28.indd 541 03/03/17 11:13 AM

TABLE 28.2 Equipment and Supplies Used for a Health Examination
Instruments and Supplies Purpose

Flashlight or penlight To view the pharynx or to determine the reactions of the
pupils of the eye
Nasal speculum To visualize the lower and middle turbinates; penlight usually
used for illumination
Ophthalmoscope (a lighted To visualize the interior of the eye

instrument)
Otoscope (a lighted To visualize the eardrum and external auditory canal (a nasal
instrument) speculum can be attached to the otoscope to inspect the
nasal cavities)
Percussion (reflex) hammer To test reflexes

(has a rubber head)
Tuning fork (a two-pronged To test hearing acuity and vibratory sense

metal instrument)
Cotton applicators To obtain specimens; to test sensory function
Disposable pads To absorb fluids
Gloves To protect the nurse and the client
Lubricant To ease insertion of instruments (e.g., vaginal speculum)

Tongue blades (depressors) To depress the tongue during assessment of the mouth and
the pharynx
M28_KOZI2703_04_SE_C28.indd 542 03/03/17 11:13 AM

Richard Tauber/Pearson Education, Inc.

FIGURE 28.1 The position of the hand for light palpation.
makes them highly sensitive to tactile discrimination.

Palpation is used to determine (a) texture (e.g., of hair);
(b) temperature (e.g., of a skin area); (c) vibration (e.g.,
FIGURE 28.2 The position of the hands for deep bimanual
of a joint); (d) position, size, consistency, and mobility palpation.
of organs or masses; (e) distension (e.g., of the urinary
bladder); (f) pulsation; and (g) the presence of tender-
ness or pain.
There are two types of palpation: light and deep. surface of the hand. General guidelines for palpation
Light (superficial) palpation should always precede deep include the following:
palpation because heavy pressure on the fingertips can
• The nurse’s hands should be clean and warm and the
dull the sense of touch. For light palpation, the nurse
fingernails short.
extends the fingers of the dominant hand parallel to the
skin surface and presses gently while moving the hand in • Areas of tenderness should be palpated last.
a circle (Figure 28.1). Skin is slightly depressed in light • Deep palpation, if indicated, should be done after
palpation. If it is necessary to determine the details of a superficial palpation.
mass, the nurse presses lightly several times, rather than
The effectiveness of palpation depends largely on
holding the pressure constant. The mass is assessed for
the client’s level of relaxation. Nurses can assist clients
location, size (length and width), shape (e.g., oval, round,
to relax by (a) gowning and draping the client appropri-
elongated), consistency (e.g., soft, hard), mobility (e.g., fixed,
ately, (b) positioning the client comfortably, (c) ensuring
mobile), presence or absence of pulsations, and tender-
that their own hands are warm before beginning, and (d)
ness to palpation.
communicating with the client during the examination.
Deep palpation is done with two hands (bimanu-
During palpation, the nurse should be sensitive to the cli-
ally) or one hand. In deep bimanual palpation, the
ent’s verbal and facial expressions indicating discomfort.
nurse extends the dominant hand as for light palpation
and then places the finger pads of the nondominant PERCUSSION Percussion is the act of striking the
hand on the dorsal surface of the distal interphalangeal body surface to elicit sounds that can be heard or vibra-
joint of the middle three fingers of the dominant hand tions that can be felt. Percussion has two types: direct
(Figure 28.2). The top hand applies pressure, while the and indirect. In direct percussion, the nurse strikes the area
lower hand remains relaxed to perceive the tactile sensa- to be percussed directly with the pads of two, three, or
tions. For deep palpation using one hand, the fingerpads four fingers or with the pad of the middle finger. The
of the dominant hand are pressed over the area to be strikes are rapid, and the movement is from the wrist.
palpated. Deep palpation is usually not done during a routine See Figure 28.3. This technique is not generally used to
examination and requires significant practitioner skill because percuss the thorax but is useful in percussing an adult’s
pressure can damage internal organs. It is usually not indicated sinuses.
in clients who have acute abdominal pain or pain that is not yet The second type, indirect percussion, is the striking of
diagnosed. an object (e.g., a finger) held against the body area to be
To test skin temperature, it is best to use the dorsum examined. In this technique, the middle finger of the
or back of the hand and fingers where skin is thinnest. nondominant hand, referred to as the pleximeter, is
To test for vibration, the nurse should use the palmar placed firmly on the client’s skin. Only the distal phalanx
M28_KOZI2703_04_SE_C28.indd 543 03/03/17 11:13 AM


FIGURE 28.4 Indirect percussion: Using the finger of one hand

to tap the finger of the other hand.
booming and can be heard over a diseased lung (e.g., in

the client with emphysema). Tympany is a musical or
drum-like sound produced from an air-filled stomach.
FIGURE 28.3 Direct percussion: Using one hand to strike the
surface of the body. On a continuum, flatness reflects the most dense tissue
(the least amount of air) and tympany the least dense
tissue (the greatest amount of air). A percussion sound is
and joint of this finger should be in contact with skin.
described according to its intensity, pitch, duration, and
The nurse strikes the pleximeter at the distal interpha-
quality. See Table 28.3.
langeal joint with the tip of the flexed middle finger of
the other hand. The tip of the middle finger that strikes AUSCULTATION Auscultation is the process of listen-
the pleximeter is known as the plexor (Figure 28.4). ing to sounds produced within the body. Auscultation
Some nurses may find a point between the distal and may be direct or indirect. Direct auscultation is the use of
proximal joints to be a more comfortable pleximeter the unaided ear, for example, to listen to a respiratory
point. The motion comes from the wrist; the forearm wheeze or the grating of a moving joint. Indirect ausculta-
remains stationary. The angle between the plexor and tion is the use of a stethoscope to listen to sounds from
the pleximeter should be 90 degrees, and the taps must within the body, such as bowel sounds or valve sounds
be firm, rapid, and short to obtain a clear sound. of the heart.
Percussion is used to determine the size and shape The stethoscope tubing should be 30 cm to 35 cm
of internal organs by establishing their borders. It indi- long and have an internal diameter of about 0.3 cm. It
cates whether tissue is fluid filled, air filled, or solid. should have both a flat-disc diaphragm and a bell-shaped
Percussion elicits five types of sound: flatness, dullness, diaphragm. (See Figure 4 in Skill 29.3, p. 647). The
resonance, hyperresonance, and tympany. Flatness is flat-disc diaphragm is best for transmitting high-pitched
an extremely dull sound produced by very dense tis- sounds (e.g., bronchial sounds), and the bell-shaped dia-
sue, such as muscle or bone. Dullness is a thud-like phragm is best for transmitting low-pitched sounds, such
sound produced by dense tissue, such as the liver, spleen, as heart sounds. The earpieces of the stethoscope should
or heart. Resonance is a hollow sound, such as that fit comfortably into the ears of the nurse, with the ear-
produced by lungs filled with air. Hyperresonance pieces facing forward. The diaphragm of the stethoscope
is not present in a healthy individual. It is described as is placed firmly but lightly against the client’s skin. If
TABLE 28.3 Percussion Sounds and Tones
Sound Intensity Pitch Duration Quality Example of Location

Flatness Soft High Short Extremely dull Muscle, bone
Dullness Medium Medium Moderate Thud-like Liver, heart
Resonance Loud Low Long Hollow Normal lung
Hyperresonance Very loud Very low Very long Booming Emphysematous lung
Tympany Loud High (distinguished mainly Moderate Musical Stomach filled with
by musical timbre) gas (air)
M28_KOZI2703_04_SE_C28.indd 544 03/03/17 11:13 AM

the client has excessive hair, it may be necessary to

dampen the hairs with a moist cloth so that they will
lie flat against skin and not interfere with clear sound
transmission. General Survey
Auscultated sounds are described according to their
pitch, intensity, duration, and quality. Pitch is the fre- INFANTS AND TODDLERS
quency of vibrations (the number of vibrations per • Observation of children’s behaviour can provide
second). Low-pitched sounds, such as some heart sounds, important data for the general survey, including physical
have fewer vibrations per second compared with high- development, neuromuscular function, and social and
interactional skills.
pitched sounds, such as bronchial sounds. Intensity
• It may be helpful to have parents hold older infants
(amplitude) refers to the loudness or softness of a sound.
and very young children for part of the assessment.
Some body sounds are loud, for example, bronchial
• To measure the height of a child under age 2 years,
sounds heard from the trachea; others are soft, for exam- place the child in the supine position with knees fully
ple, normal breath sounds heard in the lungs. The dura- extended.
tion of a sound is its length (long or short). The quality • Weigh the children without their clothing.
of a sound is a subjective description, for example, whis- • Include measurement of head circumference for
tling, gurgling, or snapping. children up to age 2 years. Standardized growth
charts include head circumference values for children
up to age 3 years.
PRESCHOOL-AGE AND SCHOOL-AGE CHILDREN

General Survey • Anxiety in preschool-age children can be decreased by
letting them handle examination equipment and thus
A physical assessment begins with a general survey, become familiar with it.
which involves observation of the client’s general appear- • School-age children may be very modest and shy about
exposing parts of their bodies.
ance and mental status and measurement of vital signs,
• Adolescents should be examined without parents
height, weight (height and weight measures are used to present.
calculate body mass index), and waist circumference.
• Children should be weighed without their shoes and with
Many components of the general survey are assessed as little clothing as possible.
while taking the client’s health history, such as the client’s
body build, posture, hygiene, and mental status (see the OLDER ADULTS
Lifespan Considerations box). • Allow extra time for clients to answer questions.
• Adapt questioning techniques as appropriate for clients
with hearing or visual limitations.
Appearance and Mental Status • Older adults with osteoporosis can lose several
centimetres in height. Be sure to document height,
The general appearance and behaviour of an indi- and ask if they are aware of becoming shorter.
vidual must be assessed in relationship to culture, • Adapt positioning during the examination to
educational level, socioeconomic status, and current accommodate age-related changes in range of
motion or pain.
circumstances. For example, an individual who has
recently experienced a personal loss may appropriately
appear depressed (sad expression, slumped posture).
The client’s age, gender, ethnicity, and race are useful Height, Weight, Body Mass Index, and
factors in interpreting findings that suggest increased Waist Circumference
risk for known conditions. Skill 28.1 describes how to
assess general appearance and mental status. Skill 28.17 In adults, the ratio of weight to height provides a general
(see p. 611) later in this chapter describes a mental sta- measure of health. By asking the client about height
tus examination in detail. and weight before actually measuring them, the nurse
obtains some idea of the person’s self-image. Excessive
discrepancies between the client’s responses and the
measurements may provide clues to actual or potential
Vital Signs problems in self-concept. It is also important that the
Vital signs are measured (a) to establish baseline data nurse and the client be aware of any significant uninten-
against which future measurements are compared and tional weight gain or loss.
(b) to detect actual and potential health problems. Refer The nurse measures height with a measuring stick
to Chapter 29 for measurements of temperature, pulse, attached to weight scales or to a wall. The client removes
respirations, blood pressure, and oxygen saturation. See shoes and stands erect, with heels together, buttocks
Chapter 30 for pain assessment. and the back of the head against the measuring stick,
M28_KOZI2703_04_SE_C28.indd 545 03/03/17 11:13 AM

SKILL 28.1 ASSESSING APPEARANCE AND MENTAL STATUS
PLANNING identifiers. Explain to the client what you are going to do,
why it is necessary, and how he or she can participate.
Equipment Discuss how the results will be used in planning further
None care or treatments.
IMPLEMENTATION 2. Perform hand hygiene, and follow other appropriate
infection prevention and control procedures.
Performance 3. Provide for client privacy.
1. Before performing the procedure, introduce yourself to
the client, and verify the client’s identity by using two
Assessment Normal Findings Deviations from Normal
General Appearance
4. Observe for signs of distress in No distress noted Bending over because of abdominal
posture or facial expression. pain; wincing, frowning, or laboured
breathing
5. Observe body build, height, and Proportionate, varies with lifestyle Excessively thin or obese
weight in relation to the client’s age,
lifestyle, and health.
6. Observe the client’s posture and gait, Relaxed, erect posture; coordinated Tense, slouched, bent posture;
standing, sitting, and walking. movement uncoordinated movement; tremors,
unbalanced gait
7. Observe the client’s overall hygiene Clean, neat Dirty, unkempt
and grooming.
8. Note body odour and breath odour. No body odour or minor body odour Foul body odour; ammonia odour;
relative to work or exercise; no breath acetone breath odour; foul breath
odour
9. Note obvious signs of health or illness Well nourished, intact skin, easy Pallor (paleness), weakness, lesions,
(e.g., in skin colour or breathing). breathing cough
10. Assess the client’s attitude (frame Cooperative, able to follow directions Negative, hostile, withdrawn, anxious
of mind).
11. Note the client’s affect (expression Appropriate to situation, stable Inappropriate to situation, blunted
of emotion) for appropriateness, or flat or expansive range; labile
range, and stability (changing)
12. Assess for level of orientation to Orientated in all spheres Not orientated in one or more
time, place, persons, and situation. spheres
13. Listen for quantity of speech Understandable, moderate pace Rapid or slow pace; overly loud
(amount and pace) and quality or soft
(loudness, clarity, inflection).
14. Listen for relevance and Logical sequence; makes sense; has Illogical sequence; flight of ideas;
organization of thoughts. sense of reality confusion; generalizations; vague
15. Document findings in the
client record.
EVALUATION
• Perform a detailed follow-up examination of other individual • Report significant deviations from normal to the appropriate
systems, based on findings that deviated from expected or members of the health care team.
normal for the client.
and eyes looking straight ahead. The nurse raises the Weight is usually measured when a client is admit-
L-shaped sliding arm on the measuring stick until it ted to a health care agency and often regularly there-
rests on top of the client’s head, or the nurse places after, for example, each morning before breakfast. The
a small flat object, such as a ruler or book, on the cli- nurse should use the same scale each time (because
ent’s head. The edge of the flat object should abut the there may be some variation among scales), take the
measuring guide. measurements at the same time each day, and make
M28_KOZI2703_04_SE_C28.indd 546 17/03/17 1:06 PM


FIGURE 28.6 A bed scale.
discusses waist circumference and its influences on

health in greater detail. See Figure 40.9 (p. 1152) for
FIGURE 28.5 A chair scale. the waist circumference measurement technique.
sure the client wears the same kind of clothing and no

shoes. The client stands on a platform, and the weight The Integument
is read from a digital display panel or a balancing arm.
Clients who cannot stand are weighed on chair scales The integument includes skin, hair, and nails. The exam-
(Figure 28.5) or built-in bed scales or machine lift bed ination begins with a generalized inspection by using
scales (Figure 28.6). a good source of lighting, preferably indirect natural
Standardized charts have the average heights and sunlight.
weights of children and adults. It is important to remem-
ber that these averages provide only general guidelines
for assessing growth, development, and nutritional status.
Skin
Body mass index (BMI) is a useful indicator of the Assessment of skin involves inspection and palpation.
overall health status of adults age 20 to 65 years. BMI In some instances, the nurse may also need to use the
does not apply to infants, children, adolescents, pregnant olfactory sense to detect unusual skin odours; these are
and breastfeeding women, and adults over the age of usually most evident in the skinfolds or in the axil-
65 years. BMI is calculated by taking the weight of the lae. Pungent body odour is frequently related to poor
individual in kilograms and dividing it by the height hygiene, hyperhidrosis (excessive perspiration), or
in metres squared. The formula is BMI = weight (kg)/ bromhidrosis (foul-smelling perspiration). The entire
height (m2). skin surface can be assessed at one time or as each aspect
For example, an individual weighing 75 kg and of the body is assessed.
measuring 150 cm in height would have a BMI of 33.3, Pallor is the result of inadequate circulating blood
which, as may be seen in Table 40.6 (p. 1151), would or hemoglobin and subsequent reduction in tissue oxy-
put him or her at high risk for health problems. See genation. It may be difficult to determine in clients
Table 40.5 (p. 1150) for the BMI nomogram and more with dark skin. It is usually characterized by absence of
discussion of BMI. Because adipose tissue located in the underlying red tones in skin and may be most readily
visceral area of the abdomen places a person at risk, seen in the buccal mucosa (mucous membrane of the
measurement of waist circumference is now becoming inside of the cheek). In brown-skinned clients, pallor
a part of the general health assessment. Chapter 40 may appear as a yellowish-brown tinge; in black-skinned
M28_KOZI2703_04_SE_C28.indd 547 03/03/17 11:13 AM

clients, skin may appear ashen grey. Pallor in all people is See Chapter 35 for discussion of skin assessment rel-
usually most evident in areas with the least pigmentation, ative to wounds and pressure injury. Skill 28.2 describes
such as the conjunctiva, oral mucous membranes, nail how to assess skin. (See also the Lifespan Considerations
beds, palms of hands, and soles of feet. box on assessing skin on page 552.)
Cyanosis, a bluish tinge, is most evident in the nail
beds, lips, and buccal mucosa. In dark-skinned clients,
close inspection of the palpebral conjunctiva (the lining of Hair
the eyelids), palms, and soles may also show evidence of
Assessment of a client’s hair includes inspecting it, con-
cyanosis. Jaundice, a yellowish tinge, may first be evident
sidering developmental changes, and determining the
in the sclera of the eyes and then in the mucous mem-
individual’s hair care practices and the factors influenc-
branes and skin. Nurses should take care not to confuse
ing them. Much of the information about hair can be
jaundice with the normal yellow pigmentation in the sclera
obtained by questioning the client.
of a dark-skinned client. If jaundice is suspected, the pos-
Normal hair is resilient and evenly distributed. In
terior part of the hard palate should also be inspected for
people with kwashiorkor (severe protein deficiency), hair
a yellowish colour tone. Erythema is redness associated
colour is faded and appears reddish or bleached, and
with a variety of skin rashes and other conditions.
the texture is coarse and dry. Some therapies cause
Localized areas of hyperpigmentation (increased
alopecia (hair loss), and some disease conditions affect
pigmentation) and hypopigmentation (decreased pig-
the coarseness of hair. For example, hypothyroidism can
mentation) may occur as a result of changes in the
cause very thin and brittle hair. Skill 28.3 describes how
distribution of melanin (the dark pigment) or in the func-
to assess hair. (Also see the Lifespan Considerations box
tion of the melanocytes in the epidermis. An example
of hyperpigmentation in a defined area is a birthmark; on assessing hair.)
an example of hypopigmentation is vitiligo. Vitiligo,
seen as patches of hypopigmented skin, is caused by
the destruction of melanocytes in the area. Albinism Nails
is the complete or partial lack of melanin in skin, hair, Nails are inspected for nail plate shape, angle between
and eyes. Other localized colour changes can indicate a the nail and the nail bed, nail texture, nail bed colour,
problem, such as edema or a localized infection. Edema and the intactness of the tissues around the nails. The
is the presence of excess interstitial fluid. When edema is parts of the nail are shown in Figure 28.8.
present, the tissues appear swollen, and skin is shiny, taut, The nail plate is normally colourless and has a
and blanched. If the edema is accompanied by inflam- convex curve. The angle between the nail and the nail
mation, skin will appear reddened (erythematous). Gen- bed is normally 160 degrees (Figure 28.9A). One nail
eralized edema is most often an indication of impaired abnormality is the spoon shape, in which the nail curves
venous circulation and, in some cases, reflects cardiac upward from the nail bed (Figure 28.9B). This condition,
dysfunction or vein abnormalities. called koilonychia, may be seen in clients with iron
A skin lesion is an alteration in a client’s normal deficiency anemia. Clubbing is a condition in which the
skin appearance. Primary skin lesions are those that angle between the nail and the nail bed is 180 degrees
appear initially in response to some change in the exter- or greater (Figures 28.9C and 28.9D). Clubbing can be
nal or internal environment of skin (Figure 28.7, 1–8). caused by a long-term lack of oxygen, such as in clients
Secondary skin lesions are those that do not with chronic respiratory or cardiac conditions.
appear initially but result from changes to the primary Nail texture is normally smooth. Excessively thick
lesion, such as those caused by trauma or infection of nails can appear in older adults, in the presence of poor
the primary lesion. For example, a vesicle or blister circulation, or in relation to a chronic fungal infection.
(primary lesion) may rupture and cause an erosion (sec- Excessively thin nails or the presence of grooves or fur-
ondary lesion). Table 28.4 describes secondary lesions. rows can reflect prolonged iron deficiency anemia. Beau’s
Nurses are responsible for describing skin lesions accu- lines are horizontal depressions in the nail that can result
rately in terms of location (e.g., face), distribution from injury or severe illness (see Figure 28.9E).
(i.e., body regions involved), and configuration (the The nail bed is highly vascular, a characteristic that
arrangement or position of several lesions—annular accounts for its pink colour in white people. A bluish or
(arranged in a circle), clustered together or grouped, purplish tint to the nail bed may reflect cyanosis, and
linear (arranged in a line), arc shaped or bow shaped, pallor may reflect poor arterial circulation. Should the
merged together, or indiscrete—as well as colour (e.g., client report a history of onychomycosis (nail fungus), a
no discoloration, a discrete colour such as brown or referral to a podiatrist or dermatologist for treatment of
red, several colours such as yellow and blue as with nail fungus may be appropriate. Symptoms of nail fun-
ecchymosis), shape (e.g., round, oval, flat), size (noted in gus include brittleness, discoloration, thickening, distor-
millimetres), texture (e.g., soft, hard, solid), and charac- tion of nail shape, crumbling of the nail, and detaching
teristics of individual lesions. (loosening) of the nail.
M28_KOZI2703_04_SE_C28.indd 548 03/03/17 11:13 AM

Scott Camazine/Alamy Stock Photo

-
Mediscan/Alamy Stock Photo

Dr. P. Marazzi/Science Source
Papular drug eruption

Psoriasis vulgaris
Multiple café-au-lait macules

GIRAND/BSIP/Alamy Stock Photo
Wellcome Image Library/Custom Medical Stock Photo
Wellcome Photo Library/Custom Medical Stock Photo

Peripheral neurofibromas
Chronic pustular psoriasis Bullous pemphigoid

Hercules Robinson/Alamy Stock Photo
Mediscan/Alamy Stock Photo
Digital mucous cyst Allergic wheals, urticaria
FIGURE 28.7 Primary skin lesions.
M28_KOZI2703_04_SE_C28.indd 549 03/03/17 11:15 AM

TABLE 28.4 Secondary Skin Lesions
Atrophy A translucent, dry, paper-like, Ulcer Deep, irregularly shaped area of

sometimes wrinkled skin surface skin loss extending into the der-
resulting from thinning or wasting mis or subcutaneous tissue; may
of skin caused by loss of collagen bleed; may leave scar
and elastin Examples: pressure ulcers, stasis
Examples: striae, aged skin ulcers, chancres
Erosion Wearing away of the superficial Fissure Linear crack with sharp edges
epidermis causing a moist, shallow extending into the dermis
depression; because erosions do Examples: cracks at the corners
not extend into the dermis, they of the mouth or in the hands,
heal without scarring athlete’s foot
Examples: scratch marks, ruptured
vesicles
Lichenification Rough, thickened, hardened area Scar Flat, irregular area of connective
of epidermis resulting from chronic tissue left after a lesion or wound
irritation, such as scratching or has healed; new scars may be
rubbing. red or purple; older scars may be
Example: chronic dermatitis silvery or white
Examples: healed surgical wound
or injury, healed acne
Scales Shedding flakes of greasy, keratin- Keloid Elevated, irregular, darkened area
ized skin tissue; colour may be of excess scar tissue caused by
white, grey, or silver; texture may excessive collagen formation
vary from fine to thick during healing; extends beyond
Examples: dry skin, dandruff, the site of the original injury;
psoriasis, and eczema higher incidence in black people
Examples: keloid from ear pierc-
ing or surgery
Crust Dry blood, serum, or pus left on Excoriation Linear erosion.

the skin surface when vesicles or Examples: scratches, some
pustules burst; can be red-brown, chemical burns
orange, or yellow; large crusts
that adhere to the skin surface are
called scabs
Examples: eczema, impetigo,
herpes, or scabs following abrasion
SKILL 28.2 ASSESSING SKIN
PLANNING IMPLEMENTATION
• Review the characteristics of primary and secondary Performance
lesions, if necessary (see Figure 28.7 p. 549 and
Table 28.4, p. 550).
• Ensure that adequate lighting is available. identifiers. Explain to the client what you are going to do,
Equipment Discuss how the results will be used in planning further
• Millimetre ruler care or treatments.
• Clean gloves 2. Perform hand hygiene, and follow other appropriate infec-
• Magnifying glass tion prevention and control procedures.
M28_KOZI2703_04_SE_C28.indd 550 17/03/17 1:07 PM

3. Provide for client privacy. members; use of medications, lotions, or home remedies;
4. Inquire whether the client has any history of the following: excessively dry or moist feel to skin; tendency to bruise
pain or itching; presence and spread of lesions, bruises, easily; association of the problem to season of year,
abrasions, pigmented spots; previous experience with stress, occupation, medications, recent travel, housing,
skin problems; presence of skin problems in other family and so on; recent contact with allergens.

5. Inspect skin colour (best assessed under Varies from light to deep brown; Pallor, cyanosis, jaundice,
natural light and on areas not exposed to from ruddy pink to light pink; erythema
the sun). from yellow overtones to olive
6. Inspect uniformity of skin colour. Generally uniform except in areas Areas of either hyperpigmentation
exposed to the sun; areas of lighter or hypopigmentation
pigmentation (palms, lips, nail beds)
in dark-skinned people
7. Assess edema, if present (i.e., location, No edema See the scale for grading
colour, temperature, shape, and the degree edema in ➊.
to which skin remains indented or pitted
when pressed with a finger). Measuring the
circumference of the extremity with a
millimetre tape may be useful for future
comparison.
1+ 2+ 3+ 4+
2 mm 4 mm 6 mm 8 mm
➊ Scale for grading edema.
8. Inspect, palpate, and describe skin Freckles, some birthmarks, some flat Interruptions in skin integrity;
lesions. Put on gloves if lesions are open and raised nevi; no abrasions or other irregular, multicoloured, or
or draining. Palpate lesions to determine lesions raised nevi
shape and texture. Describe the lesions
according to location, distribution, con-
figuration, colour, shape, size (using mil-
limetre ruler), and texture. If gloves were
applied, remove and discard gloves, and
perform hand hygiene.
9. Observe and palpate for skin moisture. Moisture in skinfolds and axillae (varies Excessive moisture (e.g., in
with environmental temperature and hyperthermia); excessive dryness
humidity, body temperature, and activity) (e.g., in dehydration)
10. Palpate for skin temperature. Compare Uniform; within normal range Generalized hyperthermia (e.g., in
the two feet and the two hands, using the fever); generalized hypothermia
backs of your fingers. (e.g., in shock); localized
hyperthermia (e.g., in infection);
localized hypothermia (e.g., in
arteriosclerosis)
11. Note skin turgor (fullness or elasticity) by lift- When pinched, skin springs back to Skin stays pinched or tented or
ing and pinching the skin on an extremity. previous state; may be slower in moves back slowly (e.g., in
older adults dehydration)
12. Perform hand hygiene.
(continued)
M28_KOZI2703_04_SE_C28.indd 551 03/03/17 11:15 AM

SKILL 28.2 ASSESSING SKIN (continued)

13. Document findings in the client record.
Draw location of skin lesions on body
surface diagrams, shown in ➋.
Right Left Left Right
➋ Diagram for charting skin lesions.

EVALUATION
• Compare findings to previous skin assessment data if avail- • Report significant deviations from expected or normal find-
able to determine if lesions or abnormalities are changing. ings to the appropriate members of the health care team.
level. Lesions on other parts of the • Flat, tan- to brown-coloured macules,

Assessing Skin body may be signs of disease or referred to as senile lentigines or mel-
abuse, and a thorough history should anotic freckles, are normally apparent
NEWBORNS AND INFANTS be taken. on the back of the hands and other
• Secondary skin lesions may occur fre- skin areas that are exposed to the
• Physiological jaundice may appear in sun. These macules may be as large
newborns 2 to 3 days after birth and quently as children scratch or expose
a primary lesion to microbes. as 1 cm to 2 cm.
usually lasts about 1 week. Pathologi-
cal jaundice, or that which indicates • With puberty, oil glands become more • Seborrheic keratosis (warty lesions)
a disease, appears within 24 hours of productive, and acne may develop. with irregularly shaped borders and a
birth and may last more than 8 days. scaly surface often occur on the face,
• In dark-skinned children, areas of shoulders, and trunk. These benign
• Newborns may have milia (whiteheads), hyperpigmentation may be found lesions begin as yellowish to tan and
small white nodules over the nose on the back, especially in the progress to a dark brown or black.
and face, and vernix caseosa (white sacral area.
• Vitiligo tends to increase with age and
cheesy, greasy material on skin).
is thought to result from an autoim-
• Premature infants may have lanugo, a OLDER ADULTS mune response.
fine downy hair covering their shoul- • Acrochordons (cutaneous tags) are
ders and back. • Skin loses its elasticity and wrinkles.
Wrinkles first appear on the skin of most commonly seen in the neck
• In dark-skinned infants, areas of hyper- the face and neck. and axillary regions. These skin
pigmentation may be found on the lesions vary in size and are soft,
back, especially in the sacral area. • Skin appears thin and translucent often flesh coloured, and pedicled
because of loss of dermis and (on a stem or stalk of tissue).
• Diaper dermatitis may be seen in subcutaneous fat.
infants. • Telangiectasias (visible, bright red,
• Skin is dry and flaky because seba- fine, dilated blood vessels) com-
• If a rash is present, inquire in detail ceous and sweat glands are
about immunization history. monly occur as a result of the thin-
less active. ning of the dermis and the loss of
• Assess skin turgor by pinching the • Skin takes longer to return to its natu- support for the blood vessel walls.
skin on the abdomen. ral shape after being tented between • Actinic keratoses (pink to slightly
the thumb and finger. red lesions with indistinct borders)
CHILDREN
• Because of the normal loss of periph- may appear at about age 50 years,
• Children may have minor skin lesions eral skin turgor in older adults, assess often on the face, ears, backs of the
(e.g., bruising or abrasions) on arms for hydration by checking skin turgor hands, and arms. They can become
and legs because of their high activity over the sternum or clavicle. malignant if left untreated.
M28_KOZI2703_04_SE_C28.indd 552 17/03/17 1:07 PM

SKILL 28.3 ASSESSING HAIR
PLANNING necessary, and how he or she can participate. Discuss how

the results will be used in planning further care or treatments.
Equipment
2. Perform hand hygiene, and follow other appropriate
Clean gloves infection prevention and control procedures.
IMPLEMENTATION 3. Provide for client privacy.

4. Inquire if the client has any history of the following: use of
Performance hair dyes, rinses, or curling or straightening preparations;
1. Before performing the procedure, introduce yourself to the recent chemotherapy (if alopecia is present); presence of
client, and verify the client’s identity by using two identi- disease, such as hypothyroidism, which can be associ-
fiers. Explain to the client what you are going to do, why it is ated with dry, brittle hair.

5. Inspect the evenness of growth over Evenly distributed hair Patches of alopecia (i.e., hair loss)
the scalp.
6. Inspect hair thickness or thinness. Thick hair Very thin hair (as in hypothyroidism)
7. Inspect hair texture and oiliness. Silky, resilient hair Brittle hair (as in hypothyroidism);
excessively oily or dry hair
8. Note the presence of infections or No infection or infestation Flaking, sores, lice, nits (louse eggs)
infestations by parting the client’s hair in
several areas and checking behind the
ears and along the hairline at the neck.
9. Inspect amount of body hair. Variable Hirsutism (excessive hairiness);
naturally absent or sparse leg hair (an
indicator of poor circulation)
EVALUATION
1. Relate findings to previous assessment data, 2. Report significant deviations from normal to the appropriate
if available. members of the health care team.
OLDER ADULTS
Assessing Hair
• The age at which the scalp hair greys is influenced largely
INFANTS by genetic factors.
• It is normal for infants to have either very little or a great • There may be loss of scalp, pubic, and axillary hair.
deal of body and scalp hair. • Older women may present with coarse facial hair.
CHILDREN • Hairs of the eyebrows, ears, and nostrils become
bristle-like and coarse.
• As puberty approaches, axillary and pubic hair will appear.
Nail bed
Nail root
Nail body Lunula
Nail bed Posterior nail fold
Lateral nail groove
Lateral nail fold
FIGURE 28.8 The parts of a nail.
M28_KOZI2703_04_SE_C28.indd 553 17/03/17 1:07 PM

Greater than180° angle Beau’s line

About 160° Flattened angle (180°)
A B C D E
FIGURE 28.9 A: A normal nail, showing the convex shape and the nail plate angle of about 160 degrees; B: A spoon-shaped nail,
which may be seen in clients with iron deficiency anemia; C: Early clubbing; D: Late clubbing (may be caused by long-term lack of
oxygen); E: Beau’s line on nail (may result from severe injury or illness).
The tissue surrounding the nails is normally intact epi- bed capillaries blanch when the tip of the nail is pressed
dermis. Paronychia refers to inflammation of the tissues but quickly (usually 2–3 seconds) turn pink or their usual
surrounding a nail (often referred to as “ingrown nail”). colour when pressure is released. A slow rate of capillary
The tissues appear inflamed and swollen, and tenderness refill may indicate peripheral circulatory problems.
is usually present. The blanch test assesses capillary Skill 28.4 describes how to assess the nails. (Also see
refill, an indicator of peripheral circulation. Normal nail the Lifespan Considerations box on assessing nails.)
SKILL 28.4 ASSESSING NAILS
PLANNING how the results will be used in planning further care or

treatments. In most situations, clients with artificial nails or
Equipment polish on fingernails or toenails are not required to remove
None these for assessment. If the assessment cannot be con-
ducted because of the presence of polish or artificial nails,
IMPLEMENTATION document this in the record.
Performance infection prevention and control procedures.
1. Before performing the procedure, introduce yourself to the 3. Provide for client privacy.
client, and verify the client’s identity by using two identi- 4. Inquire whether the client has any history of the following:
fiers. Explain to the client what you are going to do, why it diabetes mellitus, peripheral circulatory disease, previous
is necessary, and how he or she can participate. Discuss injury, or severe illness.

5. Inspect fingernail plate shape to determine its Convex curvature; angle Spoon nail (see Figure 28.9B);
curvature and angle. between nail and nail bed of clubbing (180 degrees or greater)
about 160 degrees (see (see Figures 28.9C and 28.9D)
Figure 28.9A)
6. Inspect fingernail and toenail texture. Smooth texture Excessive thickness or thinness or
presence of grooves or furrows; Beau’s
lines (see Figure 28.9E); discoloured or
detached nail, often caused by fungus
7. Inspect fingernail and toenail bed colour. Highly vascular and pink; dark- Bluish or purplish tint (may reflect
skinned clients may have cyanosis); pallor (may reflect poor
brown or black pigmentation arterial circulation)
in longitudinal streaks
8. Inspect tissues surrounding nails. Intact epidermis Hangnails; paronychia (inflammation)
9. Perform a blanch test to assess capillary refill. Press Prompt return of pink or usual Delayed return of pink or usual colour
the tip of two or more nails between your thumb colour, generally less than 2 may indicate peripheral circulatory
and index finger causing the nail bed to blanch; seconds. impairment
release and observe for the speed with which the
pink or usual colour of the nail bed returns.
EVALUATION
• Perform a detailed follow-up examination of other individual • Report significant deviations from normal to the appropriate
systems, based on findings that deviated from expected members of the health care team.
or normal for the client. Relate findings to previous assess-
ment data, if available.
M28_KOZI2703_04_SE_C28.indd 554 17/03/17 1:07 PM

LIFESPAN CONSIDERATIONS Eyes and Vision

Assessing Nails To maintain optimal vision, people need to have their
eyes examined regularly throughout life. It is recom-
INFANTS mended that people under age 40 years have their eyes
• Newborns’ nails grow very quickly, are extremely thin, tested every 3 to 5 years, or more frequently if there is a
and tear easily. family history of diabetes, hypertension, blood dyscrasia,
CHILDREN
or eye disease (e.g., glaucoma). After age 40 years, an eye
examination is recommended every 2 years to rule out
• Bent, bruised, or ingrown toenails can indicate shoes the possibility of glaucoma.
that are too tight.
An eye assessment should be carried out as part of
• Nail biting should be discussed with a caregiver as it
may be a symptom of stress. the client’s initial physical examination; periodic reas-
sessments need to be made for clients in long-term care.
OLDER ADULTS Examination of the eyes includes assessment of visual
• The nails grow more slowly and thicken. acuity (the degree of detail the eye can discern in an
• Longitudinal bands commonly develop in older adults, image), ocular movement, visual fields (the area an
and the nails tend to split. individual can see when looking straight ahead), and
• Bands across the nails may indicate protein deficiency; external structures. If the client wears contact lenses or
white spots, zinc deficiency; and spoon-shaped nails, has an artificial eye, consideration should be given to
iron deficiency. individual hygiene practices. For the anatomical struc-
• Toenail fungus is more common and difficult to eliminate tures of the eye, see Figures 28.11 and 28.12.
(although not dangerous to health).
Many people wear eyeglasses or contact lenses to
correct common refractive errors of the lens of the eye.
These errors include myopia (nearsightedness), hyper-
opia (farsightedness), and presbyopia (loss of elasticity
Head of the lens and, thus, loss of ability to see close objects).
Presbyopia begins at about 45 years of age. People with
Assessment of the head includes inspection, palpation, presbyopia have difficulty reading newsprint. Often, two
and percussion. The nurse examines the skull, face, eyes, corrective lenses (bifocals) are required—one for near
ears, nose, sinuses, mouth, and pharynx. vision or reading, the other for far vision. Astigma-
tism, an uneven curvature of the cornea that prevents
horizontal and vertical rays from focusing on the retina,
Skull and Face is a common problem that can occur in conjunction with
myopia and hyperopia.
Normal skulls come in a range of shapes. A normal Three types of eye charts are available to test visual
head size is referred to as normocephalic. The names acuity (Figure 28.13). A child acquires normal 20/20
of the areas of the head are derived from the names vision by 6 years of age. Visual acuity can be tested on
of the underlying bones: frontal, parietal, occipital, a standard Snellen chart. Visual acuity is documented
mastoid process, mandible, maxilla, and zygomatic as two numbers (e.g., 20/20). The first number indi-
(Figure 28.10). cates the distance of the client from the chart (i.e., 20
Many disorders cause a change in facial shape or feet, which is about 6 metres), and the second number
condition. Renal or cardiac disease can cause edema
of eyelids. Hyperthyroidism can cause exophthal-
mos, protrusion of eyeballs with elevation of the Sagittal suture
Parietal bone Coronal suture
upper eyelids, resulting in a startled or staring expres- Temporal bone Frontal bone
sion. Hypothyroidism can cause a puffy face with dry Lambdoid
Sphenoid bone
skin and coarse features and thinning of the scalp hair suture Zygomatic
and eyebrows. Increased adrenal hormone produc- bone
Occipital bone
Lacrimal bone
tion or administration of steroids can cause a round Temporo-
mandibular Nasal bone
face with reddened cheeks, referred to as a moon face,
joint
and excessive hair growth on the upper lips, chin, and Nasal
External acoustic
septum
sideburn areas. Prolonged illness, severe malnutrition, meatus
Mastoid process Maxilla
and dehydration can result in sunken eyes, cheeks, and
C1, Atlas Mandible
temples. C2, Axis
Skill 28.5 describes how to assess the skull and face. C3 vetebra
(Also see Lifespan Considerations box on assessing the
skull and face.) FIGURE 28.10 The bones of the head.
M28_KOZI2703_04_SE_C28.indd 555 03/03/17 11:15 AM

SKILL 28.5 ASSESSING THE SKULL AND FACE
PLANNING Discuss how the results will be used in planning further

care or treatments.
Equipment 2. Perform hand hygiene, and follow other appropriate
None infection prevention and control procedures.
3. Provide for client privacy.
IMPLEMENTATION 4. Inquire whether the client has any past problems with
Performance lumps or bumps, itching, scaling, or dandruff; any history
of loss of consciousness, dizziness, seizures, headache,
1. Before performing the procedure, introduce yourself to facial pain, or injury; when and how any lumps occurred;
the client, and verify the client’s identity by using two the length of time any other problem existed; any known
identifiers. Explain to the client what you are going to do, cause of the problem; and associated symptoms, treat-
why it is necessary, and how he or she can participate. ment, and recurrences.

5. Inspect the skull for size, shape, and Rounded (normocephalic and Lack of symmetry; increased skull
symmetry. If the skull is of abnormal symmetrical, with frontal, parietal, size with more prominent nose and
size, measure its circumference just and occipital prominences); smooth forehead; longer mandible (may
above the eyebrows. skull contour indicate excessive growth hormone
or increased bone thickness)
6. Palpate the skull for nodules or masses Smooth, uniform consistency; Sebaceous cysts; local deformities
and depressions. Use a gentle rotating absence of nodules or masses from trauma; masses, nodules
motion with the fingertips. Begin at the
front and palpate down the midline, and
then palpate each side of the head.
7. Inspect the facial features (e.g., Symmetrical or slightly asymmetrical Increased or uneven distribution of
symmetry of structures and facial features; palpebral fissures facial hair; thinning of eyebrows;
distribution of hair). equal in size; symmetrical nasolabial asymmetric features; exophthalmos
folds; even distribution of hair (bulging eyes); myxedema facies;
“moon face”
8. Inspect eyes for edema and hollowness. No edema or hollowness Periorbital edema; sunken eyes
9. Note symmetry of facial movements. Ask Symmetrical facial movements Asymmetrical facial movements
the client to elevate the eyebrows, frown, (e.g., eye on affected side cannot
lower the eyebrows, close the eyes close completely); drooping of lower
tightly, puff the cheeks, and smile and eyelid and mouth; involuntary facial
show the teeth. See Skill 28.17 (p. 611), movements (i.e., tics or tremors)
Assessing the Neurological System.
EVALUATION
• Perform a detailed follow-up examination of other systems, • Report significant deviations from expected or normal to the
based on findings that deviated from expected or normal appropriate members of the health care team.
for the client. Relate findings to previous assessment data,
if available.
fontanelle is larger, about 2 cm to 3 cm in size. It closes

Assessing the Skull and Face by 18 months.
NEWBORNS AND INFANTS • Newborns can lift their heads slightly and turn them from
side to side. Voluntary head control is well established by
• Newborns delivered vaginally can have elongated, moulded 4 to 6 months.
heads, which take on more rounded shapes after a week
or two. Infants delivered by cesarean section tend to have • Occipital flattening of positional origin results when an
smooth, rounded heads. infant spends prolonged periods with the head in the same
position against a flat surface.
• The posterior fontanelle (soft spot) is about 1 cm in
size and usually closes by eight weeks. The anterior
M28_KOZI2703_04_SE_C28.indd 556 17/03/17 1:07 PM

indicates the distance at which a normal eye can read manifests as tearing and discharge from the nasolacri-
the chart. For example, a test result of 20/200 means mal duct. Hordeolum (sty) refers to a redness, swell-
that at 20 feet, the client can read the chart that a per- ing, and tenderness of the hair follicle and glands that
son with normal vision could read at 200 feet. In other empty at the edge of the eyelids. Iritis (inflammation
words, the larger the second number, or denominator, of the iris) can be caused by local or systemic infections
the worse the visual acuity. People with denominators and results in pain, tearing, and photophobia (sensitiv-
of 40 or more on the Snellen chart, with or without ity to light). Contusions or hematomas are “black eyes”
corrective lenses, need to be referred to an optometrist resulting from injury.
or ophthalmologist. Cataracts are an opacity of the lens of the eye.
Inflammatory visual problems include conjunctivi- Most cataracts occur in individuals over age 65 years.
tis, dacryocystitis, hordeolum, iritis, and contusions or However, cataracts also occur in infants because of
hematomas of the eyelids and surrounding structures. a malformation of the lens, for example, if a mother
Conjunctivitis (inflammation of the bulbar and pal- contracts rubella in the first trimester of pregnancy. A
pebral conjunctiva) can be caused by foreign bodies, common treatment is removal of the lens and replace-
chemicals, allergenic agents, bacteria, or viruses. Red- ment of the lens with an implant. Glaucoma refers
ness, itching, tearing, and discharge occur. During sleep, to disruption in the circulation of the aqueous fluid,
the eyelids may become encrusted and matted together. which causes an increase in intraocular pressure and
Dacryocystitis (inflammation of the lacrimal sac) a reduced blood supply to the optic disc. Glaucoma is
the most common cause of blindness in people over
40 years. It can be controlled if diagnosed early. Danger
Bony orbital signs of glaucoma include blurred or foggy vision, loss
Puncta margin
of peripheral vision, difficulty focusing on close objects,
Lacrimal difficulty adjusting to dark rooms, and seeing rainbow-
Inner
gland coloured rings around lights.
canthus
Lacrimal Eyelids that lie at or fall below the pupil margin
Caruncle ducts
are referred to as ptosis and are usually associated
Lacrimal Outer with aging, edema from drug allergy or systemic disease
canaliculi canthus (e.g., kidney disease), congenital lid muscle dysfunc-
(canals)
Sclera tion, neuromuscular disease (e.g., myasthenia gravis),
Lacrimal Iris and third cranial nerve (CN) impairment. Eversion, an
Pupil
sac out-turning of the eyelid, is called ectropion; inversion,
an in-turning of the lid, is called entropion. These abnor-
Nasolacrimal duct
malities are often associated with scarring injuries or the
Orifice of
aging process.
nasolacrimal duct
The pupils are black, are equal in size (about 3 mm
to 7 mm in diameter), and have round, smooth bor-
FIGURE 28.11 The external structures and lacrimal apparatus ders. Mydriasis (enlarged pupils) can indicate injury
of the left eye. or glaucoma or result from certain drugs (e.g., atropine,
Superior rectus muscle Ciliary process

Ciliary body
Iris Macula and
Lens fovea centralis Bulbar
conjunctiva
Cornea
Optic nerve Palpebral
Pupil
conjunctiva
Anterior Optic disc Upper
chamber
eyelid
Posterior Palpebral
chamber Retina fissure
Choroid Lower eyelid
Bulbar
conjunctiva Sclera
Inferior rectus muscle
FIGURE 28.12 Anatomical structures of the right eye, lateral view.
M28_KOZI2703_04_SE_C28.indd 557 03/03/17 11:15 AM

Snellen
FIGURE 28.13 Three types of eye charts; the preschool children’s chart (left), the Snellen standard chart (centre), and the Snellen E
chart for clients unable to read (right).
cocaine, amphetamines). Miosis (constricted pupils) can examination; periodic reassessments may be necessary
indicate an inflammation of the iris or result as a side for long-term clients or those with hearing problems.
effect of some drugs, such as morphine, barbiturates, The ear is divided into three parts: (a) external
or pilocarpine. The pupils can become slightly irregu- ear, (b) middle ear, and (c) inner ear. Most of the struc-
lar and smaller in older adults, making it more difficult tures mentioned next are illustrated in Figure 28.14.
to examine the eyes. Anisocoria (unequal pupils) can The external ear includes the auricle or pinna, the
result from a central nervous system disorder; however,
slight variations may be normal. The iris is normally flat
and round. A bulging toward the cornea can indicate Malleus Stapes Semicircular
Auditory canals
increased intraocular pressure. ossicles Incus
Temporal
Skill 28.6 describes how to assess a client’s eye struc- Branches of
bone auditory nerve
tures and visual acuity. (Also see Lifespan Considerations
Pinna
box on assessing eye structures and visual acuity.)
INNER EAR
Vestibule
Cochlea
Ears and Hearing
Tragus
Lobule
Tympanic Eustachian
Assessment of the ear includes direct inspection and pal- membrane tube
Round
pation of the external ear, inspection of the remaining EXTERNAL EAR window
External
parts of the ear with an otoscope (instrument for exam- auditory canal MIDDLE EAR
ining the interior of the ear consisting of a magnifying
lens and a light), and determination of auditory acuity. FIGURE 28.14 Anatomical structures of the external, middle,
The ear is usually assessed during an initial physical and inner ear.
M28_KOZI2703_04_SE_C28.indd 558 03/03/17 11:15 AM

SKILL 28.6 ASSESSING EYE STRUCTURES AND VISUAL ACUITY
PLANNING identifiers. Explain to the client what you are going

to do, why it is necessary, and how he or she can
Place the client in an appropriate room for assessing eyes and
participate. Discuss how the results will be used in
vision. The nurse must be able to control the natural or over-
planning further care or treatments.
head lighting during some portions of the examination.
Equipment infection prevention and control procedures.
• Millimetre ruler 3. Provide for client privacy.
• Penlight 4. Inquire whether the client has any history of the
• Snellen or “E” chart following: family history of diabetes, hypertension,
• Opaque card blood dyscrasia, or eye disease, injury, or surgery;
client’s last visit to an ophthalmologist; current use of
eye medications; use of contact lenses or eyeglasses;
IMPLEMENTATION hygienic practices for corrective lenses; current
Performance symptoms of eye problems (e.g., changes in visual
acuity, blurring of vision, tearing, spots, photophobia,
1. Before performing the procedure, introduce yourself to itching, or pain).
External Eye Structures

5. Inspect the eyebrows for hair distribution Hair evenly distributed; skin Loss of hair; scaling and flakiness of skin;
and alignment and for skin quality and intact; eyebrows symmetrically unequal alignment and movement of
movement. (Ask the client to raise and aligned; equal movement eyebrows
lower eyebrows.)
6. Inspect eyelashes for evenness of distri- Equally distributed; curled Turned inward
bution and direction of curl. slightly outward
7. Inspect eyelids for surface characteristics Skin intact; no discharge; no Redness, swelling, flaking, crusting,
(e.g., skin quality and texture), position discoloration; lids close plaques, discharge, nodules, lesions;
in relation to the cornea, ability to blink, symmetrically; approximately 15 lids close asymmetrically, incompletely,
and frequency of blinking. For proper to 20 involuntary blinks per or painfully; rapid, monocular, absent, or
visual examination of the upper eyelids, minute; bilateral blinking; when infrequent blinking; ptosis, ectropion, or
elevate the eyebrows with your thumb lids open, no visible sclera entropion; rim of sclera visible between
and index fingers, and have the client above corneas, and upper and lid and iris (possible hyperthyroidism)
close the eyes. Inspect the lower eyelids lower borders of cornea are
while the client’s eyes are closed. slightly covered
8. Inspect the bulbar conjunctiva (lying over Transparent; capillaries Jaundiced sclera (e.g., in liver disease);
the sclera) for colour, texture, and the sometimes evident; sclera excessively pale sclera (e.g., in anemia);
presence of lesions. Retract the eyelids appears white (yellowish in reddened sclera; lesions or nodules (may
with your thumb and index finger, exert- dark-skinned clients) indicate damage by mechanical,
ing pressure over the upper and lower chemical, allergenic, or bacterial agents)
bony orbits, and ask the client to look
up, down, and from side to side.
9. Inspect the cornea for clarity and texture. Transparent, shiny, and smooth; Opaque; surface not smooth (may be the
Ask the client to look straight ahead. details of the iris are visible; in result of trauma or abrasion); corneal
Hold a penlight at an oblique angle older people, a thin, grayish- arcus in clients under age of 4 years
to the eye, and move the light slowly white ring around the margin,
across the corneal surface. Tangential called arcus senilis, may be
lighting best shows corneal regularity. evident
10. Inspect the pupils for colour, shape, Black in colour; equal in size; Cloudiness, mydriasis, miosis, anisocoria;
and symmetry of size. Pupil charts normally 3 to 7 mm in diameter; bulging of iris toward cornea
are available in some agencies. See round, smooth border; iris flat
➊ for variations in pupil diameters. and round
1 2 3 4 5 6 7 8 9 10
➊ Variations in pupil diameters in millimetres.
(continued)
M28_KOZI2703_04_SE_C28.indd 559 17/03/17 1:07 PM

SKILL 28.6 ASSESSING EYE STRUCTURES AND VISUAL ACUITY (continued)

11. Assess each pupil’s direct and consen- Illuminated pupil constricts Neither pupil constricts; unequal
sual reaction to light to determine the (direct response); nonilluminated responses; sluggish or absent
function of the oculomotor (third) and pupil constricts (consensual response
trochlear (fourth cranial) nerves. response); brisk response
• Partially darken the room.
• Ask the client to look straight ahead.
• By using a penlight and approach
ing from the side, shine a light on
the pupil.
• Observe the response of the illumi-
nated pupil. It should constrict (direct
response).
• Shine the light on the pupil again,
and observe the response of the
other pupil. It should also constrict
(consensual response).
12. Assess each pupil’s reaction to Pupils constrict when looking at One or both pupils fail to constrict,
accommodation. near object; pupils dilate when dilate, or converge
• Hold an object (a penlight or pencil) looking at far object; pupils
about 10 cm from the bridge of the converge when near object is
client’s nose. moved toward nose
• Ask the client to look first at the top To record normal assessment of
of the object and then at a distant the pupils, use the abbreviation
object (e.g., the far wall) behind the PERRLA (pupils equally round
penlight. Have the client alternate the and react to light and
gaze from the near object to the far accommodation)
object. Observe the pupil response.
• Next, ask the client to look at the near
object and then move the penlight or
pencil toward the client’s nose.
Visual Fields
13. Assess peripheral visual fields to deter- When looking straight ahead, Visual field smaller than normal
mine the functioning of the retina and client can see objects in the (possible glaucoma); one-half vision
neuronal visual pathways to the brain periphery in one or both eyes (possible nerve
and the optic (second cranial) nerve. damage)
• Have the client sit directly facing you Temporally, peripheral objects
at a distance of 60 cm to 90 cm. can be seen at right angles
• Ask the client to cover the right (90 degrees) to the central
eye with a card and look directly point of vision
at your nose. The upward field of vision is
• Cover or close your eye directly normally 50 degrees because
opposite the client’s covered eye the orbital ridge is in the way
(i.e., your left eye), and look directly The downward field of vision is
at the client’s nose. normally 70 degrees because
• Hold an object (e.g., a penlight or the cheekbone is in the way
pencil) in your fingers, extend your
The nasal field of vision is
arm, and move the object into the
normally 50 degrees away from
visual field from various points in the
periphery (see ➋). The object should the central point of vision
be at an equal distance from the because the nose is in the way
client and you. Ask the client to tell ➋ Assessing the client’s left peripheral
you when the moving object is first visual field.
spotted.
a. To test the temporal field of the left
eye, extend and move your right arm
in from the client’s right periphery.
M28_KOZI2703_04_SE_C28.indd 560 17/03/17 1:07 PM


b. To test the superior (upward) field of
the left eye, extend and move the
right arm down from the upward
periphery.
c. To test the inferior (downward) field
of the left eye, extend and move the
right arm up from the lower periphery.
d. To test the nasal field of the left eye,
extend and move your left arm in
from the periphery.
• Repeat the above steps for the right
eye, reversing the process.
Extraocular Muscle Tests

14. Assess six ocular movements to deter- Both eyes are coordinated, Eye movements not coordinated or
mine eye alignment and coordination. move in unison, with parallel parallel; one or both eyes fail to follow
• Stand directly in front of the client alignment a penlight in specific directions (e.g.,
and hold the penlight at a comfort- strabismus or cross-eye)
able distance, such as 30 cm in front Nystagmus (rapid involuntary
of the client’s eyes. rhythmic eye movement) other than at
• Ask the client to hold the head in a end point may indicate neurological
fixed position facing you and to follow impairment
the movements of the penlight with
the eyes only. 1 6 1
• Move the penlight in a slow, orderly Superior rectus Inferior oblique Superior rectus
(CN III) (CN III) (CN III)
manner through the six cardinal fields
of gaze, that is, from the centre of the 2 5 2
eye along the lines of the arrows in ➌ Lateral Medial Lateral
rectus rectus rectus
and back to the centre. (CN VI) (CN III) (CN VI)
• Stop the movement of the penlight
3 4 3
periodically so that nystagmus can Inferior rectus Superior oblique Inferior rectus
be detected. (CN III) (CN IV) (CN III)
➌ The six muscles that govern eye movement.

15. Assess for location of light reflex by Light falls symmetrically on both Light falls off centre on one eye
shining penlight on pupil on the corneal pupils (e.g., at 6 o’clock on both (indicates misalignment)
surface (Hirschberg test). pupils)
16. Have the client fixate on a near or far object. Uncovered eye does not move If misalignment is present, when the
Cover one eye, and observe for movement dominant eye is covered, the uncovered
in the uncovered eye (cover test). eye will move to focus on the object
Visual Acuity
17. Assess near vision by providing ade- Able to read newsprint Difficulty reading newsprint
quate lighting and asking the client to
read from a magazine or newspaper (if
the client can read and in a language the
client can read) held at a distance of 36
cm. If the client normally wears correc-
tive lenses, the glasses or lenses should
be worn during the test.
(continued)
M28_KOZI2703_04_SE_C28.indd 561 03/03/17 11:15 AM

SKILL 28.6 ASSESSING EYE STRUCTURES AND VISUAL ACUITY (continued)

18. Assess distance vision by asking the 20/20 vision on Snellen-type Denominator of 40 or more on Snellen-
client to wear corrective lenses, unless chart type chart with corrective lenses
they are used for reading only (i.e., for
distances of only 36 cm).
• Ask the client to stand or sit 6 m
(20 ft) from a Snellen or character
chart (see ➍), cover the eye not
being tested, and identify the letters
or characters on the chart.
• Take three readings: right eye, left
eye, both eyes.
• Record the readings of each eye and
both eyes (i.e., the smallest line from
which the person is able to read one
half or more of the letters).
➍ Testing distance vision.
At the end of each line of the chart are
standardized numbers (fractions). The
top line is 20/200. The numerator (top
number) is always 20, the distance
the person stands from the chart. The
denominator (bottom number) is the
distance from which the normal eye can
read the chart. Therefore, a person who
has 20/40 vision can see at 20 feet from
the chart what a normal-sighted person
can see at 40 feet from the chart. Visual
acuity is recorded as “s̄c” (without cor-
rection), or “c̄c” (with correction). You can
also indicate how many letters were mis-
read in the line (e.g., “visual acuity 20/40,
2c̄c” indicates that two letters were mis-
read in the 20/40 line by a client wearing
corrective lenses).
EVALUATION • Report significant deviations from expected or normal to the

appropriate members of the health care team. Persons with
• Perform a detailed follow-up examination of neurological denominators of 40 or more on the Snellen or character
and other systems, based on findings that deviated from chart, with or without corrective lenses, may need to be
expected or normal for the client. Relate findings to previ- referred to an optometrist or ophthalmologist.
ous assessment data, if available.
Images by: Richard Tauber/Pearson Education, Inc.
external auditory canal, and the tympanic mem- many fine hairs, glands, and nerve endings. The glands
brane, or eardrum. Landmarks of the auricle include secrete cerumen (earwax), which lubricates and pro-
the lobule (earlobe), helix (the posterior curve of the tects the canal.
auricle’s upper aspect), antihelix (the anterior curve The curvature of the external ear canal differs with
of the auricle’s upper aspect), tragus (the cartilaginous age. In the infant and toddler, the canal has an upward
protrusion at the entrance to the ear canal), triangu- curvature. By the age of 3 years, the ear canal assumes
lar fossa (a depression of the antihelix), and external the more downward curvature of adulthood.
auditory meatus (the entrance to the ear canal). The middle ear is an air-filled cavity that starts at the
Although not part of the ear, the mastoid, a bony tympanic membrane and contains three ossicles (bones
prominence behind the ear, is another important land- of sound transmission): the malleus (hammer), which is
mark. The external ear canal is curved, is about 2.5 cm the most easily seen, the incus (anvil), and the stapes
long in the adult, and ends at the tympanic membrane. (stirrup). The eustachian tube, another part of the
The tympanic membrane separates the external ear middle ear, connects the middle ear to the nasopharynx.
from the middle ear. It is covered with skin that has The tube stabilizes the air pressure between the external
M28_KOZI2703_04_SE_C28.indd 562 17/03/17 1:07 PM

Assessing Eye Structures and Visual Acuity

INFANTS • Always perform the acuity test with External Eye Structures
glasses on if a child has a prescrip- • The skin around the orbit of the eye
• Infants 4 weeks of age should gaze tion to wear lenses.
at and follow objects. may darken.
• Children should be tested for colour • The eyes may appear dry and lus-
• Ability to focus with both eyes should vision deficit. From 8% to 10% of white
be present by 6 months of age. treless because of the decrease in
males and from 0.5% to 1% of white tear production from the lacrimal
• Infants do not have tears until about females have this deficit. The Ishihara glands.
3 months of age. or Hardy-Rand-Rittler test can be used.
• The eyeball may appear sunken
• A cover test and the corneal light because of the decrease in orbital fat.
reflex (Hirschberg) test should be con- OLDER ADULTS
ducted on infants to detect misalign- • Skinfolds of the upper lids may seem
Visual Acuity
ment early and prevent amblyopia. more prominent, and the lower lids
• Visual acuity decreases as the lens may sag.
• Visual acuity is about 20/300 ages, becomes more opaque, and
at 4 months and progressively • Arcus senilis (a thin, greyish-white
loses elasticity (presbyopia).
improves. arc or ring) appears around part or
• The ability of the iris to accom- all of the cornea. It results from an
modate to darkness and dim light accumulation of a lipid substance
CHILDREN diminishes. on the cornea. The cornea tends to
• Epicanthal folds, common in persons • Peripheral vision diminishes. cloud with age.
of Asian origin, may cover the medial • The adaptation to light (glare) and • The iris may appear pale with brown
canthus and cause eyes to appear dark decreases. discolorations as a result of pigment
misaligned. Epicanthal folds may also degeneration.
be seen in young children of any race • Accommodation to far objects often
before the bridge of the nose begins improves, but accommodation to • The conjunctiva of the eye may appear
to elevate. near objects decreases. paler than in younger adults and may
• Colour vision declines; older people take on a slightly yellow appearance
• Preschool children’s acuity can be because of the deposition of fat.
checked with picture cards or the “E” are less able to perceive purple
chart. Acuity should approach 20/20 colours and to distinguish between • Pupil reaction to light and accommo-
by 6 years of age. pastel colours. dation is normally symmetrically equal
• Many older people wear corrective but may be less brisk.
• A cover test and the corneal light
reflex (Hirschberg) test should be lenses; they are most likely to have • The pupils can appear smaller in
conducted on young children to hyperopia. Visual changes are caused size, unequal, and irregular in shape
detect misalignment early and pre- by loss of elasticity (presbyopia) and because of sclerotic changes in
vent amblyopia. transparency of the lens. the iris.
atmosphere and the middle ear, thus preventing rupture Bone-conducted sound transmission occurs when
of the tympanic membrane and discomfort produced by skull bones transport the sound directly to the auditory
marked pressure differences. nerve.
The inner ear contains the cochlea, a seashell- Audiometric evaluations, which measure hearing
shaped structure essential for sound transmission and at various decibels, are recommended for older adults.
hearing, and the vestibule and the semicircular A common hearing deficit with age is loss of ability to
canals, which contain the organs of equilibrium. hear high-frequency sounds, such as f, s, sh, and ph. This
Sound transmission and hearing are complex pro- neurosensory hearing deficit does not respond well to the
cesses. In brief, sound can be transmitted by air conduc- use of a hearing aid.
tion or bone conduction. The process of air-conducted Conduction hearing loss is the result of inter-
transmission is as follows: rupted transmission of sound waves through the outer
and middle ear structures. Possible causes are a tear in
1. A sound stimulus enters the external canal and
the tympanic membrane or an obstruction, because of
reaches the tympanic membrane.
swelling or other causes, in the auditory canal. Senso-
2. The sound waves vibrate the tympanic membrane rineural hearing loss is the result of damage to the
and reach the ossicles. inner ear, the auditory nerve, or the hearing centre in
3. The sound waves travel from the vibrating ossicles to the brain. Mixed hearing loss is a combination of
the opening in the inner ear (round window). conduction and sensorineural loss.
4. The cochlea receives the sound vibrations. Skill 28.7 describes how to assess the ears and hear-
5. The stimulus travels to the auditory nerve (CN VIII) ing. (See also Lifespan Considerations box on assessing
and the cerebral cortex. ears and hearing.)
M28_KOZI2703_04_SE_C28.indd 563 03/03/17 11:15 AM

SKILL 28.7 ASSESSING EARS AND HEARING
PLANNING is necessary, and how he or she can participate. Discuss

how the results will be used in planning further care or
It is important to conduct the ear and hearing examination treatments.
in a quiet area. In addition, the location should allow the
client to be positioned sitting or standing at the same level
as the nurse.
Equipment 4. Inquire whether the client has a family history of hearing
Otoscope with several sizes of ear specula problems or loss; presence of any ear problems; medica-
tion history, especially if there are complaints of ringing in
IMPLEMENTATION ears; any hearing difficulty; its onset, factors contributing
to it, and how it interferes with activities of daily living; use
Performance of a corrective hearing device: when and from whom it
was obtained.
1. Before performing the procedure, introduce yourself to the
client, and verify the client’s identity by using two identi- 5. Position the client comfortably, seated if possible.
fiers. Explain to the client what you are going to do, why it
Auricles
6. Inspect the auricles for colour, symmetry Colour same as facial skin; Bluish colour of earlobes (e.g.,
of size, and position. To inspect posi- symmetrical; auricle aligned with cyanosis); pallor (e.g., frostbite);
tion, note the level at which the superior outer canthus of eye, about excessive redness (inflammation or
aspect of the auricle attaches to the 10 degrees from vertical (see ➊). fever); asymmetry; low-set ears
head in relation to the eye. (associated with a congenital
abnormality, such as Down
syndrome)
10
>10
Normal alignment Low-set ears and

deviation in alignment
➊ Alignment of ears.
7. Palpate the auricles for texture, elasticity, Mobile, firm, and not tender; Lesions (e.g., cysts); flaky, scaly skin
and areas of tenderness. pinna recoils after it is folded (e.g., seborrhea); tenderness when
• Gently pull the auricle upward, moved or pressed (may indicate
downward, and backward. inflammation or infection of
external ear)
• Fold the pinna forward (it should recoil).
• Push in on the tragus.
• Apply pressure to the mastoid
process.
External Ear Canal

and Tympanic Membrane
8. Inspect the external ear canal for ceru- Distal third contains hair follicles Redness and discharge; scaling;
men, skin lesions, pus, and blood. and glands; dry cerumen, greyish- excessive cerumen obstructing canal
tan colour; or sticky, wet cerumen
in various shades of brown
M28_KOZI2703_04_SE_C28.indd 564 17/03/17 1:07 PM


9. Visualize the tympanic membrane using
an otoscope.
• Attach a speculum to the otoscope.
Use the largest diameter that will fit
the ear canal without causing dis-
comfort. Rationale: This achieves
maximum vision of the entire ear
canal and tympanic membrane.
• Tip the client’s head away from you,
and straighten the ear canal. For an
adult, straighten the ear canal by
pulling the pinna up and back Normal
(see ❷). Rationale: Straightening position
the ear canal facilitates vision of
the ear canal and the tympanic
membrane.
• Hold the otoscope either (a) right ❷ Straightening the ear canal of an adult by pulling the pinna up
side up, with your fingers between and back.
the otoscope handle and the client’s
head or (b) upside down, with your
fingers and the ulnar surface of your
hand against the client’s head (see
❸). Rationale: This stabilizes the
head and protects the eardrum
Patrick Watson/Pearson Education, Inc.

and canal from injury if a quick
head movement occurs.
• Gently insert the tip of the otoscope
into the ear canal, avoiding pres-
sure by the speculum against either
side of the ear canal. Rationale:
The inner two-thirds of the ear
canal is bony; if the specu-
lum is pressed against either
side, the client will experience
discomfort. ❸ Inserting an otoscope.
10. Inspect the tympanic membrane for Pearly grey colour, semitransparent, Pink to red, some opacity;
colour and gloss. light reflex at 5 o’clock in right ear yellow-amber, white, blue, or
and 7 o’clock in left ear (see ❹) deep red; dull surface
Barbara Kozier
❹ Normal tympanic membrane with light

reflex at 7 o’clock (left ear).
Gross Hearing Acuity Tests

11. Assess the client’s response to normal Normal voice tones audible Normal voice tones not audible (e.g.,
voice tones. If the client has difficulty client requests nurse to repeat words or
hearing the normal voice, proceed with statements, leans toward the speaker,
the following tests. turns the head, cups the ears, or speaks
in loud voice)
(continued)
M28_KOZI2703_04_SE_C28.indd 565 03/03/17 11:15 AM

SKILL 28.7 ASSESSING EARS AND HEARING (continued)

11A. Perform the watch tick test. The ticking Able to hear ticking in both ears Unable to hear ticking in one or both ears
of a watch has a higher pitch than the
human voice. Have the client occlude
one ear. Out of the client’s sight, place
a ticking watch 2 cm to 3 cm from the
unoccluded ear. Ask what the client
can hear. Repeat with the other ear.
11B. Tuning Fork Tests Perform Weber’s Sound is heard in both ears or is Sound is heard better in impaired ear,
test (a test to assess bone conduction) localized at the centre of the head indicating a bone-conductive hearing loss,
by examining the lateralization (side- (Weber negative) or sound is heard better in ear without a
ward transmission) of sounds. problem, indicating a sensorineural
• Hold the tuning fork at its base. disturbance (Weber positive)
Activate it by tapping the fork gently
against the back of your hand near
the knuckles or by stroking the fork
between your thumb and index fin-
gers. It should be made to ring softly.
• Place the base of the vibrating fork
on top of the client’s head (see ❺)

and ask where the client hears the
noise.
❺ Placing the base of a tuning fork on

the client’s skull (Weber’s test).
Bone conduction time is equal to or longer
Conduct the Rinne test (a test to Air-conducted (AC) hearing time is than the air conduction time, that is, BC >
compare air conduction to bone greater than bone-conducted (BC) AC or BC = AC (negative Rinne; indicates
conduction). hearing time, that is, AC > BC conductive hearing loss)
• Ask the client to block the hearing (positive Rinne)
in one ear intermittently by moving a
fingertip in and out of the ear canal.

• Hold the handle of the activated tuning

fork on the mastoid process of one ear
(see ❻) until the client states that the
vibration can no longer be heard.
• Immediately hold the vibrating fork
prongs next of the client’s ear
canal (see ❼).
• Push aside the client’s hair, if neces-
sary. Ask whether the client now ❼ Tuning fork prongs placed next to the
hears the sound. Sound conducted ➏ Base of the tuning fork on the mastoid client’s ear (Rinne test).
by air is heard more readily than process (Rinne test).
sound conducted by bone. The
tuning fork vibrations conducted
by air are normally heard longer.
EVALUATION
• Perform a detailed follow-up examination of neurological • Report significant deviations from expected or normal to the
and other systems, based on findings that deviated from appropriate members of the health care team.
expected or normal for the client.
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Assessing Ears and Hearing

INFANTS OLDER ADULTS
• To assess gross hearing, ring a bell from behind the infant, • The skin of the ear may appear dry and be less resilient
or have the parent call the child’s name to check for a because of the loss of connective tissue.
response. Newborns will quieten to the caregiver’s voice • Increased coarse and wire-like hair growth occurs along the
and may open their eyes wider. By 3 to 4 months of age, pinna, antihelix, and tragus.
the child will turn the head and eyes toward the sound.
• The tympanic membrane is more translucent and less
• All newborns should be assessed for hearing prior to dis- flexible.
charge from the hospital.
• Earwax is drier.
CHILDREN • The pinna increases in both width and length, and the ear-
• To inspect the external canal and tympanic membrane in lobe elongates.
children younger than 3 years old, pull the pinna down and • Sensorineural hearing loss occurs.
back. Insert the speculum only 0.5 cm to 1 cm. • Presbycusis (generalized hearing loss) occurs in all
• Hearing loss is becoming more common in adolescents frequencies, although the first symptom is the loss of
and young adults, probably as a result of exposure to high-frequency sounds: the f, s, sh, and ph sounds.
loud music and prolonged use of headsets at extremely
loud volumes.
Nose and Sinuses the nose and sinuses. (See also the Lifespan Consider-
ation box on assessing the nose and sinuses.)
The nasal passages can be inspected very simply with a
flashlight. However, a nasal speculum and a penlight or an
otoscope with a nasal attachment facilitates examination Mouth and Oropharynx
of the nasal attachment. Assessment of the nose includes
inspection and palpation of the external nose (the upper The mouth and pharynx are composed of a number of
third of the nose is bone; the remainder is cartilage); structures: lips, inner and buccal mucosa, the tongue,
determination of patency of the nasal cavities; and floor of the mouth, teeth and gums, hard and soft pal-
inspection of the nasal cavities. ates, uvula, salivary glands, tonsillar pillars, and tonsils.
If the client reports difficulty or abnormality in The anatomical structures of the mouth are shown in
his or her sense of smell, the nurse may test the client’s Figure 28.16.
olfactory sense by asking the client to identify common By age 25 years, most people have all their perma-
odours, such as coffee or mint. This is done by asking the nent teeth. For information about structures of the teeth,
client to close the eyes and then placing vials containing see Chapter 31.
the scent under the client’s nose. Normally, three pairs of salivary glands empty into
The nurse inspects, palpates, and percusses the facial the oral cavity: the parotid, submandibular, and sublingual
sinuses (Figure 28.15). Skill 28.8 describes how to assess glands (see Figure 28.16). The parotid gland is the largest and
Frontal
Frontal sinus sinuses
Supraorbital
Ethmoid sinuses ridge
Ethmoid
sinuses
Sphenoid sinus
Sphenoid
sinus
Maxillary sinus
Maxillary
sinuses
Lateral view Frontal view
FIGURE 28.15 The facial sinuses.
M28_KOZI2703_04_SE_C28.indd 567 03/03/17 11:15 AM

SKILL 28.8 ASSESSING THE NOSE AND SINUSES
PLANNING why it is necessary, and how he or she can participate.

Discuss how the results will be used in planning further
Equipment care or treatments.
• Nasal speculum 2. Perform hand hygiene, and follow other appropriate infec-
• Flashlight or penlight tion prevention and control procedures.
IMPLEMENTATION 4. Inquire whether the client has a history of allergies,
difficulty breathing through the nose, sinus infections,
Performance injuries to nose or face, nosebleeds; any medications
1. Before performing the procedure, introduce yourself to taken; any changes in the sense of smell; any facial or
the client, and verify the client’s identity by using two nasal surgery.
identifiers. Explain to the client what you are going to do, 5. Position the client comfortably, seated if possible.
Nose
6. Inspect the external nose for any devia- Symmetrical and straight; no Asymmetrical; discharge from nares;
tions in shape, size, or colour and flaring discharge or flaring; uniform colour localized areas of redness or
or discharge from the nares. presence of skin lesions
7. Lightly palpate the external nose to Not tender; no lesions Tenderness on palpation; presence of
determine any areas of tenderness, lesions
masses, and displacements of bone
and cartilage.
8. Determine patency of both nasal cavi- Air moves freely as the client Air movement is restricted in one or
ties. Ask the client to close the mouth, breathes through the nares both nares
exert pressure on one naris, and breathe
through the opposite naris. Have the cli-
ent repeat this to assess patency of the
opposite naris.
9. Inspect the nasal cavities by using a
flashlight or a nasal speculum.

• Hold the speculum in your right hand
to inspect the client’s left nostril and
your left hand to inspect the client’s
right nostril.
• Tip the client’s head back.
• Facing the client, insert the tip of the
closed speculum (blades together)
about 1 cm or up to the point at
which the blade widens. Care must
be taken to avoid pressure on the
sensitive nasal septum (see ❶). ❶ Using a nasal speculum to inspect the nasal passages.
• Stabilize the speculum with your
index finger against the side of the
nose. Use the other hand to position
Nasal septum
the head, and then to hold the light.
• Open the speculum as much as pos-
sible and inspect the floor of the nose Middle turbinate
(vestibule), the anterior portion of the
septum, the middle meatus, and the Middle meatus
middle turbinates. The posterior turbi-
nate is rarely visualized because of its
position (see ❷). Inferior meatus
• Inspect the lining of the nares and the
integrity and the position of the nasal Inferior turbinate
septum.
❷ The inferior and middle turbinates of the nasal passage.
M28_KOZI2703_04_SE_C28.indd 568 17/03/17 1:07 PM


10. Observe for the presence of redness, Mucosa pink; clear, watery Mucosa red, edematous; abnormal
swelling, growths, and discharge. discharge; no lesions discharge (e.g., pus); presence of
lesions (e.g., polyps)
11. Inspect the nasal septum between the Nasal septum intact and in midline Septum deviated to the right or to
nasal chambers. the left
Facial Sinuses
12. Palpate the maxillary and frontal sinuses Not tender Tenderness in one or more sinuses
for tenderness.
EVALUATION
• Perform a detailed follow-up examination of other systems, • Report significant deviations from expected or normal to
based on findings that deviated from expected or normal the appropriate members of the health care team.
for the client.
LIFESPAN CONSIDERATION
Assessing the Nose and Sinuses

INFANTS • Ethmoid sinuses continue to grow and pneumatize until
around age 12. Sinus problems in children younger than
• A speculum is usually not necessary to examine the sep- 6 years are rare.
tum, turbinates, and vestibule. Instead, push the tip of the
nose upward with the thumb and shine a light into the • Cough and runny nose are the most common signs of
nares. sinusitis in preadolescent children.
• Ethmoid and maxillary sinuses are present at birth; frontal • Adolescents may have headaches, facial tenderness, and
sinuses begin to develop by 1 to 2 years of age; and swelling, similar to the signs seen in adults.
sphenoid sinuses develop later in childhood. Infants and
young children have fewer sinus problems than older OLDER ADULTS
children and adolescents.
• The sense of smell diminishes markedly because of a
decrease in the number of olfactory nerve fibres and
CHILDREN atrophy of the remaining fibres. Older persons are less
• A speculum is usually not necessary to examine the sep- able to identify and distinguish odours.
tum, turbinates, and vestibule. It might cause the child to • Nosebleeds can result from hypertensive disease or other
be apprehensive. Instead, push the tip of the nose upward arterial vessel changes in older adults.
with the thumb and shine a light into the nares.
empties through the Stensen’s duct opposite the second Oropharynx

molar. The submandibular gland empties through Wharton’s
Parotid gland
duct, which is situated at the side of the frenulum on the
floor of the mouth. The sublingual salivary gland lies in the Stensen’s duct
floor of the mouth and has numerous openings. opening
Dental caries (cavities) and pyorrhea (periodontal
Palatine tonsil
disease) are the two problems that most frequently affect
teeth. Both problems are commonly associated with Palatine arch
plaque and tartar deposits. Plaque is an invisible soft film
that adheres to the enamel surface of teeth; it consists of Uvula
bacteria, molecules of saliva, and remnants of epithelial Sublingual
cells and leukocytes. When plaque accumulates on teeth, gland
dental calculus (tartar) forms. Tartar is a visible, hard Wharton’s duct
deposit of plaque and dead bacteria that forms at the opening
gum line. Tartar buildup can alter the fibres that attach
teeth to the gum and eventually disrupt bone tissue. Peri- Submandibular
gland
odontal disease is characterized by gingivitis (inflamed
gums), bleeding, receding gum lines, and the formation FIGURE 28.16 Anatomical structures of the mouth.
M28_KOZI2703_04_SE_C28.indd 569 03/03/17 11:15 AM

of pockets between teeth and gums. In advanced peri- parotid salivary gland), and sordes (accumulation of
odontal disease, teeth are loose, and pus is evident when foul matter, such as food, microorganisms, and epithelial
gums are pressed. elements, on teeth and gums).
Other problems nurses may see are glossitis Skill 28.9 describes assessment of the mouth and
(inflammation of the tongue), stomatitis (inflamma- oropharynx. (See also Lifespan Considerations box on
tion of the oral mucosa), parotitis (inflammation of the assessing the mouth and oropharynx.)
SKILL 28.9 ASSESSING THE MOUTH AND OROPHARYNX
PLANNING identifiers. Explain to the client what you are going to

do, why it is necessary, and how he or she can partici-
If possible, arrange for the client to sit with his or her head pate. Discuss how the results will be used in planning
against a firm surface, such as a headrest or an examination further care or treatments.
table. This makes it easier for the client to hold the head still
during the examination.
Equipment 3. Provide for client privacy.
• Clean gloves 4. Inquire whether the client has any history of the following:
routine pattern of dental care, last visit to dentist; length
• Tongue depressor of time ulcers or other lesions have been present; any
• 5 × 5 cm gauze pads denture discomfort; any medications the client is taking.
• Penlight 5. Position the client comfortably, seated if possible.
IMPLEMENTATION
Performance
Lips and Buccal Mucosa

6. Inspect the outer lips for symmetry of Uniform pink colour (darker, e.g., bluish Pallor; cyanosis; blisters; generalized
contour, colour, and texture. Ask the hue, in Mediterranean groups and or localized swelling; fissures, crusts,
client to purse the lips as if to whistle. dark-skinned clients); soft, moist, or scales (may result from excessive
smooth texture; symmetry of contour; moisture, nutritional deficiency, or
ability to purse lips fluid deficit); inability to purse lips
(may indicate facial nerve damage)
7. Inspect and palpate the inner lips and Uniform pink colour (freckled brown Pallor; leukoplakia (white patches or
buccal mucosa for colour, moisture, pigmentation in dark-skinned clients); spots on mucous membranes),
texture, and the presence of lesions. moist, smooth, soft, glistening, and redness, bleeding; excessive dryness;
• Put on clean gloves. elastic texture (drier oral mucosa in mucosal cysts; irritations from
older clients because of decreased dentures; abrasions, ulcerations;
• Ask the client to relax the mouth, salivation) nodules
and, for better visualization, pull the
lip outward and away from teeth.
• Grasp the lip on each side between
the thumb and index finger (see ❶).
• Palpate any lesions for size, tender-
ness, and consistency.
• Inspect the front teeth and gums.
❶ Inspecting the mucosa of the lower lip.
M28_KOZI2703_04_SE_C28.indd 570 17/03/17 1:07 PM


Teeth and Gums
8. Inspect teeth and gums while examining Thirty-two adult teeth; smooth, white, Missing teeth; ill-fitting dentures;
the inner lips and buccal mucosa. shiny tooth enamel; pink gums (bluish or brown or black discoloration of the
• Ask the client to open the mouth. brown patches in dark-skinned clients); enamel (may indicate staining or
Use a tongue depressor to retract the moist, firm texture to gums; no retraction the presence of caries); excessively
cheek (see ❷). View the surface buc- of gums (pulling away from teeth) red gums; spongy texture;
cal mucosa from top to bottom and bleeding; tenderness (may indicate
back to front. A flashlight or penlight periodontal disease); receding,
will help illuminate the surface. Repeat atrophied gums; swelling that
the procedure for the other side. partially covers teeth
• Ask the client to open the mouth
again. Use a penlight for better visu-
alization, and move a finger along the
inside cheek. Another finger may be
moved outside the cheek.
• Examine the back teeth. For proper
vision of the molars, use the index
fingers of both hands to retract the
cheek (see ❸). Ask the client to relax ❷ Inspecting the buccal mucosa by using
his or her lips and first close then a tongue depressor.
open the jaw. Rationale: Closing the
jaw assists in observation of tooth
alignment and loss of teeth; open-
ing the jaw assists in observation
of dental fillings and caries.
• Observe the number of teeth, tooth
colour, the state of fillings, dental
caries, and tartar along the base of
teeth. Note the presence and fit of
partial or complete dentures.
• Inspect the gums around the molars.
Observe for bleeding, colour, retrac-
tion (pulling away from teeth), edema,
and lesions. ❸ Inspecting the back teeth.
9. Inspect the dentures. Ask the client to Smooth, intact dentures Ill-fitting dentures; irritated and
remove complete or partial dentures. excoriated area under dentures
Inspect their condition, noting in
particular broken or worn areas.
Tongue/Floor of the Mouth
10. Inspect the surface of the tongue for Central position; pink colour (some Deviated from centre, which may
position, colour, and texture. Ask the brown pigmentation on tongue borders indicate damage to the hypoglossal
client to stick out the tongue. in dark-skinned clients); moist; slightly (12th cranial) nerve; excessive trembling;
rough; thin whitish coating; smooth, smooth, red tongue (may indicate iron,
lateral margins; no lesions; raised vitamin B12, or vitamin B3 deficiency);
papillae (taste buds) dry, furry tongue (associated with fluid
deficit); white coating (may be oral
yeast infection); nodes, ulcerations,
discolorations (white or red areas);
areas of tenderness
11. Inspect tongue movement. Ask the client Moves freely; no tenderness Restricted mobility
to roll the tongue upward and move it
from side to side.
12. Inspect the base of the tongue, the Smooth tongue base with prominent Swelling, ulceration
mouth floor, and the frenulum. Ask the veins
client to place the tip of the tongue
against the roof of the mouth.
To assess the functioning of the glosso-
pharyngeal and hypoglossal nerves, see
the section on neurological assessment
later in this chapter.
(continued)
M28_KOZI2703_04_SE_C28.indd 571 03/03/17 11:16 AM

SKILL 28.9 ASSESSING THE MOUTH AND OROPHARYNX (continued)
Palates and Uvula

13. Inspect the hard and soft palates for Light pink, smooth, soft palate; lighter Discoloration (e.g., jaundice or pallor);
colour, shape, texture, and the presence pink hard palate, more irregular texture palates the same colour; irritations;
of bony prominences. Ask the client to exostoses (bony growths) growing
open the mouth wide and to tilt the head from the hard palate
backward. Then, depress the tongue
with a tongue blade, as necessary, and
use a penlight for better visualization.
14. Inspect the uvula for position and Positioned in midline of soft palate Deviation to one side from tumour
mobility while examining the palates. or trauma; immobility, which may
To observe the uvula, ask the client to indicate damage to trigeminal
say “ah” so that the soft palate rises. (fifth cranial) nerve or vagus
(10th cranial) nerve
Oropharynx and Tonsils

15. Inspect the oropharynx for colour and Pink and smooth posterior wall Reddened or edematous; presence
texture. Inspect one side at a time to of lesions, plaques, or drainage
avoid eliciting the gag reflex. To expose
one side of the oropharynx, press a
tongue blade against the tongue on the
same side about halfway back while the
client tilts the head back and opens the
mouth wide. Use a penlight for illumina-
tion, if needed.
16. Inspect the tonsils (behind the fauces) for Pink and smooth; no discharge; of Inflamed; presence of discharge;
colour, discharge, and size. normal size or not visible swelling
• Grade 1 (normal): The tonsils are • Grade 2: The tonsils are
behind the tonsillar pillars (the soft between the pillars and
structures supporting the soft palate) the uvula
• Grade 3: The tonsils touch
the uvula
• Grade 4: One or both tonsils
extend to the midline of the
oropharynx
17. Elicit the gag reflex by pressing the pos- Present Absent, which may indicate
terior tongue with a tongue blade. problems with glossopharyngeal
(ninth cranial) or vagus
(10th cranial) nerves
18. Remove and discard gloves. Perform
hand hygiene.
EVALUATION
• Perform a detailed follow-up examination of neurological • Report significant deviations from expected or normal to
and other systems, based on findings that deviated from the appropriate members of the health care team.
expected or normal for the client. Relate findings to
previous assessment data, if available.
Images by: Elena Dorfman/Pearson Education, Inc.
The Neck neck into two triangles: the anterior and the posterior
(Figure 28.17). The trachea, thyroid gland, anterior
cervical nodes, and carotid artery lie within the anterior
Examination of the neck includes the muscles, lymph triangle (Figure 28.18); the carotid artery runs parallel
nodes, trachea, thyroid gland, carotid arteries, and jugu- and anterior to the sternocleidomastoid muscle. The
lar veins. Areas of the neck are defined by the sterno- posterior lymph nodes lie within the posterior triangle
cleidomastoid muscles, which divide each side of the (Figure 28.19).
M28_KOZI2703_04_SE_C28.indd 572 17/03/17 1:07 PM

Assessing the Mouth and Oropharynx

INFANTS Decreased salivation occurs in older adults who are taking
prescribed medications, such as antidepressants, anti-
• Inspect the palate and uvula for a cleft. A bifid (forked) histamines, decongestants, diuretics, antihypertensives,
uvula may indicate an unsuspected cleft palate (i.e., a cleft tranquilizers, antispasmodics, and antineoplastics. Extreme
in the cartilage that is covered by skin). dryness is associated with dehydration.
• Newborns may have a pearly white nodule on their gums, • Some receding of the gums occurs, giving an appearance
which resolves without treatment. of increased toothiness.
• The first teeth erupt at about 6 to 7 months of age. Assess • There may be a brownish pigmentation to the gums,
for dental hygiene; parents should cleanse the infant’s especially in black persons.
teeth daily with a soft cloth or soft toothbrush.
• Taste sensations diminish with aging because of
• Children should see a dentist by 1 year of age. atrophy of the taste buds and a decreased sense of
smell. It indicates diminished function of the fifth and
CHILDREN seventh CNs.
• Tooth development should be appropriate for age. • Tiny purple or bluish-black swollen areas (varicosities)
See Chapter 31. under the tongue, known as caviar spots, are not
• White spots on teeth may indicate excessive fluoride uncommon.
ingestion. • Teeth may show signs of staining, erosion, chipping, and
• Drooling is normal up to 2 years of age. abrasions because of loss of dentin. Tooth loss occurs
as a result of gum disease but is preventable with good
• The tonsils are normally larger in children than in adults dental hygiene.
and usually extend beyond the palatine arch until the age
of 11 or 12 years. • Older adults who are housebound or are in long-term
care facilities often have teeth or dentures in need of repair
OLDER ADULTS because of the difficulty of obtaining dental care in these
situations. Do a thorough assessment of missing teeth and
• The oral mucosa may be drier than that of younger those in need of repair, whether they are natural teeth or
persons because of decreased salivary gland activity. dentures.
Hyoid bone
Thyroid cartilage
Insertion—
Sternocleidomastoid
mastoid process
muscle
and occipital bone
Cricoid cartilage
Trapezius muscle
Lobe Thyroid
Posterior triangle Isthmus gland
Sternocleidomastoid Trachea
muscle Clavicle
Clavicle Suprasternal
notch
Origin—manubrium
Anterior of sternum and Manubrium of
triangle medial third of clavicle sternum
FIGURE 28.17 Major muscles of the neck. FIGURE 28.18 Structures of the neck.
Each sternocleidomastoid muscle extends from the skull to the lateral third of the clavicle. These muscles
upper sternum and the medial third of the clavicle to draw the head to the side and back, elevate the chin, and
the mastoid process of the temporal bone behind the elevate the shoulders for shrugging.
ear. These muscles turn and laterally flex the head. Each Lymph nodes in the neck that collect lymph from
trapezius muscle extends from the occipital bone of the the head and neck structures are grouped serially
M28_KOZI2703_04_SE_C28.indd 573 03/03/17 11:16 AM

Thorax and Lungs

Postauricular Assessing the thorax and lungs is important in assessing
1 Preauricular
2
the client’s aeration status. Changes in the respiratory
4 Retropharyngeal system can occur slowly or quickly. In clients with asthma
Occipital
3 (tonsillar)
or chronic obstructive pulmonary disease (COPD), such
5 Submandibular
as chronic bronchitis or emphysema (a chronic pulmonary
Superficial
cervical chain 7 6 Submental condition in which the air sacs, or alveoli, are dilated and
Posterior distended), changes are frequently gradual. The onset
cervical 9 8 Deep
Supra- cervical
of such conditions as pneumonia or pulmonary embolus (a
clavicular 10 chain blockage of an artery in the lungs by fat, air, tumour tis-
sue, or a blood clot) is generally more acute or sudden.
FIGURE 28.19 Lymph nodes of the neck with suggested Chest Landmarks
sequence for palpation.
Before beginning the assessment, the nurse must be
familiar with a series of imaginary lines on the chest
and referred to as chains. See Figure 28.19 and wall and be able to locate the position of each rib and
Table 28.5. The deep cervical chain is not shown in some spinous processes. These landmarks help the nurse
Figure 28.19 because it lies beneath the sternocleido- identify the position of underlying organs (e.g., lobes of
mastoid muscle. the lung) and to record abnormal assessment findings.
Skill 28.10 describes how to assess the neck. (See also Figure 28.20 shows the anterior, lateral, and posterior
Lifespan Considerations box on assessing the neck.) series of lines. The midsternal line is a vertical line running
TABLE 28.5 Lymph Nodes of the Head and Neck
Node Centre Location Area Drained
Head
Occipital At the posterior base of the skull The occipital region of the scalp and the deep
structures of the back of the neck
Postauricular (mastoid) Behind the auricle of the ear or in front of the The parietal region of the head and part of
mastoid process the ear
Preauricular In front of the tragus of the ear The forehead and upper face
Floor of Mouth
Submandibular (submaxillary) Along the medial border of the lower jaw, The chin, upper lip, cheek, nose, teeth, eye-
halfway between the angle of the jaw and lids, part of the tongue, and part of the
the chin floor of the mouth
Submental Behind the tip of the mandible, in the midline, The anterior third of the tongue, gums, and
under the chin floor of the mouth
Neck
Superficial cervical chain Along the anterior to the sternocleidomastoid Skin and neck
muscle
Posterior cervical Along the anterior aspect of the trapezius The posterior and lateral regions of the neck,
muscle occiput, and mastoid
Deep cervical chain Under the sternocleidomastoid muscle The larynx, thyroid gland, trachea, and upper
part of the esophagus
Supraclavicular Above the clavicle, in the angle between The lateral regions of the neck and lungs
the clavicle and the sternocleidomastoid
muscle
M28_KOZI2703_04_SE_C28.indd 574 03/03/17 11:16 AM

SKILL 28.10 ASSESSING THE NECK
PLANNING why it is necessary, and how he or she can participate.

Discuss how the results will be used in planning further
Equipment care or treatments.
None 2. Perform hand hygiene, and follow other appropriate infec-
tion prevention and control procedures.
4. Inquire whether the client has any history of the following:
Performance problems with neck lumps; neck pain or stiffness; when
1. Before performing the procedure, introduce yourself to and how any lumps occurred; previous diagnoses of
the client, and verify the client’s identity by using two thyroid problems; and other treatments provided
identifiers. Explain to the client what you are going to do, (e.g., surgery, radiation).
Neck Muscles
5. Inspect the neck muscles (sternocleidomas- Muscles equal in size; head Unilateral neck swelling; head tilted to
toid and trapezius) for abnormal swellings or centred one side (indicates presence of masses,
masses. Ask the client to hold the head erect. injury, muscle weakness, shortening of
sternocleidomastoid muscle, scars)
6. Observe head movement. Ask the client to do Coordinated, smooth Muscle tremor, spasm, or stiffness
the following: movements with no discomfort
• Move the chin to the chest. Rationale: Head flexes 45 degrees Limited range of motion; painful
This determines the functioning of the movements; involuntary movements
sternocleidomastoid muscle. (e.g., up-and-down nodding movements
associated with Parkinson’s disease)
• Move the head back so that the chin points Head hyperextends 60 Head hyperextends less than 60
upward. Rationale: This determines the degrees degrees
functioning of the trapezius muscle.
• Move the head so that the ear is moved Head laterally flexes 40 Head laterally flexes less than 40
toward the shoulder on each side. degrees degrees
Rationale: This determines the func-
tioning of the sternocleidomastoid
muscle.
• Turn the head to the right and to the left. Head laterally rotates 70 Head laterally rotates less than 70
Rationale: This determines the func- degrees degrees
tioning of the sternocleidomastoid
muscle.
7. Assess muscle strength. Ask the client to turn Equal strength Unequal strength
the head to one side against the resistance of
your hand. Repeat with the other side.
Rationale: This determines the strength
of the sternocleidomastoid muscle.
• Ask the client to shrug the shoulders Equal strength Unequal strength
against the resistance of your hands.
Rationale: This determines the
strength of the trapezius muscles.
Lymph Nodes
8. Palpate the entire neck for enlarged lymph Not palpable Enlarged, palpable, possibly tender
nodes (see Figure 28.19). (associated with infection and tumours)
• Face the client, and bend the client’s head
forward slightly or toward the side being
examined. Rationale: This relaxes soft tis-
sue and muscles.
• Palpate the nodes by using the pads of your
fingers. Move the fingertips in a gentle rotat-
ing motion.
(continued)
M28_KOZI2703_04_SE_C28.indd 575 17/03/17 1:07 PM

SKILL 28.10 ASSESSING THE NECK (continued)

• When examining the submental and sub-
mandibular nodes, place the fingertips
under the mandible on the side nearest
the palpating hand, and pull the skin and
subcutaneous tissue laterally over the man-
dibular surface so that the tissue rolls over
the nodes.
• When palpating the supraclavicular nodes,
have the client bend the head forward to
relax the tissues of the anterior neck and
to relax the shoulders so that the clavicles
drop. Use your hand nearest the side to
be examined when facing the client (i.e.,
your left hand for the client’s right nodes).
Use your free hand to flex the client’s head
forward, if necessary. Hook your index and

third fingers over the clavicle lateral to the
sternocleidomastoid muscle (see ❶).
• When palpating the anterior cervical nodes
and posterior cervical nodes, move your
fingertips slowly in a forward circular motion
against the sternocleidomastoid and trape-
zius muscles, respectively. ❶ Palpating the supraclavicular lymph nodes.
• To palpate the deep cervical nodes, bend or

hook your fingers around the sternocleido-
mastoid muscle.
Trachea
9. Palpate the trachea for lateral deviation. Place Central placement in midline of Deviation to one side, indicating
your fingertip or thumb on the trachea in the neck; spaces equal on both possible neck tumour; thyroid
suprasternal notch (see Figure 28.18, p. 573), sides enlargement; enlarged lymph nodes
and then move your finger laterally to the left
and the right in spaces bordered by the clavi-
cle, the anterior aspect of the sternocleidomas-
toid muscle, and the trachea.
Thyroid Gland
10. Inspect the thyroid gland. Stand in front of the Not visible on inspection Visible diffuseness or local enlargement
client. Observe the lower half of the neck over-
lying the thyroid gland for symmetry and visible
masses.
• Ask the client to hyperextend the head and Gland ascends during Gland is not fully movable with
swallow. If necessary, offer a glass of water swallowing but is not visible swallowing
to make it easier for the client to swallow.
Rationale: This action determines how
the thyroid and cricoid cartilages move
and whether swallowing causes a
bulging of the gland.
11. Palpate the thyroid gland for smoothness. Note Lobes may not be palpated; if Solitary nodules
any areas of enlargement, masses, or nodules. palpated, lobes are small,
Stand in front of or behind the client, and ask smooth, centrally located,
the client to lower the chin slightly. Rationale: painless, and rise freely with
Lowering the chin relaxes the neck swallowing
muscles, facilitating palpation.
EVALUATION
for the client.
M28_KOZI2703_04_SE_C28.indd 576 17/03/17 1:07 PM

by a minor fissure into the right upper lobe and right

LIFESPAN CONSIDERATION
middle lobe (RML). This fissure runs anteriorly from the
right midaxillary line at the level of the fifth rib to the
Assessing the Neck level of the fourth rib.
These specific landmarks (i.e., T-3 and the fourth,
INFANTS AND CHILDREN fifth, and sixth ribs) are located as follows. The starting
• Examine the neck while the infant or child is lying supine. point for locating the ribs anteriorly is the angle of
Lift the client’s head, and turn it from side to side to Louis, the junction between the body of the sternum
determine neck mobility. (breastbone) and the manubrium (the handle-like
• An infant’s neck is normally short, lengthening by about superior part of the sternum that joins with the clavicles).
age 3 years. This lack of length makes palpation of the The superior border of the second rib attaches to the
trachea difficult.
sternum at this manubriosternal junction (Figure 28.22).
The nurse can identify the manubrium by first palpating
the clavicle and following its course to its attachment at
through the centre of the sternum. The midclavicular the manubrium. The nurse then palpates and counts
lines (right and left) are vertical lines from the midpoints distal ribs and intercostal spaces from the second rib. It is
of the clavicles. The anterior axillary lines (right and left) important to note that an intercostal space is numbered
are vertical lines from the anterior axillary folds (see according to the number of the rib immediately above
Figure 28.20A). Figure 28.20B shows the three imagi- the space. When palpating for rib identification, the
nary lines of the lateral chest. The posterior axillary line nurse should palpate along the midclavicular line rather
is a vertical line from the posterior axillary fold. The than the sternal border because the rib cartilages are
midaxillary line is a vertical line from the apex of the very close at the sternum. Only the first seven ribs attach
axilla. The anterior axillary line is as described for part directly to the sternum.
A. Figure 28.20C shows the posterior thorax landmarks. The counting of ribs is more difficult on the poste-
The vertebral line is a vertical line along the spinous pro- rior thorax than on the anterior thorax. For identifying
cesses. The scapular lines (right and left) are vertical lines underlying lung lobes, the pertinent landmark is T-3.
from the inferior angles of the scapulae. The starting point for locating T-3 is the spinous process
Locating the position of each rib and certain spi- of the seventh cervical vertebra (C-7) (Figure 28.23).
nous processes is essential for identifying the underlying When the client flexes the neck anteriorly, a prominent
lobes of lungs. Figure 28.21A shows an anterior view of process can be observed and palpated. This is the spi-
the chest and underlying lungs; Figure 28.21B, a poste- nous process of the seventh cervical vertebra. If two
rior view; and Figure 28.21C, right and left lateral views. spinous processes are observed, the superior one is C-7,
Each lung is first divided into upper and lower lobes by and the inferior one is the spinous process of the first
an oblique fissure that runs from the level of the spinous thoracic vertebra (T-1). The nurse then palpates and
process of the third thoracic vertebra (T-3) to the level of counts the spinous processes from C-7 to T-3. Each spi-
the sixth rib at the midclavicular line (MCL). The right nous process up to T-4 is adjacent to the corresponding
upper lobe is abbreviated RUL; the right lower lobe, rib number; e.g., T-3 is adjacent to the third rib. After
RLL. Similarly, the left upper lobe is abbreviated LUL; T-4, however, the spinous processes project obliquely,
the left lower lobe, LLL. The right lung is further divided causing the spinous process of the vertebra to lie not over
A B C Vertebral line

(centred along
Midsternal the spinous
Left
line processes
scapular
Left midclavicular from C-7 to T-12)
Right line
line (vertical from Scapula
midclavicular the midpoint of
line Left
the clavicle) Anterior axillary Right posterior
posterior
Left anterior line (vertical axillary line
axillary
axillary line from the C7
(vertical from
line T1
anterior
T2
(vertical from
T3
T4 the posterior
the anterior axillary fold) T5
T6 axillary
fold)
T7
axillary fold)
T8
Right scapular
T9
Midaxillary T 10
line (vertical
T 11
line (vertical
Posterior axillary T 12
from the from the inferior

line (vertical
Right anterior apex of the angle of the
from the posterior
axillary line axilla) scapula)
axillary fold)
FIGURE 28.20 Chest wall landmarks: A: Anterior chest; B: Lateral chest; C: Posterior chest.
M28_KOZI2703_04_SE_C28.indd 577 03/03/17 11:16 AM

A B
Left upper lobe

Horizontal Right upper lobe
fissure Left oblique fissure Spinous process
Right oblique Left
of T-3
fissure midclavicular Sixth rib 4
line midaxillary 5 Right oblique
Fifth rib 6
line fissure
midaxillary 4 Sixth rib
line 5 Left
6
Left Right
lower
Sixth rib oblique lower
lobe
fissure lobe
Spinous Apex
Fourth rib at
process of T-3 sternal border Left oblique Spinous process
Fifth rib at fissure of T-3

RUL Horizontal LUL
midaxillary line fissure

RML
Sixth rib at LLL
Right oblique RLL
midclavicular line Base
fissure
FIGURE 28.21 Chest landmarks: A: Anterior chest landmarks and underlying lungs; B: Posterior chest
landmarks and underlying lungs; C: Lateral chest landmarks and underlying lungs.
Vertebra prominens C-7

Manubrium Manubriosternal junction
(angle of Louis) C-7
of sternum
T-1
1
Clavicle 2
1 3
4
2 First
intercostal 5
3 Scapula
space 6
4 Second 7
5 intercostal 8
space 9
6 Inferior angle
10 of scapula
7 Body of 11
sternum
8 Costal 12 Spinous
9 angle Xiphoid processes
10
Costal margin
FIGURE 28.22 Location of the anterior ribs in relation to the FIGURE 28.23 Location of the posterior ribs in relation to the
angle of Louis and the sternum. spinous processes.
its correspondingly numbered rib, but over the rib below. smaller at the top than at the base. In older adults, kypho-
Thus, the spinous process of T-5 lies over the body of sis (excessive convex curvature of the thoracic spine) and
T-6 and is adjacent to the sixth rib. osteoporosis (a condition that causes bones to become thin
and porous) alter the size of the chest cavity as the ribs
move downward and forward.
Chest Shape and Size The chest can acquire several deformities (Fig-
In adults, the thorax is oval. Its anteroposterior diameter ure 28.25). Pectus carinatum (pigeon chest), a permanent
is half its transverse diameter (Figure 28.24). The overall deformity, can be caused by rickets (abnormal bone for-
shape of the thorax is elliptical; that is, its diameter is mation resulting from a lack of dietary calcium). A
M28_KOZI2703_04_SE_C28.indd 578 03/03/17 11:16 AM

Clinical appearance funnel chest, abnormal pressure on the heart can result
in altered function. A barrel chest, in which the ratio
of the anteroposterior to transverse diameter is 1:1, is
seen in clients with thoracic kyphosis (excessive convex
curvature of the thoracic spine) and emphysema (chronic
Cross-section of thorax pulmonary condition in which the alveoli are dilated and
distended). Scoliosis is a lateral deviation of the spine.
Posterior
Breath Sounds
Transverse Abnormal breath sounds, called adventitious breath
diameter sounds, occur when air passes through narrowed air-
ways or airways filled with fluid or mucus, or when
pleural linings are inflamed. Table 28.6 describes
Anteroposterior
diameter
normal breath sounds. Adventitious sounds are often
Anterior superimposed over normal sounds. The main types of
adventitious sounds—crackles (fine, coarse), friction rub,
FIGURE 28.24 Configurations of the thorax showing wheezes (sonorous, sibilant), and stridor—are described
anteroposterior diameter and transverse diameter. in Table 28.7. The absence of breath sounds over some
lung areas is also a significant finding that is associated
narrow transverse diameter, an increased anteroposterior with collapsed or surgically removed lobes.
diameter, and a protruding sternum characterize pigeon Assessment of the lungs and thorax includes all
chest. Pectus excavatum (a funnel chest), a congenital methods of examination: inspection, palpation, percus-
defect, is the opposite of pigeon chest in that the sternum sion, and auscultation. Skill 28.11 describes how to assess
is depressed, narrowing the anteroposterior diameter. the thorax and lungs. (See also Lifespan Considerations
Because the sternum points posteriorly in clients with a box on assessing the thorax and lungs.)
A B
Posterior
Posterior
Pigeon Funnel
Anterior
Anterior
C D E
Posterior
Barrel
Anterior
FIGURE 28.25 Chest deformities: A: Pigeon chest; B: Funnel chest; C: Barrel chest;
D: Kyphosis; E: Scoliosis.
M28_KOZI2703_04_SE_C28.indd 579 03/03/17 11:16 AM

TABLE 28.6 Normal Breath Sounds
Type Description Location Characteristics

Vesicular Soft-intensity, low-pitched, “gentle Over peripheral lung; best Best heard on inspiration, which is
sighing” sounds created by air heard at base of lungs about 2.5 times longer than the
moving through smaller airways expiratory phase (5:2 ratio)
(bronchioles and alveoli)
Bronchovesicular Moderate-intensity and moderate- Between the scapulae and Equal inspiratory and expiratory
pitched “blowing” sounds created lateral to the sternum phases (1:1 ratio)
by air moving through larger air- at the first and second
ways (bronchi) intercostal spaces
Bronchial (tubular) High-pitched, loud, “harsh” sounds Anteriorly over the Louder than vesicular sounds; have
created by air moving through the trachea; not normally a short inspiratory phase and
trachea heard over lung tissue long expiratory phase (1:2 ratio)
TABLE 28.7 Adventitious Breath Sounds
Name Description Cause Location

Fine crackles (for- Dry, high-pitched, discontinuous Air passing through mois- Most commonly heard in the bases
merly referred crackling, popping; sound can be ture (fluid or mucus) in of the lower lung lobes
to as rales) simulated by rolling a lock of hair small airways that sud-
near the ear; predominantly heard denly reinflate
on inspiration but can be heard
on both inspiration and expiration;
may not be cleared by coughing
Coarse crackles Discontinuous, moist, low-pitched Air passing through mois- Loud sounds can be heard over
(gurgles) crackling, gurgling; predominantly ture (fluid or mucus) in most lung areas but pre-
heard on inspiration but can be large airways that dominate over the trachea and
heard on both inspiration and expi- suddenly reinflate bronchi
ration; may be altered by coughing
Friction rub Superficial grating or creaking sounds Rubbing together of Heard most often in areas of great-
heard during inspiration and expi- inflamed pleural est thoracic expansion (e.g.,
ration; not relieved by coughing surfaces lower anterior and lateral thorax)
Sonorous wheeze Continuous, low-pitched snoring Air passing through nar- Heard over all lung fields
(formerly sound; best heard on expiration; rowing of large airways
referred to as may be cleared by coughing or obstruction of the
rhonchi ) bronchus
Sibilant wheeze Continuous, high-pitched, musical Air passing through Heard over all lung fields
sounds; best heard on expiration; narrowing of large
not usually altered by coughing airways or obstruction
of the bronchus
Stridor Continuous crowing sound, high Partial obstruction of Louder in neck than over chest wall
pitched; predominantly heard on larynx or trachea
inspiration
SKILL 28.11 ASSESSING THE THORAX AND LUNGS
PLANNING IMPLEMENTATION
For efficiency, the nurse usually examines the posterior thorax Performance
first and then the anterior thorax. For posterior and lateral tho-
rax examinations, the client is uncovered to the waist and is 1. Before performing the procedure, introduce yourself to
in the sitting position. The sitting or lying position can be used the client, and verify the client’s identity by using two
for anterior thorax examination. The sitting position is preferred identifiers. Explain to the client what you are going to do,
because it maximizes chest expansion. Good lighting is essen- why it is necessary, and how he or she can participate.
tial, especially for inspection. Discuss how the results will be used in planning further
care or treatments.
Equipment 2. Perform hand hygiene, and follow other appropriate infec-
• Stethoscope tion prevention and control procedures.
M28_KOZI2703_04_SE_C28.indd 580 17/03/17 1:08 PM

3. Provide for client privacy. For women, drape the anterior tuberculosis; lifestyle habits, such as smoking and occu-
chest when it is not being examined. pational hazards (e.g., inhaling fumes); medications being
4. Inquire whether the client has any history of the follow- taken; current problems (e.g., swellings, coughs, wheez-
ing: family history of illness, including cancer, allergies, ing, pain).
Posterior Thorax
5. Inspect the shape and symmetry of the Anteroposterior to transverse Barrel chest; increased anteroposterior to
thorax from the posterior and lateral diameter in ratio of 1:2; thorax transverse diameter; thorax asymmetrical
views. Compare the anteroposterior symmetrical
diameter to the transverse diameter.
6. Inspect the spinal alignment for defor- Spine vertically aligned Exaggerated spinal curvatures (kyphosis,
mities. Have the client stand. From a lordosis [an inward curvature of a portion of
lateral position, observe the three nor- the lumbar and cervical vertebral column])
mal curvatures: cervical, thoracic, and
lumbar.
• To assess for scoliosis, stand Spinal column is straight; right Spinal column deviates to one side, often
behind the client and have him or and left shoulders and hips are accentuated when bending over; shoulders
her stand. Observe the spinal align- at same height or hips are not even
ment. Have the client bend forward
at the waist, and then observe the
alignment again.
7. Palpate the posterior thorax.
• For clients who have no respiratory Skin intact; uniform temperature Skin lesions; areas of hyperthermia
complaints, rapidly assess
the temperature and integrity
of all chest skin.
• For clients who do have respiratory Chest wall intact; no tenderness; Lumps, bulges; depressions; areas of
complaints, palpate all chest areas no masses tenderness; movable structures (e.g., rib)
for bulges, tenderness, or abnormal
movements. Avoid deep palpation in
painful areas, especially if a fractured
rib is suspected. In such a case, deep
palpation could lead to displacement
of the bone fragment against the
lungs.
8. Palpate the posterior thorax for respira- Full and symmetrical chest Asymmetric or decreased chest
tory excursion (thoracic expansion). expansion (i.e., when the client expansion
Place the palms of both your hands takes a deep breath, your
over the lower thorax with your thumbs thumbs should move apart an
adjacent to the spine and your fingers equal distance and at the same
stretched laterally (see ❶). Ask the client time; normally the thumbs
to take a deep breath while you observe separate 3 cm to 5 cm during
the movement of your hands and any deep inspiration)
lag in movement.
❶ Position of the nurse’s hands when assessing

respiratory excursion on the posterior thorax.
9. Palpate the thorax for vocal (tactile) Bilateral symmetry of vocal Decreased or absent fremitus (associated
fremitus, the faintly perceptible vibration fremitus; fremitus is heard most with pneumothorax); increased fremitus
felt through the chest wall when the cli- clearly at the apex of the lungs (associated with consolidated lung tissue,
ent speaks. as in pneumonia)
(continued)
M28_KOZI2703_04_SE_C28.indd 581 03/03/17 11:16 AM

SKILL 28.11 ASSESSING THE THORAX AND LUNGS (continued)

• Place the ulnar surface of the hand Low-pitched voices of males
or the palmar surface of the hand at more readily palpated than
the base of the metacarpophalangeal higher-pitched voices of females
joints (see ❷) on the posterior chest,
starting near the apex of the lungs
(see ❸, position A).
• Ask the client to repeat such words
as “blue moon” or “one, two, three.”
• Repeat the two steps, moving your
hands sequentially to the base of the
lungs, through positions B to E in ❸.
➋ Palpation for tactile fremitus by using

metacarpophalangeal joint area.
• Compare the fremitus on both lungs
and between the apex and the base
of each lung, using either one hand
and moving it from one side of the A A
client to the corresponding area on
the other side or using two hands B B
that are placed simultaneously on the
corresponding areas of each side of
the thorax.
C C
D D
E E
❸ Areas and sequence for palpating tactile

fremitus on the posterior thorax.
10. Percuss the thorax. Percussion of Percussion notes resonate, Asymmetry in percussion; areas of
the thorax is performed to determine except over scapula; lowest dullness or flatness over lung tissue
whether underlying lung tissue is filled point of resonance is at the (associated with consolidation of lung
with air, liquid, or solid material and to diaphragm (i.e., at the level of tissue or a mass)
determine the positions and boundaries the 8th to 10th ribs posteriorly);
of certain organs. Because percussion note: percussion on a rib
penetrates to a depth of 5 cm to 7 cm, normally elicits dullness
it detects superficial rather than deep
lesions. Percussion sounds and tones
are described in Table 28.3. Normal
percussion sounds in the posterior chest Scapular flatness
are shown in ❹.
• Ask the client to bend the head and
fold the arms forward across the
chest. Rationale: This separates
the scapula and exposes more Resonance
lung tissue to percussion.
• Percuss in the intercostal spaces at
about 5 cm intervals in a systematic Liver dullness
sequence (see ❺). (10th ICS)
• Compare one side of the lung with Visceral dullness
the other.
• Percuss the lateral thorax every few 11th ICS
centimetres, starting at the axilla and
working down to the eighth rib. ❹ Normal percussion sounds in the posterior thorax.
M28_KOZI2703_04_SE_C28.indd 582 17/03/17 1:08 PM

2 1
1 1 2 1
1
1
3 3
4 4
5 5
6 6
6 6
7 7
7 7
❺ Pattern for percussion: Posterior thorax.
11. Auscultate the thorax by using the flat- Vesicular and bronchovesicular Adventitious breath sounds (e.g.,
disc diaphragm of the stethoscope (best breath sounds (see ❼, and crackles, wheezes, friction rub; see
for transmitting high-pitched breath Table 28.6, p. 580) Table 28.7, p. 580)
sounds). See ❻.
• Ask the client to take slow, deep Absence of breath sounds
breaths through the mouth. Listen
at each point to the breath sounds
during a complete inspiration and
expiration cycle.
• Compare findings at each point
with the corresponding point on
the opposite side of the chest. Bronchovesicular
1 Vesicular
1 1 2 2 1
1 1 V BV BV V
3 3 BV BV
BV BV
BV BV
4 4 V V
V V
5 5
V
VV V V V
6 6 6 V V
6
7 7 7
7
❻ Pattern for auscultation:

Posterior thorax. ❼ Auscultatory sounds: Posterior thorax.
Anterior Thorax
12. Inspect breathing patterns Quiet, rhythmic, and effortless See Chapter 29, Box 29.2 (p. 651),
(e.g., respiratory rate and rhythm) respirations (see Chapter 29) for altered breathing patterns and
sounds
13. Inspect the costal angle (angle formed Costal angle is less than 90 Costal angle is widened (associated with
by the intersection of the costal degrees, and the ribs insert into COPD)
margins) and the angle at which the spine at approximately a
the ribs enter the spine. 45-degree angle (see
Figure 28.22, p. 578)
14. Palpate the anterior thorax (see the
“Posterior Thorax” section).
15. Palpate the anterior thorax for Full symmetrical excursion; Asymmetrical or decreased respiratory
respiratory excursion. thumbs normally separate excursion
3 cm to 5 cm
(continued)
M28_KOZI2703_04_SE_C28.indd 583 03/03/17 11:17 AM

SKILL 28.11 ASSESSING THE THORAX AND LUNGS (continued)

• Place the palms of both your hands
on the lower thorax, with your fingers
laterally along the lower rib cage and
your thumbs along the costal margins
(see ❽).
• Ask the client to take a deep breath
while you observe the movement of
your hands.
❽ Position of nurse’s hands when assessing

respiratory excursion on the anterior thorax.
16. Palpate tactile fremitus in the same Same as posterior vocal fremitus; Same as posterior fremitus
manner as for the posterior thorax fremitus is normally decreased
and by using the sequence shown over heart and breast tissue
in ❾. If the breasts are large and cannot
be retracted adequately for palpation,
this part of the examination is usually
omitted.
1 1
2 2
3 3
❾ Palpation for tactile fremitus:

4 4
Anterior thorax.
17. Percuss the anterior thorax Percussion notes resonate down Asymmetry in percussion notes; areas of
systematically. to the sixth rib at the level of the dullness or flatness over lung tissue
• Begin above the clavicles in the diaphragm but are flat over
supraclavicular space, and proceed areas of heavy muscle and
downward to the diaphragm (see ❿). bone, dull over the heart and the
• Compare one side of the lung to liver, and tympanic over the
the other. In women, displace underlying stomach see ⓫).
breasts for proper examination.
Flatness over
heavy muscles
and bones
1 2
Resonance
4 3
5 6 Cardiac
dullness
8 7
5th
9 10 ICS
12 Liver
11
dullness
Stomach
Costal
tympany
margin
(6th ICS)
❿ Pattern for percussion: Anterior thorax. ⓫ Normal percussion sounds on the anterior thorax.
18. Auscultate the trachea. Bronchial and tubular breath Adventitious breath sounds
sounds (see ⓬ and Table 28.6, (see Table 28.7, p. 580)
p. 580)
M28_KOZI2703_04_SE_C28.indd 584 17/03/17 1:08 PM


19. Auscultate the anterior thorax. Use the Bronchovesicular and vesicular Adventitious breath sounds
sequence used in percussion (see ❿), breath sounds (see ⓬ and (see Table 28.7, p. 580)
beginning over the bronchi between the Table 28.6, p. 580)
sternum and the clavicles.
Bronchial
Tracheal
Bronchovesicular
Vesicular T
V B B V
V V V
BV BV
V V V
BV BV
V V
V V V
V V
V V
⓬ Auscultatory sounds: Anterior thorax.

EVALUATION
Relate findings to previous assessment data, if available. Report significant deviations from expected or normal to the appropriate
members of the health care team.
Images by: Elena Dorfman/Pearson Education, Inc.
Assessing the Thorax and Lungs

INFANTS may indicate the infant has inhaled a OLDER ADULTS
foreign object.
• The thorax is rounded; that is, the • The thoracic curvature may be
diameter from the front to the back accentuated (kyphosis) because
(anteroposterior) is equal to the trans- CHILDREN of osteoporosis and changes in
verse diameter. See Figure 28.26. • By about 6 years of age, the antero- cartilage resulting in collapse of the
It is also cylindrical, having a nearly posterior diameter has decreased in vertebrae.
equal diameter at the top and the proportion to the transverse diameter • The anteroposterior diameter of
base. This makes it harder for infants and is at a ratio of 1:2. the chest deepens, giving the
to expand their thoracic space. person a barrel-chested appear-
• Children tend to breathe more
• To assess tactile fremitus, place the abdominally than thoracically up to ance. This change results from
hand over the crying infant’s thorax. age 6 years. loss of skeletal muscle strength
• Infants tend to breathe by using their in the thorax and diaphragm and
• During the rapid growth spurts of constant lung inflation from
diaphragm; assess rate and rhythm adolescence, spinal curvature and
by watching the abdomen, rather excessive expiratory pressure
rotation (scoliosis) may appear. on the alveoli.
than the thorax, rise and fall. Children should be assessed for
• The right bronchial branch is short scoliosis by age 12 years and • Breathing rate and rhythm are
and angles down as it leaves the tra- annually until their growth slows. unchanged at rest; the rate
chea, making it easy for small objects Curvature greater than 10% should normally increases with activity
to be inhaled. Sudden onset of cough be referred for further medical but may take longer to return to
or other signs of respiratory distress evaluation. the resting rate.
(continued)
M28_KOZI2703_04_SE_C28.indd 585 03/03/17 11:17 AM

LIFESPAN CONSIDERATIONS (continued)

• Inspiratory muscles become less
powerful, and the inspiration reserve Clinical appearance
volume decreases. A decrease in
depth of respiration is therefore
apparent. Cross-section of thorax
• Expiration may require the use of Posterior
accessory muscles. The expiratory
reserve volume significantly increases
because of the increased amount of
air remaining in the lungs at the end Anteroposterior
of a normal breath.
diameter
• Small airways lose their cartilaginous
support and elastic recoil; as a result,
they tend to close, particularly in the
basal, or dependent, portions of the Transverse diameter
lung. Anterior
• Cilia in the airways decrease in
number and are less effective in
removing mucus; older clients are,
therefore, at greater risk for pulmo- FIGURE 28.26 Configurations of the child’s thorax showing
nary infections. anteroposterior diameter and transverse diameter.
Cardiovascular and of maximal impulse (PMI). The point of maximal

impulse refers to the point at which the apical impulse
Peripheral Vascular is most readily seen or felt.
The precordium, the area of the chest overlying
Systems the heart, is inspected and palpated simultaneously for
the presence of abnormal pulsations or lifts or heaves.
The cardiovascular system consists of the heart and the The terms lift and heave, often used interchangeably,
central blood vessels (primarily the pulmonary, coronary, refer to a rising along the sternal border with each heart-
and neck arteries and veins. The peripheral vascular beat. A lift occurs when cardiac action is very forceful. It
system includes those arteries and veins distal to the should be confirmed by palpation with the palm of the
central vessels, extending all the way to the brain and to hand. Enlargement or overactivity of the left ventricle
the extremities. produces a heave lateral to the apex, whereas enlarge-
ment of the right ventricle produces a heave at or near
the sternum.
Heart sounds can be heard by auscultation. The
Heart normal first two heart sounds are produced by closure
The heart is assessed through inspection, palpation, of the valves of the heart. The first heart sound, S1,
and auscultation, in that sequence. The heart is usually occurs when the atrioventricular (A-V) valves close and
assessed during an initial physical assessment; periodic is best heard at the apex. These valves close when the
reassessments may be necessary for long-term care or ventricles have been sufficiently filled. Although the
at-risk clients or those with cardiac problems. right and left A-V valves do not close simultaneously,
In the average adult, most of the heart lies behind the closures occur closely enough to be heard as one
and to the left of the sternum. A small portion (the sound (S1), a dull, low-pitched sound described as “lub.”
right atrium) extends to the right of the sternum. The After the ventricles empty their blood into the aorta and
upper portion of the heart (both atria), referred to as pulmonary arteries, the semilunar valves close, produc-
its base, lies posteriorly (toward the back). The lower ing the second heart sound, S2, described as “dub.” S2
portion (the ventricles), referred to as its apex, points has a higher pitch than S1 and is also shorter. The S2 is
anteriorly (forward). The apex of the left ventricle actu- best heard in the aortic and pulmonic areas. These two
ally touches the anterior chest wall at or medial to the sounds, S1 and S2 (“lub-dub”), occur within one second
left midclavicular line (MCL) and at or near the fifth left or less, depending on the heart rate.
intercostal space, which is slightly below the left nipple. Heart sounds are audible anywhere on the precor-
See Figure 29.11 (p. 641). This point where the apex dial area, but they are best heard over the aortic, pul-
touches the anterior chest wall is known as the point monic, tricuspid, and apical areas (Figure 28.27). Each
M28_KOZI2703_04_SE_C28.indd 586 03/03/17 11:17 AM

Systole
Aortic
area
Pulmonic
S1 S2
area
Mitral, tricuspid Aortic, pulmonic
Tricuspid valves close valves close
area
Apical
area
Diastole
Epigastric
area
FIGURE 28.28 Relationship of heart sounds to systole and
diastole.
FIGURE 28.27 Anatomical sites of the precordium.
area is associated with the closure of heart valves: the referred to as a gallop rhythm) occurs early in diastole
aortic area with the aortic valve (inside the aorta as it right after S2 and sounds like “lub-dub-ee” (S1, S2, S3)
arises from the left ventricle); the pulmonic area with the or “Kentuc-ky.” It often disappears when the client sits
pulmonic valve (inside the pulmonary artery as it arises up. S3 is normal in children and young adults. In older
from the right ventricle); the tricuspid area with the tri- adults, it may indicate heart failure. S4 is rarely heard in
cuspid valve (between the right atrium and the right ven- healthy young adults. It occurs near the very end of dias-
tricle); and the apical (mitral) area with the mitral valve tole just before S1 and creates the sound of “dee-lub-dub”
(between the left atrium and the left ventricle). (S4, S1, S2) or “Ten-nessee.” S4 may be heard in many
Associated with these sounds are systole and diastole. older adult clients and can be a sign of hypertension.
Systole is the period in which the ventricles contract. It An S4 may be heard following acute myocardial infarc-
begins with the first heart sound and ends at the second tion (MI) or in older adults with cardiovascular disease.
heart sound. Systole is normally shorter than diastole. The presence of an S4 indicates an increased resistance
Diastole is the period in which the ventricles relax. It to ventricular filling, which occurs because of a loss of
starts with the second sound and ends at the subsequent compliance in the ventricular walls (e.g., hypertensive
first sound. Normally, no sounds are audible during these disease, coronary heart disease).
periods (Figure 28.28). The experienced nurse, however, Normal heart sounds are summarized in Table 28.8.
may auscultate extra heart sounds (S3 and S4) during The nurse may also hear abnormal heart sounds, such
diastole. Both sounds are low in pitch and heard best at as clicks, rubs, and murmurs. These are caused by valve
the apex, with the bell of the stethoscope, and with the disorders or impaired blood flow within the heart and
client either supine or lying on the left side. S3 (often require advanced training to diagnose.
TABLE 28.8 Normal Heart Sounds
Sound Area
or Phase Description Aortic Pulmonic Tricuspid Apical
S1 Dull, low-pitched, and longer Less intensity Less intensity than S2 Louder than or Louder than or
than S2; sounds like “lub” than S2 equal to S2 equal to S2
Systole Normally silent interval

between S1 and S2
S2 Higher pitch than S1; sounds Louder than S1 Louder than S1; abnormal Less intensity Less intensity
like “dub” if louder than the aortic than or than or
S2 in adults more than equal to S1 equal to S1
40 years of age
Diastole Normally silent interval

between S2 and next S1
M28_KOZI2703_04_SE_C28.indd 587 03/03/17 11:17 AM

Central Vessels
Sternocleidomastoid
The carotid arteries supply oxygenated blood to the head muscle
and neck (Figure 28.29). Because they are the only
Internal jugular vein
source of blood to the brain, prolonged occlusion of one
of these arteries can result in serious brain damage. The Internal carotid
artery
carotid pulses correlate with central aortic pressure, thus
reflecting cardiac function better than peripheral pulses External carotid
can. When cardiac output is diminished, the peripheral artery
pulses may be difficult or impossible to feel, but the Carotid sinus
carotid pulse should be felt easily. External
The carotid is also auscultated for a bruit, and if a jugular vein
bruit is found, the carotid artery is then palpated for a Common
thrill. A bruit (a blowing or swishing sound), best heard carotid artery
with the diaphragm of the stethoscope, is created by Aortic arch
turbulence of blood flow created by either a narrowed Superior vena
arterial lumen (a common development in older people) cava
or to a condition, such as anemia or hyperthyroidism,
that elevates cardiac output. A thrill, which frequently
FIGURE 28.29 Arteries and veins of the right side of the neck.
accompanies a bruit, is a vibrating sensation, similar to
the purring of a cat or water running through a hose. It,
too, indicates turbulent blood flow because of arterial
obstruction. side of the heart and venous pressure. Bilateral jugular
The jugular veins drain blood from the head and neck vein distension may indicate right-sided heart failure.
directly into the superior vena cava and right side of the Skill 28.12 describes how to assess the heart and
heart. The external jugular veins are superficial and may central vessels. (See also Lifespan Considerations box on
be visible above the clavicle. The internal jugular veins lie assessing the heart and central vessels.)
deeper along the carotid artery and may transmit pulsa-
tions onto the skin of the neck. Normally, external neck
veins are distended and visible when a person lies down; Peripheral Vascular System
they are flat and not as visible when a person stands up
because gravity encourages venous drainage. By inspect- Assessing the peripheral vascular system includes mea-
ing the jugular veins for pulsations and distension, the suring blood pressure; palpating peripheral pulses;
nurse can assess the adequacy of function of the right inspecting, palpating, and auscultating the carotid pulse;
SKILL 28.12 ASSESSING THE HEART AND CENTRAL VESSELS
PLANNING 2. Perform hand hygiene, and follow other appropriate infec-

Heart examinations are usually performed while the client is in
a semi-reclined position. The practitioner stands at the client’s 3. Provide for client privacy.
right side, where palpation of the cardiac area is facilitated and 4. Inquire whether the client has any history of the following:
optimal inspection allowed. family history of incidence and age of heart disease, high
cholesterol levels, hypertension, cerebrovascular accident
Equipment (CVA, or stroke), obesity, congenital heart disease, arte-
• Stethoscope rial disease, and rheumatic fever; client’s past history of
rheumatic fever, heart murmur, heart attack, varicosities,
• Centimetre ruler
or heart failure; present signs or symptoms indicative of
heart disease (e.g., fatigue, dyspnea, orthopnea, edema,
IMPLEMENTATION cough, chest pain, palpitations, syncope, elevated blood
pressure, wheezing, hemoptysis); presence of problems
Performance that affect the heart (e.g., obesity, diabetes, lung dis-
1. Before performing the procedure, introduce yourself to the ease, endocrine disorders); lifestyle habits that are risk
client, and verify the client’s identity by using a minimum factors for cardiac disease (e.g., smoking, excessive
of two identifiers. Explain to the client what you are going alcohol intake, eating and exercise patterns, areas and
to do, why it is necessary, and how he or she can par- degree of stress perceived).
ticipate. Discuss how the results will be used in planning
further care or treatments.
M28_KOZI2703_04_SE_C28.indd 588 17/03/17 1:08 PM


5. Simultaneously inspect and palpate the
precordium for the presence of abnormal
pulsations, lifts, or heaves. Locate the valve
areas of the heart:
• Locate the angle of Louis. It is felt as a
prominence on the sternum.
• Move your fingertips down each side of
the angle until you can feel the second
intercostal spaces. The client’s right
second intercostal space is the aortic
area, and the left second intercostal
space is the pulmonic area (see ❶). ❶ Second intercostal space.
• Inspect and palpate the aortic and No pulsations Pulsations
pulmonic areas, observing them at
an angle and to the side, to note the
presence or absence of pulsations.
Rationale: Observing these areas
at an angle increases the likelihood
of seeing pulsations.
• From the pulmonic area, move your
fingertips down three left intercostal
spaces along the side of the sternum.
The left fifth intercostal space close to
the sternum is the tricuspid or right
ventricular area.
• Inspect and palpate the tricuspid area No pulsations; no lift or heave Pulsations; diffuse lift or heave,
for pulsations and heaves or lifts. indicating enlarged or overactive
right ventricle
• From the tricuspid area, move your
fingertips laterally 5 to 7 cm to the left
MCL. This is the apical or mitral area or
PMI (see ❷). If you have difficulty locat-
ing the PMI, have the client roll onto the
left side to move the apex closer to the
chest wall.
❷ Fifth intercostal space, MCL.

• Inspect and palpate the apical area for Pulsations visible in 50% of adults PMI displaced laterally or lower
pulsation, noting its specific location (it and palpable in most PMI in fifth left (indicates enlarged heart or
may be displaced laterally or lower) and intercostal space at or medial to the aneurysm); diameter of more than
diameter. If displaced laterally, record MCL; diameter of 1 cm to 2 cm; no 2 cm; diffuse lift or heave lateral to
the distance between the apex and the lift or heave apex (indicates enlargement or
MCL in centimetres. overactivity of left ventricle)
• Inspect and palpate the epigastric area Aortic pulsations Bounding abdominal pulsations
at the base of the sternum for abdomi- (e.g., aortic aneurysm)
nal aortic pulsations.
6. Auscultate the heart in all four anatomical S1: usually heard at all sites, usually Increased or decreased intensity;
sites: aortic, pulmonic, tricuspid, and apical louder at apical area varying intensity with different beats;
(mitral). Auscultation need not be limited S2 : usually heard at all sites, usually increased intensity at aortic area;
to these areas; however, you may need louder at base of heart increased intensity at pulmonic
to move the stethoscope to find the most Systole: silent interval, slightly shorter area; sharp-sounding ejection
audible sounds for each client. duration than diastole at normal clicks; S3 in older adults; S4 may be
heart rate (60–100 beats/min) a sign of hypertension
Diastole: silent interval, slightly
longer duration than systole at
normal heart rates
S3 : in children and young adults
S4: in many older adults
(continued)
M28_KOZI2703_04_SE_C28.indd 589 03/03/17 11:17 AM

SKILL 28.12 ASSESSING THE HEART AND CENTRAL VESSELS (continued)

• Eliminate all sources of room noise.
Rationale: Heart sounds are of low
intensity, and other noises hinder
the nurse’s ability to hear them.
• Keep the client in the supine position,
with head elevated 15 degrees
to 45 degrees.
• Use both the diaphragm and the bell of
the stethoscope to listen to all areas.
• In every area of auscultation, distinguish
both S1 and S2 sounds.
• When auscultating, concentrate on one
particular sound at a time in each area:
the first heart sound, followed by sys-
tole, then the second heart sound, and
then diastole. Systole and diastole are
normally silent intervals.
• Later, re-examine the heart while the
client is in the upright sitting position.
Rationale: Certain sounds are more
audible in certain positions.
Carotid Arteries
7. Palpate the carotid artery, using extreme Symmetrical pulse volumes; full Asymmetrical volumes (possible
caution (see Figure 28.29, p. 588) pulsations, thrusting quality; quality stenosis or thrombosis); decreased
remains same when client breathes, pulsations (may indicate impaired left
turns head, and changes from cardiac output); increased pulsations;
sitting to supine position; elastic thickening, hard, rigid, beaded,
arterial wall inelastic walls (indicate arteriosclerosis)
• Palpate only one carotid artery at a
time. Rationale: This ensures ade-
quate blood flow through the other
artery to the brain.
• Avoid exerting too much pressure
and massaging the area. Rationale:
Pressure can occlude the artery
and carotid sinus massage can
precipitate bradycardia.
• The carotid sinus is a small dilation at
the beginning of the internal carotid
artery just above the bifurcation of the
common carotid artery, in the upper
third of the neck.
• Ask the client to turn the head slightly
toward the side being examined.
This makes the carotid artery more
accessible.
8. Auscultate the carotid artery. No sound heard on auscultation Presence of bruit in one or both arteries
(suggests occlusive artery disease)
• Turn the client’s head slightly away from
the side being examined. Rationale:
This facilitates the placement of
the stethoscope.
• Auscultate the carotid artery on one
side and then the other.
• Listen for the presence of a bruit. If you
hear a bruit, gently palpate the artery to
determine the presence of a thrill.
M28_KOZI2703_04_SE_C28.indd 590 17/03/17 1:08 PM

Jugular Veins
9. Inspect the jugular veins for distension while Veins not visible (indicating right Veins visibly distended (indicating
the client is placed in the semi-Fowler’s side of heart is functioning normally) advanced cardiopulmonary disease)
position (15-degree to 45-degree angle),
with the head supported on a small pillow.
10. If jugular vein distension is present, assess Bilateral measurements of more than
the jugular venous pressure. 3 cm to 4 cm are considered elevated
(may indicate right-sided heart failure);
unilateral distension (may be caused by
local obstruction)
• Locate the highest visible point of
distension of the internal jugular vein. Level of the highest visible
Although either the internal or the exter- point of distention
nal jugular vein can be used, the internal
The vertical distance
jugular vein is more reliable. Rationale:
between the sternal angle
The external jugular vein is more and the highest level
easily affected by obstruction or of jugular distention
kinking at the base of the neck.
• Measure the vertical height of this point Level of the sternal
in centimetres from the sternal angle, angle
the point at which the clavicles meet External
(see ❸). jugular vein
• Repeat the preceding steps on the
other side.
Internal jugular vein
158 – 458
❸ Assessing the highest point of distension of the jugular vein.

EVALUATION
• Perform a detailed follow-up examination, based on findings • Report significant deviations from expected or normal to the
that deviated from expected or normal for the client. Relate appropriate members of the health care team.
findings to previous assessment data, if available.
Images by: Shirlee Snyder
Assessing the Heart and Central Vessels

INFANTS indicate an atrial-septal defect, pul- • Murmurs may be heard in newborns
monary stenosis, or another heart as the structures of fetal circulation,
• Physiological splitting of the second problem. especially the ductus arteriosus, close.
heart sound (S2) may be heard when
the child takes a deep breath, and • Infants may normally have sinus
the aortic valve closes a split second arrhythmia that is related to respira- CHILDREN
before the pulmonic valve. If split- tion. The heart rate slows during
expiration and increases when the • Heart sounds are louder because of
ting of S2 is heard during normal the thinner chest wall.
respirations, it is abnormal and may child breathes in.
(continued)
M28_KOZI2703_04_SE_C28.indd 591 03/03/17 11:17 AM

LIFESPAN CONSIDERATIONS (continued)

• A third heart sound (S3), caused as • Cardiac output and strength of con- • Extra systoles commonly occur. Ten
the ventricles fill, is best heard at the traction decrease, thus lessening the or more extra systoles per minute are
apex and is present in about one- older person’s activity tolerance. considered abnormal.
third of all children. • The heart rate returns to its rest- • Sudden emotional and physical
• The PMI is higher and more medial in ing rate more slowly after exertion stresses can result in cardiac
children younger than 8 years old. than it did when the individual was arrhythmias and heart failure.
younger.
OLDER ADULTS • S4 heart sound may be audible in
older adults as a result of a more
• If no disease is present, heart size rigid ventricle.
remains the same throughout life.
inspecting the jugular and peripheral veins; and inspect- of the physical examination. (See the section on assess-
ing skin and tissues to determine perfusion (blood ing blood pressure in Chapter 29.) Pulse sites and pulse
supply to an area) to the extremities. Certain aspects of assessments are also described in Chapter 29.
peripheral vascular assessment are often incorporated Skill 28.13 describes how to assess the peripheral
into other parts of the assessment procedure. For exam- vascular system. (See also Lifespan Considerations box
ple, blood pressure is usually measured at the beginning on assessing the peripheral vascular system.)
SKILL 28.13 ASSESSING THE PERIPHERAL VASCULAR SYSTEM
PLANNING do, why it is necessary, and how he or she can partici-

pate. Discuss how the results will be used in planning
Equipment further care or treatments.
None 2. Perform hand hygiene, and follow other appropriate
Performance 4. Inquire whether the client has any history of the following:
past history of heart disorders, varicosities, arterial
1. Before performing the procedure, introduce yourself to disease, and hypertension; lifestyle habits such as
the client, and verify the client’s identity by using two exercise patterns, activity patterns and tolerance,
identifiers. Explain to the client what you are going to smoking, and use of alcohol.

5. Palpate the peripheral pulses indi- Symmetrical pulse volumes; full Asymmetrical volumes (indicate impaired
vidually and systematically on both pulsations circulation); absence of pulsation (indicates
sides of the client’s body simultane- arterial spasm or occlusion); decreased,
ously (except the carotid pulse) to weak, thready pulsations (indicate impaired
determine the symmetry of pulse cardiac output); increased pulse volume
volume. If you have difficulty palpat- (may indicate hypertension, high cardiac
ing some of the peripheral pulses, output, or circulatory overload)
use a Doppler ultrasound probe.
Peripheral Veins
6. Inspect the peripheral veins in the In dependent position, presence of Distended veins in the thigh or lower leg or
arms and legs for the presence distension and nodular bulges at calves; on posterolateral part of calf from knee to
or appearance of superficial when limbs elevated, veins collapse ankle
veins when limbs are dependent (veins may appear tortuous or distended
and when limbs are elevated. in older people)
7. Assess the peripheral leg veins Limbs not tender; symmetrical in size Tenderness on palpation; warmth and
for signs of phlebitis (vein redness over vein; swelling of one calf or
inflammation). leg; no one sign or symptom consistently
confirms or excludes the presence of
phlebitis or a deep venous thrombosis
• Inspect the calves for redness and
swelling over vein sites.
M28_KOZI2703_04_SE_C28.indd 592 17/03/17 1:08 PM


• Palpate the calves for firmness
or tension of the muscles, the
presence of edema over the
dorsum of the foot, and areas
of localized warmth. Rationale:
Palpation augments inspec-
tion findings, particularly in
darker-skinned people in
whom redness may not be
visible.
• Push the calves from side to
side to test for tenderness.
Peripheral Perfusion
8. Inspect the skin of the hands Skin colour pink; skin temperature not Cyanotic (venous insufficiency); pallor
and feet for colour, temperature, excessively warm or cold; no edema; that increases with limb elevation;
edema, and skin changes. skin texture resilient and moist dependent rubor, a dusky red colour
when limb is lowered (arterial
insufficiency); brown pigmentation
around ankles (arterial or chronic
venous insufficiency); skin cool
(arterial insufficiency); marked edema
(venous insufficiency); mild edema
(arterial insufficiency); skin thin and
shiny or thick, waxy, shiny, and fragile,
with reduced hair and ulceration
(venous or arterial insufficiency)
9. Assess the adequacy of arte-
rial flow if arterial insufficiency is
suspected.
Capillary Refill Test

• Press at least one nail on each Immediate return of colour (less than Delayed return of colour (arterial
hand and foot between your 2 seconds) insufficiency)
thumb and index finger suf-
ficiently to cause blanching
(about 5 seconds).
• Release the pressure, and
observe how quickly normal
colour returns.
Other Assessments
• Inspect fingernails for changes
indicative of circulatory impair-
ment. See the section on
assessment of nails earlier in
this chapter (see Skill 28.4,
p. 550).
• See also peripheral pulse
assessment in Chapter 29
(Skill 29.2, p. 644).
EVALUATION
• Perform a detailed follow-up examination of the heart or • Report significant deviations from expected or normal to the
central vessels, integument, or other systems, based on appropriate members of the health care team.
findings that deviated from expected or normal for the client.
Relate findings to previous assessment data, if available.
M28_KOZI2703_04_SE_C28.indd 593 03/03/17 11:17 AM

• Arteries may be palpated more eas-

Assessing the Peripheral Vascular System ily because of loss of the supportive
surrounding tissues. Often, however,
INFANTS bleeding under the skin), can indicate the most distal pulses of the lower
serious systemic diseases in children extremities are more difficult to pal-
• Screen for coarctation (narrowing) of (e.g., leukemia, meningococcemia). pate because of decreased arterial
the aorta by palpating the peripheral perfusion.
pulses and comparing the strength
OLDER ADULTS • Systolic and diastolic blood pressures
of femoral pulses with radial and api-
cal pulses. If coarctation is present, • The overall effectiveness of blood may be increased. See Chapter 29
femoral pulses will be diminished and vessels decreases as smooth muscle for guidelines for measurement of
radial pulses will be stronger. cells are replaced by connective tis- blood pressure, follow-up, and life-
sue. The lower extremities are more style counselling.
CHILDREN likely to show signs of arterial and • Peripheral edema is frequently
• Palpation of pulses in the lower venous impairment because of the observed and is most commonly the
extremities (particularly femoral more distal and dependent position. result of chronic venous insufficiency
pulses) is essential to screen for • Peripheral arteries become thicker or low protein levels in the blood
coarctation of the aorta. and dilate less effectively because (hypoproteinemia).
• Changes in the peripheral vascu- of arteriosclerotic changes in the • Carotid artery assessment is an
lature, such as bruising, petechiae vessel walls. essential aspect of peripheral vascu-
(small purple or red spots caused by • Blood vessels lengthen and become lar examination in the older adult.
a broken blood vessel), and purpura more tortuous and prominent. Vari-
(larger red or purple spots caused by cosities occur more frequently.
Tail of Spence
Breasts and Axillae
The breasts of both men and women need to be
inspected and palpated. Men have some glandular tis-
sue beneath each nipple, a potential site for malignancy,
whereas adult women have glandular tissue throughout
Upper outer
the breast. In females, the largest portion of glandular quadrant
breast tissue is located in the upper outer quadrant of Upper inner
each breast. From this quadrant, there is a projection of quadrant
breast tissue into the axilla, called the axillary tail of
Spence (Figure 28.30). The majority of breast tumours

are located in this upper outer breast quadrant and in Lower outer
the tail of Spence. During assessment, the nurse can quadrant
Lower inner
localize specific findings by using this division of the quadrant
breast into quadrants and the axillary tail.
Skill 28.14 describes how to assess the breasts and
axillae. (See also Lifespan Considerations box on assess- FIGURE 28.30 Four breast quadrants and the axillary tail of
ing breasts and axillae.) Spence.
SKILL 28.14 ASSESSING BREASTS AND AXILLAE
PLANNING identifiers. Explain to the client what you are going to do,
Equipment Inquire whether the client has ever had a clinical breast
examination. Discuss how the results will be used in plan-
• Centimetre ruler ning further care or treatments.
IMPLEMENTATION 2. Perform hand hygiene, and follow other appropriate infec-
Performance 3. Provide for client privacy.
1. Before performing the procedure, introduce yourself to 4. Inquire whether the client has a history of breast masses
the client, and verify the client’s identity by using two and what was done about them; pain or tenderness in
M28_KOZI2703_04_SE_C28.indd 594 17/03/17 1:08 PM

the breasts and relation to the woman’s menstrual cycle; mother, sister, aunt with breast cancer; alcohol con-
discharge from the nipple; medication history (some sumption, high-fat diet, obesity, use of oral contracep-
medications, e.g., oral contraceptives, steroids, digi- tives, menarche before age 12 years, menopause after
talis, and diuretics, can cause nipple discharge; estro- age 55 years, age 30 years or older at first pregnancy, or
gen replacement therapy may be associated with the never having been pregnant). Inquire whether the client
development of cysts or cancer); risk factors that may monitors the look and feel of her breasts and notes the
be associated with development of breast cancer (e.g., normal changes in relation to her menstrual cycle.

5. Inspect breasts for size, symmetry, Females: Rounded shape; slightly Recent change in breast size;
and contour or shape while the client unequal in size; generally symmetrical swellings; marked asymmetry
is in the sitting position.
Males: Breasts even with the chest
wall; if obese, may be similar in shape
to female breasts
6. Inspect the skin of the breast for Skin uniform in colour (same in Localized discolorations or
localized discolorations or hyperpig- appearance as skin of abdomen or hyperpigmentation; retraction or
mentation, retraction or dimpling, back); skin smooth and intact; diffuse dimpling (result of scar tissue or an
localized hypervascular areas, swell- symmetric horizontal or vertical invasive tumour); unilateral, localized
ing, or edema (see ❶). vascular pattern in light-skinned hypervascular areas (associated with
people; striae (stretch marks); moles increased blood flow); swelling or
and nevi edema appearing as “pig skin” or
“orange peel” because of exaggeration
of the pores
Retraction
Lesion
❶ A lesion causing retraction of the skin.

7. Accentuate any retraction by having
the client do the following:
• Raise arms above the head.
• Push hands together, with elbows
flexed (see ❷).
• Press hands down on hips (see ❸).
❷ Pushing hands together to accentuate ❸ Pressing hands down on hips to

retraction of breast tissues. accentuate retraction of breast tissue.
8. Inspect the areola area for size, Round or oval and bilaterally the same; Any asymmetry, mass, or lesion
shape, symmetry, colour, surface colour varies widely, from light pink to
characteristics, and any masses or dark brown; irregular placement of
lesions. sebaceous glands on the surface of
the areola (Montgomery’s tubercles)
(continued)
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SKILL 28.14 ASSESSING BREASTS AND AXILLAE (continued)

9. Inspect nipples for size, shape, Round, everted, and equal in size; Asymmetrical size and colour;
position, colour, discharge, and similar in colour; soft and smooth; presence of discharge, crusts, or
lesions. both nipples point in same direction cracks; recent inversion of one or both
(out in young women and men, nipples
downward in older women); no
discharge, except from pregnant or
breast-feeding females; inversion of
one or both nipples that is present
from puberty
10. Palpate the axillary, subclavicular, No tenderness, masses, or nodules Tenderness, masses, or nodules
and supraclavicular lymph nodes
(see ❹) while the client sits with
arms abducted and supported on A Supraclavicular
the nurse’s forearm. For palpation
of clavicular lymph nodes,
see Skill 28.10 (p. 575). Use B
the flat surfaces of all fingertips
to palpate the four areas of Lateral
the axilla:
Central
• The edge of the musculus
pectoralis major (greater Infraclavicular
pectoral muscle) along the Anterior
anterior axillary line
Posterior
• The thoracic wall in the
midaxillary area
• The upper part of the humerus
• The anterior edge of the ❹ Location and palpation of lymph nodes that drain the lateral breast: A: Lymph nodes;
latissimus dorsi muscle along B: palpating the axilla.
the posterior axillary line
11. Palpate the breast for masses, No tenderness, masses, nodules, or Tenderness, masses, nodules, or
tenderness, and any discharge from nipple discharge nipple discharge
the nipples. Palpation of the breast
is generally performed while the
client is supine. Rationale: In the
supine position, the breasts
flatten evenly against the chest
wall, facilitating palpation.
• For clients who have a
history of breast masses, who
are at high risk for breast
cancer, or who have pendulous
breasts, examination in both
supine and sitting positions is
recommended.
• If the client reports a breast lump,
start with the rest of the breast to
obtain baseline data that will serve
as a comparison to the reportedly
involved breast.
• To enhance flattening of the
breast, instruct the client to
abduct the arm and place her
hand behind her head. Then
place a small pillow or rolled
towel under the client’s
shoulder.
M28_KOZI2703_04_SE_C28.indd 596 17/03/17 1:09 PM


• For palpation, use the palmar sur- 12
face of the middle three fingertips 11 1
(held together) and make a gentle
rotary motion on the breast.
• Choose one of three patterns for 10
palpation: 2
a. Hands of the clock or spokes
on wheel (see ❺) 9 3
b. Concentric circles (see ❻)
4
8
7 5
6
❺ Hands-of-the-clock or spokes-on-a-wheel ❻ Concentric circles pattern for breast

pattern of breast palpation. palpation.
c. Vertical strips pattern (see ❼) If you detect a mass, record the

• Start at one point for palpation, following data:
and move systematically to the a. Location: The exact location relative
end point to ensure that all breast to the quadrants and axillary tail, or
surfaces are assessed. the clock (as in ❺), and the distance
• Pay particular attention to the from the nipple in centimetres
upper outer quadrant area and the b. Size: The length, width, and thick-
tail of Spence. ness of the mass in centimetres.
If you are able to determine the
discrete edges, record this fact
c. Shape: Whether the mass is round,
oval, lobulated, indistinct, or irregular
d. Consistency: Whether the mass is
hard or soft
e. Mobility: Whether the mass is mov-
able or fixed
f. Skin over the lump: Whether it is
reddened, dimpled, or retracted
Start here
g. Nipple: Whether it is displaced or
retracted
h. Tenderness: Whether palpation is
❼ Vertical strips pattern of breast palpation. painful to the client
12. Palpate the areola and nipples for No tenderness, masses, nodules, or Tenderness, masses, nodules, or
masses. Compress each nipple to nipple discharge nipple discharge
determine the presence of any
discharge. If discharge is present,
milk the breast along its radius to
identify the discharge-producing lobe.
Assess any discharge for amount,
colour, consistency, and odour. Note
also any tenderness on palpation.
13. Document your findings in the client
record.
EVALUATION
Images by: Pearson Education, Inc.
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Assessing the Breasts and Axillae

INFANTS Stage 4 Projection of the areola areolae contain small, scattered,
and nipple forming a secondary elevated Montgomery’s glands.
• Newborns, both boys and girls, up
to 2 weeks of age may have breast mound over the breast • Superficial veins become more
enlargement and galactorrhea (white Stage 5 Recession of areola in prominent, and jagged linear stretch
discharge from the nipples). marks may develop.
most women by about age 14 or
• Supernumerary (extra) nipples are 15 years, leaving only the nipple • Colostrum (a thick yellow fluid) may
present infrequently as small dimples projecting be expressed from the nipples after
along the mammary chain; these may the first trimester.
• Boys can develop breast buds
be associated with renal anomalies. and have slight enlargement of
the areola in early adolescence. OLDER ADULTS
PREADOLESCENTS Gynecomastia (further enlargement • In the postmenopausal female,
AND ADOLESCENTS of breast tissue) can occur. This breasts change in shape and often
growth is transient, usually lasting appear pendulous or flaccid; breasts
• Female breast development begins about 2 years, resolving completely
between ages 8 and 13 years and lack the firmness they had in younger
by late puberty. years.
occurs in five stages. Development
may be asymmetrical. • Axillary hair usually appears by age • The presence of breast lesions may
13 years and is related to adrenal be detected more readily because of
Stage 1 Prepubertal with no notice- rather than gonadal changes. the decrease in connective tissue.
able change
• General breast size remains the
Stage 2 Breast bud with elevation PREGNANT FEMALES same. Although glandular tis-
of nipple and enlargement of sue atrophies, the amount of fat
• Breast, areola, and nipple sizes
the areola in breasts (predominantly in the
increase.
Stage 3 Enlargement of the breast lower quadrants) increases in most
• The areolae and nipples darken; women.
and areola; nipple flush with the nipples may become more erect;
breast surface
Abdomen
The nurse locates and describes abdominal findings in a
client by using two common methods of subdividing the
abdomen: quadrants and regions. To divide the abdomen
into quadrants, the nurse imagines two lines: (a) a vertical
line from the xiphoid process to the pubic symphysis and
(b) a horizontal line across the umbilicus (Figure 28.31).
These quadrants are labelled right upper quadrant (1),
left upper quadrant (2), right lower quadrant (3), and left
lower quadrant (4). Using the second method, division
into nine regions, the nurse imagines two vertical lines
that extend superiorly from the midpoints of the inguinal
ligaments, and two horizontal lines, one at the level of
the edge of the lower ribs and the other at the level of
the iliac crests (Figure 28.32). Specific organs or parts of
organs lie in each abdominal region. See Table 28.9 and RUQ LUQ
Table 28.10.
RLQ LLQ
In addition, practitioners often use certain landmarks
to locate abdominal signs and symptoms. These are the
xiphoid process of the sternum, the costal margins, the
midline (a line drawn from the tip of the sternum through
the umbilicus to the pubic symphysis), the anterosupe-
FIGURE 28.31 The four abdominal quadrants and the under-
rior iliac spine, the inguinal ligaments (Poupart’s liga-
lying organs: 1, Right upper quadrant (RUQ); 2, Left upper
ments), and the superior margin of the pubic symphysis quadrant (LUQ); 3, Right lower quadrant (RLQ); 4, Left lower
(Figure 28.33). quadrant (LLQ).
M28_KOZI2703_04_SE_C28.indd 598 03/03/17 11:17 AM

Right Left
hypochondriac hypochondriac Xiphoid process
Costal margins
Midline
Anterior superior
iliac spines
Umbilicus
Inguinal (Poupart’s)
ligaments
Right Left
lumbar Epigastric lumbar Superior margin
of pubic bone
Umbilical FIGURE 28.33 Landmarks commonly used to identify

abdominal areas.
Right Hypogastric Left

inguinal inguinal
FIGURE 28.32 The nine abdominal regions: epigastric; left and Musculoskeletal System
right hypochondriac; umbilical; left and right lumbar; hypogas-
tric (pubic); left and right inguinal or iliac. The musculoskeletal system encompasses the muscles,
bones, and joints. The completeness of an assessment of
Assessment of the abdomen involves all four meth- this system depends largely on the needs and problems
ods of examination (inspection, auscultation, palpa- of the individual client. The nurse usually assesses the
tion, and percussion). When assessing the abdomen, the musculoskeletal system for muscle strength, tone, size,
nurse performs inspection first, followed by auscultation, and symmetry of muscle development, fasciculations,
percussion, and palpation. Auscultation is done before and tremors. A fasciculation is an abnormal contrac-
palpation and percussion because these techniques tion (shortening) of a bundle of muscle fibres. A tremor
cause movement or stimulation of the bowel, which is an involuntary trembling of a limb or body part.
can increase bowel motility and, thus, heighten bowel Tremors may involve large groups of muscle fibres or
sounds, creating false results. small bundles of muscle fibres. An intention tremor
Skill 28.15 describes how to assess the abdomen. becomes more apparent when an individual attempts a
(See also Lifespan Considerations box and Clinical Alert voluntary movement, such as holding a cup of coffee. A
box on assessing the abdomen.) resting tremor is more apparent when the client is at
rest and it diminishes with activity.
Bones are assessed for normal form. Joints are
CLINICAL ALERT assessed for tenderness, swelling, thickening, crepitation
If abdominal distension is observed on inspection, evaluation (the sound of bone grating on bone), presence of nod-
of the abdominal girth is necessary. Place a measuring tape around the ules, and range of motion. Body posture is assessed for
abdomen at the level of the umbilicus. Mark the location of the measuring
tape so that additional measurements can be taken in the same location.
normal standing and sitting positions. For information
about body posture, see Chapter 39.
TABLE 28.9 Organs in the Four Abdominal Quadrants
Right Upper Quadrant Left Upper Quadrant Left Lower Quadrant Right Lower Quadrant
Liver Left lobe of liver Lower lobe of left kidney Lower lobe of right kidney
Gallbladder Stomach Sigmoid colon Cecum
Duodenum Spleen Section of descending colon Appendix
Head of pancreas Upper lobe of left kidney Left ovary Section of ascending colon
Right adrenal gland Pancreas Left fallopian tube Right ovary
Upper lobe of right kidney Left adrenal gland Left ureter Right fallopian tube
Hepatic flexure of colon Splenic flexure of colon Left spermatic cord Right ureter
Section of ascending colon Section of transverse colon Part of uterus Right spermatic cord
Section of transverse colon Section of descending colon Part of uterus
M28_KOZI2703_04_SE_C28.indd 599 03/03/17 11:17 AM

TABLE 28.10 Organs in the Nine Abdominal Regions
Right Hypochondriac Right Inguinal Umbilical

Right lobe of liver Cecum Omentum
Gallbladder Appendix Mesentery
Part of duodenum Lower end of ileum Lower part of duodenum
Hepatic flexure of colon Right ureter Part of jejunum and ileum
Upper half of right kidney Right spermatic cord
Suprarenal gland Right ovary
Right Lumbar Epigastric Hypogastric (Pubic) Left Lumbar
Ascending colon Aorta Ileum Descending colon
Lower half of right kidney Pyloric end of stomach Bladder Lower half of left kidney
Part of duodenum and jejunum Part of duodenum Uterus Part of jejunum and ileum
Pancreas
Part of liver
Left Hypochondriac Left Inguinal
Stomach Sigmoid colon
Spleen Left ureter
Tail of pancreas Left spermatic cord
Left ovary
SKILL 28.15 ASSESSING THE ABDOMEN
PLANNING 2. Perform hand hygiene, and follow other appropriate infec-

tion prevention control procedures.
• Ask the client to urinate, since an empty bladder makes the
assessment more comfortable for the client. 3. Provide for client privacy.
• Ensure that the room is warm, as the client will be exposed. 4. Inquire whether the client has any history of the following:
incidence of abdominal pain; its location, onset, sequence,
and chronology; its quality (description); its frequency; asso-
Equipment
ciated symptoms (e.g., nausea, vomiting, diarrhea); bowel
• Examining light habits; incidence of constipation or diarrhea (have
• Tape measure (metal, paper, or unstretchable cloth) client describe what client means by these terms); change
in appetite, food intolerances, and foods ingested in past
• Water-soluble skin-marking pencil
24 hours; specific signs and symptoms (e.g., heartburn,
• Stethoscope flatulence or belching, difficulty swallowing, hematemesis
[vomiting blood], blood or mucus in stools, and aggra-
IMPLEMENTATION vating and alleviating factors); previous problems and
treatment (e.g., stomach ulcer, gallbladder surgery, history
Performance of jaundice).
1. Before performing the procedure, introduce yourself to 5. Assist the client to the supine position, with the arms
the client, and verify the client’s identity by using two placed comfortably at the sides. Place small pillows
identifiers. Explain to the client what you are going to do, beneath the knees and the head to reduce tension in the
why it is necessary, and how he or she can participate. abdominal muscles. Expose only the client’s abdomen
Discuss how the results will be used in planning further from the chest line to the pubic area to avoid chilling and
care or treatments. shivering, which can tense the abdominal muscles.
Inspection of the Abdomen

6. Inspect the abdomen for skin integ- Unblemished skin; uniform colour; Presence of rash or other lesions; tense,
rity (refer to the discussion on skin silver-white striae (stretch marks) or glistening skin (may indicate ascites—an
assessment, earlier in this chapter). surgical scars accumulation of fluid in the peritoneal
cavity—or edema); purple striae
(associated with Cushing’s disease or
rapid weight gain and loss)
M28_KOZI2703_04_SE_C28.indd 600 17/03/17 1:09 PM


7. Inspect the abdomen for contour and
symmetry:
• Observe the abdominal contour Flat, rounded (convex), or scaphoid Distended
(profile line from the rib margin to (concave)
the pubic bone) while standing at
the client’s side, with the client in
the supine position.
• Ask the client to take a deep No evidence of enlargement of liver or Evidence of enlargement of liver or spleen
breath and to hold it. Rationale: spleen
This makes an enlarged liver
or spleen more obvious.
• Assess the symmetry of contour Symmetrical contour Asymmetrical contour (e.g., localized
while standing at the foot of the protrusions around umbilicus, inguinal
examination table. ligaments, or scars, which can be caused
by a hernia or tumour)
• If distension is present, measure
the abdominal girth by placing a
tape around the abdomen at the
level of the umbilicus (see ❶).
❶ Measuring abdominal girth.

8. Observe abdominal movements asso- Symmetrical movements caused by Limited movement because of pain or
ciated with respiration, peristalsis, or respiration; visible peristalsis in very disease process; visible peristalsis in
aortic pulsations. lean people; aortic pulsations in thin heavier clients (possible bowel
persons at epigastric area obstruction); marked aortic pulsations
9. Observe the vascular pattern. No visible vascular pattern Visible venous pattern (dilated veins) is
associated with liver disease, ascites, and
venocaval obstruction
Auscultation of the Abdomen

10. Auscultate the abdomen for bowel Audible bowel sounds; absence of Hypoactive (i.e., extremely soft and
sounds, vascular sounds, and perito- arterial bruits; absence of friction rub infrequent—one per minute), which can
neal friction rubs. Warm your hands indicate decreased motility and are usually
and the stethoscope diaphragms. associated with manipulation of the bowel
Rationale: Cold hands and a during surgery, inflammation, paralytic
cold stethoscope may cause the ileus, or late bowel obstruction;
client’s abdominal muscles to hyperactive or increased (i.e., high-
contract, and these contractions pitched, loud, rushing sounds that occur
may be heard during auscultation. frequently—every 3 seconds), also known
as borborygmi; hyperactive bowel
For Bowel Sounds sounds indicate increased intestinal
• Use the flat-disc diaphragm. motility and are usually associated with
Rationale: Intestinal sounds are diarrhea, early bowel obstruction, or the
relatively high pitched and best use of laxatives; true absence of sounds
accentuated by the diaphragm. (none heard in 3 to 5 minutes) indicates
Light pressure with the stetho- cessation of intestinal motility; loud bruit
scope is adequate. over aortic area (possible aneurysm); bruit
over renal or iliac arteries
(continued)
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SKILL 28.15 ASSESSING THE ABDOMEN (continued)

• Ask when the client last ate.
Rationale: Shortly after or long
after eating, bowel sounds can
normally increase.
They are loudest when a meal
is long overdue. Four to 7 hours
after a meal, bowel sounds may
be heard continuously over the
ileocecal valve area while the
digestive contents from the small
intestine empty through the valve
into the large intestine.
• Place diaphragm of the stethoscope
in each of the four quadrants of the
abdomen over all of the auscultatory ❷ Auscultating the abdomen for bowel sounds.
sites shown in ❷. Listen for active
bowel sounds. Irregular gurgling noises occurring
about every 5 to 20 seconds. The
For Vascular Sounds duration of a single sound may range
• Use the bell of the stethoscope from less than a second to more than
over the aorta, renal arteries, several seconds.
iliac arteries, and femoral arteries
(see ❸).
• Listen for bruits.
For Peritoneal Friction Rubs

• Peritoneal friction rubs are rough,
grating sounds like those produced
by rubbing two pieces of leather
together. Friction rubs may be caused
by inflammation, infections, or abnor- Aorta
mal growths.
Renal
artery
Iliac
artery
Femoral
artery
❸ Sites for auscultating for vascular sounds.
Percussion of the Abdomen

11. Percuss several areas in each of the Tympany over the stomach and gas- Large dull areas (associated with
four quadrants to determine pres- filled bowels; dullness, especially over presence of fluid or a tumour)
ence of tympany (gas in stomach and the liver and spleen, or a full bladder
intestines) and dullness (decrease,
absence, or flatness of resonance
over solid masses or fluid). Use a sys-
tematic pattern: begin in the lower left
quadrant; proceed to the lower right
quadrant, the upper right quadrant,
and the upper left quadrant (see ❹).
Percussion of the Liver

12. Percuss the liver to determine its size.
Begin in the right MCL below the
level of the umbilicus and proceed as
follows:
❹ Systematic percussion sites for all four quadrants.
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• Percuss upward over tympanic 6 cm to 12 cm in the MCL Enlarged size (associated with liver
areas until a dull percussion sound 4 cm to 8 cm at the midsternal line disease)
indicates the lower liver border.
Mark the site with a skin-marking
pencil (see ❺).
• Then percuss downward at the
right MCL, beginning from an area
of lung resonance and progressing Rib cage
downward until a dull percussion
sound indicates the upper liver Liver
border (usually at the fifth to sev-
enth interspace). Mark this site. 4 – 8 cm
• Measure the distance between the along mid-
two marks (upper and lower liver sternal line
border) in centimetres to establish
the liver span or size. 6 –12 cm
along right
• Repeat these steps at the midster- midclavi-
nal line. cular line
❺ Percussion pattern to determine liver size.
Palpation of the Abdomen

13. Perform light palpation to detect No tenderness; relaxed abdomen with Tenderness and hypersensitivity;
areas of tenderness or muscle guard- smooth, consistent tension superficial masses; localized areas of
ing. Systematically explore all four increased tension
quadrants. (Note: deep palpation is
not addressed in this fundamentals
text, as it can be risky to organs if
not performed correctly and is gener-
ally performed by experienced health
professionals). Ensure that the client’s
position is appropriate for relaxation
of the abdominal muscles, and warm
your hands. Rationale: Cold hands
can elicit muscle tension and thus
impede palpatory evaluation.
Light Palpation
• Hold the palm of your hand slightly
above the client’s abdomen, with
your fingers parallel to the abdomen.
• Depress the abdominal wall lightly,
about 1 cm or to the depth of the
subcutaneous tissue, with the pads
of your fingers (see ❻).
• Move the finger pads in a slight cir-
cular motion.
• Note areas of tenderness or super-
ficial pain, masses, and muscle
guarding. To determine areas of
tenderness, ask the client to tell you
about them, and watch for changes
in the client’s facial expressions.
• If the client is excessively ticklish,
❻ Light palpation of the abdomen.
begin by pressing your hand on top
of the client’s hand while pressing
lightly. Then, slide your hand off the
client’s and onto the abdomen to
continue the examination.
(continued)
M28_KOZI2703_04_SE_C28.indd 603 03/03/17 3:21 PM

SKILL 28.15 ASSESSING THE ABDOMEN (continued)
Palpation of the Bladder

14. Palpate the area above the pubic Not palpable Distended and palpable as smooth, round,
symphysis if the client’s history tense mass (indicates urinary retention)
indicates possible urinary retention
(see ❼).
15. Document your findings in the client
record.
❼ Palpating the bladder.
EVALUATION
• Perform a detailed follow-up examination of other systems, • Report significant deviations from expected or normal to
based on findings that deviated from expected or normal the appropriate members of the health care team.
if available.
Assessing the Abdomen

INFANTS • If the child is ticklish, guarding, or cardiac pain is usually located in the
fearful, use a task that requires con- chest. Factors aggravating gastro-
• Internal organs of newborns and centration (such as squeezing the intestinal pain are usually related to
infants are proportionately larger than hands together) to distract the child, either ingestion or lack of food intake;
those of older children and adults, or have the child place his or her gastrointestinal pain is usually relieved
so their abdomens are rounded and hands on yours as you palpate the by antacids, food, or assuming an
tend to protrude. abdomen, “helping” you to perform upright position. Common factors
• The infant’s liver may be palpable 1 to the examination. that can aggravate cardiac pain are
2 cm below the right costal margin. activity or anxiety; rest or nitroglycer-
• Umbilical hernias may be present OLDER ADULTS ine relieves cardiac pain.
at birth. • Fecal incontinence can occur in
• The rounded abdomens of older confused or neurologically impaired
adults are caused by an increase older adults.
CHILDREN in adipose tissue and a decrease in
muscle tone. • Many older adults erroneously believe
• Toddlers have a characteristic “pot that the absence of a daily bowel
belly” appearance, which can persist • The abdominal wall is slacker and movement signifies constipation.
until age 3 to 4 years. thinner, making palpation easier When assessing for constipation, the
• Late-preschool-age and school-age and more accurate than in younger nurse must consider the client’s diet,
children are leaner and have a flat clients. Muscle wasting and loss of activity, medications, and character-
abdomen. fibroconnective tissue occur with istics and ease of passage of feces
aging. as well as the frequency of bowel
• Peristaltic waves may be more visible
than in adults. • The pain threshold in older adults is movements.
often higher; major abdominal prob- • The incidence of colon cancer is
• Children may not be able to pinpoint lems, such as appendicitis or other
areas of tenderness; by observing facial higher among older adults than
acute emergencies, may therefore go younger adults. Symptoms include
expressions the examiner can deter- undetected.
mine areas of maximum tenderness. a change in bowel function, rectal
• Gastrointestinal pain needs to be bleeding, and weight loss. Changes
• The liver is relatively larger than in differentiated from cardiac pain. in bowel function, however, are asso-
adults. It can be palpated 1 cm to Gastrointestinal pain may be located ciated with many factors, such as
2 cm below the right costal margin. in the chest or abdomen, whereas diet, exercise, and medications.
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Skill 28.16 describes how to assess the musculoskel- evaluations are made. Three major considerations deter-
etal system. (See also Lifespan Considerations box on mine the extent of a neurological examination: (a) the
assessing the musculoskeletal system.) client’s chief complaints, (b) the client’s physical condi-
tion (i.e., level of consciousness and ability to ambulate),
because many parts of the examination require movement
and coordination of the extremities, and (c) the client’s
Neurological System willingness to participate and cooperate.
Examination of the neurological system includes
A thorough neurological examination can take 1 to 2 hours; assessment of (a) mental status, including level of conscious-
however, routine screening tests are usually done first. If ness, (b) cranial nerves, (c) reflexes, (d) motor function, and
the results of these tests raise questions, more extensive (e) sensory function. Parts of the neurological assessment
SKILL 28.16 ASSESSING THE MUSCULOSKELETAL SYSTEM
PLANNING Explain to the client what you are going to do, why it is nec-
essary, and how he or she can participate. Discuss how the
Equipment: results will be used in planning further care or treatments.
• Goniometer 2. Perform hand hygiene, and follow other appropriate infec-
• Tape measure
4. Inquire whether the client has any history of the follow-
IMPLEMENTATION ing: presence of muscle pain—onset, location, character,
Performance associated phenomena (e.g., redness and swelling of
joints), and aggravating and alleviating factors; limitations
1. Before performing the procedure, introduce yourself to the to movement or inability to perform activities of daily living;
client, and verify the client’s identity by using two identifiers. previous sports injuries; loss of function without pain.
Muscles
5. Inspect muscles for size. Compare the mus- Equal size on both sides Atrophy (a decrease in size) or hypertrophy
cles on one side of the body (e.g., of the of body (an increase in size), asymmetry
arm, thigh, and calf) to the same muscles
on the other side. To identify any discrepan-
cies, measure muscles with a tape.
6. Inspect muscles and tendons for No contractures Malposition of body part, such as foot drop
contractures (shortening). (foot flexed downward)
7. Inspect muscles for tremors, for example, No tremors Presence of tremor
by having the client hold the arms out in
front of the body.
8. Palpate muscles at rest to determine muscle Normally firm Atonic (lacking tone)
tonicity (the normal condition of tension, or
tone, of a muscle at rest).
9. Palpate muscles while the client is active Smooth, coordinated Flaccidity (weakness or laxness) or spasticity
and when passive for flaccidity, spasticity, movements (sudden involuntary muscle contraction)
and smoothness of movement.
10. Test muscle strength. Compare the right Equal strength on each 25% or less of normal strength
side with the left side. body side
Sternocleidomastoid: The client turns the Grading Muscle Strength
head to one side against the resistance 0 = 0% of normal strength; complete
of your hand. Repeat with the other side. paralysis
Trapezius: The client shrugs the shoulders
1 = 10% of normal strength; no move-
against the resistance of your hands.
ment, contraction of muscle is pal-
Deltoid: The client holds arm up and pable or visible
resists while you try to push it down.
2 = 25% of normal strength; full muscle
Biceps: The client fully extends each arm movement against gravity, with
and tries to flex it while you attempt to support
hold arm in extension.
(continued)
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SKILL 28.16 ASSESSING THE MUSCULOSKELETAL SYSTEM (continued)

Triceps: The client flexes each arm and then 3 = 50% of normal strength; normal
tries to extend it against your attempt to keep movement against gravity
arm in flexion. 4 = 75% of normal strength; normal
Wrist and finger muscles: The client spreads full movement against gravity and
the fingers and resists as you attempt to push against minimal resistance
the fingers together. 5 = 100% of normal strength; normal
Grip strength: The client grasps your index and full movement against gravity and
middle fingers while you try to pull your fingers against full resistance
from the client’s grasp.
Hip muscles: The client is supine, both legs
extended; client raises one leg at a time while
you attempt to hold it down.
Hip abduction: The client is supine, both legs
extended. Place your hands on the lateral sur-
face of each knee; the client spreads the legs
apart against your resistance.
Hip adduction: The client is in same position as
for hip abduction. Place your hands between
the client’s knees; the client brings the legs
together against your resistance.
Hamstrings: The client is supine, with both knees
bent. The client resists while you attempt to
straighten the legs.
Quadriceps: The client is supine, knee partially
extended; the client resists while you attempt to
flex the knee.
Muscles of the ankles and feet: The client resists
while you attempt to dorsiflex the foot and again
resists while you attempt to flex the foot.
Bones
11. Inspect the skeleton for structure. No deformities Bones misaligned
12. Palpate bones to locate any areas of edema No tenderness or swelling Presence of tenderness or swelling (may
or tenderness. indicate fracture, neoplasms, or osteoporosis)
Joints
13. Inspect joints for swelling. Palpate each joint No tenderness, swelling, One or more swollen joints; presence of
for tenderness, smoothness of movement, crepitation, or nodules; joints tenderness, swelling, crepitation, or nodules
swelling, crepitation, and presence of nodules. move smoothly
14. Assess joint range of motion. Varies to some degree in Limited range of motion in one or more joints
See Chapter 39 for the types of accordance with person’s
joint movements. genetic makeup and degree
of physical activity
• Ask the client to move selected body
parts. The amount of joint movement can
be measured by a goniometer, a device
that measures the angle of the joint in
degrees (see ❶).
❶ A goniometer is used to measure range of motion.

15. Document your findings in the client record.
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EVALUATION
if available.
Assessing the Musculoskeletal System

INFANTS CHILDREN assessed for nutritional status, physi-
cal conditioning, and safety precau-
• Palpate the clavicles of newborns. • Pronation with “toeing in” of the tions to prevent injury.
A mass and crepitus may indicate a feet is common in children between
fracture experienced during vaginal 12 and 30 months of age. • Adolescent girls who participate in
delivery. The newborn may also have strenuous athletic activities are at
• Genu varum (bowleg) is normal in risk for delayed onset of menses,
limited movement of the arm and children for about 1 year after they
shoulder on the affected side. osteoporosis, and eating disorders;
begin to walk. assessment should include a history
• When the arms and legs of newborns • Genu valgus (knock-knee) is normal of these factors.
are pulled to extension and released, in preschool and young school-age
the newborns naturally return to the children.
flexed fetal position. OLDER ADULTS
• Lordosis (swayback) is common in
• Check muscle strength by holding children before age 5 years. • Muscle mass decreases progressively
the infant lightly under the arms with with age, but wide variations exist
feet placed lightly on a table. Infants • Observe the child in normal activities among different individuals.
should not fall through the hands to determine motor function.
• The decrease in speed, strength,
and should be able to bear body • During the rapid growth spurts of resistance to fatigue, reaction time,
weight on their legs if normal muscle adolescence, spinal curvature and and coordination in the older person
strength is present. rotation (scoliosis) may appear. results from a decrease in nerve con-
• Check infants for developmental dys- Children should be assessed for duction and muscle tone.
plasia of the hip (congenital disloca- scoliosis by age 12 years and
annually until their growth slows. • The bones can become more fragile,
tion) by examining for asymmetrical and osteoporosis (if present) leads
gluteal folds, asymmetrical abduc- Curvature greater than 10% should
be referred for further medical to a loss of total bone mass. As a
tion of the legs (Ortolani and Barlow result, some older adults are predis-
tests), or apparent shortening of the evaluation.
posed to fractures and compressed
femur. • Muscle mass increases in vertebrae.
• Infants should be able to sit without adolescence, especially as children
engage in strenuous physical • In most older adults, osteoar-
support by 8 months of age, crawl by thritic changes in the joints can be
7 to 10 months, and walk by 12 to activity, and requires increased
nutritional intake. observed.
15 months.
• Children are at risk for injury related • Note any surgical scars from joint
• Observe for symmetry of muscle replacement surgeries.
mass, strength, and function. to physical activity and should be
are performed throughout the health examination. For during neurological assessment. Major areas of mental
example, the nurse performs a large part of the mental status assessment include language, orientation, memory,
status assessment during history taking and when observing and attention span and calculation.
the client’s general appearance. Also, the nurse assesses the
LANGUAGE Any defects in or loss of the power to
function of many CNs. CNs II, III, IV, and VI (ophthalmic
express self through speech, writing, or sign language or
branch) are assessed with eyes and vision, and CN VIII
to comprehend spoken or written language because of
(cochlear branch) is assessed with ears and hearing.
disease or injury of the cerebral cortex is called apha-
sia. Aphasia can be categorized as sensory or receptive
aphasia and motor or expressive aphasia.
Mental Status Sensory or receptive aphasia is the loss of the ability to
Assessment of mental status reveals the client’s general comprehend written or spoken words. Two types of sen-
cerebral function. These functions include intellectual sory aphasia are auditory (or acoustic) aphasia and visual
(cognitive) and emotional (affective) functions. aphasia. Clients with auditory aphasia have lost the abil-
If problems with the use of language, memory, con- ity to understand the symbolic content associated with
centration, or thought processes are noted during the sounds. Clients with visual aphasia have lost the ability to
nursing history, a more extensive examination is required understand printed or written letters and numbers.
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TABLE 28.11 Levels of Consciousness:

CLINICAL ALERT Glasgow Coma Scale
Nurses often chart that the client is “awake, alert, and Faculty Measured Response Score
oriented ×3 [or times three].” This refers to accurate awareness of
persons, time, and place. Remember, “person” indicates that the Eye opening Spontaneous 4
client recognizes others, not that the client can state what his or her To verbal command 3
own name is. To pain 2
No response 1
Motor response To verbal command 6
Motor or expressive aphasia involves loss of the power To localized pain 5
Flexes and withdraws 4
to express self through writing, making signs, or speak-
Flexes abnormally 3
ing. Clients may find that even though they can recall Extends abnormally 2
words, they have lost the ability to combine speech No response 1
sounds into words. Verbal response Oriented, converses 5
ORIENTATION This aspect of the assessment deter- Disoriented, converses 4
Uses inappropriate words 3
mines the client’s ability to recognize other persons
Makes incomprehensible 2
(person) (see the Clinical Alert box), awareness of when sounds
and where they presently are (time and place), and who No response 1
they are (self).
Glasgow Coma /15
MEMORY The nurse assesses the client’s recall of Scale Score
information presented seconds previously (immedi-
ate recall), events or information from earlier in the
day or examination (recent memory), and knowledge
Coma Scale was originally developed to predict recovery
recalled from months or years back (remote or long-
from a head injury; however, it is used by many profes-
term memory).
sionals to assess LOC. It tests three major areas: (a) eye
ATTENTION SPAN AND CALCULATION This compo- response, (b) motor response, and (c) verbal response. An
nent determines the client’s ability to focus on a mental assessment totalling 15 points indicates the client is alert
task that is expected to be able to be performed by per- and completely oriented. A comatose client scores 7 or
sons of normal intelligence. fewer points. See Table 28.11.
Level of Consciousness Cranial Nerves

Level of consciousness (LOC) can lie anywhere along a The nurse needs to be aware of nerve functions to detect
continuum from a state of alertness to coma. A fully alert abnormalities (see Table 28.12). In some cases, each CN
client responds to questions spontaneously; a comatose is assessed; in other cases only selected nerve functions
client may not respond to verbal stimuli. The Glasgow are evaluated.
TABLE 28.12 Cranial Nerve Functions and Assessment Methods
Cranial Name
Nerve (Mnemonic)* Type Function Assessment Method
I Olfactory (On) Sensory Smell Ask the client to close the eyes
and identify different mild aro-
mas, such as coffee, vanilla,
orange, lemon, lime, chocolate.
II Optic (Old) Sensory Vision and visual fields Ask the client to read the Snellen
chart; check visual fields by
confrontation; and conduct an
ophthalmoscopic examination.
III Oculomotor Motor Extraocular eye movement (EOM); Assess the six ocular movements
(Olympus’s) movement of sphincter of pupil; and pupil reaction.
movement of ciliary muscles of
lens; opening of upper eyelid
IV Trochlear (Towering) Motor EOM; specifically moves eyeball Assess the six ocular movements.
downward and laterally
M28_KOZI2703_04_SE_C28.indd 608 03/03/17 11:18 AM

Cranial Name
Nerve (Mnemonic)* Type Function Assessment Method
V Trigeminal (Tops)
Ophthalmic branch Sensory Sensation of cornea, skin of face, While the client looks upward,
and nasal mucosa lightly touch the lateral sclera
of the eye with sterile gauze
to elicit the blink reflex. To
test light-touch sensation,
have the client close the
eyes, pass a wisp of cotton
(formed by twirling together
a few fibres of cotton from a
cotton ball or Q-Tip) over cli-
ent’s forehead and paranasal
sinuses. To test deep sensa-
tion, use alternating blunt and
sharp ends of a safety pin
over same areas.
Maxillary branch Sensory Sensation of skin of face and Assess skin sensation as for oph-
anterior oral cavity (tongue and thalmic branch above.
teeth)
Mandibular branch Sensory Muscles of mastication; sensation Ask the client to clench the teeth.
of skin of face
VI Abducens (A) Motor EOM; moves eyeball laterally Assess the directions of gaze.
VII Facial (Finn) Motor and sensory Facial expression; taste (anterior Ask the client to smile, raise the
two-thirds of tongue); closing eyebrows, frown, puff out the
of eyelid cheeks, and close the eyes
tightly. Ask the client to identify
various tastes placed on the tip
and sides of the tongue: sugar
(sweet), salt, lemon juice (sour),
and quinine (bitter); identify
areas of taste.
VIII Auditory (And)
Vestibular branch Sensory Equilibrium Assessment methods are dis-
cussed with cerebellar func-
tions (see next section).
Cochlear branch Sensory Hearing Assess the client’s ability to hear
the spoken word and the vibra-
tions of a tuning fork.
IX Glossopharyngeal Motor and sensory Swallowing ability; tongue move- Apply different things on the pos-
(German) ment; taste (posterior tongue) terior tongue for taste identifi-
cation. Ask the client to move
the tongue from side to side
and up and down.
X Vagus (Viewed) Motor and sensory Sensation of pharynx and lar- Assessed with CN IX; assess the
ynx; swallowing; vocal cord client’s speech for hoarseness.
movement
XI Spinal accessory Motor Head movement; shrugging of Ask the client to shrug the shoul-
(Some) shoulders ders against resistance from
your hands and to turn the
head to the side against resis-
tance from your hand (repeat
for the other side)
XII Hypoglossal (Hops) Motor Protrusion of tongue; moves Ask the client to protrude the
tongue up and down and side tongue at the midline and then
to side move it from side to side.
*Mnemonic: On Old Olympus’s Towering Tops A Finn And German Viewed Some Hops.
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of superficial pain and temperature to the sensory cor-

CLINICAL ALERT tex. The posterior column conducts the sensation of
All questions and tests used in a neurological examination position. Generally, the face, arms, legs, hands, and feet
must be appropriate for age, language, education level, and culture. are tested for touch and pain, although all parts of the
Individualize questions and tests before using them. body can be tested. If the client complains of numbness,
peculiar sensations, or paralysis, the nurse should check
sensation more carefully over flexor and extensor sur-
faces of limbs, mapping out clearly any abnormality of
Reflexes touch or pain by examining responses in the area about
A reflex is an automatic response of the body to a every 2.5 cm. This is a lengthy procedure. Abnormal
stimulus. It is not voluntarily learned or conscious. The responses to touch stimuli include anesthesia (loss of
deep tendon reflex (DTR) is activated when a tendon is sensation); hyperesthesia (more than normal sensa-
stimulated (tapped) and its associated muscle contracts. tion); hypoesthesia (less than normal sensation); or
The quality of a reflex response varies among individu- paresthesia (an abnormal sensation, such as numbness
als and by age. As a person ages, reflex responses may and prickling as in “pins and needles”).
become less intense. A more detailed neurological examination includes
Reflexes are tested by using a percussion hammer. position sense, temperature sense, and tactile discrimina-
The response is described on a scale of 0 to 4. Experi- tion. Three types of tactile discrimination are generally
ence is necessary to determine the appropriate scoring tested: (a) one-point discrimination and two-point
for an individual. When assessing reflexes, it is important discrimination, the ability to sense whether one or
for the nurse to compare one side of the body with the two areas of the skin are being stimulated by pressure; (b)
other to evaluate the symmetry of response. Several stereognosis, the act of recognizing objects by touch-
reflexes are normally tested during the physical exami- ing and manipulating them; and (c) extinction, the
nation: (a) the biceps reflex, (b) the triceps reflex, (c) failure to perceive touch on one side of the body when
the brachioradialis reflex, (d) the patellar reflex, (e) the two symmetrical areas of the body are touched simulta-
Achilles reflex, and (f) the plantar (Babinski) reflex. neously (an abnormal finding).
Skill 28.17 describes how to assess the neurological
system. (See also Lifespan Considerations box on assess-
Motor Function ing the neurological system.)
Neurological assessment of the motor system evalu-
ates proprioception and cerebellar function. Structures
involved in proprioception are the proprioceptors, the
posterior columns of the spinal cord, the cerebellum, Female Genitals
and the vestibular apparatus (which is innervated by CN
VIII) in the labyrinth of the internal ear.
and Inguinal Lymph Nodes
Proprioceptors are sensory nerve terminals that
The examination of the genitals and reproductive tract
occur chiefly in the muscles, tendons, joints, and internal
of women includes assessment of the inguinal lymph
ear and give information about the movements and posi-
nodes and inspection and palpation of the external geni-
tion of the body. Stimuli from the proprioceptors travel
tals. Completeness of the assessment of the genitals and
through the posterior columns of the spinal cord. Defi-
reproductive tract depends on the health care needs of
cits of function of the posterior columns of the spinal
the individual client. In most practice settings, generalist
cord result in impairment of muscle and position sense.
nurses perform only inspection of the external genitals
Clients with such an impairment often must watch their
and palpation of the inguinal lymph nodes.
own arm and leg movements to ascertain the position of
Assessment of adolescent girls is limited to an
the limbs.
inspection of the external genitals. For sexually active
The cerebellum (a) helps control posture; (b) acts
adolescents and adult women, a Pap test is advised every
with the cerebral cortex to make body movements
1 to 3 years (depending on results) for early detection of
smooth and coordinated; and (c) controls skeletal muscles
cancer of the cervix. If an increased or abnormal vagi-
to maintain equilibrium.
nal discharge is present, specimens should be taken to
check for sexually transmitted infections (STIs).
Examination of genitals usually creates uncertainty
Sensory Function and apprehension in females, and the lithotomy position
Sensory functions include touch, pain, temperature, posi- required for the examination can cause embarrassment.
tion, and tactile discrimination. The first three are rou- The nurse must explain each part of the examination in
tinely tested. The spinothalamic tract conducts sensations advance and perform the examination in an objective
M28_KOZI2703_04_SE_C28.indd 610 03/03/17 11:18 AM

SKILL 28.17 ASSESSING THE NEUROLOGICAL SYSTEM
PLANNING Memory
If possible, determine whether a screening or full neurological 7. Listen for lapses in memory. Ask the client about difficulty
examination is indicated. This will determine the preparation of with memory. If problems are apparent, three categories
the client, the equipment required, and timing. of memory are tested: (a) immediate recall, (b) recent
memory, and (c) remote memory.
Equipment (depending on components of
examination): To assess immediate recall
• Percussion hammer • Ask the client to repeat a series of three digits (e.g., 7, 4, 3),
spoken slowly.
• Wisps of cotton wool to assess light-touch sensation
• Gradually increase the number of digits (e.g., 7, 4, 3, 5;
• Sterile safety pin for tactile discrimination
then 7, 4, 3, 5, 6; and 7, 4, 3, 5, 6, 7, 2), until the client fails
to repeat the series correctly.
IMPLEMENTATION • Start again with a series of three digits, but this time ask the
client to repeat them backward. The average person can
Performance repeat a series of five to eight digits in sequence and four to
six digits in reverse order.
identifiers. Explain to the client what you are going to do,
To assess recent memory
why it is necessary, and how he or she can participate. • Ask the client to recall recent events of the day, such as
Discuss how the results will be used in planning further how the client got to the clinic. This information must be
care or treatments. validated.
2. Perform hand hygiene, and follow other appropriate infec- • Ask the client to recall information given early in the inter-
tion prevention and control procedures. view (e.g., the name of a doctor or nurse).
3. Provide for client privacy. • Provide the client with three facts to recall (e.g., a colour, an
4. Inquire whether the client has any history of the follow- object, and an address), or a three-digit number, and ask
ing: presence of pain in the head, back, or extremities, the client to repeat all three. Later in the interview, ask the
as well as onset and aggravating and alleviating factors; client to recall all three items.
disorientation to time, place, or person; speech disorder; To assess remote memory, ask the client to describe a
history of loss of consciousness, fainting, convulsions, previous illness or surgery (e.g., 5 years ago), or a birthday
trauma, tingling or numbness, tremors or tics, limping, or anniversary.
paralysis, uncontrolled muscle movements, loss of mem-
ory, mood swings, or problems with smell, vision, taste, Attention Span and Calculation
touch, or hearing.
8. Test the ability to concentrate or maintain attention span
Language by asking the client to recite the alphabet or to count
backward from 100. Test the ability to calculate by asking
5. If the client displays difficulty speaking, do the following: the client to subtract 7 or 3 progressively from 100 (i.e.,
100, 93, 86, 79, or 100, 97, 94, 91), referred to as serial
• Point to common objects, and ask the client to name
sevens or serial threes. Normally, an adult can complete
them.
serial sevens test in about 90 seconds with three or fewer
• Ask the client to read some words and to match the errors. Because educational level, language, or cultural
printed or written words with pictures. differences affect calculating ability, this test may be inap-
• Ask the client to respond to simple verbal and written propriate for some people.
commands (e.g., “Point to your toes” or “Raise your
Level of Consciousness
left arm”).
9. Apply the Glasgow Coma Scale: eye response, motor
Orientation response, and verbal response. An assessment total-
ling 15 points indicates the client is alert and completely
6. Determine the client’s orientation to person, time, and oriented. A comatose client scores 7 or fewer points (see
place by tactful questioning. Ask the client the city and Table 28.11).
province or territory of residence, time of day, date, day
of the week, duration of illness, and names of family Cranial Nerves
members. To evaluate the response, you must know the
correct answer. More direct questioning may be necessary 10. For the specific functions and assessment methods of
for some people (e.g., “Where are you now?” “What day each CN, see Table 28.12. Test each nerve not already
is it today?”). If the client cannot answer these questions evaluated in another component of the health assessment.
accurately, also include assessment of self by asking the A quick way to remember which CNs are assessed in the
client to state his or her full name. face is shown in ❶.
(continued)
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SKILL 28.17 ASSESSING THE NEUROLOGICAL SYSTEM (continued)

Triceps Reflex
The triceps reflex tests the spinal cord level C-7 and C-8.
• Flex the client’s arm at the elbow, and support it in the
palm of your nondominant hand (see ❸).
Elena Dorfman/Al Dodge/Patrick Watson/Pearson Education, Inc.
• Palpate the triceps tendon about 2 cm to 5 cm above the

elbow.
• Deliver a blow with the percussion hammer directly to the
tendon.
• Observe the normal slight extension of the elbow.
❶ Cranial nerves by the numbers. The next time you are trying
to remember the locations and functions of the CNs, picture this ❸ The triceps reflex.
drawing. All the CNs are represented (e.g., shoulders formed by
the number “11” for CN 11, which controls neck and shoulder Brachioradialis Reflex
movement; the sides of the face and the top of the head are
The brachioradialis reflex tests the spinal cord level C-3
formed by the number “7”, as controlled by CN 7).
and C-6.
Source: From Bolek, B. (2006). Strictly clinical: Facing cranial nerve assessment. • Rest the client’s forearm in a relaxed position externally
American Nurse Today, 1(2), 21–22. Used by permission.
rotated on a firm surface.
Reflexes • Deliver a blow with the percussion hammer directly on the
radius 2 cm to 5 cm above the wrist or the styloid process,
11. Test reflexes by using a percussion hammer, comparing the bony prominence on the thumb side of the wrist (see ❹).
one side of the body with the other to evaluate the sym-
metry of response: • Observe the normal flexion and supination of the forearm.
The fingers of the hand may also extend slightly.
0 No reflex response
1 Hypoactive (minimal activity)
2 Normal response
3 More active than normal
4 Hyperactive (maximal activity)
Biceps Reflex
The biceps reflex tests the spinal cord level C-5 and C-6.
• Partially flex the client’s arm at the elbow, and rest the
forearm over the thighs, placing the palm of the hand up.
• Place the thumb of your nondominant hand horizontally ❹ The brachioradialis reflex.
over the biceps tendon.
• Deliver a blow (slight downward thrust) with the percussion Patellar Reflex
hammer to your thumb (see ❷). The patellar reflex tests the spinal cord level L-2, L-3, and L-4.
• Observe the normal slight flexion of the elbow, and feel the • Ask the client to sit on the edge of the examining table so
bicep’s contraction through your thumb. that the legs hang freely.
• Locate the patellar tendon directly below the patella
(kneecap).
tendon (see ❺).
• Observe the normal extension or kicking out of the leg as
the quadriceps muscle contracts.
• If no response occurs and you suspect the client is not
relaxed, ask the client to interlock the fingers and pull.
Rationale: This action often enhances relaxation
❷ The biceps reflex. so that a more accurate response is obtained.
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Plantar (Babinski) Reflex

The planter, or Babinski, reflex is superficial. It may be
absent in adults without pathology or overridden by
voluntary control.
• Use a moderately sharp object, such as the handle
of the percussion hammer, a key, or an applicator
stick.
• Stroke the lateral border of the sole of the client’s foot,
starting at the heel, continuing to the ball of the foot, and
❺ The patellar reflex. then proceeding across the ball of the foot toward the big
toe (see ❼).
Achilles Reflex
• Observe the response. Normally, all five toes bend
The Achilles reflex tests the spinal cord level S-1 and S-2.
downward; this reaction is called negative Babinski
• With the client in the same position as for the patellar reflex, response. In an abnormal (positive) Babinski response,
slightly dorsiflex the client’s ankle by supporting the ball of the toes spread outward and the big toe moves
the foot lightly in the hand. upward.
Achilles tendon just above the heel (see ❻).
• Observe and feel the normal plantar flexion (downward jerk)
of the foot.
❼ The plantar (Babinski) reflex.
❻ The Achilles reflex.
Motor Function
12. Gross Motor and Balance Tests
Generally, the Romberg test and one
other gross motor function and
balance tests are used.
Walking Gait
Ask the client to walk across the room and Has upright posture and steady Has poor posture and unsteady, irregular,
back, and assess the client’s gait. gait with opposing arm swing; staggering gait with wide stance; bends
walks unaided, maintaining balance legs only from hips; has rigid or no arm
movements
Romberg Test
Ask the client to stand with feet together Negative Romberg: Client may Positive Romberg: Client cannot maintain
and arms resting at the sides, first with sway slightly but is able to maintain foot stance; moves the feet apart to
eyes open, then closed. Stand close upright posture and foot stance maintain stance; if client cannot maintain
during this test. Rationale: You may balance with the eyes shut, client may
need to prevent the client from falling. have sensory ataxia (lack of coordination
of the voluntary muscles); if balance
cannot be maintained whether the eyes
are open or shut, client may have
cerebellar ataxia
Standing on One Foot with Eyes Closed

Ask the client to close the eyes and stand Maintains stance for at least Cannot maintain stance for 5 seconds
on one foot. Repeat on the other foot. 5 seconds
Stand close to the client during this test.
(continued)
M28_KOZI2703_04_SE_C28.indd 613 03/03/17 11:18 AM

Heel-to-Toe Walking
Ask the client to walk a straight line, Maintains heel-toe walking along a Assumes a wider foot gait to stay upright
placing the heel of one foot directly in straight line
front of the toes of the other foot (see ❽).
❽ Heel-to-toe walking.
Toe or Heel Walking

Ask the client to walk several steps on Able to walk several steps on toes Cannot maintain balance on toes
toes and then on heels. or heels and heels
13. Fine Motor Tests for the Upper
Extremities
Finger-to-Nose Test
Ask the client to abduct and extend the Repeatedly and rhythmically Misses the nose or gives slow response
arms at shoulder height and then rap- touches the nose
idly touch the nose alternately with one
index finger and then the other. The client
repeats the test with the eyes closed if the
test is performed easily (see ❾).
❾ Finger-to-nose test.
Alternating Supination and Pronation

of Hands on Knees
Ask the client to pat both knees with the Can alternately supinate and Performs with slow, clumsy movements
palms of both hands and then with the pronate hands at rapid pace and irregular timing; has difficulty
backs of the hands alternately at an ever- alternating from supination to pronation
increasing rate (see ❿).
M28_KOZI2703_04_SE_C28.indd 614 17/03/17 1:09 PM


❿ Alternating supination and pronation of hands on knees test.
Finger to Nose and to the Nurse’s Finger

Ask the client to touch the nose and then Performs with coordination and Misses the finger and moves slowly
your index finger, held at a distance of rapidity
about 45 cm, at a rapid and increasing
rate (see ⓫).

⓫ Finger-to-nose and to the nurse’s finger test.
Fingers to Fingers
Ask the client to spread the arms broadly Performs with accuracy and Moves slowly and is unable to touch
at shoulder height and then bring the rapidity fingers consistently
fingers together at the midline, first with
the eyes open and then closed, first slowly
and then rapidly (see ⓬).

⓬ Fingers-to-fingers test.
(continued)
M28_KOZI2703_04_SE_C28.indd 615 03/03/17 11:18 AM

Fingers to Thumb (Same Hand)

Ask the client to touch each finger of one Rapidly touches each finger to Cannot coordinate this fine discrete
hand to the thumb of the same hand as thumb with each hand movement with either one or both hands
rapidly as possible (see ⓭).

⓭ Fingers-to-thumb (same hand) test.
14. Fine Motor Tests for the Lower
Extremities
Ask the client to lie supine and to perform
these tests.
Heel Down Opposite Shin

Ask the client to place the heel of one foot Demonstrates bilateral equal Has tremors or is awkward; heel
just below the opposite knee and run the coordination moves off shin
heel down the shin to the foot. Have the
client repeat with the other foot. The client
may also use a sitting position for this test
(see ⓮).
⓮ Heel down opposite shin.
Toe or Ball of Foot to the Nurse’s Finger

Ask the client to touch your finger with the Moves smoothly, with coordination Misses your finger; cannot coordinate
large toe of each foot (see ⓯). movement

⓯ Toe or ball of foot to the nurse’s finger test.
15. Light-Touch Sensation
Compare the light-touch sensation of
symmetrical areas of the body. Rationale:
Sensitivity to touch varies among
different skin areas.
M28_KOZI2703_04_SE_C28.indd 616 17/03/17 1:09 PM


• Ask the client to close the eyes and
to respond by saying “yes” or “no”
whenever the client feels the wisp of
cotton wool touching the skin. With
a cotton wool wisp, lightly touch
one specific spot and then the same
spot on the other side of the body
(see ⓰). Test areas on the forehead,
cheek, hand, lower arm, abdomen,
foot, and lower leg. Check a distal
area of the limb first (i.e., the hand
before the arm and the foot before
the leg). Rationale: The sensory ⓰ Assessing light-touch sensation.
nerve may be assumed to be
intact if sensation is felt at its
most distal part.
• Ask the client to point to the spot Light tickling or touch sensation Anesthesia, hyperesthesia,
where the touch was felt. Rationale: hypoesthesia, or paresthesia
This demonstrates whether the
client is able to determine tac-
tile location (point localization);
that is, the client can accurately
perceive where he or she was
touched. If areas of sensory dys-
function are found, determine the
boundaries of sensation by test-
ing responses about every 2.5 cm
in the area. Make a sketch of the
sensory loss area for recording
purposes.
16. Pain Sensation
Assess pain sensation as follows: Able to discriminate “sharp” and Areas of reduced, heightened, or
• Ask the client to close the eyes and “dull” sensations absent sensation (map them out for
to say “sharp,” “dull,” or “don’t know” recording purposes)
when the sharp or dull end of the bro-
ken tongue depressor is felt.
• Alternatingly, use the sharp and dull
ends to lightly prick designated ana-
tomical areas at random (e.g., hand,
forearm, foot, lower leg, abdomen)
(see ⓱). The face is not tested in this
manner.
• Allow at least 2 seconds between
each test to prevent summation
effects of stimuli (i.e., several suc-
cessive stimuli perceived as one
stimulus).
⓱ Assessing pain sensation by using
a broken tongue depressor.
17. Position or Kinesthetic Sensation
Commonly, the middle fingers and the Can readily determine the position Unable to determine the position of
large toes are tested for the kinesthetic of fingers and toes one or more fingers or toes
sensation (sense of position).
• To test the fingers, support the client’s
arm and hand with one hand. To test
the toes, place the client’s heels on the
examining table.
• Ask the client to close the eyes.
(continued)
M28_KOZI2703_04_SE_C28.indd 617 03/03/17 11:18 AM


• Grasp a middle finger or a big toe
firmly between your thumb and index
finger, and exert the same pressure
on both sides of the finger or toe
while moving it (see ⓲).
• Move the finger or toe until it is up,
down, or straight out, and ask the cli-
ent to identify the position.
• Use a series of brisk up-and-down
movements before bringing the finger
or toe suddenly to rest in one of the
three positions.
⓲ Position or kinesthetic sensation test.

18. Document findings in the client record. Describe any abnormal findings in objective terms (e.g., “When asked to count
backwards by threes, client made seven errors and completed the task in 4 minutes”).
EVALUATION
if available.
Images by: Elena Dorfman/Al Dodge/Patrick Watson/Pearson Education, Inc.
Assessing the Neurological System

INFANTS and then flexes and brings the hands • Children should be able to walk
together; the infant may cry. backward by age 2 years, balance
Reflexes commonly tested in newborns
on one foot for 5 seconds by age
include the following: Most of these reflexes disappear 4 years, heel-to-toe walk by age 5
• Rooting: Stroke the side of the face between 4 and 6 months of age. years, and heel-to-toe walk backward
near mouth; the infant opens mouth by age 6 years.
and turns to the side that is stroked. CHILDREN
• The Romberg test is appropriate for
• Sucking: Place finger 3 cm to 4 cm • Present the procedures as games, children over age 3 years.
into the infant’s mouth, or have the whenever possible.
mother place her nipple in the infant’s • A positive Babinski reflex is abnormal OLDER ADULTS
mouth; infant sucks vigorously. after the child ambulates or at age
• Tonic neck: Place the infant in the 2 years. • A full neurological assessment can
supine position, and turn the head be lengthy. Conduct it in several ses-
• For children younger than age sions, if indicated; stop the tests if
to one side; the arm on the side to 5 years, the Denver Developmental
which head is turned extends; on the client is noticeably fatigued.
Screening Test II provides a com-
the opposite side, the arm curls up prehensive neurological evaluation, • A decline in mental status is not a
(fencer’s pose). particularly for motor function. normal result of aging. Changes are
• Palmar grasp: Place your finger on more likely the result of physical or
• Note the child’s ability to understand
the infant’s palm, and press; the psychological disorders (e.g., fever,
and follow directions.
infant curls his or her fingers around fluid and electrolyte imbalances,
• Assess immediate recall or recent medications). Acute, abrupt-onset
your finger. memory by using names of cartoon mental status changes are usually
• Stepping: Hold the infant above a characters. Normal recall in children caused by delirium. These changes
surface as if weight bearing; the is one item fewer than their age in are often reversible with treat-
infant steps along, one foot at a time. years (e.g., a 4-year-old should be ment. Chronic, subtle, insidious
• Moro: Present loud noise or unex- able to recall three items). mental health changes are usually
pected movement; the infant spreads • Assess for signs of hyperactivity or caused by dementia and are usually
the arms and legs, extends fingers, abnormally short attention span. irreversible.
M28_KOZI2703_04_SE_C28.indd 618 17/03/17 1:09 PM

• Intelligence and learning ability remain • Because older adults tire more easily • Coordination changes, including
unaltered with aging. Many factors, than younger clients, a total neuro- a reduced speed of fine finger
however, inhibit learning (e.g., anxiety, logical assessment is often done at a movements. Standing balance
illness, pain, cultural barrier). different time from the other parts of remains intact, and Romberg’s
• Short-term memory is often less the physical assessment. test remains negative.
efficient. Long-term memory is • Although there is a progressive • Reflex responses may slightly
usually unaltered. decrease in the number of functioning increase or decrease. Many show
neurons in the central nervous system loss of Achilles reflex, and the plantar
• Because aging is often associated
and in the sense organs, older adults reflex may be difficult to elicit.
with loss of support persons, depres-
sion is a common disorder. Mood usually function well because of the • When testing sensory function, the
changes, weight loss, anorexia, con- abundant reserves in the number of nurse needs to give older adults time
stipation, and early morning awaken- brain cells. to respond. Normally, older adults
ing may be symptoms of depression. have unaltered perception of light
• Impulse transmission and reaction to
touch and superficial pain, decreased
• The stress of being in unfamiliar stimuli are slower.
perception of deep pain, and
situations can cause confusion in • Many older adults have some decreased perception of temperature
older adults. impairment of hearing, vision, smell, stimuli. Many also reveal a decrease
• As a person ages, reflex responses temperature and pain sensation, or absence of position sense in the
may become less intense. memory, and mental endurance. large toes.
Source: From Bolek, B. (2006). Strictly clinical: Facing cranial nerve assessment. American Nurse Today, 1(2), 21–22. Used by permission.
and efficient manner. Appropriate draping is essential In many agencies only nurse practitioners examine
to prevent undue exposure of the client, and good the internal genitals. However, generalist nurses often
lighting is required for the nurse to ensure accuracy of assist with this examination and need to be familiar with
inspection. the procedure. Examination of the internal genitals
Skill 28.18 describes how to assess the female geni- involves (a) palpating Skene’s and Bartholin’s glands,
tals and inguinal lymph nodes. (See also Lifespan Con- (b) assessing the pelvic musculature, (c) inserting a vagi-
siderations box on assessing female genitals and inguinal nal speculum to inspect the cervix and vagina, and
lymph nodes.) (d) obtaining a Pap smear.
SKILL 28.18 ASSESSING FEMALE GENITALS AND INGUINAL LYMPH NODES
PLANNING 3. Provide for client privacy. Request the presence of another

woman, if you so desire, if required by agency policy, or if
Equipment requested by the client.
• Clean gloves 4. Inquire about the following: age of onset of menstruation,
last menstrual period (LMP), regularity of cycle, duration,
• Drape amount of daily flow, and whether menstruation is painful;
• Supplemental lighting, if needed incidence of pain during intercourse; vaginal discharge;
number of pregnancies, number of live births, labour or
delivery complications; urgency and frequency of urination
IMPLEMENTATION at night; blood in urine, painful urination, incontinence; his-
tory of STIs, past and present.
Performance
5. Cover the pelvic area with a sheet or drape at all times
1. Before performing the procedure, introduce yourself to when it is not actually being examined. Position the client
the client, and verify the client’s identity by using two in the supine position, with feet elevated on the stirrups
identifiers. Explain to the client what you are going to of the examination table. Alternatively, assist the client
do, why it is necessary, and how she can participate. into the dorsal recumbent position, with the client’s knees
Discuss how the results will be used in planning further flexed and thighs externally rotated.
care or treatments.
2. Perform hand hygiene, put on gloves, and follow other
appropriate infection prevention and control procedures.

6. Inspect the distribution, amount, Wide variations exist; generally kinky in Scant pubic hair (may indicate hormonal
and characteristics of pubic hair. the menstruating adult, thinner and problem); hair growth should not extend
straighter after menopause; distributed over the abdomen
in the shape of an inverse triangle
(continued)
M28_KOZI2703_04_SE_C28.indd 619 17/03/17 1:09 PM

SKILL 28.18 ASSESSING FEMALE GENITALS AND INGUINAL LYMPH NODES (continued)

7. Inspect the skin of the pubic area Pubic skin intact, no lesions; skin of Lice, lesions, scars, fissures, swelling,
for parasites, inflammation, swell- vulva area slightly darker than the rest of erythema, excoriations (abrasions from
ing, and lesions. To assess pubic the body; labia round, full, and relatively scratching), varicosities (swollen and
skin adequately, separate the labia symmetrical in adult females twisted veins), or leukoplakia
majora and labia minora.
8. Inspect the clitoris, urethral orifice, Clitoris does not exceed 1 cm in width Presence of lesions; presence of
and vaginal orifice when separating and 2 cm in length; urethral orifice inflammation, swelling, or discharge
the labia minora. appears as a small slit and is the same
colour as surrounding tissues; no
inflammation, swelling, or discharge
9. Palpate the inguinal lymph nodes No enlargement or tenderness Enlargement and tenderness
(see ❶). Use the pads of the
fingers in a rotary motion, noting
any enlargement or tenderness.
Superior or
10. Remove and discard gloves. horizontal
Perform hand hygiene. group
11. Document findings in the client
record.
Inferior or
vertical
group
❶ Inguinal lymph nodes.
EVALUATION
• Perform a detailed follow-up examination, based on findings • Significant deviations from expected or normal indicate the
that deviated from expected or normal for the client. Relate need for an internal vaginal examination.
Assessing Female Genitals and Inguinal Lymph Nodes

INFANTS (e.g., some provinces require that the adolescent be at
least 14 years old before being examined without parental
• Infants can be held in a supine position on the parent’s presence or permission).
lap with the knees supported in a flexed position and
separated. • Girls should be assessed for Tanner staging of pubic hair
development (see Figure 28.34).
• Because of maternal estrogen, the labia and clitoris in
newborns may be edematous and enlarged, and new- • Girls should have a Pap test done if sexually active, or by
borns may have a small amount of white or bloody vaginal age 21years.
discharge.
• Assess the mons and inguinal area for swelling or OLDER ADULTS
tenderness that may indicate the presence of an • Loss of pubic hair and a flattening of the labia occur with
inguinal hernia. aging.
• The clitoris is a potential site for cancerous lesions in older
CHILDREN females.
• Ensure that you have the approval of a parent or guardian • The vulva atrophies as a result of a reduction in vascularity,
to perform the examination, and then tell the child what elasticity, adipose tissue, and estrogen levels. Because the
you are going to do. Preschool children are taught not to vulva is more fragile, it is more easily irritated.
allow others to touch their “private parts.” • The vaginal environment becomes drier and more alkaline,
• Assessment of adolescent girls is limited to inspection resulting in an alteration of the type of flora present and a
of the external genitals, unless the girl is sexually active. predisposition to vaginitis. Dyspareunia (difficult or painful
The presence of the parent during the examination will coitus) is also a common occurrence.
depend on the nature of the clinical situation and the pro- • The cervix and uterus decrease in size.
vincial or territorial age of consent for medical investigation
M28_KOZI2703_04_SE_C28.indd 620 17/03/17 1:09 PM

• The fallopian tubes and ovaries atrophy. • Prolapse of the uterus can occur in older females, espe-
• Ovulation and estrogen production cease. cially those who have had multiple pregnancies.
• Vaginal bleeding unrelated to estrogen therapy is abnormal • Older females may be arthritic and find the lithotomy posi-
in older women. tion uncomfortable. A semi-lithotomy position may be
necessary.
Pearson Canada
1 2 3 4 5 6
FIGURE 28.34 Tanner stages of pubic hair development in females.

Stage 1 Preadolescence. No pubic hair except for fine body hair.
Stage 2 Sparse, long, slightly pigmented curly hair develops along the labia.
Stage 3 Hair becomes darker in colour and curlier and develops over the pubic symphysis.
Stage 4 Hair assumes the texture and curl of the adult but is not as thick and does not appear on the thighs.
Stage 5 Pubic hair spreads to medial thigh but does not extend up to the linea alba.
Stage 6 Sexual maturity. Hair assumes adult appearance and appears on the inner aspect of the upper thigh
the client to a lithotomy position as needed, and drape

her appropriately.
3. Supporting the client during the procedure: This involves
explaining the procedure as needed and encouraging
the client to take deep breaths that will help the pelvic
muscles relax.
4. Monitoring and assisting the client after the procedure: Assist
the client from the lithotomy position and with perineal
care as needed. Observe any discharge from the vagina.
5. Documenting the procedure: Include the date and time it was
performed, the name of the physician, and any nursing
assessments and interventions.
FIGURE 28.35 A vaginal speculum.
The speculum examination of the vagina involves the

insertion of a plastic or metal speculum that consists of Male Genitals
two blades and an adjustable thumb screw (Figure 28.35).
Various sizes are available (small, medium, and large); the and Inguinal Area
appropriate size needs to be selected for each client. The
speculum can be lubricated with water-soluble lubricant In adult men, complete examination should include
if specimens are not being collected. Most examiners assessment of the external genitals, the presence of any
lubricate the speculum with warm water. hernias, and the prostate gland. The male reproductive
The nurse’s responsibilities when assisting with an and urinary systems (Figure 28.36) share the urethra,
examination of the internal female genitals include the which is the passageway for both urine and semen.
following: Therefore, in physical assessment of the male, these two
systems are frequently assessed together.
1. Assembling equipment: These include drapes, gloves, vag- Development of secondary sex characteristics is
inal speculum of correct size, warm water or lubri- assessed in relationship to the client’s age. See Table 28.13
cant, and supplies for cytology studies. for the five stages of the development of pubic hair, the
2. Preparing the client: Advise the client not to douche penis, the testes, and the scrotum during puberty.
before the procedure. Explain the procedure. It should All male clients should be screened for the presence
take only 5 minutes and is normally not painful. Assist of inguinal or femoral hernias. A hernia is a protrusion
M28_KOZI2703_04_SE_C28.indd 621 03/03/17 11:18 AM

of the intestine through the inguinal wall or canal.

Cavernous (penile) urethra Bladder
Cancer of the prostate gland is the most common can-
cer in adult men and occurs primarily in men over age
50 years. Examination of the prostate gland is performed
Prostate with the examination of the rectum and the anus.
Spermatic Testicular cancer is much rarer than prostate can-
cord
Rectum cer and occurs primarily in young men aged 15 to
Testis
35 years. Testicular cancer is most commonly found on
Prostatic the anterior and lateral surfaces of the testes. Testicu-
Scrotum urethra
lar self-examination should be conducted monthly.
Glans Membranous See Chapter 45.
urethra Skill 28.19 describes how the nurse can conduct an
Epididymis
Urethral orifice assessment of the male genitals and inguinal area. (See
also Lifespan Considerations box on assessing male geni-
FIGURE 28.36 The male urogenital tract. tals and inguinal area.)
TABLE 28.13 Tanner Stages of Development of Pubic Hair, Penis, and Testes or Scrotum (12 to 16 Years)
Stage Pubic Hair Penis Testes/Scrotum

1 None, except for body hair, Size is relative to body size, as Size is relative to body size, as
such as that on the in childhood in childhood
abdomen
2 Scant, long, slightly pigmented Slight enlargement occurs Becomes reddened in colour
at base of penis and enlarged
3 Darker, begins to curl and Elongation occurs Continuing enlargement

becomes more coarse;
extends over pubic
symphysis
4 Continues to darken and Increase in both breadth and Continuing enlargement;

thicken; extends on the length; glans develops colour darkens
sides, above, and below
Pearson Canada
M28_KOZI2703_04_SE_C28.indd 622 03/03/17 11:18 AM

Stage Pubic Hair Penis Testes/Scrotum

5 Adult distribution that extends Adult appearance Adult appearance
to inner thighs, umbilicus,
and anus
SKILL 28.19 ASSESSING MALE GENITALS AND INGUINAL AREA
PLANNING 2. Perform hand hygiene, put on gloves, and follow other

appropriate infection prevention and control procedures.
Equipment 3. Provide for client privacy. Request the presence of another
• Clean gloves person if you so desire, if required by agency policy, or if
requested by the client.
IMPLEMENTATION 4. Inquire whether the client has any history of the following:
urinary incontinence, frequency, urgency, abdominal pain;
Performance symptoms of STIs; swellings that could indicate presence
1. Before performing the procedure, introduce yourself to the of hernia; family history of nephritis, malignancy of the
client, and verify the client’s identity by using two identi- prostate, or malignancy of the kidney. Inquire about usual
fiers. Explain to the client what you are going to do, why it voiding patterns and changes, and bladder control.
is necessary, and how he can participate. Discuss how the 5. Cover the pelvic area with a sheet or drape at all times
results will be used in planning further care or treatments. when it is not actually being examined.
Pubic Hair
6. Inspect the distribution, amount, and Triangular distribution, often spreading Scant amount or absence of hair
characteristics of pubic hair. up the abdomen
Penis
7. Inspect the penile shaft and glans penis Penile skin intact; appears slightly wrinkled Presence of lesions, nodules,
for lesions, nodules, swellings, and and varies in colour as widely as other body swellings, or inflammation
inflammation. skin; foreskin easily retractable from the
glans penis; small amount of thick white
smegma between the glans and foreskin
8. Inspect the urethral meatus for swelling, Pink and slit-like appearance; positioned Inflammation; discharge; variation in
inflammation, and discharge. at the tip of the penis meatal locations (e.g., hypospadias,
on the underside of the penile shaft,
and epispadias, on the upper side of
the penile shaft)
Scrotum
9. Inspect the scrotum for appearance, Scrotal skin is darker in colour than that Discolorations; any tightening of skin
general size, and symmetry. the skin of the rest of the body and is loose (may indicate edema or mass)
• Inspect all skin surfaces by spreading Size varies with temperature changes (the
the rugated (ridged) dartos muscles contract when the area is
surface skin and lifting the cold and relax when the area is warm)
scrotum, as needed, to observe pos- Scrotum appears asymmetrical (left
terior surfaces. testis is usually lower than right testis)
10. Palpate the scrotum to assess status of Testicles are rubbery, smooth, and free Testicles are enlarged, with uneven
underlying testes. Palpate both testes of nodules and masses; testis is about surface (possible tumour)
simultaneously for comparative purposes. 2 × 4 cm
(continued)
M28_KOZI2703_04_SE_C28.indd 623 17/03/17 1:10 PM

SKILL 28.19 ASSESSING MALE GENITALS AND INGUINAL AREA (continued)

• Using your first two fingers and
thumb, palpate each testis for size,
consistency, shape, smoothness, and
presence of masses. During assess-
ment of male adolescents, establish
the descent of the testicles into the
scrotum; note undescended testes.
• Describe all scrotal masses in terms
of their size, shape, placement, con-
sistency, and tenderness.
Inguinal Area
11. Inspect both inguinal areas for bulges No swelling or bulges Swelling or bulge (possible inguinal
while the client is standing, if possible. or femoral hernia)
• First, have the client remain at rest.
• Next, have the client hold his breath
and strain or bear down as though
having a bowel movement. Bearing
down may make the hernia more
visible.
12. Remove and discard gloves. Perform
hand hygiene.
13. Document your findings in the client record.
EVALUATION
Assessing Male Genitals and Inguinal Area

INFANTS are going to do. Preschool children are taught to not allow
others to touch their “private parts.”
• The foreskin of the uncircumcised infant is normally
tight at birth and should not be retracted. It will gradually • In young boys, the cremasteric reflex can cause the tes-
loosen as the baby grows and is usually fully retractable tes to ascend into the inguinal canal. If possible, have the
by age 2 to 3 years. Assess for cleanliness, redness, or boy sit cross-legged, which stretches the muscle and
irritation. decreases the reflex.
• Assess for placement of the urethral meatus. OLDER ADULTS
• Palpate the scrotum to determine if the testes are
descended; in the newborn and infant, the testes may • The penis decreases in size with aging; the size and
retract into the inguinal canal, especially with stimulation firmness of the testes decrease.
of the cremasteric reflex. (Lightly stroking the superior and • Testosterone is produced in smaller amounts.
medial part of the thigh causes the cremaster muscle to • More time and direct physical stimulation are required for
pull up the scrotum and testis on that side.) an older man to achieve an erection, but the client can
• Assess the inguinal area for swelling or tenderness that maintain the erection for a longer period before ejaculation
may indicate the presence of an inguinal hernia. than he could at a younger age.
• Seminal fluid is reduced in amount and viscosity.
CHILDREN
• Urinary frequency, nocturia, dribbling, and problems with
• Ensure that you have the parent or guardian’s approval to beginning and ending the stream are usually the result of
perform the examination, and then tell the child what you prostatic enlargement.
M28_KOZI2703_04_SE_C28.indd 624 17/03/17 1:10 PM

The Anus
For the generalist nurse, anal examination, an essential Skill 28.20 describes how to assess the anus. (See also
part of every comprehensive physical examination, gener- Lifespan Considerations box on assessing the anus.)
ally involves only inspection.
SKILL 28.20 ASSESSING THE ANUS
PLANNING 3. Provide for client privacy. Drape the client appropriately to

prevent undue exposure of body parts.
Equipment 4. Inquire whether the client has any history of the follow-
• Clean gloves ing: bright red blood in stools, tarry black stools, diarrhea,
constipation, abdominal pain, excessive gas, hemor-
• Water-soluble lubricant rhoids, or rectal pain; family history of colorectal cancer;
when last stool specimen for occult blood was performed
IMPLEMENTATION and the results; and for males, if not obtained during the
genitourinary examination, signs or symptoms of prostate
Performance enlargement (e.g., slow urinary stream, hesitance, fre-
1. Before performing the procedure, introduce yourself to quency, dribbling, and nocturia).
the client, and verify the client’s identity by using two 5. Position the client. In adults, the left lateral or Sims’ position
identifiers. Explain to the client what you are going to do, with the upper leg acutely flexed is required for the exami-
why it is necessary, and how he or she can participate. nation. For females, a dorsal recumbent position with hips
Discuss how the results will be used in planning further externally rotated and knees flexed or a lithotomy position
care or treatments. may be used (see Table 28.1 on page 542). For males, a
2. Perform hand hygiene, put on gloves, and follow other standing position while the client bends over the examining
appropriate infection prevention and control procedures for table may also be used. This position is commonly used to
all anal and rectal examinations. examine the prostate gland.

6. Inspect the anus and surrounding tissue Intact perianal skin; usually slightly Presence of fissures (cracks), ulcers,
for colour, integrity, and skin lesions. more pigmented than the skin of the excoriations, inflammations, abscesses,
Then, ask the client to bear down as buttocks; anal skin is normally more protruding hemorrhoids (dilated veins
though defecating. Bearing down cre- pigmented, coarser, and more moist seen as reddened protrusions of the
ates slight pressure on the skin that may than perianal skin and is usually skin), lumps or tumours, fistula
accentuate rectal fissures, rectal pro- hairless openings, or rectal prolapse (varying
lapse, polyps, or internal hemorrhoids. degrees of protrusion of the rectal
Describe the location of all abnormal mucous membrane through the anus)
findings in terms of a clock, with the
12 o’clock position toward the pubic
symphysis.
7. Remove and discard gloves. Perform hand hygiene.
8. Document findings in the client record
EVALUATION
• Perform a detailed follow-up examination, based on findings • Report significant deviations from normal to the appropriate
that deviated from expected or normal for the client. Relate members of the health care team.
CHILDREN OLDER ADULTS

Assessing the Anus
• Erythema and scratch marks • Chronic constipation and straining
INFANTS around the anus may indicate a at stool cause an increase in the
pinworm parasite. Children with this frequency of hemorrhoids and rectal
• Lightly touching the anus should condition may be disturbed by itch- prolapse.
result in a brief anal contraction ing during sleep.
(“wink” reflex).
M28_KOZI2703_04_SE_C28.indd 625 17/03/17 1:10 PM

Case Study 28
Mrs. J., a 32-year-old Inuit woman, has come
to the clinic because she has felt a lump in her
2. How would you develop nursing interventions to help put
clients at ease for an invasive procedure that has a vital
breast. When you begin the breast examina-
role in physical assessment?
tion, the client cries out, “What do you think
you are doing?” 3. How will you address clients in a manner that is likely to
gain their trust and cooperation?

1. How would you respond to this client?
KE Y TERM S
adventitious breath erythema p. 548 miosis p. 558 reflex p. 610
sounds p. 579 eustachian tube p. 562 mixed hearing loss p. 563 resonance p. 544
albinism p. 548 exophthalmos p. 555 mydriasis p. 557 resting tremor p. 599
alopecia p. 548 external auditory myopia p. 555 Rinne test p. 566
anesthesia p. 610 meatus p. 562 normocephalic p. 555 S1 p. 586
angle of Louis p. 577 extinction p. 610 nystagmus p. 561 S2 p. 586
anisocoria p. 558 fasciculation p. 599 one-point secondary skin
antihelix p. 562 flatness p. 544 discrimination p. 610 lesions p. 548
apex p. 586 fremitus p. 581 ossicles p. 562 semicircular canals p. 563
aphasia p. 607 gingivitis p. 569 otoscope p. 558 sensorineural
arcus senilis p. 563 glaucoma p. 557 pallor p. 547 hearing loss p. 563
astigmatism p. 555 glossitis p. 570 palpation p. 541 sordes p. 570
auricle p. 558 heave p. 586 paresthesia p. 610 stapes p. 562
auscultation p. 544 helix p. 562 paronychia p. 554 stereognosis p. 610
axillary tail of hernia p. 621 parotitis p. 570 sternum p. 577
Spence p. 594 hirsutism p. 553 PERRLA p. 560 stomatitis p. 570
base p. 586 hordeolum p. 557 percussion p. 543 sty p. 557
blanch test p. 554 hyperesthesia p. 610 perfusion p. 592 systole p. 587
borborygmi p. 601 hyperhidrosis p. 547 photophobia p. 557 tartar p. 569
bromhidrosis p. 547 hyperopia p. 555 pinna p. 558 testicular self-
bruit p. 588 hyperresonance p. 544 pitch p. 545 examination p. 622
caries p. 569 hypoesthesia p. 610 plaque p. 569 thrill p. 588
cataracts p. 557 incus p. 562 pleximeter p. 543 tragus p. 562
cerumen p. 562 inspection p. 540 plexor p. 544 tremor p. 599
clubbing p. 548 intensity p. 545 point of maximal triangular fossa p. 562
cochlea p. 563 intention tremor p. 599 impulse (PMI) p. 586 two-point
conduction hearing iritis p. 557 precordium p. 586 discrimination p. 610
loss p. 563 jaundice p. 548 presbycusis p. 567 tympanic
conjunctivitis p. 557 koilonychia p. 548 presbyopia p. 555 membrane p. 562
cyanosis p. 548 leukoplakia p. 570 primary skin tympany p. 544
dacryocystitis p. 557 lift p. 586 lesions p. 548 vestibule p. 563
diastole p. 587 lobule p. 562 proprioceptors p. 610 visual acuity p. 555
dullness p. 544 malleus p. 562 ptosis p. 557 visual fields p. 555
duration p. 545 manubrium p. 577 pyorrhea p. 569 vitiligo p. 548
edema p. 548 mastoid p. 562 quality p. 545 Weber’s test p. 566
M28_KOZI2703_04_SE_C28.indd 626 03/03/17 11:18 AM


• The health examination is conducted to assess the the client’s care, and evaluate the outcomes of
function and integrity of the client’s body parts. nursing care.
• The health examination may entail a complete head-to-toe • Initial assessment findings provide baseline data about
assessment or individual assessment of a body system or the client’s functional abilities against which subsequent
body part. assessment findings are compared.
• The health assessment is conducted in a systematic manner • Skills in inspection, palpation, percussion, and auscul-
that requires the fewest position changes for the client. tation are required for the physical health examina-
• Data obtained in the physical health examination tion; these skills are used in that order throughout the
supplement, confirm, or refute data obtained during examination except during abdominal assessment, when
the nursing history. the order is inspection, auscultation, percussion, and
palpation.
• Nursing history data help the nurse focus on specific
aspects of the physical health examination. • Knowledge of the normal structure and function of
body parts and systems is a prerequisite to conducting
• Data obtained in the physical health examination a physical assessment.
help the nurse establish nursing diagnoses, plan
N CL EX- ST YLE PR ACTI CE QUI Z

1. A nurse is preparing to do a physical assessment on a 4. A nurse is inspecting an older client’s skin and notes
3-year-old, who is sitting on the examination table wear- that the legs are hairless below the knees. What should
ing only shorts. What is the correct sequence for the be the nurse’s next assessment?
nurse to perform this assessment? Place the options in a. Have the blood glucose test performed.
order. All options must be used.
b. Move to the auscultation part of the assessment.
a. Auscultate the child’s chest.
c. Palpate pedal pulses.
b. Assess range of motion.
d. Complete a vascular assessment.
c. Palpate the child’s abdomen.
d. Take the child’s temperature. 5. A student nurse has completed a newborn assessment.
The circumference of the neonate’s head is 2 cm larger
2. An adolescent has stopped by the school nurse’s office than the chest size. The educator asks the student to
to ask a question. While the two are chatting the nurse interpret this result. Which statement by the student
is doing a general survey of the teen. Based on this provides the correct interpretation of this assessment
survey the nurse suspects the teen has compromised car- finding?
diovascular health. What findings did the nurse observe a. “This is a normal finding for a newborn.”
during the survey that led the nurse to suspect the teen
b. “The measurement should be equal at this point in
has compromised cardiovascular health? Select all that
the baby’s development.”
apply.
c. “The chest circumference should be larger than the
a. Pallor
head size.”
b. Vitiligo d. “The large head may indicate hydrocephalus, so this
c. Clubbing needs further follow-up.”
d. Bromhidrosis
6. A nurse has finished auscultating the abdomen. Which
3. A client had a right-sided carotid endarterectomy. The finding should the nurse report for further follow up?
nurse is assessing function for cranial nerves (CNs) VII, a. Bruit isolated to one area of the abdomen
XII, and XII as part of the postoperative assessment. b. Absence of bowel sounds for 60 seconds
How can the nurse best assess these nerves?
c. Continuous bowel sounds over the ileocecal valve
a. Have the client smile, do a shoulder shrug, and stick
out the tongue. d. An irregular pattern of bowel sounds
b. Instruct the client to swallow, blink, and puff out cheeks. 7. A nurse is unable to locate the client’s popliteal pulse
c. Direct the client to protrude tongue, close eyes, and during a routine examination. What should the nurse
check pupil reaction. do next?
d. Ask the client to bare teeth, swallow, and talk. a. Check for a pedal pulse.
b. Check for a femoral pulse.
M28_KOZI2703_04_SE_C28.indd 627 03/03/17 11:18 AM

c. Take the client’s blood pressure on that thigh. b. Have the client describe his or her childhood illnesses.
d. Ask another nurse to try to locate the pulse. c. Ask the client to describe how he or she arrived at
the clinic.
8. Which of the following techniques should the nurse use d. Ask the client to count backward from 100 subtract-
to palpate the lymph nodes? ing 7 each time.
a. Use the flat part of all four fingers in a vertical and
then side-to-side motion. 10. An older client with a history of left ventricular hyper-
b. Use the back of the hand and feel for temperature trophy, hypertension, and sleep apnea has been admit-
variation between the right and left sides. ted to hospital for heart failure. A nurse is preparing to
c. Use the pads and tips of the index and middle fin- complete a cardiovascular assessment. Where should the
gers in a circular motion. nurse anticipate to find the point of maximal impulse
(PMI)?
d. Compress the nodes between the index fingers of
both hands. a. At the fifth intercostal space (ICS) at the left midcla-
vicular line (MCL)
9. A client complains of having difficulty remembering b. At approximately the fifth ICS between the left MCL
recent events. What should the nurse plan to do next? and the axillary line
a. Have the client repeat a series of three numbers, if c. Just left of the sternum at the second ICS
possible. d. The left fourth ICS close to the sternum
RE F ERENCES
Bolek, B. (2006). Strictly clinical: Facing cranial nerve assessment. Ilic, D., Neuberger, M. M., Djulbegovic, M., Dahm, P. (2013).
American Nurse Today, 1(2), 21–22. Screening for prostate cancer. Cochrane Database of Systematic
Canadian Cancer Society. (2015). Prostate cancer statistics 2015. Reviews 1, CD004720. DOI: 10.1002/14651858.CD004720.
Toronto, ON: Author. Retrieved from http://www.cancer.ca/en/ pub3.
cancer-information/cancer-type/prostate/statistics.
Canadian Cancer Society. Prevention and screening. Retrieved
from http://www.cancer.ca/en/prevention-and-screening/
early-detection-and-screening/screening/?region=on.
M28_KOZI2703_04_SE_C28.indd 628 03/03/17 11:18 AM

Chapter 29
Vital Signs
Updated by
Em M. Pijl Zieber, BScN, MEd, RN
Instructor (Community Health), Faculty of Health Sciences,
University of Lethbridge
T
LEARNING OUTCOMES
After studying this chapter, you will be able to he traditional vital signs
1. Describe factors that affect the vital signs and accurate are body temperature,
measurement of them. pulse, respirations, and
2. Identify the normal range variations in body temperature, pulse, blood pressure. Pulse oximetry or
respirations, and blood pressure that occur across the lifespan. oxygen saturation as well as pain
3. Describe the body’s system of thermoregulation and identify levels are also commonly measured
factors influencing the body’s heat production. at the same time as the four tradi-
4. Explain and distinguish oral, rectal, axillary, tympanic membrane, tional vital signs. Pain assessment is
and temporal artery methods of measuring body temperature and
their relative merits. covered in Chapter 30. Vital signs are
5. Outline appropriate nursing care for alterations in body assessed to monitor the functions of
temperature. the body; they are interrelated with
6. Perform accurate body temperature assessment using the correct each other and are an important part
method for the patient. of a comprehensive patient assess-
7. Identify nine sites commonly used to assess the pulse and state ment. Vital signs reflect changes in
the reasons for use of each. function that otherwise might not be
8. Describe the characteristics that should be included when observed. Monitoring a patient’s vital
assessing pulses.
signs should be a thoughtful, scien-
9. Perform accurate apical pulse and apical–radial pulse
tific assessment, not merely an auto-
measurement.
matic or routine procedure. When
10. Describe the mechanics of breathing and the mechanisms that
control respirations. assessed, vital signs must be evalu-
11. Identify the components of a respiratory assessment. ated with reference to the patient’s
12. Perform accurate respiration rate and quality assessment. present and prior health status and
13. Summarize the physiology of blood pressure and what it indicates also compared with accepted nor-
about patient health. mal standards. Vital signs cannot be
14. Identify noninvasive methods for measuring blood pressure interpreted in isolation of each other
and differentiate between systolic and diastolic blood pressure, but must be interpreted together.
including the five phases of Korotkoff sounds.
When and how often to assess a
15. Perform accurate blood pressure measurement.
specific patient’s vital signs are pri-
16. Discuss measurement of blood oxygenation by using pulse
marily nursing judgments, depending c
oximetry and the correct interpretation of oximetry measurements.
M29_KOZI2703_04_SE_C29.indd 629 17/03/17 1:13 PM

c on the patient’s health status. Some agencies have policies about taking patients’ vital signs and
about when this must occur. Physicians may specify frequency (e.g., “blood pressure q2h”), but this
should be considered the minimum; a nurse should measure vital signs more often if the patient’s
health status requires it. Examples of times to assess vital signs include the following:
• On admission to a health care agency or nursing unit, to obtain baseline data
• When a patient’s health status changes or he or she reports symptoms
• Before and after invasive diagnostic procedures or demanding treatments
• Before or after the administration of a medication that has a direct effect or side effects, such as alter-
ing respirations, heart rate, or blood pressure (medications such as digoxin and morphine and other
opioids are examples)
• Before and after any nursing intervention that could affect the vital signs (e.g., ambulating a patient
who has been on bed rest)
The Fifth Vital Sign thorax, abdominal cavity, and pelvic cavity. It remains
relatively constant and is typically measured using a pul-
The debate about what constitutes the “real” fifth vital sign
monary artery catheter. Accurate core body temperature
has been ongoing for several years. Those who advocate
measurement is invasive and impractical and reserved
for pain as the fifth vital sign point to the longstanding
underassessment of pain and its significant negative impact
for high-risk patients undergoing surgery or in the inten-
on physiological and psychological processes as merit- sive care unit (Brandes, Perl, Bauer, & Bräuer, 2015).
ing this rank. Those who advocate that oxygen saturation The surface temperature is the temperature of skin,
has this status, point to it as a true “sign of life” in that subcutaneous tissue, and fat. It, in contrast to core body
one cannot survive without oxygen. Interestingly, some temperature, fluctuates in response to the environment
argue that only pulse and respirations are vital signs, as and is much less invasive to measure. Surface tempera-
blood pressure and temperature require instruments for ture is routinely measured in all patients and provides an
measuring and, as such, are results of diagnostic testing. estimate of the core temperature.
Depending on the nature of the clinical agency, specialty, The normal core body temperature of an adult
or both, other contenders for the “fifth” spot include level of
is variable and generally ranges between 36.7°C and
emotional distress, blood glucose level, urine output, body
37°C (Brandes, Perl, Bauer, & Bräuer, 2015). Small
mass index, pupil size and reaction, and the list goes on!
One thing for sure is that since pain and oxygenation have
fluctuations of 0.2°C to 0.4°C can occur without the
been emphasized as meriting consideration as “vital signs,” body mounting a response to bring it back to normal.
clinicians have given these important areas greater atten- Measured orally, the normal range in adults is between
tion—all in an effort to improve the client’s health status 36.5°C and 37.5°C, although, given the variations in the
and ability to rally when ill. literature for what constitutes a “normal” oral tempera-
ture, many practice settings accept a range of 36°C to
38°C as “normal” in adults (Figure 29.1). More impor-
tantly, temperature measurements must be interpreted
For purposes of this chapter on “vital signs,” the fol- in light of the patient’s other vital signs and in consider-
lowing will be presented: temperature, pulse, respiration, ation of the patient’s usual and previous temperatures.
blood pressure, and oxygen saturation. Pain and other For example, older people often have a body temperature
assessments, such as blood glucose and neurological vital below 37°C and, as such, a temperature of 37°C may, in
signs, are discussed in other chapters in this text. fact, represent a febrile state. As such, when working with
older people, it is beneficial to also observe for signs, such
as increased heart and respiration rates, change in blood
pressure, signs of confusion, and a decline in functional
Body Temperature status. Table 29.1 identifies accepted norms for body
temperature in children by route of measurement.
Body temperature reflects the balance between the The body continually produces heat as a byproduct
heat produced and the heat lost from the body, and it is of metabolism. When the amount of heat produced by
measured in units called degrees. The body has two kinds the body exactly equals the amount of heat lost, the per-
of temperatures: (a) core temperature and (b) surface son is said to be in heat balance (Figure 29.2).
temperature. Core temperature is the temperature A number of factors affect the body’s heat produc-
of the deep tissues of the body, such as the cranium, tion. The five most important are as follows:
M29_KOZI2703_04_SE_C29.indd 630 27/02/17 1:36 PM

Chapter 29 Vital Signs 631
8F 8C
107.6 42 Death
105.8 41 Hyperpyrexia Heat production Heat loss
104.0 40 • Basal metabolism • Radiation

• Muscular activity • Conduction/
102.2 39 Pyrexia (shivering) convection
• Thyroxine and • Evaporation
epinephrine
100.4 38
(stimulating effects
on metabolic rate)
98.6 37 Normal • Temperature effect
Average
range on cells
96.8 36
95.0 35
Hypothermia
93.2 34 Death
FIGURE 29.2 As long as heat production and heat loss are

properly balanced, body temperature remains constant. Fac-
tors contributing to heat production (and temperature rise) are
shown on the left side of the scale; those contributing to heat
loss (and temperature drop) are shown on the right side.
Source: Marieb, Elaine N.; Hoehn, Katja N., Human Anatomy & Physiology, 9th Ed.,
©2013. Reprinted and Electronically reproduced by permission of Pearson Education, Inc.,
FIGURE 29.1 Terms used to describe alterations in body tem- New York, NY.
perature (oral measurements) and ranges in Celsius and Fahren-
heit scales.
1. Basal metabolic rate. The basal metabolic rate causes the release of epinephrine and norepineph-
(BMR) is the rate of energy utilization in the body rine. These hormones directly affect liver and muscle
required to maintain essential activities, such as cells, thereby increasing cellular metabolism and heat
breathing. Metabolic rates decrease with age. In gen- production.
eral, the younger the person, the higher the BMR. 5. Fever. Fever increases the cellular metabolic rate and
2. Muscle activity. Muscle activity, including shivering, thus further increases the body’s temperature.
increases the BMR.
Heat is lost from the body through radiation, conduc-
3. Thyroxine output. Increased thyroxine output by the tion, convection, and vaporization.
thyroid gland increases the rate of cellular metabo-
lism throughout the body. • Radiation is the transfer of heat from the surface of
one object to the surface of another without contact
4. S y m p a t h e t i c s t i m u l a t i o n , i n cl u d i n g re l e a s e o f
between the two objects, mostly in the form of infra-
epinephrine and norepinephrine. Sympathetic stimulation
red rays.
of the autonomic nervous system (e.g., during stress)
• Conduction is the transfer of heat from one mol-
TABLE 29.1 Range of Normal Body Temperatures by Route ecule to a molecule of lower temperature. Conductive
of Measurement transfer cannot take place without contact between
the molecules and normally accounts for minimal heat
Route of Measurement Temperature Range loss, except, for example, when the body is immersed
Core 36.7°C–37.0°C in cold water. The amount of heat transferred depends
Oral 36.0°C–38.0°C on the temperature difference and the amount and
duration of the contact.
Rectal 36.7°C–38.0°C
Tympanic 35.5°C–38.0°C
• Convection is the dispersion of heat by air currents.
The body usually has a small amount of warm air
Temporal artery 36.7–38.0°C
adjacent to it. This warm air rises and is replaced by
Axillary 35.4°C–37.4°C cooler air, and so people always lose a small amount
Sources: Adapted from Canadian Paediatric Society. (2010). Temperature measure- of heat through convection. This can be useful in clin-
ment in paediatrics. Position Statement: Canadian Pediatric Society. Retrieved from
http://www.cps.ca/english/statements/CP/cp00-01.htm; Estes, M. E. Z. (2014). Health
ical practice, as in the use of fans to help cool a patient
Assessment and Physical Examination (5th Ed.). Toronto, ON: Nelson. who has a high temperature.
M29_KOZI2703_04_SE_C29.indd 631 03/03/17 10:19 AM

• Evaporation is continuous vaporization of mois-
Oral temperature (C)

37.2 Awake Asleep
ture from the respiratory tract, from the mucosa
37.0
of the mouth, and from skin. This continuous and
36.8
unnoticed water loss is called insensible water
36.6
loss, and the accompanying heat loss is called
36.4
insensible heat loss. Insensible heat loss accounts
36.2
for about 10% of basal heat loss. When the body tem-
perature increases, vaporization accounts for greater 0400 0800 1200 1600 2000 2400 0400
4 AM 8 AM 12 Noon 4 PM 8 PM 12 Midnight 4 AM
heat loss.
Time (hours)
Figure 29.3 Range of oral temperatures during 24 hours for

Regulation of Body Temperature a healthy young adult.
The system that regulates body temperature has three
main parts: (a) sensors on the skin and in the body’s core,
(b) an integrator in the hypothalamus, and (c) an effector 1. Age. The infant is greatly affected by the tempera-
system that adjusts the production and loss of heat. Most ture of the environment and must be protected from
sensors or sensory receptors are in skin. Skin has more recep- extreme changes. Until puberty, children’s temperatures
tors for cold than for warmth. Therefore, skin sensors continue to be more labile (changeable) than those of
detect cold more efficiently than warmth. adults. Many older people, particularly those older than
When skin becomes chilled over the entire body, 75 years, are at risk of hypothermia (temperatures
three physiological processes take place to increase the below 36°C) for a variety of reasons, such as inad-
body temperature: equate diet, loss of subcutaneous fat, lack of activ-
ity, and reduced thermoregulatory efficiency. Older
1. Shivering increases heat production. people are also particularly sensitive to extremes in
2. Sweating is inhibited to decrease heat loss. the environmental temperature because of decreased
3. Vasoconstriction decreases heat loss. thermoregulatory controls.
2. Diurnal variations (circadian rhythms). Body temperatures
The hypothalamic integrator, the centre that
normally change throughout the day, varying by as
controls the core temperature, is located in the ante-
much as 1°C between the early morning and the late
rior region of the hypothalamus (Taylor, Tipton &
afternoon. The point of highest body temperature
Kenny, 2014). When the sensors in the hypothalamus
is usually reached between 1600 and 1800 hours
detect heat, they send out signals intended to reduce the
(4 p.m. and 6 p.m.), and the lowest point is reached
temperature, that is, to decrease heat production and
during sleep between 0400 and 0600 hours (4 a.m.
increase heat loss. When the cold sensors are stimulated,
and 6 a.m.) (see Figure 29.3).
signals are sent out to increase heat production and
decrease heat loss. 3. Exercise. Hard work or strenuous exercise can increase
The signals from the cold-sensitive receptors of body temperature to as high as 38.3°C to 40°C.
the hypothalamus initiate effectors, such as vasoconstric- 4. Hor mones. Women usually experience more hor-
tion, shivering, and the release of epinephrine, which mone fluctuations than men do. In women, proges-
increases cellular metabolism and, hence, heat produc- terone secretion at the time of ovulation raises body
tion. When the warmth-sensitive receptors in the hypo- temperature by about 0.3°C to 0.6°C above basal
thalamus are stimulated, the effector system sends out temperature.
signals that initiate sweating and peripheral vasodilation.
5. Stress. Stimulation of the sympathetic nervous sys-
Also, when this system is stimulated, the person con-
tem can increase the production of epinephrine and
sciously makes appropriate adjustments, such as putting
norepinephrine, thereby increasing metabolic activ-
on additional clothing in response to cold or turning on
ity and heat production. Nurses can anticipate that a
a fan in response to heat.
highly stressed or anxious patient could have an ele-
vated body temperature for that reason.
6. Environment. Extremes in environmental temperatures
Factors Affecting Body Temperature can affect a person’s temperature regulatory systems.
Nurses should be aware of the factors that can affect a If the temperature is assessed in a very warm room and
patient’s body temperature to recognize normal temper- the body temperature cannot be modified by convec-
ature variations and understand the significance of body tion, conduction, or radiation, the temperature will be
temperature measurements that deviate from normal. elevated. Similarly, if the patient has been outside in
Among the factors that affect body temperature are the extremely cold weather without suitable clothing, the
following: body temperature may be low.
M29_KOZI2703_04_SE_C29.indd 632 02/03/17 5:25 PM

Alterations in Body Temperature tachycardia, and skeletal muscle rigidity, prior to develop-
ing a life-threatening rapid increase in core body temper-
Two primary alterations in body temperature occur: ature (Heytens, Forget, Scholtès, & Veyckemens, 2015).
pyrexia (hyperthermia, fever) and hypothermia The clinical signs of fever vary with the onset,
Pyrexia A body temperature above the normal range course, and abatement stages of the fever (see the Clini-
is called pyrexia, or hyperthermia. In many cases, cal Manifestations box). These signs occur as a result of
hyperthermia, or pyrexia, indicates fever, but not always. changes in the set point of the temperature control mech-
Fever is a regulated rise in core body temperature or anism regulated by the hypothalamus. Under normal
change in temperature set point, which is regulated by conditions, whenever the core temperature rises above
the hypothalamus, the body’s thermostat. Hyperther- 37°C the rate of heat loss becomes greater than heat
mia, in contrast, is an unregulated rise in body tem- production, resulting in a fall in temperature toward the
perature caused by the body’s inability to eliminate heat set point level. Conversely, when the core temperature
adequately, such as in the case of heat stroke (Marieb & falls below 37°C the rate of heat production becomes
Hoehn, 2013). The patient who has a fever is referred to greater than heat loss, resulting in a rise in temperature
as febrile; many agencies consider a patient to be febrile toward the set point.
if he or she has an oral temperature of 38.3°C once In a fever, however, the set point of the hypothalamic
or 38.0°C or greater sustained for more than 1 hour. A thermostat changes suddenly from the normal level to a
“high fever” is greater than 39.5°C (Laupland et al., 2012) higher-than-normal value (e.g., 39.5°C) as a result of
and a very high fever, above 41°C, is called hyperpy- the effects of tissue destruction, pyrogenic substances,
rexia (Figure 29.1). Patients who do not have a fever are or dehydration on the hypothalamus. Although the set
referred to as afebrile. point changes rapidly, the core body temperature reaches
Fever is a physiological response to a stimulus, such this new set point only after several hours. During this
as infection, and can be a beneficial mechanism with interval, the usual heat production responses that cause
respect to its effects on enhanced leukocyte function. elevation of the body temperature occur: chills, feeling
Four common types of fevers are intermittent, remittent, of coldness, cold skin resulting from vasoconstriction,
relapsing, and constant. During intermittent fever, the and shivering. This is referred to as the cold or chill phase.
body temperature alternates at regular intervals between When the core temperature reaches the new set
periods of fever and periods of normal or subnormal point, the person feels neither cold nor hot and no longer
temperatures. This occurs, for example, with malaria. experiences chills (the plateau phase). Depending on the
During a remittent fever, such as with a cold or influ- degree of temperature elevation, various other signs may
enza, a wide range of temperature fluctuations (more occur at this stage. Very high temperatures, such as 41°C
than 2°C) occurs in 24 hours, all of which are above to 42°C, damage the parenchyma of cells throughout
normal. In a relapsing fever, short febrile periods the body, particularly in the brain, where destruction of
of a few days are interspersed with periods of 1 or neuronal cells is irreversible. Damage to the liver, kid-
2 days of normal temperature. During a constant neys, and other body organs can also be great enough
fever, the body temperature fluctuates minimally but to disrupt functioning and eventually cause death. When
always remains above normal. This can occur with the cause of the high temperature is suddenly removed,
typhoid fever. A temperature that rises to fever level the set point of the hypothalamic thermostat is suddenly
rapidly following a normal temperature and then returns reduced to a lower value, perhaps even back to the origi-
to normal within a few hours is called a fever spike. nal normal level. In this instance, the hypothalamus now
Bacterial blood infections often cause fever spikes. attempts to lower the temperature to 37°C, and the usual
In some conditions, an elevated temperature is not heat loss responses causing a reduction of the body tem-
always a true fever. Three examples of this are heat perature occur. This sudden change of events is known
exhaustion, heat stroke, and malignant hyperthermia. as the flush or defervescent stage of a pyrexic condition. The
Heat exhaustion is a result of excessive heat and clinical signs and symptoms associated with each phase
dehydration. Signs of heat exhaustion include pallor, of fever are listed in the Clinical Manifestations box.
dizziness, nausea, vomiting, fainting, and a moderately Nursing interventions for a patient who has a fever
increased temperature (38.5°C to 39°C). Persons expe- are designed to support the body’s normal physiological
riencing heat stroke generally have been exercising processes, provide comfort, and prevent complications.
in hot weather, have warm, flushed skin, and often do During the course of the fever, the nurse must monitor
not sweat. They usually have a temperature of 41°C the patient’s vital signs closely. Nursing measures during
or higher and may be delirious, unconscious, or having the chill phase are designed to help the patient decrease
seizures. A very rare form of hyperthermia is malig- heat loss. At this time, the body’s physiological processes
nant hyperthermia, a pharmacogenetic disorder, are attempting to raise the core temperature to the new
which can be triggered by exposure to certain anesthetic set-point temperature. During the flush or crisis phase,
agents. Individuals who develop this condition display the body processes are attempting to lower the core tem-
elevated carbon dioxide production, profuse sweating, perature to the reduced or normal set-point temperature.
M29_KOZI2703_04_SE_C29.indd 633 27/02/17 1:36 PM

Clinical Manifestations
Stages of Fever
Fever can manifest itself in three phases:
Onset (Cold or • Cessation of sweating • Increased thirst Defervescence

Chill Stage) • Mild to severe dehydration (Fever Abatement
• Increased heart rate Course (Plateau • Drowsiness, restlessness, or Flush Phase)
• Increased respiratory rate Phase) delirium, or convulsions • Skin that appears flushed
and depth • Absence of chills • Herpetic lesions of the and feels warm
• Shivering • Skin that feels warm mouth • Sweating
• Pallid, cold skin • Photosensitivity • Loss of appetite (if the • Decreased shivering
fever is prolonged)
• Complaints of feeling cold • Glassy-eyed appearance • Possible dehydration
• Malaise, weakness, and
• Cyanotic nail beds • Febrile seizure (in children) aching muscles
• “Gooseflesh” appearance • Increased pulse and respi-
of the skin ratory rates
At this time, the nurse takes measures to increase heat Hypothermia Hypothermia is a core body tempera-
loss and decrease heat production. Nursing interventions ture below the lower limit of normal, typically less than
for a patient with fever are shown in Box 29.1. 36°C (Hernandez, Cutter, & Apfelbaum, 2013). The
three physiological mechanisms of hypothermia are (a)
excessive heat loss, (b) inadequate heat production to
counteract the heat loss, and (c) impaired hypothalamic
thermoregulation. The clinical signs of hypothermia are
Box 29.1 Nursing Interventions given in the Clinical Manifestations box.
for Patients with Fever Hypothermia can be induced or accidental. Induced
hypothermia is the deliberate lowering of the body tempera-
Nurses can do several things to help a patient through each
stage of a fever:
ture to decrease the need for oxygen by the body tissues.
Induced hypothermia can involve the whole body or a
• Monitor vital signs at least every 2 hours if the patient is
critically ill. body part. It may be indicated for certain surgical cases
• Assess skin colour, temperature, and other physiological
(e.g., neurosurgery). Accidental hypothermia can occur as a
signs associated with fever. result of (a) exposure to a cold environment, (b) immersion
• Monitor white blood cell count, hematocrit value, and in cold water, or (c) lack of adequate clothing, shelter, or
other pertinent laboratory reports for indications of infec- heat. In older people, the problem can be compounded by
tion or dehydration. a decreased metabolic rate and the use of sedative medica-
• Remove any excess blankets during the plateau and tions. If skin and underlying tissues are damaged by freezing
defervescence phase (when the patient feels warm), but cold, it results in frostbite. Frostbite most commonly occurs
provide extra warmth during the onset phase (when the
patient feels chilled).
• Provide adequate nutrition and fluids (e.g., 2500–3000 mL
per day, if not contraindicated) to meet the increased meta- Clinical Manifestations
bolic demands and prevent dehydration.
• Measure intake and output. Hypothermia
• Reduce physical activity to limit heat production, espe-
cially during the defervescence stage. Hypothermia typically manifests in the following ways:
• Administer antipyretics (drugs that reduce the level of • Decreased body temperature
fever), if this is part of the patient’s treatment plan. (Note: • Severe shivering (initially)
More and more agencies are recommending the admin- • Feelings of cold and chills
istration of antipyretics only if the patient is uncomfortable • Pale, cool, waxy skin
with the fever or has risk factors that limit the ability to
tolerate the increased BMR—as a result of evidence of • Hypotension
the beneficial effects that a fever has on leukocyte func- • Decreased urinary output
tion and shifting practices to “support the fever.” • Lack of muscle coordination
• Provide oral hygiene to keep the mucous membranes • Disorientation
moist. • Drowsiness progressing to coma
M29_KOZI2703_04_SE_C29.indd 634 27/02/17 1:36 PM

in the hands, feet, nose, and ears of an exposed person. obtain a temperature measurement and when interpret-
Managing hypothermia involves removing the patient from ing the obtained readings. See the Clinical Alert box
the cold and warming the patient’s body. For the patient (page 636) on deciding which route to use when measur-
with mild hypothermia, the body is warmed by applying ing temperature; in addition, see the Clinical Alert box
blankets and covering the head; for the patient with severe (page 637) on ensuring reliability of temperature mea-
hypothermia, an electric hyperthermia blanket is applied, surement over time.
and warm intravenous fluids are given. Rapid rewarming The body temperature is frequently measured orally.
may be dangerous and even life threatening. Rewarm- If a patient has ingested hot food or fluids or has been
ing interventions should be advised from an experienced smoking, the nurse should wait 30 minutes before taking
member of the health care team. Do not immerse a hypo- the temperature orally to ensure that the temperature
thermic patient in warm or hot water, apply heating pads of the mouth has not been affected by the temperature
to extremities, or rub or massage the patient, as all of these of the food, fluid, or warm smoke.
can cause tissue damage. Wet clothing should be replaced Rectal temperature readings are considered to be
with dry clothing. The focus of care should be on heat very accurate. Because inserting a rectal thermometer
retention, restoring normal core body temperature, and the can produce vagal stimulation, which can cause brady-
preservation of tissue (Petrone, Asensio, & Marini, 2014). cardia and syncope, taking rectal temperatures is gener-
ally contraindicated in patients with cardiac arrhythmias
or recovering from a myocardial infarction. Rectal tem-
peratures are usually contraindicated in patients who
Assessing Body Temperature are undergoing rectal surgery, have diarrhea or diseases
There are several possible sites for measuring body tem- of the rectum, are immunosuppressed, have a clotting
perature including oral, rectal, axillary, tympanic mem- disorder, or have significant hemorrhoids.
brane, skin, and temporal artery sites. Each of the sites The axilla is often the preferred site for measur-
has advantages and disadvantages (see Table 29.2). A ing temperature in newborns because it is accessible
wide range of preferred practices and norms exist in the and offers no possibility of rectal perforation. However,
measurement of temperature. Nurses need to consider research indicates that the axillary method is inaccurate
numerous factors when deciding which route to use to when assessing a fever (El-Radhi, 2014). Nurses should
Table 29.2 Advantages and Disadvantages of the Five Sites for Body Temperature Measurement
Site Advantages Disadvantages

Oral Accessible and convenient; con- Thermometers can break if bitten by patient; inaccurate if patient has
sistent measurement; close to ingested hot or cold food or fluid or smoked within the past 30 minutes;
core temperature could injure the mouth following oral surgery; not appropriate for some
patients who are confused, unconscious, or unable to follow directions
Rectal Reliable measurement; closest Inconvenient and more unpleasant for patients; difficult for patient who can-
to core temperature not turn to the side; could injure the rectum; presence of stool may inter-
fere with thermometer placement; if the stool is soft, the thermometer
may be embedded in stool rather than against the mucosal wall of the
rectum. If the stool is impacted, the depth of thermometer insertion may
be insufficient; may stimulate a vagal reaction that leads to bradycardia
and syncope; in newborns and infants, insertion of rectal thermometer
has caused ulcerations and rectal perforations
Axillary Safe and noninvasive The thermometer must be left in place a long time to obtain an accurate
measurement; readings are accurate but must be adjusted, as they are
consistently lower than oral (by 0.5C°) and rectal (by 1.0°C); may be inac-
curate if patient has bathed within the past 30 minutes or if patient is
experiencing vasoconstriction, vasodilation, or sweating (Sund-Levander
& Grodzinsky, 2013)
Tympanic Readily accessible; reflects core Can be uncomfortable and involves risk of injuring the membrane if the probe
membrane temperature; very fast is inserted too far; repeated measurements may vary between and within
patients; right and left measurements can differ; more variable results than
oral or rectal thermometry; presence of cerumen can affect the reading;
subject to considerable error if tympanic thermometer is used incorrectly.
Temporal artery Safe and noninvasive; very fast; Requires electronic equipment that may be expensive or unavailable; varia-
does not require patient tion in technique needed if the patient has perspiration on the forehead
cooperation
M29_KOZI2703_04_SE_C29.indd 635 27/02/17 1:36 PM

check agency protocol when taking the temperature of

newborns, infants, toddlers, and children. The axillary
temperature assessment method is appropriate for adult
patients for whom other temperature sites are contrain-
dicated (e.g., following oral surgery, agitation).
The tympanic membrane, in the ear canal, is a frequent
site for estimating core body temperature. Like the sublin-
gual oral site, the tympanic membrane has an abundant
arterial blood supply, primarily from branches of the exter-
nal carotid artery. Because temperature sensors applied
directly to the tympanic membrane can be uncomfortable
and involve risk of membrane injury or perforation, non-
invasive infrared thermometers are used to detect the tempera-
ture of the thermal radiation emitted from the tympanic
membrane (eardrum) and surrounding ear canal.
The temperature can also be measured on the fore-
head by using a chemical thermometer or a temporal
artery thermometer. Forehead temperature measure-
ments are most useful for infants and children on occa-
Hugo Marchand
sions when a more invasive measurement is not necessary.
Types of Thermometers Traditionally, body tem- A
peratures have been measured by using mercury-in-glass
thermometers. These are rarely seen anymore, as mercury
thermometers can be hazardous if cracked or broken,
leaking out toxic mercury. These thermometers can also
be difficult to read and use properly. Clients who have glass
thermometers in their homes should be encouraged to
bring them to a pharmacy for proper disposal and replace
them with a non-mercury-type thermometer.
Electronic thermometers can provide a reading in as little
as two seconds, depending on the model. The equipment
kontur-vid/Fotolia
consists of a battery-operated portable electronic unit
(Figure 29.4), a probe, and a disposable probe cover.
Chemical disposable thermometers have liquid crystal dots
B
or bars that change colour to indicate temperature. One
type that has small chemical dots at one end is shown in Figure 29.4 Electronic thermometers. A, Institutional
Figure 29.5. To read the temperature, the nurse notes the model; B, One-piece home digital thermometer.
highest reading among the dots that have changed colour.
Temperature-sensitive tape can also be used to obtain a by the manufacturer (e.g., 15 seconds), a colour appears
general indication of body surface temperature. It does on the tape. The tape is removed and discarded after the
not indicate the core temperature. The tape contains liq- colour has been compared with the scale provided by the
uid crystals that change colour according to temperature. manufacturer. This method is particularly useful at home
When applied to dry skin, usually on the forehead or abdo- and for infants whose temperatures are to be monitored.
men, the temperature digits on the tape respond by chang- Infrared thermometers sense body heat in the form
ing colour (Figure 29.6). After the length of time specified of infrared energy given off by a heat source, which,
A
Clinical Al ert
When deciding which route to use to measure a patient’s
body temperature, the nurse should use the least invasive route for
patients who are not critically ill or merely being screened for fever and B
the route that will yield the most accurate measurement for patients who
are critically ill, unstable, or requiring a definitive diagnosis of fever. If C
trying to determine the presence or absence of fever in a patient, use the
same route of measurement as used previously with the patient to make
the most accurate assessment, and compare previous measurements to
the most recent measurement. Figure 29.5 Chemical dot thermometers: A, Axillary (note the
“Ax”); B, Rectal (note the plastic cover); C, oral.
M29_KOZI2703_04_SE_C29.indd 636 27/02/17 1:37 PM

Mihai Bogdan/Shutterstock
Pearson Education, inc.
Figure 29.8 A temporal artery thermometer.

Figure 29.6 A temperature-sensitive skin tape.
in the ear canal, is primarily the tympanic membrane • Possibility of inaccuracy when measuring tempera-
(Figure 29.7). The infrared thermometer makes no tures under 36.5°C
contact with the tympanic membrane but detects the
Temporal artery (TA) thermometers use scanning infrared
temperature of the thermal radiation emitting from it.
rays to compare arterial temperature in the temporal
Infrared tympanic membrane thermometry is a common
artery of the forehead with the temperature in the room
method of assessing body temperature in care settings
and calculate the heat balance to approximate the core
because of its relative convenience. However, there are
temperature of blood in the pulmonary artery. The
numerous sources of error that can lead to false readings.
probe of the thermometer is placed in the middle of
These errors can include
the forehead and then drawn laterally to the hairline. If
• Improper technique, such as ineffective positioning the patient has perspiration on the forehead, the probe is
inside the ear or incorrect “ear tug” also touched behind the earlobe so the thermometer can
• Improper probe size relative to the ear canal compensate for evaporative cooling (Figure 29.8).
Patients may need to be taught how to use and read
• Reduced accuracy because of the presence of ceru-
a thermometer properly when they are sent home. See
men in the ear canal
the Teaching: Home Care box.
• Inaccurate measurement because of the equipment Skill 29.1 explains how to measure body tempera-
(e.g., dirty lens, instrument temperature being differ- ture. (See also the Lifespan Considerations box on assess-
ent from ambient environment temperature, improper ing body temperature.)
instrument calibration, and variations among differ-
ent brands in terms of design, technology, offsets, and
operating instructions)
Pulse
The pulse is a wave of blood created by contraction
of the left ventricle of the heart. Generally, the pulse
wave represents the stroke volume output (the amount
of blood entering the arteries with each ventricular con-
traction). Compliance of the arteries is their ability to
contract and expand. When a person’s arteries lose their
distensibility, as can happen in old age, greater pressure
is required to pump the blood into the arteries.
Dorling Kindersley Publishing, Inc.
Clini cal Alert

To increase the reliability of temperature measurements in
a patient over time, the nurse should use the same method and route
of measurement as much as possible. Otherwise, measurements cannot
be compared with one another and used to establish a consistent trend
Figure 29.7 An infrared (tympanic) thermometer used to within the patient.
measure the tympanic membrane temperature.
M29_KOZI2703_04_SE_C29.indd 637 02/03/17 5:25 PM

TEACHING HOME CARE
Temperature
Being able to take their temperature at home is an important • Discuss means of keeping the thermometer clean,
skill for patients to have. such as warm water and soap, and avoiding cross-
contamination.
• Teach the patient to accurately use and read the
type of thermometer to be used. Many patients have • Ensure that the patient has water-soluble lubricant if
tympanic thermometers but are not aware that these using a rectal thermometer.
instruments require a level of skill to ensure accurate • Instruct the patient or family member to notify the
readings. Examine the thermometer used by the patient health care provider if the temperature is 38°C or
in the home for safety and proper functioning. Facilitate higher.
the disposal (generally at a pharmacy) and replacement • Check that the patient knows how to record the tem-
of mercury thermometers with nonmercury ones. perature, if required.
• Observe the patient or caregiver taking and reading a • Discuss relevant and appropriate measures to take
temperature. Reinforce the importance of reporting the during illness.
site and type of thermometer used and the value of
using one consistently.
SKILL 29.1 ASSESSING BODY TEMPERATURE
PURPOSE 3. Provide for patient privacy.

• To establish baseline data for subsequent evaluation 4. Place the patient in the appropriate position (e.g., lateral or
Sims’ position for inserting a rectal thermometer).
• To identify whether the core temperature is within normal range
5. Place the thermometer (see ❶ through ❺).
• To determine changes in the core temperature in response
to specific therapies (e.g., antipyretic medication, immuno- • Apply a protective sheath or probe cover, if appropriate.
suppressive therapy, invasive procedure) • Lubricate the rectal thermometer.
• To monitor patients at risk for alterations in temperature 6. Wait the appropriate amount of time. Electronic and tym-
(e.g., patients at risk for infection or diagnosis of infection) panic thermometers will indicate that the reading is com-
plete through a light or tone. Check package instructions
ASSESSMENT for length of time to wait before reading chemical dot or
tape thermometers.
Assess
7. Remove the thermometer, and discard the cover or wipe with
• Clinical signs of fever (pyrexia) a tissue, if necessary. If gloves were applied, remove them.
• Clinical signs of hypothermia • Perform hand hygiene.
• Site most appropriate for measurement 8. Read the temperature (prior to recapping if electronic) and
• Factors that can alter core body temperature record it. If the temperature is obviously too high, too low,
or inconsistent with the patient’s condition, recheck it with
Equipment a thermometer known to be functioning properly.
• Thermometer 9. Wash the thermometer, if necessary, and return it to the
storage location.
• Thermometer sheath or cover
10. Perform hand hygiene, and follow other appropriate infec-
• Water-soluble lubricant and tissue, if the rectal site is used tion prevention and control procedures.
• Clean gloves for a rectal temperature
11. Document the temperature in the patient record. A rectal
• Towel for axillary temperature temperature may be recorded with an “R” next to the value
• Tissues or wipes or with the mark on a graphic sheet circled. An axillary
temperature may be recorded with “AX” or marked on a
graphic sheet with an “X.”
IMPLEMENTATION
Preparation EVALUATION
Check that all equipment is functioning normally. • Compare the temperature measurement to baseline
data, the normal range for the age of the patient, and the
Performance patient’s previous temperatures. Analyze by considering the
time of day and any additional influencing factors and other
1. Before performing the procedure, introduce yourself to vital signs.
the patient, and verify the patient’s identity by using two
• Conduct appropriate follow-up, such as notifying the appro-
identifiers. Explain to the patient what you are going to do,
priate members of the health care team, giving a medica-
tion, removing heavy coverings, or altering the patient’s
2. Perform hand hygiene, and follow other appropriate infec- environment.
tion prevention and control procedures. Put on gloves, if
performing a rectal temperature.
M29_KOZI2703_04_SE_C29.indd 638 17/03/17 1:14 PM

Thermometer Placement
Oral Rectal
Place the tip under the tongue in the sublingual pocket Put on clean gloves. Apply a thermometer cover, if required by
beside the frenulum (see ❶). device.
Apply lubricant to the insertion end of the thermometer.
Instruct the patient to take a slow deep breath during insertion (see ❷).
Never force the thermometer if resistance is felt.
Insert 3.5 cm in adults.

❶ Oral thermometer placement.).
❷ Inserting a rectal thermometer.
Axillary Tympanic
Pat the axilla dry if very moist. Pull the pinna slightly upward and backward (see ❹).
The tip is placed in the centre of the axilla (see ❸), then Point the probe slightly anteriorly, toward the eardrum.
adduct the arm over the thermometer. Insert the probe slowly by using a circular motion until snug.

❸ Placing the tip of the thermometer in the centre of
the axilla. ❹ Inserting and pointing the tympanic thermometer.
Temporal Artery
Brush hair aside if it is covering the temporal artery area.
With the probe flush on the centre of the forehead,
depress the red button, and keep it depressed. Slowly
slide the probe midline across the forehead to the hairline,
not down the side of the face (see ❺A). Lift the probe
Courtesy Exergen Corporation
from the forehead and touch it on the neck, just behind

the earlobe (see ❺B). Release the button.
❺A and ❺B Positioning the temporal artery thermometer.
M29_KOZI2703_04_SE_C29.indd 639 02/03/17 5:25 PM

Assessing Body Temperature

Infants
• The body temperature of newborns is labile, and newborns
must be kept warm and dry to prevent hypothermia.
• When using the axillary site, hold the infant’s arm against
the chest (see Figure 29.9).
Figure 29.10 Pull the pinna of the ear back

and up for placement of a tympanic thermom-
eter in a child over 3 years of age and back

and down in children under 3 years.
Patrick Watson/
• The oral route can be used for children over age 3 years,
but unbreakable electronic thermometers are recommended.
Figure 29.9 Axillary thermometer • For a rectal temperature, place the child prone across your
placement for a child. lap or in the side-lying position with the knees flexed. Insert
the thermometer 2.5 cm into the rectum.
• The axillary route may not be as accurate as other routes
for detecting fevers in children.
Older Adults
• The tympanic route is fast and convenient but needs to be
avoided if the child has an active ear infection or drainage • Older adults’ temperatures tend to be lower than those of
tubes. Place the infant in the supine position, and stabilize middle-aged adults; they also tend to have a diminished
the head. Pull the pinna straight back and slightly downward. fever response as a result of physiological changes associ-
Direct the probe tip anteriorly and insert far enough to seal ated with aging.
the canal. The tip will not touch the tympanic membrane. • Their temperatures are strongly influenced by environ-
• The tympanic membrane route may be more accurate in mental temperature changes as thermoregulation control
determining temperature in febrile infants. processes are not as efficient as when they were younger,
• Infants tolerate temporal artery thermometry well. and they are at higher risk for both hypothermia and
hyperthermia.
• The rectal route is least desirable for use in infants. How-
ever, sometimes it is used to obtain definitive temperature • Older adults can develop significant buildup of ear cerumen
measurements. that may interfere with tympanic thermometer readings.
• Inspect the anus for hemorrhoids before taking a rectal
Children temperature.
• Older adults’ temperatures may not be a valid indication
• Tympanic or temporal artery sites are preferred. of the seriousness of the pathology of a disease. In the
• For the tympanic route, have the child held on an adult’s lap presence of fever, there is a strong possibility of infection,
with the child’s head held gently against the adult for sup- the source of which should be determined and treated
port. Pull the pinna straight back and upward for children promptly.
over age 3 years (Figure 29.10). • Other symptoms, such as confusion and restlessness, may
• Avoid the tympanic route in a child with active ear infections be displayed and need follow-up.
or tympanic membrane drainage tubes.
Cardiac output is the volume of blood pumped pulse. See the section on assessing the apical pulse later
into the arteries by the heart and equals the result of in this chapter. A peripheral pulse is located in the
the stroke volume (SV) multiplied by the heart rate (HR) periphery of the body, such as in the foot, hand, or neck.
per minute. For example, 65 mL × 70 beats per minute The apical pulse, in contrast, is a central pulse; that is,
= 4.55 L per minute. When an adult is resting, the heart it is located at the apex of the heart. It is also referred to
pumps about 5 L of blood each minute. as the point of maximal impulse (PMI).
In a healthy person, the pulse reflects the heartbeat;
that is, the pulse rate is the same as the rate of the ven-
tricular contractions of the heart. However, in some types Factors Affecting Pulse Rate
of cardiovascular disease, the heartbeat and pulse rates The rate of the pulse is expressed in beats per minute
can differ. For example, a patient’s heart may produce
(beats/min). A pulse rate varies according to a number
very weak or small pulse waves that are not detectable in
of factors. The nurse should consider each of the follow-
a peripheral pulse distal to the heart. In these instances,
ing factors when assessing a patient’s pulse:
the nurse should assess the heartbeat and the peripheral
M29_KOZI2703_04_SE_C29.indd 640 02/03/17 5:25 PM

• Age. As age increases, the pulse rate gradually Pulse Sites

decreases. See Table 29.3 for specific variations in
pulse rates from birth to adulthood. A pulse can be measured in nine sites—eight peripheral
sites (Figure 29.11) and one at the apex of the heart
• Sex. After puberty, the average male’s pulse rate is
(Figure 29.12):
slightly lower than the average female’s.
• Exercise. The pulse rate normally increases with activ- 1. Temporal, where the temporal artery passes over the
ity. The rate of increase in the professional athlete temporal bone of the head. The site is superior (above)
is often less than in the average person because of and lateral (away from the midline of) to the eye.
greater cardiac size, strength, and efficiency. 2. Carotid, at the side of the neck where the carotid artery
• Fever. The pulse rate increases (a) in response to the runs between the trachea and the sternocleidomastoid
lowered blood pressure that results from peripheral muscle. See the Clinical Alert box.
vasodilation associated with elevated body tempera-
ture and (b) with an increased metabolic rate.
• Medications Some medications decrease the pulse rate,
and others increase it. For example, cardiotonics (e.g.,
digitalis) and beta-blockers decrease the heart rate; Temporal artery
epinephrine increases it.
• Hypovolemia. Loss of blood from the vascular system
Common carotid
increases pulse rate. An adult has about 5 L of blood in
artery
the circulatory system and can usually lose up to 10%
without adverse effects. Fluid volume deficits caused
by extensive diarrhea and vomiting or prolonged lack
of fluid intake can also cause increased pulse rate.
• Stress. In response to stress, sympathetic nervous stimu-
lation increases the overall activity of the heart. Stress
Brachial
increases the rate as well as the force of the heartbeat.
artery
Fear and anxiety, as well as the perception of severe
pain, stimulate the sympathetic system. Radial
• Position. When a person assumes a sitting or standing artery
position, blood usually pools in dependent vessels of the
venous system. Pooling results in a transient decrease in
the venous blood return to the heart and a subsequent
reduction in blood pressure and increase in heart rate.
• Pathology. Certain diseases, such as some heart condi-
tions or those that impair oxygenation, can alter the
Femoral
resting pulse rate.
artery
Table 29.3 Variations in Pulse and Respirations by Age

Popliteal
Pulse Average Respirations Average artery
Age (and Range) (and Range)
Newborn 120 (100–170) 35 (30–80)
(0–4 weeks)
<1 year 120 (80–140) 30 (20–40)
1–4 years 110 (80–120) 25 (20–30) Posterior

tibial artery
5–8 years 100 (75–120) 20 (15–25)
Dorsalis
9–10 years 70 (50–90) 19 (15–25) pedis artery
11–19 years 75 (50–90) 18 (15–20)

Figure 29.11 Body sites where the peripheral pulse is most
20–64 years 80 (60–100) 16 (12–20) easily palpated.
Source: From D’Amico, D., et al. (2012). Health & Physical Assessment in Nursing,
>65 years 70 (60–100) 16 (15–20) Canadian Edition, Pearson Education Canada. Reprinted with permission by Pearson
Canada Inc.
M29_KOZI2703_04_SE_C29.indd 641 27/02/17 1:37 PM

Midclavicular line Anterior axillary line

Midsternal line
Apical pulse
Clavicle before age
4 years
Angle of
Louis
Apical pulse
Body of at ages
sternum 4 to 6 years
Xiphoid Apical pulse

process in adult
Figure 29.12 Locations of the apical pulse in a child younger than 4 years, a child 4 to 6 years, and an adult.
Source: From D’Amico, D., et al. (2012). Health & Physical Assessment in Nursing, Canadian Edition, Pearson Education Canada. Reprinted with permission by Pearson Canada Inc.
9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes

Clinical Al ert over the bones of the foot. This artery can be palpated
Never press both carotid arteries at the same time, as this by feeling the dorsum (upper surface) of the foot on an
can cause a reflex drop in blood pressure or pulse rate. imaginary line drawn from the middle of the ankle to
the space between the big and second toes.
The radial site is most commonly used. It is easily
detected in most people and readily accessible. The rea-
3. Apical, at the apex of the heart. In an adult, this is sons for use of each site are given in Table 29.4.
located on the left side of the chest, no more than
8 cm to the left of the sternum (breastbone) and at the
Table 29.4 Reasons for Using Specific Pulse Site
fourth, fifth, or sixth intercostal space (area between
the ribs). In older adults, the apex may be further left Pulse Site Reasons for Use
if there are conditions that have led to an enlarged
heart. Before age 4 years, the apex is left of the mid- Radial Readily accessible
clavicular line (MCL); between ages 4 and 6 years, it is Temporal Used when radial pulse is not accessible
at the MCL (see Figure 29.12). For a child 7 to 9 years Carotid Used during cardiac arrest or shock in
of age, the apical pulse is located at the fourth or fifth adults
intercostal space.
To determine circulation to the brain
4. Brachial, at the inner aspect of the biceps muscle of
the arm (especially in infants) or medially in the ante- Apical Routinely used in infants and children up to
3 years of age
cubital space.
5. Radial, where the radial artery runs along the radial To determine discrepancies with radial pulse
bone, on the thumb side of the inner aspect of the To monitor some medication effects
wrist. Brachial To measure blood pressure
6. Femoral, where the femoral artery passes alongside the
During cardiac arrest in infants
inguinal ligament.
Femoral Used in cases of cardiac arrest or shock
7. Popliteal, where the popliteal artery passes behind the
knee. This point may be difficult to locate, but it can To determine circulation to the leg
be palpated if the patient flexes the knee slightly. Popliteal To determine circulation to the lower leg
8. Posterior tibial, on the medial surface of the ankle, Posterior tibial To determine circulation to the foot
where the posterior tibial artery passes behind the
Pedal To determine circulation to the foot
medial malleolus.
M29_KOZI2703_04_SE_C29.indd 642 27/02/17 1:37 PM

Assessing the Pulse between beats of a normal pulse. A pulse with an

irregular rhythm is referred to as a dysrhythmia or
A pulse is commonly assessed by palpation or ausculta- arrhythmia. It may consist of random, irregular beats
tion. A peripheral pulse is normally palpated by apply- or a predictable pattern of irregular beats referred to
ing moderate pressure with the three middle fingers of as regular-irregular arrhythmia. When a dysrhythmia is
the hand. The pads on the most distal aspects of the detected, the apical pulse should be assessed. An elec-
finger are the most sensitive areas for detecting a pulse. trocardiogram (ECG) is necessary to further define the
The thumb is not used to palpate because it has its own dysrhythmia.
pulse, which can be confused with the patient’s pulse. Pulse volume, also called pulse strength oramplitude,
Excessive pressure can obliterate a pulse, whereas too refers to the force of blood with each beat. Usually, pulse
little pressure may make it undetectable. A stethoscope volume is the same with each beat. It can range from
is used for assessing apical pulses. A Doppler ultrasound absent to bounding. A normal pulse can be felt with
stethoscope (DUS; see Figure 29.13) with a volume- moderate pressure of the fingers and can be obliterated
controlled audio unit is used for pulses that are difficult with greater pressure. A forceful or full blood volume
to assess. that is obliterated only with difficulty is called a full
Before the nurse assesses the resting pulse, the patient orbounding pulse. A pulse that is readily obliterated with
should assume a comfortable position. The nurse should pressure from the fingers is referred to as weak, feeble,
also be aware of the following: orthready. A pulse volume can be measured on a scale of
• Any medication that could affect the heart rate 0 to 4 (indicated by ×/4):
• Whether the patient has been physically active; if so,
wait 10 to 15 minutes until the patient has rested and 0 Absent, not discernible
the pulse has returned to its usual rate +1 Thready or weak, difficult to feel
• Any baseline data about the usual heart rate for the +2 Normal, detected readily, obliterated by
patient; for example, a physically fit athlete may have strong pressure
a heart rate below 60 beats/min +3 Increased
• Whether the patient should assume a particular posi- +4 Bounding
tion (e.g., sitting); in some patients, the rate changes
with the position because of changes in blood flow The elasticity of the arterial wall reflects its expan-
volume and autonomic nervous system activity sibility or its deformities. A healthy, normal artery feels
When assessing the pulse, the following data are col- straight, smooth, soft, and pliable. Older people often
lected: rate, rhythm, volume, arterial wall elasticity, and have inelastic arteries that feel tortuous (twisted) and irreg-
presence or absence of bilateral equality. Tachycardia ular on palpation.
is an excessively fast heart rate (e.g., more than 100 When assessing a peripheral pulse to determine the
beats/min in an adult); bradycardia is a heart rate that adequacy of blood flow to a particular area of the body,
is lower than normal (e.g., less than 60 beats/min in an the corresponding pulse on the other side of the body
adult). If a person has tachycardia or bradycardia, the should be assessed to compare the pulses. For example,
apical pulse should be assessed. when assessing the blood flow to the right foot, the nurse
The pulse rhythm is the pattern of the beats assesses the right dorsalis pedis pulse and then the left
and the intervals between the beats. Equal time elapses dorsalis pedis pulse. If the patient’s right and left pulses
are the same, the patient’s dorsalis pedis pulses are bilater-
ally equal.
When a peripheral pulse is located, it indicates that
pulses more proximal to that location will also be present.
For example, if the dorsalis pedis, the most distal pulse
of the lower extremity, cannot be felt, the nurse next
palpates for the posterior tibial pulse. If it is not felt, the
popliteal pulse must be assessed. If the popliteal pulse is

found, it is not necessary to assess the femoral pulse, since
it must also be present for the more distal pulse to exist.
Skill 29.2 provides guidelines for assessing a periph-
eral pulse.
Apical Pulse Assessment Assessment of the apical

pulse is indicated for patients whose peripheral pulse is
irregular as well as for patients with known cardiovas-
Figure 29.13 A Doppler ultrasound stethoscope (DUS). cular, pulmonary, and renal diseases. It is commonly
M29_KOZI2703_04_SE_C29.indd 643 27/02/17 1:37 PM

SKILL 29.2 ASSESSING A PERIPHERAL PULSE
PURPOSES
• To establish baseline data for subsequent evaluation
IMPLEMENTATION
• To identify whether the pulse rate is within normal range
• To determine whether the pulse rhythm is regular and the Preparation
pulse volume is appropriate If using a DUS, ensure that the equipment is functioning
• To compare the equality of corresponding peripheral pulses normally.
bilaterally
Performance
• To monitor and assess changes in the patient’s health
status 1. Before performing the procedure, introduce yourself to the
• To monitor patients at risk for pulse alterations (e.g., those patient, and verify the patient’s identity by using two identi-
with a history of heart disease or experiencing cardiac fiers. Explain to the patient what you are going to do, why it
arrhythmias, hemorrhage, acute pain, infusion of large vol- is necessary, and how he or she can participate.
umes of fluids, fever) 2. Perform hand hygiene, and follow other appropriate infec-
• To evaluate blood perfusion to the extremities tion prevention and control procedures.
3. Provide for patient privacy.
ASSESSMENT 4. Select the pulse point. Normally, the radial pulse is taken,
unless it cannot be exposed or circulation to another body
Assess area is to be assessed.
• Clinical signs of cardiovascular alterations, such as dys- 5. Assist the patient to a comfortable resting position. When
pnea, fatigue, pallor, cyanosis, palpitations, syncope, or the radial pulse is assessed, with the palm facing down-
impaired peripheral tissue perfusion, as evidenced by skin ward, the patient’s arm can rest alongside the body or the
discoloration and cool temperature forearm can rest at a 90-degree angle across the chest.
For the patient who can sit, the forearm can rest across
• Factors that may alter pulse rate (e.g., emotional state and
the thigh, with the palm of the hand facing downward or
activity level)
inward.
• Which site is most appropriate for assessment based on
6. Palpate and count the pulse. Place two or three middle
the purpose
fingertips lightly and squarely over the pulse point
(see ❶). Rationale: Using the thumb is contraindicated
Equipment because the nurse’s thumb has a pulse that could be
mistaken for the patient’s pulse.
• Watch with a second hand or indicator
• Count for 30 seconds and multiply by 2 to obtain beats
• If using a Doppler ultrasound stethoscope (DUS): trans- per minute. If taking a patient’s pulse for the first time,
ducer probe, stethoscope headset, transmission gel, and when obtaining baseline data, or if the pulse is irregular
tissues or wipes or difficult to assess, count for a full minute. If an irregu-
lar pulse is found, take the apical pulse also.
❶ Assessing the pulses.
A Radial B Brachial
D Femoral
C Carotid
M29_KOZI2703_04_SE_C29.indd 644 17/03/17 1:15 PM

• Hold the probe against the patient’s skin over the pulse
site. Use light pressure, and keep the probe in contact
with the skin (see ❷). Rationale: Too much pressure
can stop the blood flow and obliterate the signal.
• After assessing the pulse, remove all of the gel from
the probe and clean the transducer with a water-based
solution. Rationale: Alcohol or other disinfectants
may damage the face of the transducer. Remove
all of the gel from the patient’s skin.
E Popliteal
❷ Using a DUS to assess the posterior tibial pulse.

F Posterior tibial
7. Assess pulse rhythm and volume.

• Assess pulse rhythm by noting the pattern of the inter-
vals between the beats. A normal pulse has equal
periods between beats. If this is an initial assessment,
assess for 1 minute.
• Assess pulse volume. A normal pulse can be felt with
moderate pressure, and the pressure is equal with each
beat.
G Pedal (dorsalis pedis) 9. Document pulse rate, rhythm, and volume (e.g., 76, regular,
2+) and your actions in the patient record. Also record per-
tinent related data, such as any variation in pulse rate com-
Variation: Using a DUS pared with normal for the patient and abnormal skin colour
and skin temperature.
• Adjust the volume, if necessary. Distinguish artery
sounds from vein sounds. The artery sound (signal) is Evaluation
distinctively pulsating and has a pumping quality. The
venous sound is intermittent and varies with respirations. • Compare the pulse rate to baseline data or the usual range
Both artery and vein sounds are heard simultaneously for the age of the patient.
through the DUS because major arteries and veins are • Relate pulse rate and volume to other vital signs, and relate
situated close together throughout the body. If arterial pulse rhythm and volume to baseline data and health
sounds cannot be easily heard, reposition the probe. status.
• Apply transmission gel either to the probe at the narrow • If assessing peripheral pulses, evaluate equality, rate, and
end of the plastic case housing the transducer or to the volume in corresponding extremities.
patient’s skin. Rationale: The gel makes an airtight • Conduct appropriate follow-up, such as notifying the
seal, which then promotes optimal ultrasound appropriate members of the health care team or giving
wave transmission. medication.
• Press the “On” button.
Images by: Richard Tauber/Pearson Education, Inc.
M29_KOZI2703_04_SE_C29.indd 645 27/02/17 6:04 PM

assessed before administering medications that affect APICAL–RADIAL PULSE ASSESSMENT An apical–
heart rate. The apical site is also used to assess the radial pulse may need to be assessed for patients with
pulse for newborns, infants, and children up to age 2 to certain cardiovascular disorders. Normally, the apical
3 years. Skill 29.3 presents guidelines for assessing the and radial rates are identical. An apical pulse rate greater
apical pulse. than a radial pulse rate can indicate that the thrust of the
SKILL 29.3 ASSESSING AN APICAL PULSE
PURPOSES Performance
• To obtain the heart rate of newborns, infants, and children 1. Before performing the procedure, introduce yourself to the
age 2 to 3 years or of an adult with an irregular peripheral patient, and verify the patient’s identity by using two identi-
pulse fiers. Explain to the patient what you are going to do, why it
• To establish baseline data for subsequent evaluation is necessary, and how he or she can participate.
• To determine whether the cardiac rate is within normal 2. Perform hand hygiene, and follow other appropriate infec-
range and the rhythm is regular tion prevention and control procedures.
• To monitor patients with cardiac disease and those receiv- 3. Provide for patient privacy.
ing medications to improve heart action 4. Position the patient appropriately and comfortably in the
supine position or in the sitting position. Expose only the
ASSESSMENT area of the patient’s chest over the apex of the heart. Be as
discrete as possible. Keep the patient’s breasts covered as
Assess much as possible.
• Clinical signs of cardiovascular alterations (e.g., dyspnea, 5. Locate the apical impulse. This is the point over the apex of
fatigue or weakness, pallor, cyanosis, syncope) the heart where the apical pulse can be most clearly heard.
• Factors that may alter pulse rate (e.g., emotional state, • Palpate the angle of Louis (the angle between the
activity level, and medications that affect heart rate, such as manubrium, the top of the sternum, and the body of the
digoxin or beta-blockers) sternum). It is palpated just below the suprasternal notch
and is felt as a prominence (see Figure 29.12).
Equipment • Slide your index finger just to the left of the sternum, and
palpate the second intercostal space (see ❶).
• Watch with a second hand or indicator • Place your middle or next finger in the third intercostal
• Stethoscope space, and continue palpating downward until you
• Antiseptic wipes locate the fifth intercostal space (see ❷).
• If using a DUS: the transducer probe, the stethoscope • Move your index finger laterally along the fifth intercostal
headset, transmission gel, and tissues or wipes space toward the MCL (see ❸). Normally, the apical
impulse is palpable at or just medial to the MCL.
IMPLEMENTATION • If the patient is a female with large breasts, displace the
breast to find the apical impulse.
Preparation 6. Auscultate and count heartbeats.
If using a DUS, ensure that the equipment is functioning • Use antiseptic wipes to clean the earpieces and dia-
normally. phragm of the stethoscope. Rationale: This promotes
infection control.
❶ Second intercostal space. ❷ Third intercostal space. ❸ Fifth intercostal space, MCL.
M29_KOZI2703_04_SE_C29.indd 646 17/03/17 1:16 PM

• Warm the diaphragm of the stethoscope by holding it

in the palm of the hand for a moment. Rationale: This
promotes comfort, as the metal of the diaphragm
is usually cold.
• Insert the earpieces of the stethoscope into your ears
in the direction of the ear canals, or slightly forward.
Rationale: This facilitates hearing.
• Tap your finger lightly on the diaphragm to be sure it is
the active side of the head. If necessary, rotate the head
to select the diaphragm side (see ❹).
• Place the diaphragm of the stethoscope over the api-
cal impulse and listen for S1 and S2 heart sounds (see
Chapter 28); each pairing of S1 and S2 represents one
heartbeat (see ❺). Rationale: The heartbeat is nor-
mally loudest over the apex of the heart. S1
represents closure of the atrioventricular valves; ❹ A Stethoscope with both bell-shaped and flat-disc amplifiers.
S2 occurs when the semilunar valves close after
the ventricles empty.
• If you have difficulty hearing the apical pulse, ask the
supine patient to roll onto his or her left side or the sit-
ting patient to lean slightly forward. Rationale: This
positioning moves the apex of the heart closer to
the chest wall.
• If the rhythm is regular, count the heartbeats for 30 sec-
onds and multiply by 2. If the rhythm is irregular or for
giving certain medications, such as digoxin, count the
beats for 60 seconds. Rationale: A 60-second count
provides a more accurate assessment of an irregu-
lar pulse compared with a 30-second count.
7. Assess the rhythm of the heartbeat by noting the pattern of
intervals between the beats. A normal pulse has equal peri-
ods between beats.
8. Perform hand hygiene, and follow other appropriate infec- ❹ B Close up of a diaphragm (L) and a bell (R).
9. Document the pulse site, rate, rhythm, and nursing actions
in the patient record. Also, record other pertinent data,
such as variation in pulse rate compared with the usual
for the patient and any abnormal skin colour and skin
temperature.
Evaluation
• Relate pulse rate to other vital signs. Relate pulse rhythm to
baseline data and health status.
• Report to the appropriate members of the health care team
any abnormal findings, such as irregular rhythm, reduced
ability to hear the heartbeat, pallor, cyanosis, dyspnea,
tachycardia, or bradycardia.
• Conduct appropriate follow-up, such as administering medi-
cation prescribed on the basis of the apical heart rate. ❺ Taking an apical pulse by using the diaphragm of the stethoscope.
Images by: Patrick Watson/Elena Dorfman/Pearson Education, Inc.
blood from the heart is too weak for the wave to be felt at rates and needs to be reported promptly. In no instance
the peripheral pulse site, or it can indicate that vascular is the radial pulse greater than the apical pulse.
disease is preventing impulses from being transmitted. A An apical–radial pulse can be taken by two nurses
pulse deficit is a discrepancy between the two pulse or one nurse, although the two-nurse technique is more
M29_KOZI2703_04_SE_C29.indd 647 27/02/17 6:04 PM

accurate. Skill 29.4 outlines the steps for assessing an Inhalation or inspiration refers to the intake of
apical–radial pulse. (See also the Lifespan Consider- air into the lungs. Exhalation or expiration refers to
ations box on assessing an apical–radial pulse.) breathing out, or the movement of gases from the lungs
to the atmosphere. Ventilation is also used to refer to
the movement of air in and out of the lungs.
Breathing is of basically two types: costal (tho-
Respirations racic) breathing and diaphragmatic (abdominal)
breathing. Costal breathing involves the external inter-
Respiration is the act of breathing. External respi- costal muscles and other accessory muscles, such as the
ration refers to the interchange of oxygen and carbon sternocleidomastoid muscles. It can be observed by the
dioxide between the alveoli of the lungs and the pulmo- movement of the chest upward and outward. By contrast,
nary blood. Internal respiration, in contrast, takes diaphragmatic breathing involves the contraction and
place throughout the body; it is the interchange of these relaxation of the diaphragm, and it is observed by the
same gases between the circulating blood and the cells movement of the abdomen, which occurs as a result of
of body tissues. the diaphragm’s contraction and downward movement.
SKILL 29.4 ASSESSING AN APICAL–RADIAL PULSE
PURPOSE 6. Count the apical and radial pulse rates.

• To determine adequacy of peripheral circulation or presence Two-Nurse Technique
of pulse deficit
• Place the watch where both nurses can see it, and decide
ASSESSMENT on a time to begin counting (e.g., when the second hand
is on 12 or an even number on a digital clock). One nurse
Assess says “Start.” Rationale: This ensures that simultaneous
counts are taken.
• Clinical signs of hypovolemic shock (hypotension, pallor,
• Each nurse counts the pulse rate for 60 seconds ending
cyanosis, and cold, clammy skin)
with one nurse saying “Stop.” Rationale: A full 60-second
Equipment count ensures accurate assessment of any discrep-
ancies between the two pulse sites.
• Watch with a second hand or indicator • The nurse who assesses the apical rate also assesses the
• Stethoscope apical pulse rhythm. If the pulse is irregular, note whether
• Antiseptic wipes the irregular beats come at random (called irregular-
irregular) or at predictable times (called regular-irregular).
IMPLEMENTATION • The nurse assessing the radial pulse rate assesses the
radial pulse rhythm and volume.
Preparation
If using the two-nurse technique, ensure that another nurse is One-Nurse Technique
available at this time. • Assess the apical pulse for 60 seconds then assess the
radial pulse for 60 seconds.
Performance
1. Before performing the procedure, introduce yourself to the tion prevention and control procedures.
patient, and verify the patient’s identity by using two identi-
fiers. Explain to the patient what you are going to do, why it 8. Document the apical–radial (AR) pulse data and any pulse
is necessary, and how he or she can participate. deficit in the patient record. Also record related data, such
as variation in pulse rate compared with the normal for the
2. Perform hand hygiene, and follow other appropriate infec- patient and other pertinent observations, such as pallor,
tion prevention and control procedures. cyanosis, or dyspnea.
3. Provide for patient privacy.
4. Position the patient in a comfortable supine or sitting posi-
EVALUATION
tion. Expose the area of the chest over the apex of the • Relate pulse rate and rhythm to other vital signs, to baseline
heart. If previous measurements had been taken, determine data, and to general health status.
what position the patient had assumed then, and use the • Report to the appropriate members of the health care team
same position. Rationale: This ensures an accurate any changes from previous measurements or any discrep-
comparative measurement. ancy between the two pulses.
5. Locate the apical and radial pulse sites. In the two-nurse • Conduct appropriate follow-up, such as administering
technique, one nurse locates the apical impulse by palpa- medication or other actions to be taken for a discrepancy in
tion or with the stethoscope while the other nurse palpates the apical and radial pulse rates.
the radial pulse site (see Skills 29.2 and 29.3).
M29_KOZI2703_04_SE_C29.indd 648 17/03/17 1:17 PM

Assessing the Apical–Radial Pulse

Infants Children • Count the pulse before performing
other uncomfortable procedures so
• Use the apical pulse for the heart rate • To take a peripheral pulse, position that the rate is not artificially elevated
of newborns, infants, and children the child comfortably in the adult’s by the discomfort.
age 2 to 3 years to establish baseline arms, or have the adult remain close
data for subsequent evaluation, to by. This may decrease anxiety in the
determine whether the cardiac rate child and yield more accurate results. Older Adults
is within normal range, and to deter- • To assess the apical pulse, assist a • Cardiac changes in older adults,
mine whether the rhythm is regular. young child to the sitting position. such as a decrease in cardiac output,
• Place the baby in the supine position, • Demonstrate the procedure to the sclerotic changes to heart valves,
and offer a pacifier if the baby is cry- child by using a stuffed animal or and dysrhythmias, often indicate that
ing or restless to avoid any increase doll, and allow the child to handle the obtaining an apical pulse will be more
in the pulse rate. stethoscope before beginning the accurate.
• Locate the apical pulse in the fourth procedure. This will decrease anxiety • Older adults often have decreased
intercostal space, lateral to the mid- and promote positive engagement peripheral circulation, so pedal pulses
clavicular line during infancy. with the procedure. should also be checked for regularity,
• Brachial, popliteal, and femoral pulses • The apex of the heart is normally volume, and symmetry.
may be palpated. Because of a nor- located in the fourth intercostal space • The pulse returns to baseline after
mally low blood pressure and rapid in young children and in the fifth inter- exercise more slowly than with other
heart rate, infants’ other distal pulses costal space in children age 7 years age groups.
may be hard to feel. and older.
• Newborn infants may have heart • Locate the apical impulse along the
murmurs that are not pathological but fourth intercostal space, between the
reflect functional incomplete closure of MCL and the anterior axillary line (see
the ductus arteriosus or foramen ovale. Figure 29.12).
Mechanics and Regulation of Breathing and the sternum moves inward, thus decreasing the size
of the thorax as the lungs are compressed. Normally,
During inhalation, the following processes normally occur breathing is carried out automatically and effortlessly.
(Figure 29.14): The diaphragm contracts (flattens), the An inspiration lasts 1 to 1.5 seconds, and an expiration
ribs move upward and outward, and the sternum moves lasts 2 to 3 seconds.
outward, thus enlarging the thorax and permitting the Respiration is controlled by (a) the respiratory
lungs to expand. During exhalation (Figure 29.15), the centres in the medulla oblongata and the pons of the
diaphragm relaxes, the ribs move downward and inward, brain and (b) the chemoreceptors located centrally in
Diaphragm
contracts
Sternum moves
outward
Diaphragm
contracts Ribs move
upward and
outward
Lateral view Anterior view

Figure 29.14 Respiratory inhalation: Left, Lateral view; Right, Anterior view.
M29_KOZI2703_04_SE_C29.indd 649 27/02/17 1:37 PM

Diaphragm
relaxes
Sternum moves
inward
Diaphragm
relaxes Ribs move
downward
and inward
Lateral view Anterior view

Figure 29.15 Respiratory exhalation: Left, Lateral view; Right, Anterior view.
the medulla and peripherally in the carotid and aortic Factors Affecting Respirations
bodies. These centres and receptors respond to changes
in the concentrations of oxygen (O2), carbon dioxide Several factors influence respiratory rate. Those that
(CO2), and hydrogen (H+) in the arterial blood. See increase the rate include increased metabolism (as caused
Chapter 43 for details. by exercise, fever), stress (as a result of epinephrine release),
increased environmental temperature, and lowered arte-
rial oxygen concentration. Factors that may decrease the
respiratory rate include certain medications (e.g., opioids,
Assessing Respirations barbiturates), sleep, and increased intracranial pressure.
Respirations should be assessed when the patient is The depth of a person’s respirations can be estab-
relaxed because exercise affects respirations, increasing lished by watching the movement of the chest. Respira-
their rate and depth. Anxiety is likely to affect respiratory depth is generally described as normal, deep, or
tory rate and depth as well. Respirations may also need shallow. Deep respirations are those in which a large vol-
to be assessed after exercise to identify the patient’s toler- ume of air is inhaled and exhaled, inflating most of the
ance to activity. Before assessing a patient’s respirations, lungs. Shallow respirations involve the exchange of a small
a nurse should be aware of the following: volume of air and often the minimal use of lung tissue.
During a normal inspiration and expiration, an adult
• The patient’s normal breathing pattern takes in about 500 mL of air. This volume is called the
• The influence of the patient’s health problems on tidal volume. For further information about pulmo-
respirations nary volumes and pulmonary capacities, see Chapter 43.
• Any medications or therapies that might affect Body position also affects the amount of air that
respirations can be inhaled. People in the supine position experience
• The relationship of the patient’s respirations to car- two physiological processes that suppress respiration: an
diovascular function increase in the volume of blood inside the thoracic cav-
ity and compression of the chest. Consequently, patients
The rate, depth, rhythm, and special character- lying on their back have poorer lung aeration, which
istics of respirations should be assessed. The respira- predisposes them to the stasis of fluids and subsequent
tory rate is normally described in breaths per minute. infection, such as pneumonia.
Breathing that is normal in rate and depth is called Respiratory rhythm or pattern refers to the reg-
eupnea. Abnormally slow respirations are referred to ularity of the expirations and the inspirations. Normally,
as bradypnea, and abnormally rapid respirations are respirations are evenly spaced. Respiratory rhythm can
called tachypnea. Apnea is the absence of breathing. be described as regular or irregular. An infant’s respiratory
Hyperventilation refers to very deep, rapid respira- rhythm may be less regular than an adult’s. See Chapter
tions; hypoventilation refers to very shallow, slow 43 for details about abnormal respiratory rhythms.
respirations. For the respiratory rates for different age Respiratory quality or character refers to those
groups, see Table 29.3 on page 641. aspects of breathing that are different from normal,
M29_KOZI2703_04_SE_C29.indd 650 27/02/17 1:37 PM

effortless breathing. Two of these are the amount of effort Skill 29.5 provides guidelines for assessing respi-
a patient must exert to breathe and the sound of breath- rations. (See also the Lifespan Considerations box on
ing. Usually, breathing does not require noticeable effort; assessing respirations.)
some patients, however, exhibit visible effort in breathing
(e.g., using accessory muscles), called laboured breathing.
The sound of breathing is also significant. Normal
breathing is silent, but a number of abnormal sounds,
such as a wheeze, are obvious to the nurse’s ear. Many
Blood Pressure
sounds occur as a result of the presence of fluid in the Arterial blood pressure is a measurement of the
lungs and are most clearly heard using a stethoscope. See pressure exerted by the blood on the vessel walls as it
Chapter 28 for methods (e.g., auscultation, percussion, flows through the arteries. Because the blood moves
etc.) used to assess lung sounds. For details about altered in waves, two blood pressure measures exist. Systolic
breathing patterns and terms used to describe patterns pressure is the pressure of the blood exerted on the
and sounds, see Box 29.2. artery wall as a result of contraction of the left ven-
The effectiveness of respirations is measured, in tricle, that is, the maximum pressure of the height of
part, by the uptake of oxygen from the air into blood the blood wave. Diastolic pressure is the pressure
and the release of carbon dioxide from blood into the when the ventricles are at rest. Diastolic pressure is the
expired air. The amount of hemoglobin in arterial blood lower pressure present at all times within the arteries.
that is saturated with oxygen can be measured indirectly The difference between systolic and diastolic pressures is
through pulse oximetry. A pulse oximeter provides a called pulse pressure. Normal pulse pressure is about
digital readout of both the patient’s pulse rate and the 40 mm Hg but can be as high as 100 mm Hg during
oxygen saturation. (See Skill 29.7 on page 663).
Box 29.2 Altered Breathing Patterns and Sounds
The following lists describe altered breathing patterns and Breath Sounds
sounds:
Audible without Amplification
Breathing Patterns • Stridor: a shrill, harsh sound heard during inspiration with
Rate laryngeal obstruction
• Stertor: snoring or sonorous respiration, usually caused by
• Tachypnea: rapid respiration marked by quick, shallow
a partial obstruction of the upper airway
breaths
• Wheeze: continuous, high-pitched musical squeak or
• Bradypnea: abnormally slow breathing
whistling sound occurring on expiration and sometimes on
• Apnea: cessation of breathing inspiration when air moves through a narrowed or partially
obstructed airway
Volume
• Bubbling: gurgling sounds heard as air passes through
• Hyperventilation: an increase in the amount of air in the moist secretions in the respiratory tract
lungs, characterized by increased rate and depth of
breaths Chest Movements
• Hypoventilation: a reduction in the amount of air in the • Intercostal retraction: indrawing between the ribs
lungs, characterized by shallow respirations
• Substernal retraction: indrawing beneath the breastbone
• Kussmaul’s respiration: abnormally deep, very rapid sighing
• Suprasternal retraction: indrawing above the clavicles
respirations as in diabetic ketoacidosis
• Flail chest: the ballooning out of the chest wall through
Rhythm injured rib spaces; results in paradoxical breathing, dur-
ing which the chest wall balloons on expiration but is
• Cheyne-Stokes respiration: rhythmic waxing and waning of
depressed or sucked inward on inspiration
respirations, from very deep to very shallow breathing and
temporary apnea; associated with increased intracranial Secretions and Coughing
pressure or brain damage and can indicate impending death
• Hemoptysis: the presence of blood in sputum
Ease or Effort
• Productive cough: a cough accompanied by expectorated
• Dyspnea: the subjective sensation of difficult or uncomfort- secretions
able breathing or breathlessness (shortness of breath) • Nonproductive cough: a dry, harsh cough without
• Orthopnea: ability to breathe only in upright sitting or secretions
standing positions
• Nasal flaring: widening of nostrils during inspiration, which
may indicate respiratory distress
M29_KOZI2703_04_SE_C29.indd 651 27/02/17 1:37 PM

SKILL 29.5 ASSESSING RESPIRATIONS
PURPOSES conscious and alert patient, it is best if the nurse counts

respirations as an extension of taking the patient’s pulse.)
• To acquire baseline data against which future measure-
ments can be compared 2. Perform hand hygiene, and follow other appropriate infec-
• To monitor abnormal respirations and respiratory patterns
and identify changes 3. Provide for patient privacy.
• To assess respirations before or after the administration of a 4. Observe or palpate and count the respiratory rate.
medication that influences breathing, such as morphine or • The patient’s awareness that the nurse is counting the
general anesthetics respiratory rate could cause the patient to purposefully
• To monitor patients at risk for respiratory alterations (e.g., alter the respiratory pattern. If you anticipate this, place
those with fever, pain, acute anxiety, chronic obstructive the patient’s arm across the chest and observe the chest
pulmonary disease, respiratory infection, pulmonary edema movements while supposedly taking the radial pulse.
or emboli, chest trauma or constriction, brain stem injury) • Count the respiratory rate for 30 seconds if the respi-
rations are regular. Count for 60 seconds if they are
ASSESSMENT irregular. An inhalation and an exhalation count as one
respiration.
Assess 5. Observe the depth, rhythm, and character of respirations.
• Skin and mucous membrane colour (e.g., cyanosis or • Observe the respirations for depth by watching the
pallor) movement of the chest. Rationale: This helps assess
if respirations are deep, shallow, or normal.
• Position assumed for breathing (e.g., use of orthopneic
[upright] position) • Observe the respirations for regular or irregular rhythm.
Rationale: Normally, respirations are evenly
• Signs of cerebral hypoxia (e.g., irritability, restlessness,
spaced.
drowsiness)
• Observe the character of respirations—the sound
• Chest movements (e.g., intercostal retractions)
they produce and the effort they require. Rationale:
• Activity tolerance Normally, respirations are silent and effortless.
• Chest pain 6. Perform hand hygiene, and follow other appropriate infec-
• Subjective respiratory complaints (e.g., dyspnea) tion prevention and control procedures.
• Medications affecting respiratory rate 7. Document respiratory rate, depth, rhythm, and character on
the appropriate record.
Equipment
• Watch with a second hand or indicator EVALUATION
• Relate respiratory rate to other vital signs, in particular,
IMPLEMENTATION pulse rate; relate respiratory rhythm and depth to the
patient’s baseline data and health status.
Preparation
• Report to the appropriate members of the health care team any
For a routine assessment of respirations, determine the
respiratory rate significantly above or below the normal range
patient’s activity schedule, and choose a suitable time to moni-
and any notable change in respirations from previous assess-
tor the respirations. A patient who has been exercising will
ments; irregular respiratory rhythm; inadequate respiratory
need to rest for a few minutes to permit the accelerated respi-
depth; abnormal character of breathing (orthopnea, wheezing,
ratory rate to return to normal.
stridor, or bubbling); and any complaints of dyspnea.
Performance • Conduct appropriate follow-up, such as administering
oxygen or other appropriate medications, treatments, or
1. Before performing the procedure, introduce yourself to the positioning the patient to ease breathing, and requesting
patient, and verify the patient’s identity by using two identi- involvement of other members of the health care team,
fiers. Explain to the patient what you are going to do, why such as the respiratory therapist.
it is necessary, and how he or she can participate. (For the
Assessing Respirations
INFANTS • Infants and young children use their diaphragms for inhala-
tion and exhalation. If necessary, place your hand gently on
• An infant or a child who is crying will have an abnormal the infant’s abdomen to feel the rapid rise and fall during
respiratory rate and rhythm and needs to be quieted before respirations.
respirations can be accurately assessed.
M29_KOZI2703_04_SE_C29.indd 652 17/03/17 1:18 PM

• Most newborns are obligate nose breathers, and nasal place your hand gently on the abdomen to feel the rapid
obstruction can be life threatening. rise and fall during respirations.
• Some newborns display periodic breathing, in which they • Count respirations before performing other uncomfortable
pause for a few seconds between respirations. This condi- procedures so that the respiratory rate is not artificially
tion can be normal, but parents should be alert to pro- elevated by the discomfort.
longed or frequent pauses between 15 and 20 seconds • Have an adult hold the child gently to reduce movement
(apnea) or pauses with a decrease in heart rate below while counting respirations.
100 beats/min, as this requires immediate medical
attention.
Older Adults
• Compared with adults, infants have fewer alveoli, and
their airways have a smaller diameter. As a result, infants’ • Ask the patient to remain quiet, or surreptitiously count
respiratory rate and effort of breathing will increase with respirations after taking the pulse.
respiratory infections. • Older adults experience anatomical and physiological
• Assess infant respirations for one full minute. changes that cause the respiratory system to be less effi-
cient. Any changes in rate or type of breathing should be
Children reported immediately.
• Because young children are diaphragmatic breathers,

observe the rise and fall of the abdomen. If necessary,
exercise. A consistently elevated pulse pressure occurs Determinants of Blood Pressure

in arteriosclerosis. A low pulse pressure (e.g., less than
25 mm Hg) occurs in such conditions as severe heart Arterial blood pressure is determined by blood flow and
failure. the resistance to blood flow as indicated in the following
Blood pressure is measured in millimetres of mer- formula: MAP = CO × SVR, where MAP refers to mean
cury (mm Hg) and recorded as a fraction: the systolic arterial pressure (the pressure in the arteries throughout the
pressure over the diastolic pressure. Traditionally, novice cardiac cycle), CO refers tocardiac output, and SVR refers
health care professionals assumed that the average blood to systemic vascular resistance.
pressure of a healthy adult is 120/80 mm Hg (pulse Cardiac Output Cardiac output is the volume of blood
pressure of 40). However, blood pressure is more com- pumped into the arteries by the heart. It is seen as an
plex than that. The Canadian Hypertension Education indicator of the pumping action of the heart. When
Program (CHEP, 2016) has identified the optimal systolic the pumping action of the heart is weak, less blood is
blood pressure as less than 120 mm Hg and the diastolic pumped into arteries, and the blood pressure decreases.
blood pressure as less than 80 mm Hg. CHEP (2016) When the heart’s pumping action is strong and the
considers adult blood pressure measurements between volume of blood pumped into the circulation increases,
130 mm Hg and 139 mm Hg systolic or 85 mm Hg blood pressure increases.
and 89 mm Hg diastolic as high–normal and this result
calls for annual follow-up. A diagnosis of hypertension Systemic Vascular Resistance Systemic
is made when the systolic blood pressure is 140 mm vascular resistance (SVR), which is the resistance
Hg or greater and/or the diastolic blood pressure is against which the heart must pump to eject blood into
90 mm Hg or greater. Hypertension should be medically the systemic circulation (excluding the pulmonary vas-
treated (until it is below 140/90 mm Hg in most patients culature), is influenced by the size of the arterioles and
and below 130/80 mm Hg in patients with diabetes or capillaries, the compliance of the arteries, the blood
chronic kidney disease (CHEP, 2016). Table 29.5 con- volume, and the blood viscosity. Increased SVR leads to
tains an approximate guide to the classification of blood an increased blood pressure; decreased SVR leads to a
pressure. A single blood pressure reading is not enough
to make a diagnosis of hypertension.
Table 29.5 Classification of Blood Pressure
A number of health conditions can be indicated by
changes observed in blood pressure recordings in indi- Category Systolic (mm Hg) Diastolic (mm Hg)
viduals. It is important for the nurse to know a specific Optimal <120 and/or <80
patient’s baseline blood pressure as blood pressure can
Normal <130 and/or <85
vary considerably. For example, if a patient’s usual blood
pressure is 120/80 mm Hg and it is assessed following High Normal 130–139 and/or 85–89
surgery to be 80/40 mm Hg, this significant drop in Stage 1 HTN 140–159 and/or 90–99
measure may indicate complications, and the primary Stage 2 HTN >160 and/or ≥100
health care provider needs to be informed. The trend or Source: Adapted from Canadian Hypertension Education Program. (2016). The 2016
pattern of blood pressure readings is usually of greater Canadian Hypertension Education Program Recommendations. Ottawa, ON: Author.
Retrieved from http://www.hypertension.ca/.
significance than a single result.
M29_KOZI2703_04_SE_C29.indd 653 27/02/17 1:37 PM

decreased blood pressure. Diastolic pressure is especially • Obesity. Generally, overweight and obese people have
affected by the resistance in the peripheral vasculature. higher blood pressure than people of normal weight.
The internal diameter, or the capacity of the arte- Both childhood and adult obesity predispose people
rioles and the capillaries, influences SVR in that the to hypertension.
smaller the lumen of a vessel, the greater is the resis- • Sex. After puberty, females usually have lower blood
tance. Normally, the arterioles are in a state of partial pressures compared with males of the same age; this
constriction. Increased vasoconstriction, as occurs with difference is thought to be caused by hormonal varia-
smoking, raises the SVR and, hence, blood pressure; tions. Women generally have higher blood pressure
vasodilation, as occurs during a long and hot shower, following menopause.
lowers the SVR (leading to lower blood pressure).
• Medications. Many medications can increase or decrease
If the normal elastic and muscular tissues of the
blood pressure (e.g., sympathomimetic decongestants
arteries are replaced with fibrous tissue, as occurs in
and caffeine increase blood pressure; opioids and
arteriosclerosis, their compliance (distensibility, elastic-
beta-blockers lower blood pressure); nurses should be
ity) is decreased. The arteries account for most of the
aware of over-the-counter and “natural” products that
systemic resistance.
a patient is taking and review their possible impact on
When the blood volume decreases (e.g., as a result of
blood pressure.
a hemorrhage or dehydration), blood pressure decreases
because of decreased fluid exerting pressure on the • Sodium intake. A high sodium intake can increase the
arteries. Conversely, when the volume increases (e.g., as release of natriuretic hormone, which indirectly con-
a result of a rapid intravenous infusion), blood pressure tributes to hypertension. Additionally, sodium stimulates
increases because of the greater fluid volume within the vasopressor mechanisms, which cause vasoconstriction.
circulatory system, until homeostasis is restored. A sodium intake of no more than 2000 mg is recom-
Viscosity is a physical property that results from fric- mended for the prevention of hypertension (CHEP,
tion of molecules in a fluid. A viscous (or thick) fluid has a 2016).
great deal of friction among the molecules as they slide by • Diurnal variations. Blood pressure is usually lowest early
one another. The viscosity of blood is mostly determined in the morning, when the metabolic rate is lowest,
by hematocrit (the proportion of red blood cells to blood then rises throughout the day, and peaks in the late
plasma). Blood pressure is higher when blood is highly afternoon or early evening.
viscous (i.e., when the hematocrit is more than 0.6 to 0.65). • Medical conditions. Any condition affecting the cardiac
output, blood volume, blood viscosity, or compliance
of the arteries has a direct effect on blood pressure.
Factors Affecting Blood Pressure The Teaching: Wellness box identifies several strate-
Age, exercise, stress, race, obesity, sex, medications, gies to maintain a healthy blood pressure.
sodium intake, diurnal variations, and medical condi-
tions are factors influencing blood pressure.
• Age. Newborns have a mean systolic pressure of about Hypertension
75 mm Hg. The pressure rises with age, reaching a Blood pressure that is persistently above normal is called
peak at the onset of puberty, and then tends to decline hypertension. A single elevated blood pressure reading
somewhat. In older adults, elasticity of the arter- indicates the need for reassessment. Blood pressure that is
ies is decreased—the arteries are more rigid and less consistently more than 140/90 mm Hg is considered high
yielding to the pressure of the blood. This produces and diagnostic of hypertension. Hypertension is a wide-
elevated systolic pressure. Because the walls no longer spread health problem that affects approximately 20% of
retract as flexibly with decreased pressure, diastolic the Canadian adult population (more than 7 million) with
pressure may also be high. many people not even knowing they have it (Daskalopou-
• Exercise. Physical activity increases the cardiac output lou et al., 2015). More than one in five adult Canadians
and hence blood pressure; thus, 30 minutes of rest fol- have hypertension, and the lifetime risk of developing
lowing exercise is indicated before the resting blood hypertension is approximately 90% (CHEP, 2016). Usually
pressure can be reliably assessed. asymptomatic, hypertension—sometimes called “the silent
• Stress. Stimulation of the sympathetic nervous system killer”—is the number-one risk factor for cerebrovascular
increases cardiac output and vasoconstriction of the accidents and a major risk factor for myocardial infarction,
arterioles, thus increasing blood pressure. The white coat heart failure, peripheral vascular disease, and blindness.
effect describes the elevation in blood pressure that occurs The CHEP makes annual recommendations related
by virtue of the stress generated by going to a hospital or to the diagnosis, treatment, and follow-up of hyperten-
clinic for assessment. Severe pain, however, can decrease sion in the most efficient and effective way. The CHEP
blood pressure greatly and cause shock by inhibiting the supports the use of ambulatory and home assessment of
vasomotor centre and producing vasodilation. blood pressure, if these are available, to monitor people
M29_KOZI2703_04_SE_C29.indd 654 03/03/17 10:22 AM

and 110 mm Hg in an adult. Orthostatic hypoten-

TEACHING WELLNESS sion is blood pressure that falls when the patient sits
or stands as evidenced by a decrease in systolic or dia-
Maintaining Healthy Blood Pressure stolic blood pressure of 10 mm Hg or a rise in pulse of
The following are some ways to maintain healthy blood 20 beats/min without any change in blood pressure. In
pressure and reduce the risk for hypertension: the latter situation, the blood pressure does not actually
drop owing to the compensatory increase in heart rate.
1. Maintain a healthy diet that is high in fresh fruits, veg-
It is usually the result of peripheral vasodilation in which
etables, low-fat dairy products, dietary and soluble fibre,
whole grains, and nonanimal protein (e.g., soy) and low the blood leaves the central body organs, especially the
in saturated fat and cholesterol. brain, and moves to the periphery, often causing the per-
2. Reduce sodium intake to no more than 2000 mg/day son to feel faint. Hypotension can also be caused by opi-
and be aware that adequate sodium intake is 1500 mg/ oids, bleeding, severe burns, and prolonged diarrhea and
day, if aged 19 to 50 years; 1300 mg, if aged 51 to vomiting. It is important to monitor hypotensive patients
70 years; and up to 1200 mg per day, if older than carefully to prevent falls. When assessing for orthostatic
71 years. hypotension, follows these steps:
3. Take part in regular physical activity according to Canadi-
an Physical Activity Guidelines (see Chapter 39). • Place the patient in the supine position for at least
4. Reduce alcohol consumption to ≤2 standard drinks per 5 minutes to allow blood pressure and pulse to stabi-
day and ≤14/week for men and ≤9/week for women lize in this position.
(CHEP, 2016). • Record the patient’s pulse and blood pressure.
5. Attain and maintain a healthy body mass index (BMI:
18.5–24.9 kg/m2) and waist circumference (<102 cm
• Assist the patient to slowly sit or stand. Support the
for men and <88 cm for women) in all normotensive and patient in case he or she feels faint.
hypertensive individuals for prevention and management • After 1 to 3 minutes in the upright position, recheck
of hypertension (CHEP, 2016). (See Chapter 40.) the pulse and blood pressure in the same sites as
6. Abstain from smoking, and maintain a smoke-free envi- previously.
ronment.
• Record the results. A rise in pulse of 20 beats/min or
7. Practise stress management (see Chapter 47).
a decrease in systolic or diastolic blood pressure of
Source: Summarized with permission from Canadian Hypertension Education
10 mm Hg indicates orthostatic hypotension. How-
Program. (2016). The 2016 Canadian Hypertension Education Program Recommen- ever, interpret these changes with caution, since wide
dations. Ottawa, ON: Author. Retrieved from https://www.hypertension.ca/images/
CHEP_2016/CHEP2016_Full_EN.pdf.
discrepancies exist in the literature about the mag-
nitude of the orthostatic response and its correla-
tion with intravascular volume status (e.g., a healthy
individual can have a drop in blood pressure despite
with diabetes, chronic renal disease, and “white coat normal vascular volume; a person with significantly
effect,” or masked hypertension (blood pressure con- low vascular volume may not have a postural drop)
trolled at clinic visits but not at home). (Estes, 2014).
Elevated blood pressure of unknown cause is called
primary hypertension. Elevated blood pressure of known
cause is called secondary hypertension. The majority (90%) of
hypertension diagnoses are of the primary type. Factors
Assessing Blood Pressure
associated with primary hypertension include thickening EQUIPMENT Traditionally, blood pressure has been
of the arterial walls, which reduces the size of the arte- measured with a blood pressure cuff, a sphygmomanometer,
rial lumen, and loss of elasticity of the arteries, as well as and a stethoscope. The traditional blood pressure cuff
lifestyle factors, such as cigarette smoking, obesity, heavy consists of a rubber bladder that can be inflated with
alcohol consumption, caffeine consumption, lack of physi- air (Figure 29.16). The bladder is covered with cloth and
cal exercise, high blood cholesterol levels, and continued has two tubes attached to it. One tube connects to a bulb
exposure to stress. Follow-up care should include counsel- that inflates the bladder. A small valve on the side of this
ling for lifestyle changes as well as monitoring blood pres- bulb releases the air from the bladder. When the valve is
sure itself. Secondary hypertension causes include renal closed, air pumped into the bladder remains there.
failure and tumours of the adrenal medulla. The other tube is attached to a sphygmomanometer.
The sphygmomanometer indicates the pressure of the
air within the bladder. Sphygmomanometers come in
two types: aneroid and digital. The aneroid sphygmoma-
Hypotension nometer is a calibrated dial with a needle that points
Hypotension is blood pressure that is below normal, to markings that correlate with blood pressure values
that is, a systolic reading consistently between 85 mm Hg (see Figure 29.16).
M29_KOZI2703_04_SE_C29.indd 655 03/03/17 10:27 AM

Bladder
length
Cuff Bladder
Madeleine Buck/Pearson Education, Inc.

Bladder
width
Bulb
Aneroid
sphygmomanometer
Figure 29.16 An aneroid sphygmomanometer, bulb, and cuff. Note the location,
length, and width of the bladder.
Most agencies use electronic (oscillometric) sphyg- over auscultation. However, learning the skill of manual
momanometers (Figure 29.17), which eliminate the need assessment is still important to set up the machine, pre-
to listen to the sounds of the patient’s systolic and dia- pare the patient, and verify findings.
stolic blood pressures through a stethoscope. The CHEP See Evidence-Informed Practice box for an indica-
(2016) currently recommends that measurement using tion of how the CHEP disseminates its recommenda-
electronic (oscillometric) upper arm devices is preferred tions to Canadian health care professionals.
Doppler ultrasound stethoscopes (DUSs) are also
used to assess blood pressure (see Figure 29.13 on page 643).
These are of particular value when blood pressure
C linical Al ert sounds are difficult to hear, such as in infants, obese
The registered nurse (RN) is responsible for the overall
assessment, determination of patient status, care planning, interventions,
and care evaluation when tasks are delegated to an unregulated care
provider (such as a health care aide). Under certain conditions, an RN
may delegate selected tasks (if permitted by the agency), such as some
aspects of vital signs assessment, if it is in the best interests of the patient;
Evidence-Informed Practice
if the patient is stable; if his or her condition is straightforward; and if the
unregulated care provider has sufficient training, supervision, and support
to perform the delegated task safely. However, the nurse remains respon- How the Canadian Hypertension
sible for patient care and assessment. The Canadian Hypertension Educa-
tion Program (2016) recommends that measurement of blood pressure Education Program (CHEP) Provides
only be conducted by health care professionals who have been specifically Current Information to Canadian
trained to do so (CHEP, 2016).
Health Care Professionals
The Canadian Hypertension Education Program (CHEP) pro-
vides annual recommendations to ensure that Canadian
Thermometer
health care professionals have up-to-date resources for the
prevention, diagnosis, and treatment of hypertension. Health
Finger
care professionals often have difficulty keeping abreast of
sensor Digital hypertension prevention and management recommenda-
for pulse display of tions and resources. The CHEP focuses on developing and
and O2 systolic and enhancing mechanisms to assist health care professionals
saturation diastolic BP,
temperature, and patients to stay up to date with the latest evidence and
pulse, and resources to prevent, diagnose, and manage hypertension.
O2
Nursing Implications: Nurses must remain up to
saturation
date on the latest recommendations for preventing,
screening for, and controlling hypertension. The CHEP
is an excellent evidence-based resource for all nurses
and other health professionals.
Based on new evidence, changes are made to the CHEP recommendations

Figure 29.17 Electronic blood pressure monitors register on an annual basis. The full CHEP recommendations are available at
systolic and diastolic pressures and often other vital signs. https://www.hypertension.ca/images/CHEP_2016/CHEP2016_Full_EN.pdf.
M29_KOZI2703_04_SE_C29.indd 656 27/02/17 1:37 PM

can be taken. To obtain a thigh blood pressure, apply an

appropriate-sized cuff to the thigh and auscultate the
pulsations of blood over the popliteal artery.
Assessing blood pressure on a patient’s thigh is usu-
ally indicated when blood pressure cannot be measured
on either arm (e.g., because of burns or other trauma)
or if blood pressure in one thigh is to be compared with
blood pressure in the other thigh.
Bladder Blood pressure is not measured on a particular limb
of cuff (arm or leg) in the following situations:
• The shoulder, arm, or hand (or the hip, knee, or ankle)
is injured or diseased.
• A cast or bulky bandage is on any part of the limb.
• Axilla or inguinal lymph nodes have been removed on
the side of the limb (such as after radical mastectomy).
• Intravenous infusion is being given in that limb.
• The patient has an arteriovenous fistula (e.g., for renal
dialysis) in that limb.
Methods Blood pressure can be assessed directly or

indirectly. Direct (invasive monitoring) measurement involves
the insertion of a catheter into the brachial, radial, or
femoral artery. Arterial pressure is represented as wave-
like forms displayed on an oscilloscope. With correct
placement, this pressure reading is highly accurate.
Figure 29.18 Determining that the bladder of a blood pres- Two noninvasive indirect methods of measuring blood
sure cuff is 40% of the arm circumference or 20% wider than pressure are auscultatory and palpatory methods. The
the diameter of the midpoint of the limb. auscultatory method is most commonly used in hospitals,
clinics, and homes. Required equipment is a sphygmo-
manometer, a cuff, and a stethoscope. When carried out
correctly, the auscultatory method is relatively accurate.
patients, and patients in shock. A systolic blood pressure When taking a blood pressure by using a stetho-
assessed with a DUS is recorded with a capital “D,” (e.g., scope, the nurse identifies the five phases in the
85D). Systolic pressure may be the only blood pressure series of arterial sounds called Korotkoff sounds
obtainable with some ultrasound models. (Figure 29.19 on the next page). First, the nurse pumps
Blood pressure cuffs come in various sizes; the blad- the cuff up to about 30 mm Hg above the palpatory sys-
der must be the correct width and length for the patient’s tolic pressure (when the pulse is no longer felt—this is the
arm. If the bladder is too narrow, the blood pressure point when the blood flow in the artery is stopped). Pres-
reading will be erroneously elevated; if it is too wide, sure is released slowly (2 mm Hg/beat), while the nurse
the reading will be underestimated. The circumference observes the readings on the manometer and relates
of the limb determines the cuff size. The bladder width them to the sounds heard through the stethoscope. Five
should be 40% of the limb circumference or 20% wider phases occur:
than the diameter of the midpoint of the limb, and the
bladder length should cover 80% to 100% of the limb • Phase I: The pressure at which the first faint, clear tap-
circumference (Figure 29.18). When using an electronic ping or thumping sounds are heard. These sounds
device, the cuff size should be determined on the basis gradually become more intense. The first tapping
of the manufacturer’s recommendations (CHEP, 2016). sound heard during deflation of the cuff is the systolic
Blood pressure cuffs are made of nondistensible blood pressure.
material so that an even pressure is exerted around the • Phase II: The period during deflation of the cuff when
limb. Most cuffs are held in place by Velcro. the sounds have a muffled or swishing quality.
Blood Pressure Sites Blood pressure is usually
• Phase III: The period during which the blood flows freely
assessed in the patient’s arm at the brachial artery site through the increasingly open artery, and the sounds
and by using a standard stethoscope. If the arm is very increase in crispness and develop a thumping quality.
large or grossly misshapen and the conventional cuff can- • Phase IV: The time when the sounds become muffled
not be properly applied, leg or forearm measurements again and have a soft, blowing quality.
M29_KOZI2703_04_SE_C29.indd 657 27/02/17 1:37 PM

pulsations, identifies the point at which the pressure in

Korotkoff phases the cuff nears diastolic pressure. This vibration is no
140 longer felt when the cuff pressure is below diastolic pres-
sure. To palpate diastolic pressure, the nurse applies light
Phase I
A sharp to moderate pressure over the pulse point.
tapping
130
Common Errors
A swishing in Assessing Blood Pressure
Phase II
or whooshing The importance of the accuracy of blood pressure

120
sound assessments cannot be overemphasized. Many judg-
ments regarding a patient’s health are made on the basis
A thump of blood pressure. It is an important indicator of the
Phase III
softer than 110 patient’s condition and is used extensively as a basis for
the tapping nursing interventions. Some reasons for erroneous blood
in phase 1 pressure readings are given in Table 29.6.
Skill 29.6 provides guidelines for assessing blood
A softer 100 pressure using auscultatory and palpatory methods and
Phase IV
blowing using aneroid and digital blood pressure equipment. (See

muffled also the Lifespan Considerations box on assessing blood
sound that pressure on page 661 and the Teaching: Home Care box
fades 90 on page 661 for how to instruct clients to take their own
blood pressure at home.)
Phase V
Silence
80 Table 29.6 Selected Sources

of Error in Blood Pressure Assessment
Error Effect
Figure 29.19 Korotkoff sounds can be differentiated into five Bladder cuff too narrow Erroneously high
phases. In the illustration, blood pressure is 138/90 mm Hg or
138/102/90 mm Hg. Bladder cuff too wide Erroneously low
Arm unsupported Erroneously high

• Phase V: The pressure level when the last sound is Insufficient rest before the Erroneously high
heard. This is followed by a period of silence. The assessment
pressure at which the last sound is heard is the dia-
Repeating assessment too Erroneously high systolic or
stolic blood pressure, and it is the point at which the
quickly low diastolic readings
sounds disappear.
Cuff wrapped too loosely or Erroneously high
Some agencies require the recording of phase I, unevenly
phase IV, and phase V measurements.
The palpatory method is sometimes used when Korot- Deflating cuff too quickly Erroneously low systolic and
koff sounds cannot be heard and electronic equipment high diastolic readings
to amplify the sounds is not available, or when an auscul- Deflating cuff too slowly Erroneously high diastolic
tatory gap occurs. An auscultatory gap, which occurs readings
particularly in hypertensive patients, is the temporary
disappearance of sounds normally heard over the bra- Failure to use the same arm Inconsistent measurements
consistently
chial artery when the cuff pressure is high, followed by
the reappearance of the sounds at a lower level. This Arm above level of the heart Erroneously low
temporary disappearance of sounds occurs in the latter
Assessing immediately after Erroneously high
part of phase I and phase II and may cover a range of a meal or while patient
40 mm Hg. Instead of listening for blood flow sounds, smokes or has pain
the nurse palpates the pulsations of the artery as the
pressure in the cuff is released. Systolic pressure is read Failure to identify ausculta- Erroneously low systolic
from the sphygmomanometer when the first pulsation is tory gap pressure and erroneously
low diastolic pressure
felt. A single whip-like vibration, felt in addition to the
M29_KOZI2703_04_SE_C29.indd 658 27/02/17 1:37 PM

SKILL 29.6 ASSESSING BLOOD PRESSURE
PURPOSES • The elbow should be slightly flexed with the palm of the
hand facing up and the forearm supported at heart level
• To obtain a baseline measure of arterial blood pressure for
(see ❶). Readings in any other position should be speci-
subsequent evaluation
fied. Blood pressure is normally similar in the sitting,
• To determine the patient’s hemodynamic status (e.g., blood standing, and lying positions, but it can vary significantly
vessel resistance) by position in certain persons. Rationale: Blood pres-
• To identify and monitor changes in blood pressure resulting sure increases when the arm is below the heart
from a disease process and medical therapy level and decreases when the arm is above the
heart level.
ASSESSMENT • Expose the upper arm.
Assess
• Signs and symptoms of hypertension (e.g., occipital head-
ache, ringing in the ears, flushing of face, nosebleeds,
keeping in mind that hypertension may have NO symptoms)
• Signs and symptoms of hypotension (e.g., tachycardia, diz-
ziness, mental confusion, restlessness, cool and clammy
skin, pale skin, syncope)
• Factors affecting blood pressure (e.g., activity, emotional stress,
pain, and time the patient last smoked or ingested caffeine)
Equipment
• Stethoscope or DUS ❶ Location of the brachial artery and application of the cuff.
• Blood pressure cuff of the appropriate size
5. Wrap the deflated cuff evenly around the bare upper arm.
• Sphygmomanometer Locate the brachial artery (see Figure 29.11 on page 641).
Apply the centre of the bladder directly over the artery.
IMPLEMENTATION Rationale: The bladder inside the cuff must be directly
over the artery to be compressed to obtain an accu-
Preparation rate reading.
1. Ensure that the equipment is intact and functioning properly. • For an adult, place the lower border of the cuff 3 cm
Check for leaks in the tubing of the sphygmomanometer. above the antecubital space (CHEP, 2016).
2. Make sure that the patient has not smoked or ingested caffeine 6. If this is the patient’s initial examination, perform a pre-
within 60 minutes before measurement. Rationale: Smok- liminary palpatory determination of systolic pressure.
ing constricts blood vessels, and caffeine increases the Rationale: The initial estimate indicates the maximal
pulse rate. Both cause a temporary increase in blood pressure to which the manometer needs to be ele-
pressure (CHEP, 2016). vated in subsequent determinations. It also prevents
3. Make sure the patient has not exercised in the preceding underestimation of systolic pressure or overestima-
30 minutes. tion of diastolic pressure should an auscultatory gap
occur.
4. The patient should be seated comfortably with back sup-
• Palpate the brachial artery with your fingertips.
port for at least 5 minutes before commencing the blood
pressure assessment (CHEP, 2016). • Close the valve on the bulb.
• Pump up the cuff until the brachial pulse is no longer
Performance felt. At that pressure the blood cannot flow through the
1. Before performing the procedure, introduce yourself to the artery. Note the pressure on the sphygmomanometer at
patient, and verify the patient’s identity by using two identi- which the pulse is no longer felt. Rationale: This gives
fiers. Explain to the patient what you are going to do, why an estimate of systolic pressure.
it is necessary, and how he or she can participate. Discuss • Release the pressure completely in the cuff, and wait
how the results will be used in planning further care or 1 to 2 minutes before making further measurements.
treatments. Rationale: A waiting period gives the blood trapped
2. Perform hand hygiene, and follow other appropriate infec- in the veins time to be released. Otherwise, false
tion prevention and control procedures. high systolic readings will occur.
3. Provide for patient privacy. 7. Position the stethoscope appropriately.
4. Position the patient appropriately. • Clean the earpieces with antiseptic wipe.
• The adult patient should be sitting with back support, • Insert the ear attachments of the stethoscope in your
unless otherwise specified. Both feet should be flat on ears so that they tilt slightly forward. Rationale: Sounds
the floor (CHEP, 2016). Rationale: Legs crossed at are heard more clearly when the ear attachments
the knee result in elevated systolic and diastolic follow the direction of the ear canal.
blood pressures).
(continued)
M29_KOZI2703_04_SE_C29.indd 659 17/03/17 1:18 PM

SKILL 29.6 ASSESSING BLOOD PRESSURE ( continued )

• Ensure that the stethoscope hangs freely from the ears
to the diaphragm. Rationale: If the stethoscope tub-
ing rubs against an object, the noise can block the
sounds of the blood within the artery.
• Place the bell or diaphragm side of the stethoscope gen-
tly and steadily over the brachial pulse site. Rationale:
Because blood pressure is a low-frequency sound,
it is best heard with the bell-shaped diaphragm.
Place the stethoscope directly on skin, not on
clothing over the site to avoid noise made from
rubbing the amplifier against cloth. Hold the dia-
phragm with the thumb and index finger.
8. Auscultate the patient’s blood pressure.
• Pump up the cuff rapidly until the sphygmomanometer
❷ Measuring blood pressure in the patient’s thigh.
reads 30 mm Hg above the point where the brachial
pulse disappeared (CHEP, 2016). Rationale: This
reduces the chance of a systolic auscultatory gap. • Expose the thigh, taking care not to expose the patient
unduly.
• Release the valve on the cuff carefully so that the pres-
sure decreases at the rate of 2 mm Hg per heart beat • Locate the popliteal artery (see Figure 29.11 on page 641).
(CHEP, 2016). Rationale: If the rate is faster or • Wrap the cuff evenly around the mid-thigh with the com-
slower, an error in measurement may occur. pression bladder over the posterior aspect of the thigh and
• As the pressure falls, identify the manometer reading at the bottom edge above the knee. Rationale: The bladder
Korotkoff phases I, IV, and V. Rationale: There is no must be directly over the posterior popliteal artery for
clinical significance to phases II and III. the reading to be accurate.
• Auscultate at least 10 mm Hg below phase V. • If this is the patient’s initial examination, perform a prelimi-
Rationale: This excludes a diastolic auscultatory nary palpatory determination of systolic pressure by palpat-
gap. ing the popliteal artery.
• Deflate the cuff rapidly and completely. • In adults, systolic pressure in the popliteal artery is usually
20 mm Hg to 30 mm Hg higher than that in the brachial
• Wait at least 1 to 2 minutes before making further artery because of use of a larger bladder; diastolic pressure
determinations. Rationale: This permits the blood is usually the same.
trapped in the veins to be released.
• Repeat the above steps two more times to confirm the Variation: Using an Electronic Indirect Blood Pressure
accuracy of the reading. Reject the first reading and Monitoring Device
average the next two (CHEP, 2016). These additional
steps are especially important if the blood pressure • Place the blood pressure cuff on the extremity, according to
reading falls outside of the normal range (although this the manufacturer’s guidelines.
may not be routine procedure for hospitalized or well • Turn on the blood pressure measuring device.
patients). If there is greater than 5 mm Hg difference • If appropriate, set the device for the desired number of min-
between the two readings, additional measurements utes between blood pressure determinations.
may be taken and the results averaged.
• When the device has determined the blood pressure read-
9. If this is the patient’s initial examination, repeat the proce- ing, note the digital results.
dure on the patient’s other arm and with the patient in the
standing position (arm must be supported). The difference 10. Remove the cuff.
between the arms should be no more than 10 mm Hg. The
11. Wipe the cuff with an approved disinfectant. Rationale:
arm found to have the higher pressure should be used for
This helps prevent transmission of microorganisms.
subsequent examinations.
Variation: Obtaining Blood Pressure tion prevention and control procedures.
by the Palpation Method
If it is not possible to use a stethoscope to obtain blood pres- 13. Document and report all pertinent assessment data,
sure, or if Korotkoff sounds cannot be heard, palpate the radial according to agency policy. Record blood pressure to the
or brachial pulse site as the cuff pressure is released. The nearest 2 mm Hg (or 1 mm Hg on electronic devices).
manometer reading at the point where the pulse reappears is Record two pressures in the form “130/80” where “130” is
an estimate of systolic value. systolic pressure (phase 1) and “80” is diastolic (phase V)
pressure. Record three pressures in the form “130/90/0,”
Variation: Taking Thigh Blood Pressure where “130” is systolic pressure, “90” is the first diastolic
• Help the patient to assume the prone position. If the patient pressure (phase IV), and “0” denotes that sounds are
cannot assume this position, measure blood pressure while audible even after the cuff is completely deflated. Use the
the patient is in the supine position with his or her knee abbreviations RA or RL for right arm or right leg and LA
slightly flexed. Slight flexing of the knee will facilitate placing or LL for left arm or left leg. Record a difference of greater
the stethoscope on the popliteal space (see ❷). than 10 mm Hg between the two arms or legs.
M29_KOZI2703_04_SE_C29.indd 660 17/03/17 1:19 PM

• Report any significant change in the patient’s blood pres-

Clinical Al ert sure. Also report these findings:
• Systolic blood pressure (of an adult) above 130 mm Hg
An electronic or automatic blood pressure cuff can be left
in place for many hours. Remove the cuff and check skin condition • Diastolic blood pressure (of an adult) above 85 mm Hg
periodically. • Systolic blood pressure (of an adult) below 100 mm Hg
• Conduct appropriate follow-up, such as administration of
Evaluation medication.
• Relate blood pressure to the patient’s other vital signs, to
baseline data, and to health status.
Assessing Blood Pressure

Infants
• Use a pediatric stethoscope with small diaphragm.
• The lower edge of the blood pressure cuff can be closer to
the antecubital space of an infant.
• Use the palpation method if auscultation with a stethoscope
Al Dodge/Pearson Education, Inc.

or DUS is unsuccessful.
• Arm and thigh pressures are equivalent in children less than
1 year of age.
Children
• Blood pressure should be measured in all children over
3 years of age and in children age less than 3 years of age
with certain medical conditions (e.g., heart disease, renal
malformation, medications that affect blood pressure). Figure 29.20 Pediatric blood pressure cuffs.
• Explain each step of the process and what it will feel like.
Demonstrate on a doll. Older Adults
• Use the palpation technique for children age less than 3 years. • Skin may be very fragile. Do not allow cuff pressure to
• Cuff bladder width should be 40% and length should be remain high any longer than necessary.
80% to 100% of the arm circumference (Figure 29.20). • Determine whether the patient is taking antihypertensives
• Take the blood pressure before performing other uncom- and, if so, when the last dose was taken.
fortable procedures so that the blood pressure is not artifi- • Medications that cause vasodilation (e.g., certain antihy-
cially elevated by the discomfort. pertensive agents), along with the loss of baroreceptor
• In children, diastolic pressure is considered to be the onset efficiency in older adults, place them at increased risk for
of phase 4, where the sounds become muffled. having orthostatic hypotension. Measuring blood pressure
• In children, thigh pressure is about 10 mm Hg higher than while the patient is in the lying, sitting, and standing posi-
arm pressure. tions and noting any changes can determine this.
• One quick way to determine the normal systolic blood pres- • If the patient has arm contractures, assess the blood pres-
sure of a child is to use the following formula: Normal sys- sure by palpation, with the arm in a relaxed position. If this
tolic blood pressure = 80 + (2 × child’s age in years). is not possible, take thigh blood pressure.
Teaching Home Care
Blood Pressure
If taught properly, clients can take blood pressure readings at • Observe the client or family member taking the blood
home: pressure, and provide feedback if further instruction is
needed.
• Home blood pressure measurement done by the client
or family can detect elevated pressures not identified • Clients should purchase home blood pressure
when the client is seen in a medical setting. Home blood monitoring devices, preferably with data-recording
pressure measurements can also be used when a cli- capabilities, that have “Recommended by the
ent is suspected of having white coat hypertension—an Canadian Hypertension Society” noted on the packag-
elevated blood pressure when measured in a medical ing. (Visit the CHEP website for photos of approved
setting but an otherwise normal blood pressure at home. equipment.)
M29_KOZI2703_04_SE_C29.indd 661 27/02/17 1:37 PM


FIGURE 29.21 Vital signs monitor (1) systolic blood pressure; FIGURE 29.22 Fingertip oximeter sensor (adult).
(2) diastolic blood pressure; (3) mean arterial pressure; (4) pulse;
(5) peripheral oxygen saturation (SpO2).
blood and reports it as SpO2. Normal SpO2 as measured
by pulse oximetry is 95% to 100%; values below 70%
CLINICAL ALERT may be unreliable. It is important to note that oximeters
do not measure the actual tissue oxygenation or how
Automated and digital assessment of vital signs is replacing
well a patient is ventilated. Therefore, it is essential that
conventional and manual assessments in most clinical sites. Make sure
you verify any unexpected vital signs using conventional measurement and oximetry measurements be interpreted in conjunction
confirm any vital signs that are inconsistent with the patient’s presentation. with other patient factors, including signs and symptoms
Although values displayed on the vital signs monitor (see Figure 29.21) of hypoxia (low level of oxygenation of body tissue).
may appear normal, the nurse does not have data about the pulse vol- Pulse oximeters with various types of sensors are
ume, the patient’s skin temperature, or other relevant data that would by
available from several manufacturers. The oximeter unit
obtained by “touching” the patient. Maintain your skills in the assessment
of vital signs, as human touch and clinical wisdom cannot be replaced by consists of an inlet connection for the sensor cable and a
technology. Remember: You are monitoring the patient, not the machine. faceplate that indicates (a) the oxygen saturation measure-
ment (expressed as a percentage) and (b) the pulse rate. A
preset alarm system signals high and low SpO2 measure-
Oxygen Saturation ments and a high and low pulse rate. Alarm limits can be
changed according to the manufacturer’s directions.
A pulse oximeter is a noninvasive device that estimates

a patient’s arterial blood oxygen saturation by means of Factors Affecting Oxygen Saturation
a sensor attached to the patient’s finger (Figure 29.22),
toe, nose, earlobe, or forehead (or around the hand or
Readings
foot of a neonate). Pulse oximetry is often used instead Several factors can affect oxygen saturation readings:
of the riskier, more painful, and invasive arterial blood
• Hemoglobin. If the hemoglobin is fully saturated with
gas measurement of blood oxygen saturation. The pulse
oxygen, the SpO2 will appear normal, even if the total
oximeter can detect hypoxemia (low oxygenation of
arterial blood) before clinical signs and symptoms, such
as dusky (darker) skin colour and dusky nail bed colour,
develop. Box 29.3 contains guidelines for understand- BOX 29.3 OXIMETRY: UNDERSTANDING THE
ing the values obtained from oximetry. Oxygen satura- NUMBERS
tion assessed using the invasive approach is documented
SpO2, % Oxygenation
as SaO2 (arterial oxygen saturation) ; oxygen satura-
tion assessed by pulse oximetry is documented as SpO2 95–100 Normal
(peripheral oxygen saturation or tissue oxygenation). 91–94 Mild hypoxia
The pulse oximeter’s sensor has two parts: (a) two 86–90 Moderate hypoxia
light-emitting diodes (LEDs)—one red, the other infra- <85 Severe hypoxia
red—that transmit light through nails, tissue, venous Note: Oximetry measurements should always be interpreted
blood, and arterial blood; and (b) a photodetector placed in conjunction with other patient factors, including signs and
directly opposite the LEDs (e.g., the other side of the symptoms of hypoxia.
finger, toe, or nose). The photodetector measures the
Source: Adapted from Valdez-Lowe, C., Ghareeb, S. A., & Artinian, N. T. (2009). Pulse
amount of red and infrared light absorbed by oxygen- oximetry in adults. American Journal of Nursing, 109(6), 52.
ated and deoxygenated hemoglobin in peripheral arterial
M29_KOZI2703_04_SE_C29.indd 662 03/03/17 10:32 AM

hemoglobin level is low. Thus, the patient could be monoxide (CO) versus oxygen. In this case, other
severely anemic and have inadequate oxygen to sup- measures of oxygenation are needed (Chan, Chan, &
ply tissues, but the pulse oximeter would return a nor- Chan, 2013).
mal value. • Bright lights. Bright lights may cause falsely low
• Circulation. The oximeter will not provide an accurate oximeter readings (Schuman, 2014).
reading if the area under the sensor has impaired • Nail polish. Newer models of pulse oximeters are less
circulation or poor perfusion (Chan, Chan, & Chan, affected by the presence of nail polish than older ver-
2013). For example, if the patient has cold fingers sions. The impact of nail polish on oximetry remains
because of low room temperature, low cardiac output, a matter of debate (Chan, Chan, & Chan, 2013;
or vasoconstriction oximetry readings may be inaccu- Hakverdioğlu Yönt, Akin Korhan, & Dizer, 2014;
rate (Nitzan, Romem, & Koppel, 2014). Jubran, 2015).
• Activity. Shivering, tremors, wiggling, seizures or exces-
Skill 29.7 outlines the steps in measuring oxygen
sive movement of the sensor site can interfere with
saturation. (See also the Lifespan Considerations box
accurate readings (Jubran, 2015; Schuman, 2014).
on pulse oximetry.) See Chapter 43 for a more extensive
• Carbon monoxide poisoning. Pulse oximeters cannot dis- discussion of oxygenation.
criminate between hemoglobin saturated with carbon
SKILL 29.7 MEASURING OXYGEN SATURATION
PURPOSES IMPLEMENTATION
• To estimate the arterial blood oxygen saturation Preparation
• To detect the presence of hypoxemia before visible signs Check that the oximeter equipment is functioning normally.
develop
Performance
ASSESSMENT 1. Before performing the procedure, introduce yourself to the
Assess patient, and verify the patient’s identity by using two identi-
fiers. Explain to the patient what you are going to do, why it
• The best location for a pulse oximeter sensor, based on is necessary, and how he or she can participate.
the patient’s age and physical condition; unless contraindi- 2. Perform hand hygiene, and follow other appropriate infec-
cated, the finger is usually selected for adults tion prevention and control procedures.
• The patient’s overall condition, including risk factors for 3. Provide for patient privacy.
development of hypoxemia (e.g., respiratory or cardiac dis-
ease) and hemoglobin level 4. Choose a sensor appropriate for the patient’s weight and
size and the desired location. Because weight limits of sen-
• Vital signs, skin colour and temperature, nail bed colour, sors overlap, a pediatric sensor could be used for a small
and tissue perfusion of extremities as baseline data adult.
• Adhesive allergy • If the patient is allergic to adhesive, use a clip or sen-
sor without adhesive. If using an extremity, assess the
PLANNING proximal pulse and capillary refill at the point closest to
Many hospitals and clinics have pulse oximeters readily avail- the site.
able for use with other vital signs equipment (or even as an • If the patient has low tissue perfusion because of
integrated part of the electronic blood pressure device). Other peripheral vascular disease or therapy that uses vaso-
facilities may have a limited supply of oximeters, and the nurse constrictive medications, use a nasal sensor or a
may need to request it from the central supply department. reflectance sensor on the forehead. Avoid using
lower extremities that have compromised circulation and
Equipment extremities that are used for infusions or other invasive
monitoring.
• Nail polish remover (if required)
5. Prepare the site.
• Sheet or towel, as needed
• Clean the site with an alcohol wipe before applying the
• Alcohol wipe
sensor.
• Pulse oximeter
(continued)
M29_KOZI2703_04_SE_C29.indd 663 17/03/17 1:22 PM

SKILL 29.7 MEASURING OXYGEN SATURATION ( continued )

• It may be necessary to remove a patient’s dark nail • Inspect the sensor site tissues for irritation from adhe-
polish and artificial acrylic fingernails. Rationale: sive sensors.
These can interfere with accurate measurements. 9. Ensure the accuracy of measurement.
Alternatively, position the sensor on the side of the finger
rather than perpendicular to the nail bed. • Minimize motion artifacts by using an adhesive sensor,
or immobilize the patient’s monitoring site. Rationale:
6. Apply the sensor, and connect it to the pulse oximeter. Movement of the patient’s finger or toe may be
• Make sure the LED and photodetector are accurately misinterpreted by the oximeter as arterial pulsa-
aligned, that is, opposite each other on either side of tions.
the finger, toe, nose, or earlobe. Many sensors have • If indicated, cover the sensor with a sheet or towel to
markings to facilitate correct alignment of the LEDs and block large amounts of light from external sources (e.g.,
photodetector. sunlight, procedure lamps, or bilirubin lights in the nurs-
• Attach the sensor cable to the connection outlet on ery). Rationale: Bright room light may be sensed by
the oximeter. Turn on the machine, according to the the photodetector and alter the SpO2 value.
manufacturer’s directions. Appropriate connection will • Compare the pulse rate indicated by the oximeter to
be confirmed by an audible beep indicating each arte- the radial pulse periodically. Rationale: A large dis-
rial pulsation. Some devices have a wheel that can be crepancy between the two values may indicate
turned clockwise to increase the pulse volume and oximeter malfunction.
counterclockwise to decrease it.
• Bear in mind that the pulse rate as seen on the pulse
• Ensure that the bar of light or waveform on the face of oximeter many not reflect the actual heart rate nor the
the oximeter fluctuates with each pulsation. adequacy of perfusion.
7. Set and turn on the alarm when using continuous 10. Perform hand hygiene, and follow other appropriate infec-
monitoring. tion prevention and control procedures.
• Check the preset alarm limits for high and low oxygen 11. Document the SpO2 as measured by pulse oximetry on
saturation and high and low pulse rates. Change these the appropriate record at designated intervals.
alarm limits, according to the manufacturer’s directions,
as indicated. Ensure that the audio and visual alarms are EVALUATION
on before you leave the patient. A tone will be heard and
• Compare the SpO2 with the patient’s previous oxygen
a number will blink on the faceplate.
saturation level, including any invasive SaO2 measurements.
8. Ensure patient safety. Relate findings to the pulse rate and other vital signs.
• Inspect and change the location of an adhesive toe or • Conduct appropriate follow-up, such as notifying the appro-
finger sensor every 4 hours and a spring-tension sensor priate members of the health care team or adjusting oxygen
every 2 hours. therapy.
Pulse Oximetry
INFANTS • Use a forehead or earlobe sensor if indicated (Figure 29.23)
• If an appropriate-sized finger or toe sensor is not available,
consider using an earlobe or forehead sensor.
• High and low SpO2 levels are generally preset at 95% and
80% for neonates.
• High and low pulse rate alarms are usually preset at 200
and 100 beats/min for neonates.
• The oximeter may need to be taped, wrapped with an elas-
Bruno Boissonnet/Science Source
tic bandage, or covered by a stocking to keep it in place.
CHILDREN
• Instruct the child that the sensor does not hurt. Disconnect
the probe, whenever possible, to allow for movement.
OLDER ADULTS
• Use of vasoconstrictive medications, poor circulation, or
thickened nails in older adults may make finger or toe sen- FIGURE 29.23 Oximeter sensor on an earlobe.
sors inaccurate.
M29_KOZI2703_04_SE_C29.indd 664 17/03/17 4:33 PM

Case Study 29
Mrs. Awosoga, 75 years old, has just been transferred to her
own bed from the postanesthesia care unit stretcher, following 2. What is your analysis of the blood pressure reading of
total hip replacement for osteoarthritis. After a verbal report from 180/110 mm Hg? What further data do you need to
the registered nurse, you assess Mrs. Awosoga’s vital signs. On collect?
taking her blood pressure, you are unable to hear any Korotkoff 3. How would you interpret her temperature, pulse, and
sounds during release of the valve. You repeat the procedure respiratory rate?
after 3 minutes and obtain a reading of 180/110 mm Hg LA
supine. Her temperature (tympanic) is 35.8°C and pulse (radial) Check the eText in MyNursingLab for answers and
is 90 beats/min, regular, 2+/4 amplitude. Her respirations are explanations.
28 and shallow. The pulse oximeter indicates
a SpO2 of 95%. She is awake and oriented,
and her skin is warm; but it is difficult to dis-
cern skin colour as it relates to oxygenation
because of the dark pigmentation of her skin.
1. What would you say to her when you were unable to

hear the Korotkoff sounds?
Key Terms
afebrile p. 633 diaphragmatic (abdomi- hypothermia p. 634 pulse oximeter p. 662
apical pulse p. 640 nal) breathing p. 648 hypoventilation p. 650 pulse pressure p. 651
apical–radial diastolic pressure hypoxemia p. 662 pulse rhythm p. 643
pulse p. 646 p. 651 hypoxia p. 662 pulse volume p. 643
apnea p. 650 dysrhythmia p. 643 inhalation p. 648 pyrexia p. 633
arrhythmia p. 643 eupnea p. 650 insensible heat radiation p. 631
arterial blood evaporation p. 632 loss p. 632 relapsing fever p. 633
pressure p. 651 exhalation p. 648 insensible water remittent fever p. 633
auscultatory gap p. 658 expiration p. 648 loss p. 632 respiration p. 648
basal metabolic rate external inspiration p. 648 respiratory quality
(BMR) p. 631 respiration p. 648 intermittent or character p. 650
blood pressure p. 651 febrile p. 633 fever p. 633 respiratory rhythm
body temperature fever p. 633 internal respiration or pattern p. 650
p. 630 fever spike p. 633 p. 648 surface temperature
bradycardia p. 643 heat balance p. 630 Korotkoff p. 630
bradypnea p. 650 heat exhaustion p. 633 sounds p. 657 systematic vascular
cardiac output p. 640 heat stroke p. 633 malignant resistance (SVR)
compliance p. 637 hematocrit p. 654 hyperthermia p. 633 p. 653
conduction p. 631 hyperpyrexia p. 633 orthostatic systolic pressure p. 651
constant fever p. 633 hypertension p. 654 hypotension p. 655 tachycardia p. 643
convection p. 631 hyperthermia p. 633 peripheral pulse p. 640 tachypnea p. 650
core temperature hyperventilation p. 650 point of maximal tidal volume p. 650
p. 630 hypotension p. 655 impulse (PMI) p. 640 ventilation p. 648
costal (thoracic) hypothalamic pulse p. 637 vital signs p. 629
breathing p. 648 integrator p. 632 pulse deficit p. 647
M29_KOZI2703_04_SE_C29.indd 665 27/02/17 1:37 PM

C hapter Highlig hts

• Vital signs reflect changes in body function that otherwise • Although the radial pulse is the site most commonly used,
might not be observed. eight other sites can be used in certain situations.
• Body temperature is the balance between heat produced • The difference between apical and radial pulses is called
by the body and heat lost from the body. pulse deficit.
• Factors affecting body temperature include age, diurnal • Respirations are normally quiet, effortless, and automatic
variations, exercise, hormones, stress, and environmental and are assessed by observing respiratory rate, depth,
temperatures. rhythm, quality, and effectiveness.
• Four common types of fever are intermittent, remittent, • Blood pressure reflects cardiac output and peripheral vas-
relapsing, and constant. cular resistance.
• During a fever, the set point of the hypothalamic thermo- • Among the factors influencing blood pressure are age,
stat changes suddenly from the normal level to a higher- exercise, stress, obesity, sex, medications, sodium intake,
than-normal level, but several hours elapse before the diurnal variations, and medical conditions.
core temperature reaches the new set point.
• Maintaining a healthy diet, reducing sodium intake, par-
• Hypothermia involves three mechanisms: exces- ticipating in regular physical activity, reducing alcohol
sive heat loss, inadequate heat production by body consumption, maintaining a healthy BMI, smoke cessa-
cells, and increasing impairment of hypothalamic tion, and practising stress management are ways to main-
thermoregulation. tain a healthy blood pressure.
• The nurse selects the most appropriate site to measure • Orthostatic hypotension occurs when blood pressure falls
temperature, according to the client’s age and condition. as the client assumes an upright position, as evidenced by
• Pulse rate and volume reflect the stroke volume output, a reduction in blood pressure or a compensatory increase
the compliance of the client’s arteries, and the adequacy in heart rate.
of blood flow.
• It is imperative that blood pressure be measured using
• Normally, the peripheral pulse reflects the client’s heart- best practice guidelines as outlined by the Canadian
beat, but it may differ from the heartbeat in clients with Hypertension Education Program to reduce falsely high
certain cardiovascular diseases; in these instances, the or low measurements.
nurse takes an apical pulse reading and compares it with
• During blood pressure measurement, the artery must be
the peripheral pulse.
held at heart level.
• Many factors may affect a person’s pulse rate: age, sex,
exercise, presence of fever, certain medications, hypovo- • Pulse oximetry is a noninvasive means of measuring the
lemia, stress, position changes (in some situations), and percentage of hemoglobin saturated with oxygen. A nor-
pathology. mal SpO2 result is 95% to 100%.
N clex- St yle Practic e Qu i z

1. The client’s temperature at 0800 hours taken by using an b. 45 seconds

oral electronic thermometer is 36.1°C. All other vital signs c. 60 seconds
are within normal range. What would the nurse do next?
d. 120 seconds
a. Wait 15 minutes and retake it
b. Check what the client’s temperature was the last time 4. An 85-year-old client has had a cerebrovascular acci-
c. Retake it by using a different thermometer dent (stroke) resulting in right-sided facial drooping
d. Chart the temperature, as it is normal and difficulty swallowing. The client is unable to move
or maintain a position unaided. Which of the fol-
lowing would be an appropriate site(s) for taking the
2. For which of the following clients would the nurse take temperature?
an apical pulse rather than a radial pulse?
a. Oral
a. A client in shock
b. Rectal
b. A client with no existing baseline data
c. Axillary, oral, or temporal artery
c. A client with a dysrhythmia
d. Axillary, tympanic, or temporal artery
d. A client less than 24 hours after surgery
5. Which of the following would the nurse anticipate
3. A client had a previous blood pressure of 138/74 mm finding in a client with ineffective peripheral tissue
Hg and pulse of 64. How long should the nurse take perfusion?
to release the blood pressure cuff in order to obtain an
accurate reading? a. Bounding radial pulse
a. 20 seconds b. Irregular apical pulse
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c. Radial pulse that is obliterated by strong pressure c. Stage 3 hypertension

d. Absent posterior tibial and pedal pulses d. High normal
6. A nurse has taken the vital signs on a 3-year-old child. 9. A nurse is providing wellness teaching to a 72-year-old
The results are pulse 110, respiratory rate (RR) 26, client with a new diagnosis of hypertension. Which of
blood pressure 84/50, temperature 36.5, and SpO2 the following should the nurse recommend?
97%. How should the nurse describe the respiratory a. The client should go from a lying to a standing posi-
rate? tion gradually.
a. Tachypnea b. The client should aim to reduce sodium intake to
b. Hyperventilation approximately 1200 mg per day.
c. Kussmaul’s respirations c. The client should avoid all stressful situations.
d. Eupnea d. The client should aim to participate in moderate to
vigorous intensity aerobic physical activity at least 1
7. A client states, “I feel so breathless all the time.” Which hour a week.
of the following terms should the nurse use to accu-
rately document the client experience? 10. The nurse obtains an oxygen saturation value (SpO2)
a. Hypoventilation of 70% by pulse oximeter in a client who is alert and
oriented and who has come to an ambulatory clinic
b. Laboured breathing because of feeling short of breath. The client’s respira-
c. Dyspnea tory rate is 16 per minute; her heart rate is 74 beats per
d. Orthopnea minute, regular and +2/4 amplitude. What is the first
thing the nurse should do in this situation?
8. When auscultating a blood pressure on an older man, a. Seek help
on two separate visits, the nurse records the blood pres- b. Administer oxygen therapy
sure as 166/102 mm Hg on visit one and 164/98 mm c. Auscultate the lungs
Hg on visit two. How should the nurse interpret these
findings? d. Reassess oxygen saturation
a. Stage 1 hypertension
b. Stage 2 hypertension
Refe r e nc es
Brandes, I. F., Perl, T., Bauer, M., & Bräuer, A. (2015). Evaluation Hernandez, M., Cutter, T. W., & Apfelbaum, J. L. (2013).
of a novel noninvasive continuous core temperature measurement Hypothermia and hyperthermia in the ambulatory surgical
system with a zero heat flux sensor using a manikin of the human patient. Clinics in Plastic Surgery, 40(3), 429–438.
body. Biomedizinische Technik. Biomedical Engineering, 60(1), 1–9. Heytens, L., Forget, P., Scholtès, J. L., & Veyckemans, F. (2015). The
Canadian Hypertension Education Program. (2016). The 2015 changing face of malignant hyperthermia: Less fulminant, more
Canadian Hypertension Education Program recommendations. Ottawa: insidious. Anaesthesia & Intensive Care, 43(4), 506–511.
Author. Retrieved from https://www.hypertension.ca/images/ Jubran, A. (2015). Pulse oximetry. Critical Care (London, England), 19,
CHEP_2015/CHEP2015_Full_EN.pdf. 272–272.
Canadian Paediatric Society. (2010). Temperature measurement in pae- Laupland, K. B., Zahar, J. R., Adrie, C., Schwebel, C., Goldgran-
diatrics. Position Statement: Canadian Pediatric Society. Retrieved from Toledano, D., Azoulay, E., . . . & Timsit, J. F. (2012). Determinants
http://www.cps.ca/english/statements/CP/cp00-01.htm. of temperature abnormalities and influence on outcome of criti-
Chan, E. D., Chan, M. M., & Chan, M. M. (2013). Pulse oximetry: cal illness. Critical Care Medicine, 40(1), 145–151.
Understanding its basic principles facilitates appreciation of its Marieb, E. N. & Hoehn, K. N. (2013). Human anatomy and physiology
limitations. Respiratory Medicine, 107(6), 789–799. (9th ed.). Upper Saddle River, NJ: Pearson Education Inc.
D’Amico, D., Barbarito, C., Twomey, C., & Harder, N. (2012). Nitzan, M., Romem, A., & Koppel, R. (2014). Pulse oximetry:
Health & Physical Assessment in Nursing (Canadian ed.). Toronto, ON: fundamentals and technology update. Medical Devices: Evidence &
Pearson Education Canada. Research, 7, 231–239.
Daskalopoulou, S. S., Rabi, D. M., Zarnke, K. B., Dasgupta, K., Petrone, P., Asensio, J. A., & Marini, C. P. (2014). Management of
Nerenberg, K., Cloutier, L., . . . & Padwal, R. S. (2015). The 2015 accidental hypothermia and cold injury. Current Problems in Surgery,
Canadian Hypertension Education Program recommendations 51(10), 417–431.
for blood pressure measurement, diagnosis, assessment of risk, Schuman, A. J. (2014). Pulse oximetry. Contemporary Pediatrics, 31(10),
prevention, and treatment of hypertension. Canadian Journal of 44–46.
Cardiology, 31(5), 549–568. Sund-Levander, M., & Grodzinsky, E. (2013). Assessment of body
El-Radhi, A. S. (2014). Determining fever in children: the search for temperature measurement options. British Journal of Nursing, 22(15),
an ideal thermometer. British Journal of Nursing, 23(2), 91–94. 880–888.
Estes, M. E. Z. (2014). Health Assessment and physical examination Taylor, N. A. S., Tipton, M. J., & Kenny, G. P. (2014). Considerations
(5th ed.). Toronto, ON: Nelson. for the measurement of core, skin and mean body temperatures.
Hakverdioğlu Yönt, G., Akin Korhan, E., & Dizer, B. (2014). The Journal Of Thermal Biology, 46, 72–101.
effect of nail polish on pulse oximetry readings. Intensive and Critical Valdez-Lowe, C., Ghareeb, S. A., & Artinian, N. T. (2009). Pulse
Care Nursing, 30(2), 111–115. oximetry in adults. American Journal of Nursing, 109(6), 52.
M29_KOZI2703_04_SE_C29.indd 667 27/02/17 1:37 PM

Chapter 30
Pain Assessment and
Management
Updated by
Céline Gélinas, N, B.Sc.(N), MSc(N), PhD, Post Doc
A
LEARNING OUTCOMES
After studying this chapter, you will be able to ccording to the princi-
1. Identify types and categories of pain according to duration, origin, ples of beneficence and
location, etiology, and intensity. nonmaleficence, nurses,
2. Differentiate pain threshold from pain tolerance. as health care professionals, must
provide comfort and pain relief for all
3. Describe pain transduction, transmission, perception, and
modulation. clients, regardless of status, heritage,
and type of health problem. In sup-
4. Discuss pain theory, nervous system plasticity, and their
application to nursing care. port of this, the International Asso-
ciation for the Study of Pain (IASP)
5. Outline subjective and objective data to collect and analyze when
assessing pain. issued a statement that pain relief
is a fundamental human right (IASP,
6. Identify and use valid pain scales for verbal and nonverbal client
populations. 2004). Being the first-line advocate
for humane and quality care of their
7. List examples of nursing diagnoses for clients with pain.
clients (Canadian Nurses Associa-
8. Discuss pharmacological and nonpharmacological interventions for
tion [CNA], 2008), nurses have an
pain.
essential responsibility to ensure that
9. Identify rationales for using various analgesic delivery routes.
their clients have the best pain relief
10. State outcome criteria by which to evaluate a client’s response to possible.
interventions for pain.
Canada has a rich history in the
11. Identify barriers to effective pain management. interprofessional study and treatment
12. Define tolerance, physical dependence, and addiction. of pain. Seminal work by Melzack and
Wall (1965), in addition to their strong
humanitarian commitment to caring
for clients suffering from pain, paved
the way for other exceptional Cana-
dian researchers to understand pain
mechanisms and their implications for
effective pain management. Pain is c
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Chapter 30 Pain Assessment and Management 669
c known as an unpleasant, multidimensional, and subjective experience, and only the person experiencing
pain can describe it (if he or she is able to communicate by verbal or other means). No two people experi-
ence pain the same way; the experience of pain and its related responses are unique to each client and
are influenced by the person’s context and past pain experiences. Although the person’s self-report is
the most valid measure of pain, some people may be unable to communicate because of their develop-
mental stage (e.g., neonates, infants, and preverbal children), a cognitive impairment, such as advanced
dementia, or temporary clinical conditions, such as being unconscious. When the self-report of pain
cannot be obtained, the nurse should rely on other indicators to detect the presence of pain, including
the use of valid behavioural pain scales developed for specific populations and in a given context (Herr,
Coyne, Manworren, McCaffery, Merkel, Pelosi-Kelly, & Wild, 2006). Therefore, effective pain manage-
ment requires skillful communication and assessment on the part of the nurse.
Although great advancements in pain research have been made over the past 5 decades, unre-
lieved acute pain remains a ubiquitous problem with numerous physiological, psychological, and
economic consequences (McGillion, Watt-Watson, LeFort, & Stevens, 2007). Significant numbers of
hospitalized clients unnecessarily experience moderate to severe pain after surgery or interventional
procedures, which can delay recovery and discharge from hospital (Morrison et al., 2003). One of the
main consequences of undetected and unrelieved acute pain is the development of chronic pain, which
often leads to the impairment of cognitive functioning, emotional distress, fatigue, and depression
(Dunwoody, Krenzischek, Pasero, Rathmell, & Polomano, 2008). Major contributors to unrelieved pain
are knowledge gaps and pain-related misbeliefs among health care professionals, clients, and families.
Despite advancements in the understanding of pain and its consequences among scientists,
health care professional groups, and client advocacy organizations in Canada, pain management
practices generally need improvement. Historically, many health care professionals have not asked
clients about their pain, and major discrepancies have been noted between clients’ pain experiences
and health care professionals’ pain assessments. The problem has been compounded by the fact that
many clients expect to have pain while in hospital, do not admit to having pain, and are reluctant to
ask for help. Efforts in client care improvement, such as the Best Practice Guidelines launched by the
Registered Nurses’ Association of Ontario (RNAO) in 2004, paved the way for many improvements in
pain detection and pain control for the clients inside and outside of the hospital. In addition to these
Canadian guidelines, a position statement from the American Society of Pain Management Nursing
(ASPMN) was published (Herr et al., 2006) to provide nurses with clinical recommendations for the
assessment of pain in nonverbal client populations.
A major priority for nurses is the development of in-depth knowledge about pain mechanisms,
assessment, and pharmacological and nonpharmacological management strategies. The Canadian
Pain Society (CPS) emphasizes that clients have a right to the best pain relief possible (Watt-Watson,
Clark, Finley, & Watson, 1999) and that nurses should be familiar with the following principles:
1. Unrelieved acute pain complicates recovery.
2. Routine assessment that includes clients’ self-reports and the use of behavioural pain scales for
nonverbal clients is essential for effective pain management.
3. The best pain management strategies involve clients, families, and health care professionals, with
the clients and families being encouraged to communicate the presence of pain and health care
professionals being knowledgeable about pain-relief options.
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The Nature of Pain anticipation of pain can all modify its multidimensional
properties. Structures in the frontal cortex are thought
to be implicated in mediating between the cognitive and
Pain has been defined as “an unpleasant sensory and affective features of pain.
emotional experience associated with actual or poten- When treating a client with pain, the nurse must
tial tissue damage, or described in terms of such dam- understand that pain is defined in terms of its sensory,
age” (IASP, 2012). In accordance with this definition, affective, and cognitive determinants and that it cannot
Pasero and McCaffery (2011) highlighted that pain is be ascribed to only one of them. The therapeutic impli-
“whatever the experiencing person says it is, existing cations of this definition of pain is choosing a pain man-
whenever he/she says it does.” On the basis of this, the agement plan that treats pain as not only a sensory but a
person’s self-report of pain represents the most valid cognitive–affective experience; this means providing the
measure, or “gold standard,” for the presence of pain, client with holistic care that includes analgesia as well as
and it should be obtained whenever possible. The lat- nonpharmacological interventions, such as relaxation or
ter definition helped to change practice by emphasiz- anxiety management.
ing that health care professionals must believe clients
with respect to their report and must pay particular
attention to the client’s subjective experience of pain.
To overcome pain definitions that rely on self-report, Origin of Pain
experts have proposed an alternative definition of pain, Pain can be classified by its inferred origin into two
stating that behavioural changes caused by pain are major types: (a) nociceptive pain and (b) neuropathic
valuable forms of self-report and should be considered pain. Common pain syndromes of both types are briefly
alternative indicators of the presence of pain (Anand described in the Clinical Manifestations box.
& Craig, 1996). A report by the IASP (2012) includes
the statement that “the inability to communicate ver- Nociceptive Pain Nociceptive pain is directly
bally does not negate the possibility that an individual related to tissue damage and nociception. It may be
is experiencing pain and is in need of appropriate somatic (e.g., damage to skin, muscle, bone) or visceral
pain-relieving treatment.” Therefore, pain assessment (e.g., damage to organs). It is the result of the nor-
must be designed to conform to the communication mal physiological processing of harmful or potentially
capabilities of the client. When the person is not able to harmful noxious stimuli that are perceived as being
self-report, the nurse should select and use behavioural painful (Pasero & McCaffery, 2011). This type of pain
pain scales that have been shown to be valid for their is a result of the stimulation of nociceptors (nerves
client population. that transmit noxious stimuli) that is often the case with
The experience of pain is complex and multidi- tissue damage resulting from trauma or inflammation.
mensional, with sensory–discriminative, motivational– Further, nociceptive pain can be categorized accord-
affective, and cognitive–evaluative components (Melzack ing to its origin as somatic or visceral. Somatic pain
& Casey, 1966). The traditional definition describes pain originates in the skin, muscles, bone, or connective tis-
as an unpleasant feeling that is the opposite of enjoy- sue. The sharp sensation of a paper cut or aching and
ment. This highlights that pain is a sensory experience, throbbing of a sprained ankle are examples of somatic
yet pain is different from other senses because it is pain. Visceral pain results from the stimulation of
inseparable from its affective and cognitive properties. The pain receptors in the organs. Visceral pain tends to be
sensory component of pain is supported by the nerve diffuse and often feels like deep somatic pain, that is,
pathways dedicated to delivering the pain signal to the burning, aching, or a feeling of pressure. Visceral pain is
brain and to determining its quality, magnitude, and frequently caused by stretching of the tissues, ischemia,
location. Once the brain perceives the pain signal, other or muscle spasms. For example, an obstructed bowel
cortical structures detect the unpleasant effect of pain or blocked coronary artery will result in visceral pain
and determine whether it is a trigger for action, such (Pasero & McCaffery, 2011).
as withdrawal, avoidance, or aggression. This motiva- Neuropathic Pain Neuropathic pain is the result
tional–affective component of pain is directed by the of injury to the nerves or an abnormal processing of
limbic system and the reticular formation in the brain stimuli by the peripheral or central nervous system.
stem (Melzack & Casey, 1966). By activating these struc- The nerves may be abnormal because of illness (e.g.,
tures, pain can disrupt everyday tasks, demand atten- postherpetic neuralgia, diabetic peripheral neuropa-
tion, and become overwhelming. The central control thy), injury (e.g., phantom limb pain, spinal cord injury
exerted by the cortex provides the cognitive–evaluative pain), or undetermined reasons. Neuropathic pain
component of pain, which refers to the significance or that arises after surgery or another invasive procedure
meaning of the pain experience. The client’s cultural that resulted in nerve damage is called iatrogenic neuro-
background, personal beliefs, anxiety, attention, and pathic pain. Neuropathic pain is persistent in nature; it is
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Clinical Manifestations of Common Pain Syndromes
The following are some common pain syndromes:

• Postherpetic neuralgia: An episode of herpes zoster (shingles) has two phases: (a) a vesicular eruption and (b) neurological
pain that often encircles the body at the level of the affected dermatome(s). In postherpetic syndrome, severe pain persists for
months or years with burning or electric-shock pain in the area of the original eruption. Advancing age is a risk factor for per-
sistent postherpetic neuralgia. A vaccine has been approved and is recommended for all people over age 60 years to prevent
shingles and the possibility of postherpetic neuralgia.
• Phantom pain: Phantom sensation, the feeling that a lost body part is present, occurs in most people after amputation. For
many, this sensation is painful; it may occur spontaneously or be evoked (e.g., by using a poorly fitting prosthesis). When the
amputation involves a limb, it is termed phantom limb pain, whereas pain following breast removal is called postmastectomy
pain. Phantom pain varies and may be burning, severe, crushing pain or a cramping sensation. This pain is neuropathic in
nature, and its etiology is complex because of the loss of sensory input into the CNS from the amputated region (Melzack
et al., 2001; Saarto & Wiffen, 2010; Wolff et al., 2011).
• Trigeminal neuralgia: Trigeminal neuralgia is episodic; it is an intense stabbing pain that is transmitted by one or more
branches of the trigeminal (fifth cranial) nerve. The pain is usually experienced in small parts of the face and head, for exam-
ple, gums, cheek, and surface of the head.
• Headaches and migraines: Headache is a common somatic pain that can be caused by either intracranial or extracranial
problems. Although often similar to “common” headaches, migraines are thought to be a neurovascular disorder character-
ized by severe throbbing headaches that are normally (but not always) unilateral. Attacks of migraines may be accompanied
by nausea, vomiting, and photophobia (Schurks et al., 2009). In addition to appropriate medication (e.g., administration of
nonspecific treatments, such as acetylsalicylic acid and acetaminophen, or migraine-specific drugs, such as ergotamine), both
headaches and migraines can be treated by nonpharmacological approaches (e.g., avoidance of the triggers, education, and
proper diet) (Goadsby, Lipton, & Ferrari, 2002).
• Low back pain: Nearly everyone suffers from low back pain at some time during their lives. Most occurrences go away within
a few days. Chronic back pain is back pain that persists for more than 3 months. It is often progressive, and the cause can
be difficult to determine.
• Fibromyalgia: Fibromyalgia is a chronic pain disorder that is characterized by widespread musculoskeletal pain, fatigue, and
multiple tender points. A tender point is tenderness that occurs in a precise, localized area, particularly in the neck, spine,
shoulders, or hips. People with this syndrome can also experience sleep disturbances, morning stiffness, irritable bowel syn-
drome, anxiety, and other symptoms. Although the symptoms present as muscle pain, stiffness, and weakness, it is consid-
ered by many to be a problem of abnormal CNS functioning, particularly as it relates to the way nerves process pain
(Mease, 2005).
characterized by ongoing pain with the sensation of (hyperexcitability), thus initiating a vicious cycle of
burning, prickling, and often a concomitant sensory maintained pain. Continued noxious stimulation can
discrimination deficit in the affected area. The most also increase the receptive field of dorsal horn neurons.
common presentations of this condition are hyper- If not eliminated, it may produce prolonged excitability
algesia (increased sensation of pain in response to a that is maintained without further stimulation (Coderre
normally painful stimulus) and allodynia (sensation of et al., 1993; Melzack et al., 2001). Neuropathic pain
pain from a stimulus, such as light touch, that normally conditions tend to be difficult to treat. Unfortunately,
does not produce pain). It is thought that the phenom- evidence suggests that in some instances, neuropathic
enon of neuroplasticity is a contributing factor to some pain results from a failure to effectively treat acute pain
of the abnormal changes that take place in many types episodes, such as that during the perioperative period
of neuropathic pain (Pasero & McCaffery, 2011). Neu- (Manias, Bucknall, & Botti, 2005).
roplasticity is the ability of the brain to reorganize Neuropathic pain can be classified into two subcat-
its signalling and the processing of stimuli in accor- egories based on the assumed mechanism that is respon-
dance with the input from the environment. These sible for the pain: (a) peripheral neuropathic pain and (b)
changes take place on a cellular level, but they have central neuropathic pain.
the ability to rearrange the functionality of the larger Peripheral neuropathic pain (e.g., phantom
regions of the central nervous system (CNS) (Coderre, limb pain, postherpetic neuralgia, carpal tunnel syn-
Katz, Vaccarino, & Melzack, 1993). Peripheral pain- drome) follows damage, sensitization, or abnormal
ful stimuli may sensitize neural structures involved in changes of peripheral nerve fibres (Pasero & McCaffery,
pain perception. For example, a prolonged noxious 2011). Peripheral neuropathic pain is typically chronic;
stimulus can result in changes to the sensitivity of the it is described as burning, an electric shock, or tingling,
dorsal horn neurons that can be maintained even after dull, and aching; episodes of sharp, shooting pain can
the stimulus is removed (Melzack, Coderre, Katz, & also be experienced (Adler, Nico, VandeVord, & Skoff,
Vaccarino, 2001). Smaller noxious stimuli to the same 2009; Herr, 2002)
area may result in a higher amount of pain as well as Central neuropathic pain (e.g., spinal cord
a further increase in dorsal horn neuron sensitivity injury pain, post–cerebrovascular accident pain, multiple
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sclerosis pain) results from malfunctioning nerves in the cancer, its treatment, or some other factor in individuals
CNS (brain and spinal cord). The neurons in the CNS with cancer). Because its onset can be subtle, it may be
may exhibit abnormal hyperexcitability as a result of difficult for the client to determine when the chronic
complex changes induced by the ongoing firing of affer- pain started. It can also often be difficult to pinpoint the
ent nociceptors. These changes can occur anywhere in location of chronic pain, as it is typically more diffuse
the CNS. One of the well-characterized central neu- compared with acute pain. Chronic pain is complex and
ropathic pain mechanisms is the increased release and can become all consuming, causing irritability, insom-
binding of the excitatory neurotransmitters in the milieu nia, and withdrawal from family, friends, and interests
of the central neurons that are responsible for pain (Watt-Watson, Evans, & Watson, 1988).
processing. Another mechanism, termed central dis- Intractable pain, a type of persistent pain, is a
inhibition, causes hyperexcitability of the central pain pain state (generally severe) for which no cure is possible,
neurons because of the loss of control mechanisms that even after accepted medical evaluation and treatments
usually inhibit the conduction of a pain signal (Pasero & have been implemented. The focus of treatment turns
McCaffery, 2011). from cure to pain reduction, functional improvement,
Complex regional pain syndrome (CRPS) is and the enhancement of quality of life.
a term used for a number of pain conditions whose Table 30.1 outlines some common differences
etiology is poorly understood (Dunwoody et al., 2008; between acute and persistent (chronic) pain.
Harden, Bruehl, Stanton-Hicks, & Wilson, 2007). The
causative mechanisms of this group of pain conditions
may include both peripheral nervous system (PNS) and Concepts Associated with Pain
CNS abnormalities. To be diagnosed with this condi- Two additional terms used in the context of pain are pain
tion, clients must have continuous moderate to severe threshold and pain tolerance. Pain threshold is the mini-
pain along with edema and vasomotor, motor, or sen- mum level of noxious stimulation necessary for a person
sory changes in the affected area. In addition, all other to label a sensation as pain. A person’s pain threshold
diagnoses that explain the symptoms must be excluded is generally fairly uniform, relative to the location of
(Harden et al., 2007). Pain in clients suffering from CRPS the pain and the kind of noxious stimulus experienced.
proves a difficult target to treat completely, and it usu- The pain thresholds of two different individuals may be
ally requires multimodal pharmacological and holistic markedly different (Mader, Blank, Smithline, & Wolfe,
approaches (Gibbs, Drummond, Finch, & Phillips, 2008). 2003). Therefore, the same stimulus can cause various
levels of pain in different individuals. The understanding
of the pain threshold variability should remind a nurse
Duration of Pain to always elicit a client’s report of his or her pain level
Pain can be classified as acute, persistent (chronic), or

intractable, on the basis of its duration. Table 30.1 Differences between Acute and Persistent
(Chronic) Pain
Acute pain is awareness of noxious signalling from
recently damaged tissue, complicated by sensitization in Acute Pain Persistent (Chronic) Pain
the PNS and within the CNS. Its intensity and resolution
Mild to severe Mild to severe
change with inflammatory processes, tissue healing, and
movement. Unpleasant acute pain promotes survival. Related to tissue injury; Continues beyond healing
resolves with healing
Acute pain is short-term pain of less than 12 weeks’
duration (IASP, 2012). Acute pain is purposeful, inform- Sympathetic nervous Parasympathetic nervous
system responses: system responses:
ing the person that something is wrong. Typically, the
• Increased pulse rate • Vital signs nor-
onset of acute pain is sudden because of a noxious • Increased respiratory mal (because of
stimulus, such as trauma, and the location of the pain rate adaptation)
can usually be easily identified. This type of pain should • Elevated blood • Dry, warm skin
not exceed 6 months, and if not adequately treated pressure • Pupils normal or
can become chronic (Joshi & Ogunnaike, 2005; Kehlet, • Diaphoresis dilated
Jensen, & Woolf, 2006). • Dilated pupils
Persistent (chronic) pain is pain that persists Client may be restless and Client may appear
after the usual time for healing (in pain after trauma or anxious depressed and
surgery). It can also be secondary to chronic disorders or withdrawn
nerve malfunctions that produce ongoing pain after Client reports pain Client may not mention pain
healing is complete. Chronic pain lasts beyond 6 months unless asked
(Bonica, 1990; Merskey & Bogduk, 1994) and has no Client may exhibit crying, Behaviour indicative of pain
purpose. Chronic pain can be further classified as non- rubbing or holding pain- often absent
cancer pain or cancer pain (pain associated with ful area
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to detect pain and provide adequate analgesia (Pasero Transduction

& McCaffery, 2011). Pain tolerance is the maximum
amount of painful stimuli that a person is willing or The PNS includes primary afferent sensory neurons
able to endure without seeking avoidance of the pain or specialized to detect noxious, or injurious, stimuli, which
relief. Pain tolerance can vary widely among individuals can be thermal, chemical, or mechanical in nature (see
and cultures, as it relates to the cognitive–affective and Table 30.2). The nerve fibres that transmit noxious
subjective experience of each individual. For example, information are called primary afferent nociceptors. Nocicep-
a woman may withstand severe pain for a prolonged tors are located throughout the skin and mucosa and
period during childbirth for a more natural or drug-free less frequently in deep structures, such as joints, arteries,
experience; however, she may want pain relief for a and viscera; their terminals possess a broad array of
regular headache. very selective molecular receptors. When a sufficiently
See the Clinical Alert box about major contributors noxious stimulus is in the peripheral microenvironment
to unrelieved pain. (e.g., injury to cells or tissue), the nociceptors can be
activated by the direct stimulus (e.g., heat, cold, or pres-
sure) or by the biochemical mediators released from the
milieu (local tissues, immune cells, and nerve endings)
Physiology of Pain: via their receptors (Caterina, Gold, & Meyer, 2005). The
mediators that activate and further sensitize the nocicep-
Nociception tors include serotonin, histamine, potassium, bradykinin,
prostaglandins, and substance P (Figure 30.1). Trans-
Nociception represents the neural and cortical activ- duction occurs when the excited nociceptor converts
ity that is necessary, but not sufficient, for pain and the surrounding noxious stimuli into an action potential
involves four processes: (a) transduction, (b) transmission, (i.e., electrochemical impulse) that is then transmitted to
(c) perception, and (d) modulation (Pasero & McCaffery, the spinal cord to ultimately reach the CNS.
2011). The process of pain transduction and transmis-
sion involves three types of neurons: (a) the afferent
or sensory neurons, (b) the efferent or motor neurons, Substance P
and (c) the interneurons or connector neurons. Pain is
the conscious experience that emerges from nociception
(Charlton, 2005).
Clinical Alert
Second-order Primary afferent
Unrelieved acute pain should not be left untreated; it has neuron neuron
numerous physiological, psychological, and economic consequences.
Major contributors to unrelieved pain are knowledge gaps and misbeliefs
about pain that exist not only in the client but also in health care profes- Figure 30.1 Substance P assists the transmission of
sionals and society in general. impulses across the synapse from the primary afferent neuron
to a second-order neuron.
Table 30.2 Types of Noxious Stimuli
Stimulus Type Physiological Causes of Pain

Mechanical
1. Trauma to body tissues (e.g., surgery) Tissue damage; direct irritation of the pain receptors; inflammation
2. Alterations in body tissues (e.g., edema) Pressure on pain receptors
3. Blockage of a body duct Distension of the lumen of the duct
4. Tumour growth Pressure on pain receptors; irritation of nerve endings
5. Muscle spasm Stimulation of pain receptors (also see “Chemical” below)
Thermal
Extreme heat or cold (e.g., burns, frostbite) Tissue destruction; stimulation of thermosensitive pain receptors
Chemical
1. Tissue ischemia (e.g., blocked coronary artery) Stimulation of pain receptors because of accumulated lactic acid (and
2. Muscle spasm other chemicals, such as bradykinin and enzymes) in tissues
3. Toxins Tissue ischemia secondary to mechanical stimulation (see above)
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Transmission few fibres terminate in the reticular areas of the brain

stem, but most nerve fibres of the spinothalamic tract
Transmission occurs when information about a nox- terminate in the thalamus. From there, signals are sent
ious stimulus is conducted through the spinal cord to the to the basal areas of the brain and to the somatic sen-
brain via two types of peripheral afferent nociceptive sory cortex. A-delta fibres allow for the detection of
fibres: (a) A-delta fibres and (b) C fibres. A-delta fibres “first pain”—this is a mechanism of quick detection and
have a relatively large diameter, are myelinated, and localization of pain that would allow for a fast protective
rapidly conduct the impulse. These fibres are associated response, such as a withdrawal reflex (Dahl & Moiniche,
with the sensation of sharp, pricking pain. The other set 2004; Manias et al., 2005; Marchand, 2008).
of nociceptive fibres is the small-diameter, unmyelinated The slow C fibres conduct impulses from mechani-
C fibres. C fibres transmit the impulse more slowly and cal, thermal, and chemical stimuli. C-fibre pain, or the
mediate long-lasting, burning pain. See Figure 30.2. “second” pain, is an aching pain that is poorly local-
The terminals of afferent nociceptors enter the dor- ized (Dahl & Moiniche, 2004; Marchand, 2008). The
sal horn of the spinal cord through the dorsal root and impulses from C fibres often pass through one or more
synapse onto second-order neurons in substantia gelati- additional short neurons in the dorsal horn before travel-
nosa. Impulse transmission from the sensory (afferent) ling up to the brain via the spinothalamic tract.
nerve fibres to the second-order neurons in the dorsal
horn happens via the release of neurotransmitters, ace-
tylcholine, norepinephrine, epinephrine, serotonin, and
dopamine. The fast A-delta fibres primarily conduct
Perception
impulses from mechanical and thermal pain. They syn- Perception occurs when a client becomes conscious
apse with second-order neurons (long fibres) in the dorsal of the pain. Four key regions of the cerebral cortex
horn that cross immediately to the opposite side of the are thought to be activated by noxious stimuli via the
spinal cord. They later enter the lateral spinothalamic ascending pathways: (a) the insular cortex, (b) the ante-
tract and ascend to the brain, where the information rior cingulate cortex, (c) the primary somatosensory cor-
about the pain stimulus is perceived and processed. A tex, and (d) the secondary somatosensory cortex (Craig
Pain
perception
Descending
pathway
Modulation
(Descending
system)
Ascending
pathway Releases
Nociceptors endogenous
(receptors) Spinal opioids and
Lateral spinothalamic tract
ganglia serotonin and
A-delta fibers Dorsal horn norepinephrine
(fast transmission of (pain signal modified)
sharp, localized pain)
inhibits or
reduces ascending
Tissue Release of painful impulses
injury neurotransmitters
C fibers
(slow transmission of dull,
burning chronic pain)
Transduction Transmission
Figure 30.2 Physiology of pain perception. Pain processing involves the ascending (in red) and descending (in blue) pathways.
M30_KOZI2703_04_SE_C30.indd 674 27/02/17 1:38 PM

& Sorkin, 2011). These regions, together with other areas and interpretation. For example, many clients report
of the forebrain, produce the sensory–discriminative, lesser pain intensity when they are distracted or when
motivational–affective, and cognitive–evaluative aspects they use imagery techniques to control their pain (Lorenz,
of the pain experience, as well as motoric integration of Minoshima, & Casey, 2003). We have incomplete under-
noxious stimuli and pain memory (Basbaum & Bushnell, standing of the mechanisms of cortical pain modulation,
2002; Basbaum & Jessell, 2000; Craig & Sorkin, 2011). but it is thought to involve multiple levels of the CNS.
One such pathway is the opioid-sensitive descending
pathway from the prefrontal cortex to the amygdala,
the rostral ventral medulla, and the periaqueductal grey
Modulation matter (Villemure & Bushnell, 2002). Other affective–
Modulation is a process by which painful messages that motivation structures involved in the modulation of pain
travel from the nociceptors to the CNS may be enhanced perception are located in the thalamus.
or inhibited. Modulation happens at every level of the
pain pathway and includes the structures of the spinal
cord, the brain stem, and the cortex. Pain can be modu- Gate Control Theory
lated by ascending and descending mechanisms. A typi-
In 1965, Melzack and Wall’s gate control theory (GCT)
cal example of ascending pain modulation is rubbing an
(Melzack, 1990; Melzack & Wall, 1965, 1973, 1982) pro-
injury site, thus activating large non-nociceptive nerve
posed that interneurons of the substantia gelatinosa act
fibres in the periphery. Stimulation of these large A-beta
as a gate, regulating the input of large and small nerve
fibres activates inhibitory interneurons in the dorsal
fibres to lamina V cells (Figure 30.3).
horn of the spinal cord, effectively preventing noxious
According to GCT, pain is not a simple sensory
signal transmission from the periphery to the higher
experience but one that involves central perception and
brain regions. The physiological basis of this mechanism
cognitive–appraisal mechanisms. This theory suggests
of pain modulation was elucidated by Melzack and Wall
that if small nociceptive fibre activity in the dorsal horn
(1965) in their work on gate control theory (GCT), which
reaches a critical threshold without being blocked, noci-
is described later in the chapter.
ceptive impulses are transmitted to the thalamus and
Inhibition may also be produced at the level of the
cerebral cortex (Melzack & Wall, 1965, 1973, 1982). Pain
spinal cord and the brain stem (spinothalamic pathway)
perception can be modulated centrally through descend-
via the release of endogenous opioids and neurotrans-
ing mechanisms that can be influenced by peoples’ past
mitters. Endogenous opioids are naturally occurring
experiences, attention, and emotion. The modulation
morphine-like pentapeptides found throughout the ner-
of the nociceptive signal happens via a “gating mecha-
vous system. They exist in three general classes: (a)
nism” in the substantia gelatinosa within the dorsal horn
enkephalins, (b) dynorphins, and (c) beta-endorphins.
(Melzack & Wall, 1965, 1973, 1982).
These substances block neuronal activity related to nox-
ious impulses by binding to opiate receptor sites in the
central and peripheral nervous systems (Melzack & Wall,
1996). The opiate-binding receptor sites are identified as Theoretical gate
mu (m), kappa (ĸ), and delta (δ) and are the same sites to (open)
which exogenous opioid analgesics (e.g., oxycodone) bind
Dorsal horn
to provide pain relief. In the ascending pain modulation
mechanism, endogenous opioids may be produced in the Large-diameter fibre
brain stem and the dorsal horn, or exogenous opioids Small-diameter fibre
may be introduced by an administration of an opioid carrying pain impulses
analgesic. The released or introduced opioids bind to the to brain
m-opioid receptors on nociceptive nerve fibres, blocking Spinal cord
the release of substance P. In the descending mechanism,
the efferent spinothalamic nerve fibres that descend
from the brain can inhibit the propagation of the pain
signal by triggering the release of endogenous opioids Theoretical gate
in the brain stem and in the spinal cord. Serotonin (closed)
and norepinephrine are two other important nonopioid Large-diameter fibre
pain-inhibitory neurotransmitters that are involved in carrying nonpain
endogenous analgesic mechanisms. These substances impulses to brain
are released by the descending fibres of the descending
Small-diameter fibre
spinothalamic pathway. carrying pain impulses
Endogenous pain control by higher cortical struc-
tures accounts for many differences in pain perception FIGURE 30.3 A schematic illustration of gate control theory.
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This gating mechanism can be open, partially open, mechanism are (a) substance P and (b) glutamate. These
or closed. The position of the gate is influenced by the neurotransmitters cause an increase in intracellular cal-
relative amounts of activity in large non-nociceptive cium levels and lower the threshold for the firing of an
(A-beta) and small nociceptive (A-delta and C) fibres. action potential (Argoff, Albrecht, Irving, & Rice, 2009;
Increased activity in the large fibres closes the gate Khasabov et al., 2002; Latremoliere & Woolf, 2009).
and inhibits the transmission of noxious messages car- One of the possible consequences of central sensitiza-
ried by the small fibres to transmission cells (T cells) in tion is wind-up, a condition where, because of the
the substantia gelatinosa (Melzack & Wall, 1965, 1973, repeated firing of C fibres, the spinal cord neurons
1982). However, if noxious impulses are not blocked by become hyperresponsive, and their receptive fields in the
large-fibre activity (i.e., the gate is open or partially open) corresponding organs expand. As a result, the client may
and reach a critical level, they will be transmitted to present with secondary hyperalgesia (Herrero, Laird, &
second-order neurons in the substantia gelatinosa. The Lopez-Garcia, 2000).
noxious impulse is then transmitted to the thalamus and
the cerebral cortex via the ascending nociceptive second-
Factors Affecting
order neurons.
Since GCT was developed, pain knowledge has
greatly evolved. Cumulative research has led to more
advanced understanding of the nature of pain and its the Pain Experience
mechanisms, including sensitization, cortical process-
ing, as well as spinal and supraspinal mechanisms of Numerous factors can affect a person’s perception of
pain control, beyond Melzack and Wall’s original theory. and reaction to pain as well as his or her preferences for
Although GCT greatly enhanced the understanding of treatment. These include the person’s ethnic and cultural
the complexity of the pain experience and the potential values, developmental stage, environment and support
consequences of unrelieved pain, it is largely a theory people, previous pain experiences, and the meaning of
of acute pain. GCT cannot, for example, explain why the current pain.
a person develops chronic pain long after the original
injury has healed.
Ethnic and Cultural Values
Ethnic background and cultural heritage have long been
Nervous System Plasticity: recognized as factors that influence both a person’s reac-
tion to pain and the expression of that pain. Behaviour
Peripheral and Central Sensitization related to pain is a part of the socialization process.
The role of plasticity of the nervous system in peripheral In addition to some variations in pain threshold,
and central sensitization is now being recognized, along with cultural background can affect the level of pain that an
the individuality of pain perception and response (Bas- individual is willing to tolerate. In some Middle Eastern
baum & Jessell, 2000). In the context of pain, nervous and African cultures, self-infliction of pain is a sign
system plasticity refers to the fact that pain mecha- of mourning or grief. In other groups, pain is antici-
nisms in the PNS and CNS can change in response to pated as part of the ritualistic practices, and therefore,
continued noxious stimulation, a process known as sen- tolerance of pain signifies strength and endurance.
sitization. For example, peripheral sensitization Moreover, the expression of pain varies widely. Stud-
of peripheral nociceptors can occur after injury, sur- ies have shown that individuals of northern European
gery, or inflammation because of inflammatory media- descent tend to be more stoic and less expressive of
tors released from damaged cells, such as bradykinin, their pain than individuals from southern European
histamine, and prostaglandins. Peripheral sensitization backgrounds. Persons of Asian descent, especially those
can change the properties of nociceptors so that they of Chinese origin, may believe that pain is an essential
transmit spontaneous discharges and respond at a low- part of life and tend to underreport their levels of pain
ered threshold to both noxious and non-noxious stimuli (Gordon, 1997; IASP, 2001; Kumasaka, 1996; Munoz &
(Basbaum & Jessell, 2000). Moreover, prolonged firing of Luckmann, 2005).
nociceptors with severe or persistent injury, such as sur- Nurses must realize that they have their own attitudes
gery, causes dorsal horn spinal cord neurons to become and expectations about pain (see the Clinical Alert box).
more responsive to all inputs, resulting in a phenomenon For example, nurses may place a higher value on silent
known as central sensitization. Central sensitization suffering or self-control in response to pain. Nurses
can result in abnormal interpretation of normal stimuli expect people to be objective about pain and to be able
(allodynia), the amplification or prolongation of the to provide a detailed description of the pain. Since many
pain signal (hyperalgesia), and chronic pain that lasts clients have individual and cultural differences in pain
long after the original trauma (Basbaum & Jessell, 2000). reporting and in treatment preferences, nurses must be
The two major neurotransmitters that play a role in this competent to elicit a report and to accurately assess pain
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other indicators (Champion, Goodenough, von Baeyer,

Clinical Alert & Thomas, 1998). When self-report cannot be obtained
It is imperative that nurses are aware of their “hidden” biases (e.g., infants, preverbal children, and children or older
in pain assessment, that is, biases that he or she may not be conscious adults with cognitive impairment, and critically ill cli-
of and that may cause the nurse to either under- or overestimate their ents), behavioural observation should be the primary
clients’ pain or to omit pain assessment altogether. These biases may source for pain assessment (RNAO, 2013).
include the client’s physical appearance, gender, age, race, or culture, as
well as the nurse’s personal experiences with pain.
Environment and Support People

The psychological state of a person can affect their
in each of their clients. To become culturally competent, attention to pain, as well as the interpretation and
nurses must become knowledgeable about differences perception of pain. The surrounding environment can
in the meaning of and appropriate responses to pain affect the psychological state of an individual; it can
in their client’s culture while being sympathetic to their cause many reactions from relaxation to excitation and
concerns and developing the skills needed to address anxiety. Notably, a strange environment, such as a hos-
pain in a culturally sensitive way. pital with its noises, lights, and activity, can compound
the state of stress or anxiety. Although there is no proven
causal relationship between anxiety and pain, being
in an unfamiliar environment may cause a psychologi-
Developmental Stage cal discomfort that can have an indirect effect on the
The ages and developmental levels of clients are impor- affective component of pain and increase the psycho-
tant factors that will influence their reactions to and logical suffering of the person who is experiencing it.
expressions of pain. Some age variations and related People who consider their family and friends supportive
nonpharmacological nursing interventions are presented show fewer pain behaviours and higher levels of activity
in Table 30.3. and report lower levels of emotional distress (Jamison &
The field of pain management for infants and Virts, 1990). Finally, satisfaction with perceived social
children has grown significantly over the past years. It is support was shown to be associated with lower pain
now accepted that anatomical, physiological, and bio- intensity and lower depression levels (Lopez-Martinez,
chemical elements necessary for pain transmission are Esteve-Zarazaga, & Ramirez-Maestre, 2008).
present in newborns, regardless of gestational age (Bar- Expectations of society or significant others can
tocci, Bergqvist, Lagercrantz, & Anand, 2006; Grunau affect a person’s perceptions of and responses to pain.
et al., 2005; Hall & Anand, 2005; Slater et al., 2006). In some situations, for example, girls may be permitted
However, children’s pain is often undertreated because to express pain more openly compared with boys. Family
they may be less able to articulate their pain experience roles can also affect how a person perceives or responds
and needs compared with adults (Ellis et al., 2002; Stevens, to pain. For instance, a single mother supporting three
1999). children may ignore pain because of her need to stay on
The likelihood of experiencing pain increases with the job. The presence of support people often changes a
age as older adults are more likely to suffer from chronic client’s reaction to pain. For example, toddlers often toler-
conditions that can cause pain, such as arthritis, diabe- ate pain more readily when supportive parents or nurses
tes, and joint disorders. In addition, as the body system are nearby (Lopez-Martinez et al., 2008; Schiff, Holtz,
ages, older adults may require more medical interven- Peterson, & Rakusan, 2001).
tions, such as surgery, that may result in acute pain.
Older adults may also experience age-related changes in
nociception that may result in a higher pain threshold.
For example, the transduction and transmission of the
Past Pain Experiences
pain signal in the older adult may be delayed by a reduc- The adaptation model of pain proposed by Rollman
tion in substance P and the density of myelinated and (1979) suggests that an individual’s judgment of a pain
nonmyelinated fibres. The nurse should not conclude signal is based on the stimulus, its contextual meaning,
that an older adult has lower pain intensities. In fact, if the motivational state of the subject, and a number of
such a client chooses to report pain, the nurse should experiential factors. This model implies that previous
be alerted by the possibility of a greater underlying pain experiences can influence a client’s response to
pathology. For clients of all ages, the nurse may attempt pain. People who have personally experienced pain or
to assess pain by using self-report and observational who have been exposed to the suffering of someone
or behavioural and physiological measures (RNAO, close are often more threatened by anticipated pain than
2013). Ideally, the nurse should use a composite mea- are people without a pain experience (Rollman, Abdel-
sure that includes self-report and one or more of the Shaheed, Gillespie, & Jones, 2004).
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Table 30.3 Age Variations in the Pain Experience
Age Group Pain Perception and Behaviour Selected Nursing Interventions

Infant Perceives pain Promote breast-feeding during painful procedures.
Responds to pain with increased sensitivity Use tactile stimulation (e.g., gently rub the other side
Older infant tries to avoid pain; for example, turns of the affected area).
away and physically resists Play music or tapes of a heartbeat.
Toddler and Develops the ability to describe pain and its intensity Distract the child with toys, books, pictures. Involve
preschooler and location the child in blowing bubbles as a way of “blowing
Often responds with crying and anger because a child away the pain.”
perceives pain as a threat to security Appeal to the child’s belief in magic by using a
Reasoning at this stage is not always successful “magic” blanket or glove to take away the pain.
May consider pain a punishment Hold the child to provide comfort.
Feels sad Explore misconceptions about pain.
May learn there are gender differences in pain
expression
Tends to hold someone accountable for the pain
School-age Tries to be brave when facing pain Use imagery to turn off “pain switches.”
child Rationalizes in an attempt to explain the pain Provide a behavioural rehearsal of what to expect
Responsive to explanations and how it will look and feel.
Can usually identify the location and describe the pain Provide support.
With persistent pain, may regress to an earlier stage of
development
Adolescent May be slow to acknowledge pain Provide opportunities to discuss pain.
Recognizing pain or “giving in” may be considered Provide privacy.
weakness Present choices for dealing with pain. Encourage
Wants to appear brave in front of peers and not report music or TV viewing as a distraction.
pain
Adult Behaviours exhibited when experiencing pain may be Deal with any misbeliefs about pain.
gender-based behaviours learned as a child Focus on the client’s control in dealing with the pain.
May ignore pain because to admit it is perceived as a Allay fears and anxiety, when possible.
sign of weakness or failure Spend time with the client, and listen carefully.
May use pain for secondary gain, for example, to get
attention
Fear of what pain means may prevent some adults
from taking action
Older adult May perceive pain as part of the aging process Explore and clarify misbeliefs.
May have decreased sensations or perceptions of the Encourage independence, whenever possible.
pain
Lethargy, anorexia, and fatigue may be indicators of
pain
May withhold complaints of pain because of fear of
the treatment, of any lifestyle changes that may be
involved, or of becoming dependent
May describe pain differently, that is, as “ache,” “hurt,”
or “discomfort”
May consider it unacceptable to admit to or show pain
associated with it. These clients may view pain as a tem-

Meaning of Pain porary inconvenience rather than a potential threat or
The meaning of pain can contribute to the overall pain disruption to daily life.
experience (Arntz & Claassens, 2004; McGillion et al., In contrast, clients with unrelenting chronic pain
2007). Some clients may accept pain more readily than may suffer more intensely. Chronic pain affects the body,
others, depending on the circumstances and the client’s mind, spirit, and social relationships in an undesirable
interpretation of its significance. A client who associates way. Physically, the pain limits functioning and contrib-
pain with a positive outcome may withstand it amaz- utes to disuse or deconditioning. For many, changes in
ingly well. For example, a woman giving birth to a child activities of daily living (ADLs; e.g., eating, sleeping,
or an athlete undergoing knee surgery to prolong his toileting) also take a toll. The side effects of the various
career may tolerate pain better because of the benefit medications used to try to control pain also place a heavy
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burden on the sufferer’s body. Socially, pain often strains Because it has been found that many people will not
valued relationships, in part because of the impaired voice their pain unless asked about it, pain assessments
ability to fulfill role expectations. Together, these changes must be initiated by the nurse. Some of the many reasons
caused by pain may create a sense of loss (e.g., loss of why clients may be reluctant to report pain include
work, friends, identity, or pleasure) to the client.
• Unwillingness to trouble staff who are perceived as
Mentally, individuals with chronic pain change their
busy
outlook, becoming more pessimistic, often to the point
of helplessness and hopelessness. Mood often becomes • Concern about being labelled as a complainer or “bad
impaired when pain persists: The sadness of being patient”
unable to do important or enjoyable activities, combined • Fear of the injectable route of analgesic administra-
with self-doubts and learned helplessness, can contribute tion—children, in particular
to depression. The anxiety surrounding the timing of • Belief that pain is to be expected as part of the recov-
pain flare-ups, the worry about the physical ability to do ery process
what is needed, and the uncertainty about coping with
• Belief that pain is a normal part of aging or a neces-
multiple competing demands (including pain control)
sary part of life—older adults, in particular
can escalate emotionally, to the point of panic.
Spiritually, pain can be viewed in a variety of ways. • Belief that expressing pain reveals weakness
It may be perceived as a punishment for wrongdoing, a • Difficulty expressing personal discomfort
betrayal by a higher power, a test of fortitude, or a threat • Concern about potential risks associated with opioid
to the essence of who the person is. As such, pain can be drugs (e.g., addiction)
a source of spiritual distress or be a source of strength and
• Fear about the cause of pain or that reporting pain
enlightenment (Gatchel, Peng, Peters, Fuchs, & Turk, 2007).
will lead to further tests
• Concern about the possibility of unwanted side
effects, especially of opioid drugs
Pain Assessment • Concern that use of drugs now will render the drug
inefficient if or when the pain becomes worse
Accurate pain assessment is the foundation of effective When conducting pain assessments, it is essential
pain management. In fact, many health facilities are that nurses listen to and rely on the client’s perceptions
making pain assessment the “fifth” vital sign. Because of pain because it is a subjective experience. Believing
pain is a complex, subjective, and multidimensional the person who is conveying their perceptions of pain is
experience, no simple method can objectively determine also crucial in establishing a sense of trust.
how much pain an individual experiences. Nurses should Whenever possible, the nurse should question the
tailor pain assessments to the unique developmental client about his or her pain experience. In the nonverbal
levels, communication capabilities, and cultural needs of client (i.e. infants, older adults with cognitive deficits,
their clients. unconscious clients), the nurse will look for observational
In general, pain should be screened on admission to indicators to detect the presence of pain. The goal of
an acute or long-term care agency; at a visit with a health pain assessment is to get a comprehensive description of
care professional; after a change in medical status; and this subjective experience.
prior to, during, and after a procedure (RNAO, 2013).
However, the extent and frequency of the pain assess-
ment will vary according to the situation. For clients
experiencing acute or severe pain, the nurse may focus Pain Assessment in Clients
only on location, quality, severity, and early intervention. Able to Self-Report
Clients with less severe or persistent pain can usually
The gold standard of pain assessment is the client’s
provide a more detailed description of the experience.
self-report (IASP, 2012). The nurse must provide an
The frequency of pain assessment usually depends on
opportunity for clients to express, in their own words,
the pain management intervention being used and the
how they perceive their pain. The commonly used mne-
clinical circumstances. For example, in the initial post-
monic PQRSTU helps ensure that the pain assessment
operative period, pain is often assessed as often as every
is thorough.
15 minutes and then extended to every 2 to 4 hours.
Following pain management interventions, pain inten- P: Provoking/Palliating Factors Provoking factors
sity should be reassessed at an interval appropriate for are events that normally cause the pain or that aggravate
the intervention. For example, following the intravenous it. For example, physical exertion may precede chest
administration of 2.5 mg of morphine, the severity of pain and cause muscle spasms in the neck, shoulders,
pain should be reassessed at the peak effect, which is or back; abdominal pain may occur after eating. These
within 10 to 15 minutes. observations can help prevent pain and determine its
M30_KOZI2703_04_SE_C30.indd 679 27/02/17 1:38 PM

cause. Environmental factors, such as extreme cold or Table 30.4 Present Pain Intensity (PPI)
heat, can affect some types of pain. For example, sudden
Client’s Name: Date:
exercise on a hot day can cause muscle spasm. Physical
and emotional stressors can also precipitate pain. Strong None Mild Moderate Severe
emotions can trigger a migraine headache or an episode Throbbing 0 1 2 3
of angina. Some clients, especially those with chronic
Shooting 0 1 2 3
pain, may not be able to tell what brings on their pain.
By working together with the client and going over their Stabbing 0 1 2 3
daily routines and events that precede the pain, a nurse Sharp 0 1 2 3
may be able to help them determine whether their pain Cramping 0 1 2 3
is related to any precipitating factors. Gnawing 0 1 2 3
Assessing palliating factors consists of taking note of
Hot–Burning 0 1 2 3
all the strategies that the client has tried to decrease
Aching 0 1 2 3
the pain and whether or not they were helpful. These
may include medical procedures; home remedies, such Heavy 0 1 2 3
as herbal teas; medications; rest; applications of heat or Tender 0 1 2 3
cold; prayer; or distractions, such as watching television. Splitting 0 1 2 3
It is important to explore the effect that both pharmaco- Tiring–Exhausting 0 1 2 3
logical and nonpharmacological strategies have had on
Sickening 0 1 2 3
the pain. This information may provide the nurse with
valuable clues on how to tailor the client’s pain manage- Fearful 0 1 2 3
ment plan to his or her unique situation. Any side effects Punishing–Cruel 0 1 2 3
of pain-relieving strategies should also be documented. No pain Worst Possible Pain
Q: Quality/Quantity Quality refers to the client’s PPI (Present Pain Intensity)

description of the pain sensation. Descriptive adjectives 0 No Pain 4 Horrible
help people communicate the quality of their pain and 1 Mild 5 Excruciating
can provide information on the nature of the pain (i.e., 2 Discomforting
nociceptive, neuropathic, or a combination of both). A 3 Distressing
headache may be described as “being hit with a ham- Source: From the “Short Form McGill Pain Questionnaire.” Copyright R. Melzack, 1984;
1987, reprinted with permission from Dr. Melzack and www.mapigroup.com.
mer” or an abdominal pain as “piercing, like being
stabbed with a knife.” Sometimes, clients have difficulty
describing their pain because they have never experi-
enced any sensation like it. This is particularly true for
children, older adults, and adults who have neuropathic The NRS is widely used in clinical practice and con-
pain. sists of an 11-point scale from 0 (no pain) to 10 (worst
Nurses need to record the exact words clients use possible pain) (Figure 30.4, B). The VAS (Huskisson,
to describe pain. Exact information can be significant 1983) consists of a 10-cm line with one end indicating
in both the diagnosis of the pain etiology and the “no pain” and the other end indicating “pain as bad
treatment choices. For example, key descriptors, such as it could possibly be.” The distance on the line is cal-
as “burning” and “electrical,” may help the nurse to culated in millimetres (from 0 to 100) (see Figure 30.4,
identify neuropathic pain. To help gather information, A). The advantages of both scales include the ease of
a nurse can use a validated pain questionnaire (e.g., use, their applicability to many communicative client
McGill Pain Questionnaire or MPQ; see Table 30.4) populations, and their sensitivity and validity. The VRS
gives the client a list of adjectives that describe pain in
(Melzack, 1975).
a ranked order. Each adjective can also be assigned a
Quantity refers to pain intensity. Valid and reliable
score. For example, a VRS may consist of “no pain,”
self-report measures of pain intensity include the 0–10
“mild,” “moderate,” and “severe” pain that are assigned
Numerical Rating Scale (NRS), the Visual Analogue
the scores of 0, 1, 2, and 3, respectively (Ohnhaus &
Scale (VAS), the Verbal Rating Scale (VRS), and the
Adler, 1975).
Faces Pain Scales (FPSs). Such scales provide consistency
Various FPSs that are based on facial expressions
for nurses to communicate with the client and other
associated with different pain levels have been devel-
health care providers. Nurses can affect the quality of
oped. Each face can refer to a number to help docu-
the pain report by selecting pain scales that are appropri-
ment the pain intensity. Among them, the Faces Pain
ate for their target populations. Some clients may require
Scale—Revised (FPS-R) (Hicks, von Baeyer, Spafford,
the nurse to teach them how to use the scale or to fill in
van Korlaar, & Goodenough, 2001), shown in Figure
the pain assessment with them. Some of the commonly
30.4, B, can be used with school-age children (Stinson,
used pain scales are described below.
Kavanagh, Yamada, Gill, & Stevens, 2006). The Faces
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A Visual Analogue Scale (VAS)

10
9
No Pain as bad
pain as it could 8
possibly be 7
C 6
B
5
0 1 2 3 4 5 6 7 8 9 10 4
3
No Moderate Worst
pain pain possible 2
pain
1
0
0 2 4 6 8 10
Figure 30.4 Commonly used self-report pain scales. A: The Visual Analogue Scale. B: The 0–10 Numeric Rating Scale (NRS) and
the Faces Pain Scales-Revised (FPS-R) combined. C: The Faces Pain Thermometer.
A: The Visual Analogue Scale (VAS). The client is asked to rate their pain on a 10-cm long line from “no pain” to “pain as bad as it could possibly be.”
The pain rating is calculated on the basis of how many millimetres the client’s pain is removed from the “no pain” end of the line (e.g., 40 mm means
the client’s pain rating is 40 out of a possible 100).
B: The 0–10 Numeric Rating Scale (NRS) and the Faces Pain Scales-Revised (FPS-R) combined in a horizontal format. Clients may have a choice of
the pain rating scale, when the scale is presented in this format. The left-most face shows “no pain,” and the right-most face shows “worst possible
pain.” Clients are asked to point to the face that shows how much they hurt right now.
C: The Faces Pain Thermometer (Gelinas, 2007) has a vertical orientation that may be easier for older adults to use.
Sources: A and B: From Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacological management (pp. 56–57).St. Louis, MO: Mosby.
A is in the public domain. B has been reproduced with the permission of the International Association for the Study of Pain. Permission to use the FPS-R for purposes other than clinical
practice or research can be obtained by emailing IASPdesk@iasp-pain.org. The NRS is in the public domain. C, The Faces Pain Thermometer, is from Gelinas, C. (2007). Le thermomètre
d’intensité de douleur: Un nouvel outil pour les patients adultes en soins critiques. Perspective infirmière, 4(4), 12–20. Permission by C. Gelinas.
Pain Thermometer (FPT), depicted in Figure 30.4, C, removed from the tissues causing the pain. For exam-
was developed for use with adults (Gelinas, 2007). ple, pain from one part of the abdominal viscera
Not all clients can understand or relate to num- may be perceived in an area of the skin remote from
bers (i.e., NRS). These include children who are unable the organ causing the pain (Figure 30.5). Referred
to verbally communicate their pain and clients with pain is complex and occurs most often with damage
impairments in cognition or communication. FPSs may to visceral organs. The mechanisms of referred pain
be easier to use for these clients (Hadjistavropoulos & relate to the spatial organization of the grey matter
Craig, 2002; Jensen & Karoly, 2001). For example, when of the spinal cord into five distinct laminae (I to V)
measuring pain intensity in children, it is critical that the or layers. It is thought that noxious stimuli from
nurse use a self-report measure recommended for the both somatic and visceral structures may converge
child’s age and developmental level. via lamina V neurons, making it difficult for higher
Many scales, including the NRS, the FPT, and the brain centres to discriminate the original sources of
FPS-R, have been shown to be valid and reliable when these noxious inputs (Basbaum & Jessell, 2000).
used with clients who have cognitive deficits (Taylor & To ascertain the specific location, ask the individual
Herr, 2003; Zhou, Petpichetchian, & Kitrungrote, 2011). to point to the site of the pain or discomfort. It is also
Interestingly, it was found that older adults find it easier important to determine whether the pain radiates from
to use the vertical pain intensity scale, rather than its the indicated site. For example, a client with gallbladder
horizontal version, because it reminds them of a ther- colic may feel pain in the back and shoulder. A body
mometer (Herr & Mobily, 1993). outline can assist in identifying pain locations. The client
marks the location of pain on the body outline. This tool
R: Region/Radiation Pain can be described accord-
can be especially effective with clients who have pain in
ing to where it is experienced in the body. Radiat-
more than one location.
ing pain is perceived at the source of the pain and
extends to nearby tissues. For example, cardiac pain S: Signs/Symptoms Also included in a comprehen-
may be felt not only in the chest but also along the sive pain assessment are signs (e.g., changes in vital
left shoulder and down the left arm. Referred pain signs, redness, edema, and diaphoresis) and other associ-
is pain felt in a part of the body that is considerably ated symptoms, such as nausea, vomiting, and dizziness.
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Heart
Lungs and
diaphragm
Liver
Gallbladder
Heart
Liver
Stomach
Liver
Kidneys
Ovaries
Appendix
Ureters
Bladder
Kidney
Anterior Posterior
Figure 30.5 Common sites of referred pain from various body organs.
These signs and symptoms may relate to the onset of the

pain or they may result from the presence of the pain.
Client’s History
Their description can also help in diagnosing the client’s In addition to the description of the pain experience
condition. using PQRSTU, the nurse needs to gather other infor-
mation related to the client’s overall health history, such
T: Timing The pattern or timing of pain includes the
as any allergies, use of medications and other substances,
time of onset, duration, and recurrence or intervals with-
past medical history, and other relevant aspects of the
out pain. The nurse, therefore, determines when the pain
clients living situation that may be relevant, for example,
began; how long the pain lasts; whether it recurs and, if
type of employment and roles in the family. The Assess-
so, the length of the interval without pain; and when the
ment: Interview box summarizes an interview related to
pain last occurred. With this information, the nurse can
pain assessment.
tailor pain interventions, such as analgesics administra-
tion, to precede the onset of pain. For example, a nurse
might suggest taking an analgesic before exercise or
physiotherapy to some clients. Coping Resources
U: Understanding The assessment of understanding and Affective Responses
includes eliciting the client’s opinion on what causes the Each individual will exhibit personal ways of coping with
pain, how it influences ADLs, social life, the emotional pain. Strategies may relate to earlier pain experiences or
significance of the pain, and the resources available to the specific meaning of the pain; some may reflect reli-
cope with the cumulative burden of pain on all aspects gious or cultural influences. Nurses can encourage and
of the client’s life. support the client’s use of methods known to have helped
It is important for the nurse to ask clients what in modifying pain, unless they are specifically contrain-
they make of their pain. Many pain sufferers, especially dicated. Strategies may include seeking quiet and soli-
those with chronic pain, will have a unique idea of why tude, learning about their condition, pursuing interesting
they are experiencing pain. Some clients may think that activities as a form of distraction, saying prayers (or
pain is a normal part of life or that it needs to be tol- engaging in other meaningful rituals), or socializing.
erated; others may think that their pain is caused by a Affective responses vary according to the situation,
specific event in their lives or even by their actions and the degree and duration of the pain, the interpretation
behaviours. of it, and many other factors. The nurse needs to explore
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It is important for the nurse to obtain accurate data on a cli- is your reaction to the food/product/environment that you
ent’s pain. Examples of PQRSTU pain assessment questions: are allergic to?
• Precipitating/Palliating (aggravating/alleviating) factors: • Medications/substances:
How did your pain start? What were you doing when • Do you take any prescription medications? If so, what
the pain appeared? What makes the pain worse? What is the name/dosage/reason for the prescription? When
makes the pain better? What have you tried to alleviate did you take the last dose?
your pain, and has it helped?
• Do you take any nonprescription medications, vitamins,
• Quality/Quantity: In your own words, describe what the or herbal supplements? (name/dose/reason/time of
pain feels like. Some of the descriptors the client may use last dose)
are burning, aching, dull, sharp, gnawing, shooting, or
stabbing. On a scale from 0 to 10 (with 0 meaning “No • Do you consume alcohol, smoke cigarettes, or use
pain” and 10 meaning “Worst possible pain”), how would drugs? (quantity/frequency/since when?)
you rate the level of pain you are having? • Are your vaccinations up to date? Type (tetanus, flu,
• Region/Radiation: Where do you feel the pain? (point/ hepatitis, etc.)
describe). Does the pain radiate to any other regions of • Do you drink caffeinated beverages (coffee, tea, energy
your body? drinks)? How much, and how many a day? At what
• Signs, Symptoms: Do you have any swelling, redness, time of the day?
fever? Do you have any other symptoms or sensations • Past medical history: Do you have a diagnosed medi-
(e.g., nausea, dizziness, blurred vision, shortness of cal problem? To your knowledge, do you have any dis-
breath, anxiety, fatigue) in addition to your pain? eases? If yes, what type? When were you diagnosed?
• Timing: When did or does the pain start? How long have Did you receive treatment? Is the problem still present?
you had it, or how long does it usually last? How long are Are there medical problems in your family? Have you
the pain-free periods, if there are any? What is the fre- ever been hospitalized, and if so, for what reason/when?
quency of the pain attacks? Have you ever had surgery? If yes, for what reason/
when?
• Understanding: How do you interpret your pain? Have
you felt a similar kind of pain before, and if so, can you • Living situation: Where do you live? Do you live alone?
describe the situation? What outcomes (implications) do If not, who do you live with? Where do you work?
you anticipate from this pain? What do you fear most Do you find work stressful? What are your roles and
about your pain? How does the pain make you feel (e.g., obligations?
anxious, depressed, frightened, tired)? • Coping resources: How have you been able to cope with
your pain? Do you have friends or family who can provide
Examples of questions related to health history, living situa- support? Do you feel well supported?
tion, coping resources and affective responses are as follows: • Affective responses: Please describe your emotional state
• Allergies/reactions: Do you have any known allergies? Are in relation to your experience with this pain. Are you feel-
you sensitive to any foods/products/environments? What ing anxious? Fearful? Depressed?
the client’s feelings of anxiety, fear, exhaustion, level severity, treatment relief, and the effect of pain on key
of function, depression, or a sense of failure. Because areas of function, such as general activity, mood, walk-
many people with persistent pain become depressed and ing ability, normal work, relations with people, sleep,
potentially suicidal, it may also be necessary to assess the and enjoyment of life. This tool is especially useful for
client’s suicide risk. initial pain assessment and tracking the progress of pain
(Cleeland & Ryan, 1994; Wu, Beaton, Smith, & Hagen,
2010). Another commonly used pain questionnaire is the
Pain Questionnaires for Nursing Practice Leeds Assessment of Neuropathic Symptoms and Signs
(LANSS) used to differentiate between nociceptive and
Pain questionnaires are useful tools for a nurse to elicit a neuropathic pain when the pain pathology is unclear
more descriptive picture of the client’s pain, to organize it, (Bennett, 2001; Kaki, El-Yaski, & Youseif, 2005).
and to make conclusions about possible nursing diagno-
ses related to pain. Some questionnaires have the ability
to distinguish between different types of pain (e.g., neu-
ropathic or somatic), whereas others can help the nurse
Daily Pain Diary
understand the nature of the pain as it is experienced by For clients who experience chronic pain, a daily diary
the client. For example, the McGill Pain Questionnaire may help the client and the nurse identify pain patterns
(MPQ) (Melzack, 1975) and the Present Pain Intensity and factors that exacerbate or moderate the pain experi-
(PPI) scale (Melzack, 1987; see Table 30.4) were shown ence. In home care, the family or the caregiver can be
to be reliable and valid multidimensional questionnaires taught to complete the diary. The record can include
of pain for different types of pain in adults. The Brief time or onset of pain, activity before pain, pain-related
Pain Inventory (BPI) collects information about pain positions or behaviours, pain intensity level, duration of
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pain, and the use of pharmacological and nonpharma- may be indicative of pain (Prkachin, 1992). Vocaliza-
cological pain management strategies. Recorded data tions, such as moaning, groaning, crying, or screaming,
can provide the basis for developing or modifying the are also associated with pain (Mateo & Krenzischek,
plan for care. For this tool to be effective, it is important 1992). A client who remains immobile with the purpose
for the client to use it routinely. Therefore, the nurse of avoiding movement may also be in pain and should
should educate the client and the family about the value be assessed (Puntillo et al., 1997). The client with chest
and use of the diary in achieving effective pain control. pain often holds the left arm across the chest. A person
Determining the client’s abilities to use the diary is with abdominal pain may assume the position of great-
essential. est comfort, often flexing the knees and hips and moving
reluctantly.
Purposeless or rhythmic body movements are other
cues of pain. For example, clients may toss and turn in
Pain Assessment in Clients bed or fling their arms about. Involuntary movements,
Who Cannot Self-Report such as a reflexive jerking away from a needle inserted
Clients who are unable to self-report their pain are through the skin, may also indicate pain (Feldt, 2000;
a particularly vulnerable group that present multiple Odhner, Wegman, Freeland, Steinmetz, & Ingersoll,
challenges in pain detection and control. Clients who 2003). An adult may be able to control this reflex;
may experience pain but are unable to communicate it, however, a child may be unable or unwilling to do so.
among others, include older adults with cognitive defi- An adult or child may assume the fetal position and
cits, infants and preverbal toddlers, intubated or uncon- rock back and forth when experiencing abdominal pain
scious clients, and clients at the end of life. (Cohen et al., 2008). Rubbing an affected area is also
Recommendations for pain assessment in the non- a known pain indicator (Feldt, 2000). During labour, a
verbal client are described in the position statement of woman may massage her abdomen rhythmically with
the American Society for Pain Management Nursing her hands.
(ASPMN). The approach to pain assessment is hierar- Behavioural changes, such as confusion and rest-
chical, with no single pain scale being sufficient by itself. lessness, may be indicative of pain in both cognitively
Rather, pain assessment should be based on a combina- intact and cognitively impaired older adults. A change
tion of pain evaluation techniques including the follow- in behaviours with others, including becoming hostile
ing (Herr et al., 2006): or aggressive, may also be observed in older adults
with chronic pain (Gibson & Helme, 2001; Odhner
1. Attempt to elicit the client’s self-report of pain. et al., 2003).
2. Search for potential causes of pain (e.g., pathologi- It is important to note that some behavioural
cal conditions or procedures that can cause pain, responses can be controlled, and the nurse must develop
such as surgery, physiotherapy activities, turning and competent interpersonal observation skills to detect
positioning, blood draws, pressure ulcers). Assume reflexive pain behaviours (Hadjistavropoulos et al.,
that pain is present if any pain-causing condition is 2007). For example, vocalization or body movements in
identified. response to pain can be controlled, but facial expressions,
3. Observe the client’s pain behaviours. Use valid evi- especially the reflexive movements of the upper face,
dence-based behavioural pain scales developed for were shown to be under less conscious control (Rinn,
specific client groups and contexts. 1984). Also, many behavioural responses (e.g., crying) are
not unique to pain. When pain is chronic, overt behav-
4. Use surrogate reporting from family, parents, or ioural responses are rare, as pain behaviours habituate
caregivers. over time, and the individual develops personal coping
5. Attempt an analgesic trial if the presence of pain is styles for dealing with the pain. When looking for indica-
suspected. Administer appropriate analgesics and tors of chronic pain, the nurse can focus on changes in
re-evaluate behaviours. If there is an improvement in a the patterns of daily living, such as sleep, appetite, activ-
potentially pain-related behaviour, then pain was pres- ity levels, social interactions, and avoidance behaviours
ent (Herr, Coyne, et al., 2006). (Shankland, 2011).
Valid and reliable assessment tools can be used to
Behavioural Responses to Pain People show measure a client’s behavioural responses to pain. Cur-
wide variations in behavioural responses to pain. In the case rently, no behavioural observation tool is acceptable for
of clients who are very young, aphasic, confused, or have all client populations. Indeed, a pain assessment tool can
an altered level of consciousness, nonverbal expressions only be shown to be valid when used for a specific pur-
may be the only means of communicating pain. Facial pose in a specified group of respondents and in a given
expression is often the first indicator of pain, and it may context (American Educational Research Association,
be the only one. Frowning, brow lowering, eyes tightly American Psychological Association, & National Council
shut, clenched teeth or open mouth, and grimacing on Measurement in Education, 1999). The scope of this
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Table 30.5 List of Behavioural Pain Assessment Scales
FLACC (Face, Legs, Activity, A five-item scale; each item is scored from 0 to 2, with final scale score from 0 to 10. Developed
Cry, and Consolability) for infants and children from 2 months to 7 years old and used to quantify pain behaviours
in children who cannot verbalize the presence of pain or its severity during or after a variety
of surgical and medical procedures (Merkel, Voepel-Lewis, & Malviya, 2002; Merkel, Voepel-
Lewis, Shayevitz, & Malviya, 1997).
PIPP (Premature Infant Pain A seven-item scale scored from 0 to 21, developed for premature and term neonates and
Profile) used for the detection of acute pain in neonates and the assessment of procedural pain
in the neonatal intensive care unit (NICU) (Ballantyne, Stevens, McAllister, Dionne, & Jack,
1999; Stevens, Johnston, Petryshen, & Taddio, 1996; Stevens, Johnston, Taddio, Gibbins,
& Yamada, 2010).
CPOT (Critical-Care Pain A four-item scale scored from 0 to 8, developed for critically ill adults who are mechanically venti-
Observation Tool) lated or not and used for the detection of pain in medical, surgical, and trauma ICUs (Gelinas,
Fillion, Puntillo, Viens, & Fortier, 2006; Gelinas & Arbour, 2009; Gelinas & Johnston, 2007). The
scale is easy to use while it describes four different behavioural domains.
BPS (Behavioral Pain Scale) A three-item scale scored from 3 to 12, developed for critically ill and mechanically ventilated
adults and used for the detection of pain in medical, surgical, and trauma ICUs (Payen, et al.,
2001).
Doloplus A 10-item scale with each item scored from 0 to 3 with a maximum score of 30. Developed for
older adults with cognitive impairment, including nonverbal older adults and mainly used in the
chronic care settings (Torvik et al., 2010; Wary, Serbouti, & Doloplus, 2001).
PACSLAC (Pain Assessment A checklist of 60 items developed for older adults whose communication capacity is limited
Checklist for Seniors because of dementia. The scale is intended for the use by caregivers, and it was developed
with Limited Ability to based on the observations of behavioural (facial and body movements or aggression) as well
Communicate) as ADL changes (eating/sleeping) and includes physiological indicators (Fuchs-Lacelle &
Hadjistavropoulos, 2004).
chapter cannot provide an exhaustive list of the avail- assessment tools (Herr, Coyne, McCaffery, Manworren,
able behavioural pain assessment tools. A few examples & Merkel, 2011).
of pain assessment tools developed for nonverbal client The Evidence-Informed Practice box addresses best
groups are described in Table 30.5. practice guidelines relative to the assessment and man-
agement of pain.
Physiological Responses to Pain Elevated or
lowered vital signs as well as changes from the cli-
ent’s baseline may indicate but are not specific to pain.
Early in the onset of acute pain, the sympathetic ner-
Diagnosing
vous system is stimulated, resulting in increased blood When writing a diagnostic statement related to pain,
pressure, heart rate, respiratory rate, pallor, diapho- the nurse should specify the specific location (e.g., right
resis, and pupil dilation. Although the nociceptors do ankle pain, or left frontal headache), etiological factors
not adapt to painful stimuli, the sympathetic nervous and precipitating factors, and when known, and may
system does, making the physiological responses less include both physiological and psychological factors.
evident or even absent. With visceral pain, signs of For example, in addition to the injurious agent, related
parasympathetic stimulation may be observed, such as factors may include knowledge deficit of pain manage-
decreased blood pressure and heart rate, pupil con- ment techniques or fear of drug tolerance or addiction.
striction, and warm dry skin (McCance & Huether, Examples of a few possible nursing diagnoses related
2006). Physiological responses are likely to be absent in to pain include acute somatic pain related to surgical
people with chronic pain because of CNS adaptation repair of right hip fracture and movement; chronic
(McEwen, 2001). neuropathic pain interfering with quality of life and
The evidence supporting the use of vital signs as mental status; ineffective acute visceral pain manage-
valid indicators of pain is varied. Vital signs can be ment related to fear of analgesics and personal beliefs
affected by many physiological and psychological changes about the need to endure pain regardless of its inten-
other than pain (e.g., distress, medication, biochemical sity; insomnia, impaired physical mobility, and social
changes in the body, medical conditions). Therefore, vital isolation related to allodynia; high pain tolerance when
signs alone should not be used as pain indicators, but, experiencing visceral anginal pain negatively impacting
rather, they should be used as cues to prompt for further on client’s use of nitroglycerine potentiating the risk
pain assessment and in conjunction with other pain of myocardial infarction; risk of unintentional injury
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• Demonstrate actions to control pain and associated

symptoms.
Evidence-Informed Practice
Examples of desired outcomes for each of these
What Are the Best Practices Related goals, although established in the planning phase, are
provided in Table 30.11 in the “Evaluating” section later
to Nursing Care of People with Pain? in this chapter.
Canadian nurses play a pivotal role in assessing, interven- Examples of nursing interventions to assist clients
ing, and evaluating pain in whatever setting they choose experiencing pain include specific nursing activities
to practise. To help nurses provide the best care pos- associated with each of these interventions, which can
sible, the Registered Nurses Association of Ontario (RNAO) be selected to meet the individual needs of the cli-
conducted an extensive review of a range of aspects
ent. See the “Implementing” section of this chapter
related to the nursing care of people with pain. From this
review, the RNAO created best practice guidelines that for details. A Sample Nursing Care Plan is provided
provide evidence-based recommendations for nurses and below.
other members of the interprofessional team. The review When planning, nurses need to choose pain relief
yielded 20 recommendations falling under the categories of measures appropriate for the client on the basis of the
assessment, planning, intervention, evaluation, education, assessment data and input from the client or support
and organization. The recommendations with the highest persons. Nursing interventions can include a variety of
level of evidence (1a and 1b) were as follows: screen for the
pharmacological and nonpharmacological pain man-
presence, or risk of, any type of pain on admission or visit
with a health-care professional, after a change in medical agement strategies. Developing a plan that incorporates
status, and prior to, during and after a procedure; perform a wide range of interventions is usually most effective.
comprehensive pain assessments by using a systematic Whether in acute care or in home care, it is important
approach; document the pain assessment; collaborate for everyone involved in pain management to under-
with the person in pain to establish their goals relative to stand the plan of care. The plan should be documented
pain relief; implement pain management plans that maximize in the client’s record; in home care, a copy needs to be
efficacy while minimizing the adverse effects of pharmaco-
made available to the client, support persons, and care-
logical interventions; evaluate nonpharmacological inter-
ventions; teach the person, his or her family, and caregivers givers. Involvement of the client and support persons is
about the pain management strategies and address any essential in pain management.
misbeliefs; and promote interprofessional collaboration When the client’s pattern and level of pain can be
in the management of pain. Other recommendations are anticipated or is already known, regular or scheduled
included in the document. administration of analgesics can provide a therapeutic
Nursing Implications: Given the prevalence of pain plasma level. The importance and meaning of a stable
in Canadian society, nurses are likely to encounter peo- drug level in pain management should be explained to
ple in pain wherever they may be working. The RNAO the client. With acute pain, this may be possible in the
best practice guideline on assessment and manage- first 24 to 48 hours following surgery, when the client is
ment of pain is an excellent resource that provides spe- likely to have pain requiring opioid analgesics. Frequency
cific, evidence-based recommendations for addressing
of medication administration can be adjusted to prevent
pain. The document also includes relevant assessment
tools and grids for monitoring and documenting pain. pain from recurring. When persistent cancer-related pain
These guidelines provide nurses with a relevant “tool exists, analgesics should be given around the clock (ATC)
box” to enhance their nursing practice repertoire. with additional breakthrough (as needed: prn) doses
available. Nonpharmacological interventions should also
Source: Based on Registered Nurses’ Association of Ontario. (2013). Assessment
and management of pain (3rd ed.). Toronto, ON: Registered Nurses’ Association of be regularly scheduled. The additional advantage of
Ontario. scheduling measures is that the client spends less time in
pain and does not experience the anxiety or fear of the
pain recurring.
(e.g., scald, cut) related to reduced nociception from
peripheral nerve block.
Planning for Home Care

Planning In preparation for discharge, the nurse needs to deter-
mine the client’s and family’s needs, strengths, and
resources. The Assessment: Home Care box describes
The established goals will vary according to the diagno-
the specific assessment data required when establish-
sis, but possible examples include the following:
ing a discharge plan. By using the assessment data, the
• Modify or minimize pain to enable partial or com- nurse tailors a teaching plan for the client and family.
plete resumption of daily activities. (See the Teaching: Home Care box on monitoring
• Enhance abilities to control pain or to cope with pain. pain.)
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Sample Care Plan for Acute Pain

Assessment Data
Nursing Assessment Physical Examination Client Goal
Mr. Chin is a 57-year-old Chinese- Height: 188 cm Client goal

Canadian businessman who was Weight: 90 kg The client will experience minimal inci-
admitted to the surgical unit of an Body mass index (BMI): 25.5 sional pain and discomfort.
urban hospital for the treatment of a Desired Health Outcomes
Temperature: 37°C oral
strangulated inguinal hernia. Two days
Heart rate: 90 beats/min, 2+ ampli- 1. Pain control, as evidenced by
ago, he had a partial bowel resection.
tude, regular demonstrating willingness and
Postoperative orders include NPO (no
Respirations: 24/min, shallow ability to report pain to the health
food orally), intravenous infusion of 5%
care team and use pharmacologi-
dextrose in 0.45% sodium chloride (D5 Blood pressure: 158/82 mm Hg
cal and nonpharmacological pain
1/2NS) at 125 mL/h left arm, nasogas- Oxygen Saturation (SpO2): 96% relief measures appropriately.
tric tube to low intermittent suction with
Skin pale, pupils dilated; intact midline 2. Pain level controlled as evidenced
continuous drainage of 20–30 mL/h.
abdominal incision, sutures dry, no by no or mild reported pain;
Mr. Chin is in the dorsal recumbent
exudate, no erythema along wound increased movement and use of
(supine) position and is attempting to
edges inspirometer, decreased nausea,
draw up his legs. He appears rest-
less and is complaining of pain (7 on a Diagnostic Data protective body positioning; return
scale of 0 to 10) along his abdominal Chest radiography and urinalysis nega- to baseline of blood pressure (BP),
incision line; he describes the pain as tive, white blood count (WBC) 6.2 × heart rate (HR), respirations (R).
“throbbing” and aggravated by move- 109/L
ment and coughing—as a result, he Nursing Diagnosis
is not using his incentive inspirometer Acute Severe Somatic Pain, related to
and avoiding getting out of bed; allevi- surgical incision stimulation of mecha-
ated somewhat (5/10) with splinting (he nosensitive receptors; accompanied by
“hugs” a pillow); no radiation; accom- behavioural (grimacing, restlessness),
panied by nausea and poor quality of and physiological cues (e.g., elevated
sleep; his understanding of the pain is, pulse, respirations, systolic blood pres-
“It is expected after a big operation—I sure; and dilated pupils); Mr. C.’s cop-
will try not to move too much, and it ing strategy of limiting physical activity
will likely go away on its own in a cou- to deal with the uncontrolled acute
ple of days. I don’t want to be a bother pain places him at risk for postopera-
to anyone.” tive complications (e.g., atelectasis,
urinary retention, venous thromboem-
bolism); nausea could lead to vomit-
ing, thus increasing intra-abdominal
pressure and placing client at risk for
wound dehiscence; his fear of being a
burden may limit his disclosure of pain
or request for help in managing it.
Strengths: No apparent signs/symp-
toms of wound infection (a possible
reason for incisional pain); nasogastric
tube is patent (a blocked nasogastric
[NG] tube can cause abdominal disten-
sion and visceral pain)
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Sample Care Plan for Acute Pain (continued)

Nursing Interventions Rationale
Pain Assessment and Management

• Perform ongoing comprehensive pain assessment using Pain is a subjective experience and, whenever possible, must be
PQRSTU. described by the client to plan and monitor treatment; ongoing
assessment will ensure that the nurse monitors the pain in the
event that Mr. Chin continues to underreport it.
• Consider cultural influences on Mr. Chin’s pain response Each person experiences and expresses pain in a unique man-
(e.g., cultural beliefs about pain can result in a stoic ner by using a variety of sociocultural adaptation techniques.
attitude). Personal factors can influence pain and pain tolerance. Those fac-
tors that may be precipitating or increasing pain should be reduced
or eliminated to enhance the overall pain management program.
• Reduce or eliminate factors that may precipitate or worsen The use of nonpharmacological pain relief measures can
Mr. Chin’s pain experience (e.g., fear, fatigue, blocked NG increase the release of endorphins and enhance the therapeutic
tube, a brupt movements). effects of analgesics.
• Teach the use of nonpharmacological techniques (e.g., Each client has a right to expect maximum pain relief. Optimal
relaxation, guided imagery, music therapy, distraction) pain relief is achieved with use of analgesics, which includes
before, after, and, if possible, during potentially painful determining the preferred route, drug, dosage, and frequency for
activities (e.g., deep breathing and coughing exercises, each individual.
wound care, ambulation); before pain occurs or increases;
and along with other pain relief measures.
• Medicate before an activity to increase participation, but Turning and ambulation activities will be enhanced if pain is
evaluate the hazard of sedation. controlled.
• Evaluate the effectiveness of the pain control measures He is at risk of silently tolerating the pain if not specifically asked
used through ongoing assessment of Mr. Chin’s pain about it. It is therefore important for the nurse to routinely assess
experience. pain.
Analgesic Administration
• Check the prescription for drug (e.g., opioid, nonsteroidal The choice of analgesia varies with the type of pain (e.g., acute,
anti-inflammatory drug [NSAID], other), dose, route, and chronic, neuropathic) and the quantity (e.g., mild, moderate,
frequency of analgesic prescribed. severe) and client variables, such as renal and liver function.
Around-the-clock (rather than “as-needed”) analgesia provides
better control for acute somatic pain. Mr. Chin will not be able
to receive oral analgesia as long as he has a draining NG tube—
topical, rectal, and parenteral (e.g., subcutaneous) routes must
be used.
• Institute regular dosing (around-the-clock) and monitoring,
as appropriate, relative to the analgesic pharmacodynam-
ics and pharmacokinetics.
• Evaluate the effectiveness of the analgesic at regular, fre- The analgesic dose may not be adequate to achieve pain control
quent intervals after each administration at the peak effect or may be causing intolerable or dangerous side effects or both.
and especially after the initial doses, also observing for any Ongoing evaluation will assist in making necessary adjustments
signs and symptoms of untoward effects (e.g., sedation, for effective pain management.
respiratory depression, nausea and vomiting, dry mouth,
and constipation).
• Encourage Mr. Chin to communicate before his pain is at Severe pain is more difficult to control and requires around-
a 4/10 or greater and request prn (as needed) analgesia the-clock administration of analgesia as well as additional “as-
for breakthrough pain. needed” analgesia until pain is better controlled. Mr. Chin is
already reluctant to report his pain, so ongoing encouragement
may help reduce his concerns of being a burden.
• Document Mr. Chin’s response to analgesics and any Side effects of opioid narcotics, among others, include drowsi-
untoward effects. Implement actions to decrease untow- ness, sedation, respiratory depression, constipation, and urinary
ard effects of analgesics (e.g., constipation, urinary retention. A treatment plan to prevent occurrence of side effects
retention). and their monitoring should be instituted at the beginning of
analgesic therapy.
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Sample Care Plan for Acute Pain (continued)

Nursing Interventions Rationale
Nonpharmacological pain relief measures

• Inquire if Mr. Chin has a preference for the type of strategy Mr. Chin may have preferences for nonpharmacological pain
to be used. Investigate if he is receptive to nonpharmaco- management strategies. He has already learned that splinting is
logical pain management strategies other than splinting, helpful and may have other preferred pain management strate-
such as relaxation therapy. gies that he practises at home.
• Consider Mr. Chin’s willingness and ability to participate, The client must feel comfortable trying a different approach to
preference, past experiences, and contraindications pain management. To avoid ineffective strategies, the client
before selecting a specific relaxation strategy. should be involved in the planning process.
• Elicit conditioned behaviours that produce relaxation, such Relaxation techniques help reduce skeletal muscle tension and
as deep breathing, peaceful imaging, or meditation. anxiety, which will reduce the intensity of the pain.
• Create a quiet environment with dim lights and comfort- Each person may find different images or approaches to relax-
able temperature, when possible. ation more helpful than others.
• Demonstrate and practise the relaxation technique with Return demonstrations by the participant provide an oppor-
Mr. Chin, if he is agreeable. tunity for the nurse to evaluate the effectiveness of teaching
sessions.
• Discuss the possible use of distraction (e.g., reading, Distraction reduces the perception of nociception.
Sudoku, television).
• Evaluate and document his response to relaxation Conveys to the health care team effective strategies in reducing
therapy. or eliminating pain.
Assessment Home Care
Pain
The nurse needs to determine the client’s and family’s ability to effectively cope with pain once the client is discharged:
Client Family
• Level of knowledge: Mastery of pharmacological and • Caregiver availability, skills, and willingness: Primary and
nonpharmacological pain relief measures prescribed secondary persons able and willing to assist with pain
and selected; adverse effects and measures to counter- management; shopping if the client has restricted activ-
act these effects; warning signs to report to health care ity; ability to comprehend selected therapies (e.g., infusion
provider pumps, imagery, massage, positioning, and relaxation
• Self-care abilities for analgesic administration: Ability techniques) and perform them or assist the client with
and mental capacity to use analgesics appropriately them, as needed
(e.g., to prepare correct dosages of analgesics and • Family role changes and coping: Effect on financial status,
adhere to scheduled administration); physical dexter- parenting and spousal roles, sexuality, social roles
ity to take pills or to administer intravenous medica-
tions and to store medications safely; ability to obtain Community
prescriptions or over-the-counter medications at the
pharmacy; and need for assistance in any one of the • Resources: Availability of and familiarity with resources,
described tasks such as supplies, home care aid, or financial assistance
Implementing of analgesic medications requires a physician’s prescrip-

tion. However, the decision to administer the prescribed
medication is frequently the nurse’s, often requiring
Pain management is the alleviation of pain or a judgment as to the dose to be given and the time of
reduction in pain to a level of comfort that is acceptable administration.
to the client. It includes two basic types of nursing inter-
ventions: pharmacological and nonpharmacological. Nursing
management of pain consists of both independent and
collaborative nursing actions. In general, nonpharma-
Barriers to Pain Management
cological pain relief measures can be executed as an Misbeliefs and knowledge deficits of nurses, other health
independent nursing function, whereas administration care professionals, and clients can interfere with effective
M30_KOZI2703_04_SE_C30.indd 689 02/03/17 5:44 PM

Teaching Home Care
Monitoring Pain
Understanding pain and monitoring it for changes are impor- • Provide accurate information about tolerance, physi-
tant tasks when a client returns home: cal dependence, and addiction if opioid analgesics are
prescribed and these topics are of concern.
• Teach the client to keep a pain diary to monitor pain
onset, activity before pain, pain intensity, aggravating • Instruct the client to use pain control measures before
and alleviating factors, use of analgesics or other pain the pain becomes moderate to severe.
relief measures. • Inform the client of the consequences of untreated pain.
• Instruct the client to contact a health care professional • Demonstrate and have the client or caregiver re-
if planned pain control measures are ineffective or demonstrate appropriate skills to administer analgesics
adverse effects arise and are problematic. (e.g., skin patches, injections, infusion pumps, or
patient-controlled analgesia [PCA]), when appropriate.
Pain Control
• Teach the use of selected nonpharmacological tech- Resources
niques, such as relaxation, guided imagery, distraction, Nurses should provide appropriate information about how
music therapy, massage, and so on. to access community resources, home care agencies, and
• Discuss the actions, potential adverse effects, dos- associations that offer self-help strategies and educational
ages, frequency, and route of administration of materials. See the Weblinks section of this chapter for useful
prescribed analgesics. websites.
• Suggest ways to handle adverse effects of medications
and describe warning signs of medication overdose.
Table 30.6 Common Misbeliefs about Pain
Misbelief Correction
Clients experience severe pain only when they have had major Even after minor surgery, clients can experience intense pain.
surgery.
The nurse or other health care professionals are the authorities The person who experiences the pain is the only authority on
on a client’s pain. its existence and nature.
Administering analgesics regularly for pain will lead to Less than 5% of clients without a history of substance abuse
addiction. develop addiction when treated for acute pain.
The amount of tissue damage is directly related to the amount Pain is a subjective experience, and the intensity and duration
of pain. of pain vary considerably among individuals.
Unconscious or sedated clients cannot experience pain. Unconscious or sedated individuals may still experience pain;
clients with altered levels of consciousness may have the
ability for conscious pain perception (Boly et al., 2008;
Laureys et al., 2002). The absence of pain-related behav-
iours in unconscious or sedated clients does not necessar-
ily indicate absence of pain.
Visible physiological or behavioural signs accompany pain and Even with severe pain, periods of physiological and behavioural
can be used to verify its existence. adaptation can occur.
pain management. Some of these involve attitudes of the medication, or they feel it would distract or prejudice
nurse or the client as well as knowledge deficits. Clients the health care provided. Other common misbeliefs are
respond to pain on the basis of their culture, personal shown in Table 30.6.
experiences, and the meaning the pain has for them.
For many people, pain is expected and accepted as a
normal aspect of illness and treatments, such as surgery.
Clients and families may lack knowledge of the adverse
effects of pain and may have misinformation and fears
Key Strategies in Pain Management
regarding the use of analgesics. Clients may not report Acknowledging and Accepting Basic to effective
pain because they expect that nothing can be done, they pain management is comprehensive pain assessment (see
think it is not severe enough, they do not want to take the “Pain Assessment” section in this chapter), which
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begins with believing the client. Four ways of communi- becoming aware of any prejudices they may have and
cating this belief are as follows: discarding them when caring for a client, educating
themselves about different manifestations of pain, and
1. Verbally acknowledge the presence of the pain, and
getting to know the client and his or her background.
use standardized measures to clarify pain intensity,
quality, and impact. Reducing Fear and Anxiety It is important to
2. Listen attentively to what the client says about the address the meaning of pain, along with the emotional
pain, restating your understanding of the reported components, such as anxiety or fear, associated with the
pain. Use empathetic statements, such as “I’m sorry pain experience. When clients have no opportunity to
you are hurting. It must be upsetting. I want to help talk about the pain and associated fears, their perceptions
you feel better.” and reactions to the pain can intensify; in particular, the
meaning of pain can affect pain intensity (Arntz & Claas-
3. Convey that you need to understand the client’s pain sens, 2004). If the nurse establishes an effective pattern
experience and whether pain treatments are effective of assessment and communication and promptly attends
or not. Ask, for example, “Has the pain treatment to the client’s pain-related needs, effective pain relief is
reduced the intensity of your pain?” more likely. By providing accurate explanations, the nurse
4. Attend to the client’s needs for pain relief promptly. It is can also reduce many of the client’s fears, such as a fear
unconscionable to believe the client’s report of pain and of addiction or a fear that the pain will always be present.
then do nothing!
Preventing Pain A preventive approach to pain
relief involves the provision of measures to treat the
Assisting Caregivers Caregiver persons often need
pain before it occurs or before it becomes moderate
assistance to respond to the client experiencing pain.
to severe. Preemptive analgesia is the administra-
Nurses can help by giving them accurate information
tion of analgesics before an activity or an invasive or
about the pain and providing opportunities for them to
operative procedure to treat pain before it occurs. For
discuss their emotional reactions, which may include
example, evidence suggests that treating clients peri-
anger, fear, frustration, and feelings of inadequacy. Enlist-
operatively with local infiltration of an anesthetic or
ing the aid of support persons in the provision of pain
parenteral administration of an opioid can reduce post-
relief to the client may diminish their feelings of help-
operative pain and decrease the potential for the devel-
lessness and foster a more positive attitude toward the
opment of chronic pain (Katz, 2003). Intraoperative
client’s pain experience. Support persons also may need
and postoperative administration of analgesics is also
the nurse’s understanding and reassurance, and perhaps
important for optimal pain relief. Nurses can use a pre-
access to resources that will help them cope as they add
ventive approach by providing analgesics, as prescribed,
the caregiver role to an already stressful life circumstance.
around the clock rather than as needed.
Reducing Misbeliefs About Pain Reducing a cli-
ent’s misbeliefs about the pain and its treatment will help
to prevent inadequate pain management. The nurse
should explain to clients that the perception of pain is
highly individualized and that they need to help clini-
cians understand their pain experience. Misbeliefs are
Pharmacological Pain
also dealt with when nurses and clients have comprehen- Management
sive discussions about the client’s pain experience, includ-
ing the intensity and quality of the pain, the impact of Pharmacological pain management involves the use of
the pain, its aggravating and alleviating factors, and any opioids, NSAIDs, and coanalgesics (see Table 30.7).
fears and concerns the client may be struggling with,
such as fears of opioid addiction, or common opioid
adverse effects, such as constipation (Watt-Watson, 1992;
Watt-Watson, Stevens, Streiner, Garfinkel, & Gallop,
Opioid Analgesics
2001). For example, a client may refuse analgesia out of Opioid analgesics include naturally occurring and syn-
concern about the risk of addiction, explaining that the thetic opium derivatives, such as morphine and codeine.
pain is more tolerable as long as he or she remains totally In clinical settings, opioids were commonly referred to
still. The misconception about the risk of addiction as narcotics; this language is not appropriate, as narcot-
(less than 5% in people without a history of substance ics include drugs not used for pain treatment. Opioids
abuse develop addition when treated for acute pain) relieve pain by binding to opiate receptors in the spinal
underestimates the risks associated with immobility (e.g., cord and by blocking its transmission to the brain where
atelectasis, muscle atrophy, pressure ulcers, and infec- decreased pain level is perceived. Opioids also activate
tions). Nurses must be aware of any personal misbeliefs endogenous pain modulation in the CNS. Opiate recep-
that they may have about the client’s pain. This includes tors are of several different types, including mu (m),
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Table 30.7 Categories and Examples of Analgesics

Clinical Alert
Opioid Analgesics for Moderate Pain
• Codeine (Tylenol No. 3) Nurses must question the general use of meperidine
• Hydrocodone (Vicodin) (Demerol) if prescribed in the clinical setting. This drug has a short
• Tramadol (Utracet) duration (2 to 3 hours), and its toxic metabolite, normeperidine, accu-
mulates with repetitive dosing, causing CNS excitability and the lower
Opioid Analgesics for Severe Pain seizure threshold. Several organizations issued cautions against the use
• Fentanyl citrate (Duragesic) of meperidine, including the IASP and the Institute for Safe Medication
• Hydromorphone hydrochloride (Dilaudid) Practices (ISMP) Canada. Meperidine use is still recommended for very
• Oxycodone (OxyContin) few clinical cases, such as for the prevention and treatment of postop-
• Morphine sulphate (morphine) erative shivering and rigors caused by certain drugs and blood product
• Methadone (Dolophine, Methadose) administration; or for the management of acute pain episodes for clients
with significant adverse reactions to other opioid analgesics (Ashley &
Nonopioid Analgesics for Mild Pain Given, 2008; Dobbins, 2010). In these cases, meperidine should be
• Acetaminophen (Tylenol) given only if the frontline medications (e.g., clonidine or tramadol) are
• Acetylsalicylic acid (Aspirin) ineffective or cause an adverse reaction. Meperidine should never be
• Diclofenac sodium (Voltaren) given to clients with poor kidney function or those taking monoamine
• Ibuprofen (Motrin, Advil) oxidase inhibitor (MAOI) medications (Daniel & Schmelzer, 2009; Pasero
• Indomethacin sodium trihydrate (Indocid) & McCaffery, 2011).
• Naproxen (Naprosyn)
• Piroxicam (Feldene)
• Tolmetin sodium (Tolectin)
• Celecoxib (Celebrex)
a k-receptor site. If a client has been receiving an
• Ketorolac (Toradol)
m-agonist (e.g., morphine) daily for more than a
Coanalgesics couple of weeks, the administration of a mixed ago-
• Tricyclic antidepressants (amitriptyline [Elavil] nortriptyline
nist–antagonist may result in the inactivation of the
[Aventyl])
• Anticonvulsants (carbamazepine [Tegretol], gabapentin morphine effect and in increased pain. These drugs
[Neurontin], pregabaline [Lyrica]) have a ceiling effect (larger doses of a medication
have progressively smaller incremental effects) that
limits the dose. They are not recommended for use in
terminally ill clients.
delta (d), and kappa (k) receptors. The m–opioid recep-
3. Partial agonists: Partial agonists have a ceiling effect.
tor is most commonly associated with pain relief. These
These drugs, such as buprenorphrine (Buprenex), block
drugs are prescribed by a physician or nurse practitioner
the m-receptors or are neutral at that receptor but bind
practising under medical directive. The nurse requires
at a k-receptor site. Buprenorphrine has good analgesic
knowledge of appropriate dose, duration of effect, time
potency and is emerging as an alternative to methadone
to onset, and strategies to manage adverse effects of
for opioid maintenance treatment programs.
opioid medications.
Opioids are available in three primary types: Opioids are the most effective analgesic for the relief
1. Full agonists: Full agonists bind to opioid recep- of moderate to severe pain and must be given on a regu-
tors, mimicking the effects of endogenous opioids, or lar basis to prevent pain from recurring. Acetaminophen
endorphins. Examples of full agonists include mor- is a nonopioid analgesic that is often used in a combina-
phine, codeine, methadone, and hydromorphone. tion with a number of opioids, such as oxycodone and
Meperidine (Demerol) is also a full agonist, but its codeine.
use is not recommended (see the Clinical Alert box). Full Adverse effects of opioids vary with the physiological
agonists have no ceiling dose, the level at which state of the client. Box 30.1 provides suggested measures
increasing the dose results in no further increase in to prevent the side effects of opioid analgesics. Respira-
analgesia. Hence, their dose can be steadily increased tory depression is one of the most dangerous side effects
to relieve pain. of opioid administration, and if the client is not moni-
tored and treated promptly, negative outcomes may occur
2. Mixed agonists–antagonists: Agonist–antagonist anal- (Box 30.2). As sedation is another common side effect,
gesic drugs can act similarly to opioids and relieve nurses should assess and document the client’s level of
pain (agonist effect) when given to a client who has awareness. If sedation is a problem, respiratory status
not taken any pure opioids. However, they can block must also be frequently monitored. Early recognition of
or inactivate other opioid analgesics when given to an increasing level of sedation or respiratory depression
a client who has been taking pure opioids (antago- will enable the nurse to implement appropriate measures
nist effect). These drugs include dezocine (Dalgan), promptly.
pentazocine hydrochloride (Talwin), butorphanol When administering opioids, it is important to dis-
tartrate (Stadol), and nalbuphine hydrochloride tinguish among the effects of tolerance, physical dependence,
(Nubain). They block the m-receptor site and activate and addiction.
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Box 30.1 COmmon Opioid Adverse Effects: Preventive and Treatment Measures
Opioids can have a number of side effects that nurses
can help prevent:
Constipation • Consider the administration of a stimulant in the morning

(e.g., caffeine).
• If the client’s condition allows it, increase the client’s fluid
intake (e.g., 6 to 8 glasses daily). • Observe the client for evidence of respiratory depression
that may occur with sedation.
• Add more fibre and bulk-forming agents to the client’s
diet (e.g., fresh fruits and vegetables). Increased exercise
is often ineffective in controlling this type of constipation. Respiratory Depression
• Administer prophylactic daily stool softeners combined • Observe the client’s frequency of respiration and oxygen
with a mild laxative (e.g., senna [Senokot], docusate saturation as their decreased values may indicate respi-
sodium [Colace]) as a first line of prevention against con-
ratory depression, a life-threatening side effect of opioid
stipation for clients on opioid maintenance therapy.
administration. See Box 30.2 for details.
• Stimulants (e.g., bisacodyl), osmotic laxatives (e.g., lactu-
lose, sorbitol, and polyethylene glycol), enemas (e.g., tap Pruritus
water and sodium phosphate), and even prokinetic agents
(e.g., metoclopramide) may be needed for treating refrac- • Apply cool packs and lotion, and provide a diversional
tory constipation. activity.
• Administer an antihistamine (e.g., diphenhydrAMINE
Nausea and Vomiting hydrochloride [Benadryl]), as ordered. As with antiemetic
medications, caution must be exercised if the client is
• Inform the client that tolerance to this emetic effect gen- prescribed an antihistamine because of its depressant
erally develops after several days of opioid therapy. effect on the CNS.
• Antiemetics (e.g., dimenhyDRINATE [Gravol], ondansetron • Inform the client that tolerance to pruritus also develops.
[Zofran]) or gastrointestinal stimulants (e.g., metoclo-
pramide) are sometimes prescribed to treat opioid-
induced nausea. Because they are CNS depressants and Urinary Retention
may precipitate or increase respiratory depression, their • The nurse may need to catheterize the client or change
concomitant use with opioids is not recommended. or lower the opioid dose.
• Change the dose or analgesic agent as indicated.
Sedation
• Inform the client that tolerance usually develops over sev-
eral days.
Tolerance With tolerance, progressively larger body’s adaptation to opioids (Pasero & McCaffery, 2011).
doses are needed to produce the same analgesic effects. Because full agonist opioids do not have a ceiling or
The consensus paper written by the American Academy maximum amount, drug tolerance should not preclude
of Pain Medicine (AAPM), the American Pain Society achievement of adequate analgesia, with incremental
(APS), and the American Society for Addiction Medicine dosage increases, as ordered. Many clients with nonpro-
(ASAM) defines tolerance as a “state of adaptation in gressive pain are able to find a stable dose of opioids that
which exposure to a drug induces changes that result in provide adequate analgesia.
a diminution of one or more of the drug’s effects over Physical Dependence With physical depen-
time” (AAPM, APS, & ASAM, 2001). The full mecha- dence, people experience a need to continue to use the
nism of tolerance is not well known. A possible theory drug to prevent symptoms of withdrawal. The AAPM,
suggests that it is caused by the progressive desensitiza- the APS, and the ASAM (2001, p. 2) define it as “a state
tion of opioid receptors (DuPen, Shen, Ersek, 2007). In of adaptation that is manifested by a drug class–specific
humans, tolerance to certain opioid drug effects can start withdrawal syndrome that can be produced by abrupt
taking place on the first administration, but usually it is cessation, rapid dose reduction, decreasing blood level
not clinically significant. Clinicians are more concerned of the drug, and/or administration of an antagonist.”
about tolerance that happens over time with prolonged Withdrawal symptoms can include vomiting, diarrhea,
opioid administration and which requires increasingly abdominal cramping, tremors, chills, diaphoresis, myal-
high doses of the drug. The need for dose escalation is gia, arthralgia (joint pain not caused by inflammation),
often misdiagnosed as tolerance; however, it can often and coryza (inflammation of the mucous membranes
be caused by disease or pain progression and not the of the nose). The term “dependence” is often used to
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Box 30.2 Opioid-Induced Respiratory Depression
Definition
Opioid-induced respiratory depression is a decrease in the effectiveness of an individual’s ventilatory function after opioid adminis-
tration that is usually (but not always) preceded by sedation. It is characterized by poor respiratory effort (shallow breathing) and a
respiratory rate below 10 breaths per minute.
Risk Factors
Physical and Lifestyle Characteristics
• Age >65 years (>55 years if client has sleep apnea)

• Hypertension
• Obesity (BMI >30 kg/m2)
• Smoking (>20 pack/year)
• Untreated obstructive or central sleep apnea and their predisposing factors
Primary and Comorbid Medical Conditions
• Dependent functional status (unable to walk four blocks or two flights of stairs without assistance)
• Preexisting pulmonary or cardiac disease or dysfunction (e.g., history of chronic obstructive pulmonary disease [COPD] or heart failure)
• Major organ failure (e.g., decreased hepatic or renal function)
• Poor nutritional status
Medical Factors
• Prolonged surgery lasting more than 2 hours

• Thoracic and other large incisions that may interfere with circulation
• Concomitant administration of other agents with a depressant effect on the central nervous system (antihistamines, benzodiaz-
epines, some antiemetics)
• Large single-bolus techniques (e.g., 10 mg IV morphine)
• Continuous opioid infusion in opioid-naïve clients (those who have not recently received any opioid doses).
• Prior naloxone administration (naloxone is a short-acting medication, which puts clients at risk of repeated respiratory depres-
sion once the action wears off)
• Opioid-naïve clients who require large opioid administration
• Opioid-tolerant clients who are given large administrations of opioids in addition to their own opioid regimen
• General anesthesia (as opposed to other types of anesthesia)
• Timing of opioid administration (clients are at a greater risk in the first 24 hours)
Required Monitoring
Purposeful and systematic serial assessments of pain intensity, level of sedation, and respiratory status (quality, character, rate,
and effectiveness).
• Pain intensity using a valid scale (refer to the “Pain Questionnaires for Nursing Practice” section)
• Oxygenation (pulse oximetry)
• Capnography monitoring (end-tidal carbon dioxide [ETCO2] measures)
• Respiratory rate (rhythm, rate, depth of chest excursion)
• Ventilation efficacy (depth and rhythm of respirations, snoring, loud breathing)
• Sedation status (e.g., Sedation-Agitation Scale [SAS], Ramsay Scale, Richmond Agitation and Sedation Scale [RASS], or Pas-
ero Opioid-Induced Sedation Scale)
Treatment
• Immediately arouse all clients with signs of advancing sedation (i.e., those who are frequently drowsy, drift off to sleep during
conversation, or always somnolent with minimal or no response to physical stimulation), poor respiratory effort, or noisy respi-
ration (e.g., snoring).
• Instruct the client to take deep breaths (inspirometer may be used to motivate the client).
• Alert other members of the care team.
• Monitor the client closely until the respiratory status is recovered.
• Administer an opioid antagonist, such as naloxone hydrochloride (Narcan), per hospital protocol, if needed.
Source: Republished with permission of Elsevier Science and Technology Journals, from American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-induced
Sedation and Respiratory Depression. Pain Management Nursing by Jarzyna et al, 12(3), 118–145, 1969 ; permission conveyed through Copyright Clearance Center, Inc.
M30_KOZI2703_04_SE_C30.indd 694 27/02/17 1:38 PM

describe a person who is addicted or has psychologi- Table 30.8 Equianalgesic Chart for Some Common
cal dependence on the drug. Therefore, although it is Opioids
appropriate to say that a person who has or could have Equianalgesic Dosages
withdrawal symptoms after the discontinuation of a drug
is “physically dependent,” the nurse must be careful to Opioid Oral Parenteral
strictly avoid using the term “dependent” on its own. Morphine 30 mg 10 mg
Physical dependence and drug tolerance are invol-
Codeine 200 mg NR 130 mg
untary behaviours and are the physiological result of
Fentanyl* — 100 μg/h (0.1 mg)
frequent, ongoing opioid administration. Although phys-
is equal to 2–
ical dependence and tolerance develop, symptoms of 4 mg/h mor-
withdrawal rarely occur because as pain decreases, the phine IV
dosage is gradually tapered and no symptoms are expe- Hydromorphone 7.5 mg 1.5–2 mg
rienced. Physical dependence and drug tolerance do not represent
Meperidine 300 mg NR 75–100 mg
addiction.
Methadone 20 mg 10 mg
Addiction No universally accepted definition of addic- Hydrocodone 30 mg —
tion to opioids exists. According to the AAPM, the APS,
Oxycodone 15–20 mg —
and the ASAM (2001, p. 2) addiction is characterized
Note: For comparison, a dosage of 10 mg of parenteral morphine is established.
by the presence of adverse behaviours that feature a NR = not recommended.
compulsion for the drug, craving, and a preoccupation *Fentanyl is also available in the transdermal route (Duragesic).
Source: Critical Care Nursing of Older Adults : Best Practices, Third Edition by
with drug use predominantly for psychological effect, Springer Publishing Company. Reproduced with permission of Springer Publishing
despite actual or potential harm. Determination of opi- Company in the format Book via Copyright Clearance Center.
oid addiction requires expert assessment of the client’s
history, risk factors for addiction, and potential biopsy-
chological factors. Clinicians should not presume that morphine ratio is 3:1, meaning IV morphine is three
clients’ persistence or expression of the urgent need for times as potent as oral morphine. Thus, a client who has
pain relief is drug seeking or addictive behaviour. True required 100 mg of IV morphine per day will require
opioid addiction is rare if opioids are prescribed and 300 mg of oral morphine per day to control the same
monitored appropriately. For most clients, opioid-seeking level of pain. If a different client who had an opioid
behaviours usually stop when the pain is adequately requirement of 40 mg IV morphine per day were to
controlled. It is important to note that opioids can be be switched to oral hydromorphone, the equianalge-
effective for those with a history of chemical dependency sia chart informs the nurse that 10 mg IV morphine
on opioids; this requires prescription, supervision, and is equivalent to 7.5 mg hydromorphone. By using the
support by clinicians with expertise in pain management cross-multiplication technique (x represents the unknown
and chemical dependency. Guidelines for safe adminis- dose), the following steps are calculated:
tration of opioids are available from a number of pain
societies, such as the CPS and the IASP. 10 mg IV morphine = 7.5 mg oral hydromorphone
Equianalgesic Dosing As nurses are responsible for 40 mg IV morphine = x mg hydromorphone
evaluating the effectiveness of analgesics, monitoring Cross-multiply:
for adverse effects, and advocating for change when an 10x = 7.5 × 40
analgesic is not effective, it is important to understand
10x = 300
the concept of equianalgesia, which refers to the
relative potency of various opioid analgesics compared x = 30 mg hydromorphone
with a standard dose of morphine. An equianalgesic
Thus, 30 mg of oral hydromorphone per day would
dose is the dose of one analgesic that has the same pain-
provide equivalent analgesia to 40 mg of IV morphine
relieving effect as another drug. This concept makes it
per day. The hydromorphone dose is then divided on the
possible to change one analgesic for another or to change
basis of the duration of action of the available prepara-
the route of administration, for example, from parenteral
tions (e.g., every 4 hours).
to oral opioid doses. Equianalgesic dosing also allows
comparisons to be made between weak analgesics, such Routes For Opioid Delivery Opioids have tradi-
as codeine, for mild pain, and stronger analgesics, such tionally been administered by the oral route; subcuta-
as morphine, for moderate to severe pain. See Table 30.8 neous (SC) route, including continuous subcutaneous
for equianalgesic doses of common opioid medications. infusions; intramuscular (IM) route; and intravenous
The two basic techniques for calculating doses based (IV) route. In addition, newer methods of delivering
on equianalgesic equivalents are (a) the ratio method opioids, for example, transnasal, transdermal, and rectal
and (b) the cross-multiplication method. For example, drug therapy, as well as intraspinal infusion, have been
with the ratio technique, it is known that the oral–IV developed.
M30_KOZI2703_04_SE_C30.indd 695 27/02/17 1:38 PM

Oral Oral administration of opioids remains the pre- by continuous IV infusion, or by patient-controlled anal-
ferred route of delivery because of ease of admin- gesia (PCA). (See the discussion on PCA later in this
istration. Because the duration of action of most chapter.)
immediate-release (IR) opioids is approximately 4 hours,
people with chronic pain have had to awaken several Transnasal Transnasal administration has the advan-
times during the night to medicate themselves for pain. tage of rapid action of the medication because of direct
To circumvent this problem, long-acting, or slow-release absorption through the vascular nasal mucosa. A com-
(duration of 8–12 hours) forms of opioids have been monly used agent is the mixed agonist–antagonist butor-
developed. Examples of long-acting preparations are phanol (Stadol) for acute headaches.
MS Contin, OxyContin, and Hydromorph Contin. Cli- Transdermal Transdermal drug therapy is advantageous
ents receiving long-acting preparations also require as- in that it delivers the drug at a relatively stable plasma
needed (prn) doses of IR analgesics (e.g., short-acting level and is noninvasive. Fentanyl (Duragesic) is an opioid
morphine, Percocet) for acute breakthrough pain. currently available as a skin patch with various dosages. It
Subcutaneous The SC route has been used extensively provides drug delivery for up to 72 hours. The time before
to deliver opioids, and another technique uses SC cath- the medication given via this route begins to take effect
eters and infusion pumps to provide continuous subcutaneous is between 12 to 16 hours; in the meanwhile, the client
infusion (CSCI). The SC route is helpful for people who should be provided with short-acting opioids to relieve pain.
need long-term use of parenteral opioids and are unable The transdermal route is distinguished from the topical route
to take opioids orally over the long-term, such as those in that the effects of the medications are systemic after the
experiencing dysphagia or gastrointestinal obstruction. medication is absorbed; topical medications placed on the
CSCI involves the use of a small, light, battery-oper- skin work locally at the point they are placed on the body.
ated pump that administers the drug through a 23- or Rectal Several opioids are now available in suppository
25-gauge butterfly needle. The needle should be rotated form. The rectal route is particularly useful for clients
between sites on the abdomen and thigh areas every 3 to who have dysphagia (difficulty swallowing), nausea, or
7 days. Client mobility can be maintained by attaching vomiting.
the pump to a belt, or using a shoulder bag or holster to
hold the pump. Intraspinal An increasingly popular method of deliv-
Because the client or the caregivers must operate ery is the infusion of opioids into the epidural or intra-
the pump and change and care for the injection site, the thecal (subarachnoid) space (Figure 30.6). Analgesics
nurse needs to provide appropriate instruction on assess- administered via the intraspinal route are delivered
ment of pump functioning and care. Clients or their adjacent to the opioid receptors in the dorsal horn
caregivers need to be able to do the following: of the spinal cord. Two commonly used medications
are morphine sulphate and fentanyl. All medicines
• Describe the basic parts and symbols of the system. administered by the intraspinal route need to be sterile
• Identify ways to determine whether the pump is and preservative free (preservatives are neurotoxic).
working. The major benefit of intraspinal drug therapy is supe-
rior analgesia with less medication used. The epidural
• Change the battery. space is most commonly used because the dura mater
• Change the medication. acts as a protective barrier against infection, includ-
• Demonstrate stopping and starting the pump. ing meningitis, and there is less risk of developing a
• Demonstrate tubing care, site care, and changing of spinal headache. Intraspinal catheters are not in con-
the injection site. stant contact with blood, and thus an infusion can be
stopped and restarted later without the concern that
• Identify signs indicating the need to change an injec- the catheter is no longer patent.
tion site. Intrathecal administration delivers medication
• Describe general care of the pump when the client is directly into the cerebrospinal fluid (CSF) that bathes
ambulatory, bathing, sleeping, or travelling. and nourishes the spinal cord. Medicines quickly and
• Identify actions to take when the alarm signals. efficiently bind to the opioid receptor sites in the dor-
sal horn when administered in this way, speeding the
Intramuscular The IM route should not be used to onset and peak effect, while prolonging the duration of
administer analgesia; it is the least desirable route for action of the analgesic. An example of how the route of
opioid administration because of variable absorption, administration affects the relative potency of opioids is
pain involved in administration, and the need to repeat as follows: A client who needs 300 mg of oral morphine
administration every 3 to 4 hours. per day to control pain will need 100 mg of paren-
teral morphine, 10 mg of epidural morphine, and only
Intravenous The IV route provides rapid and effective 1 mg of intrathecal morphine in a 24-hour period. Very
relief of acute pain. The analgesic can be administered little drug is absorbed by blood vessels into the systemic
M30_KOZI2703_04_SE_C30.indd 696 27/02/17 1:38 PM

Spinal cord
Pia mater
Subarachnoid space
Dura mater and
arachnoid mater
Epidural space
Catheter in
epidural space
Epidural
analgesia
Vertebra
Spinal cord
L2-L 3
intervertebral
space
Figure 30.6 Placement of intraspinal catheter in the epidural space
circulation. In fact, the drug must circulate through the administer bolus doses on an as-needed basis. Check
CSF to be excreted. As a result, onset of respiratory agency policy regarding who can provide these bolus
depression can be delayed (24 hours after the adminis- doses, how they are documented, and the postbolus
tration) as medication that has left the spinal opioid sites monitoring procedures.
travels through the brain to be eliminated. Therefore, it 2. Continuous infusion administered by pump: The pump can
is essential that the nurse continues diligent monitoring be external (for acute or chronic pain) or surgically
of respiratory depression in clients receiving intrathecal implanted (for chronic pain) to provide a continuous
opioids. infusion of pain relievers into the epidural or intrathe-
In contrast, the epidural space is separated from the cal space.
spinal cord by the dura mater, which acts as a barrier to
3. Continuous plus intermittent bolus: With this mode of opera-
drug diffusion. In addition, it is filled with fatty tissue and
tion, the client receives a continuous infusion, with
an extensive venous system. With this diffusion delay,
bolus rescue doses administered for breakthrough pain.
some medications (especially fat-soluble medications,
Often, a pump with patient-controlled epidural analgesia
such as fentanyl) from the epidural space enter the sys-
(PCEA) capabilities is used for this mode of operation.
temic circulation via the venous plexus. Thus, a higher
This is similar to PCA (detailed later) in which a basal
dose of opiate is required to create the desired effect,
rate may or may not be used to meet the client’s antici-
which can produce side effects, such as itching, urinary
pated analgesic need, with the client’s ability to request
retention, and respiratory depression. Often, a mixture
an incremental dose by pressing a button at set intervals.
of an opioid (e.g., fentanyl) and a local anesthetic (e.g.,
PCEA is often used to manage acute postoperative pain,
bupivacaine) are combined to lower the dose of opioid
chronic pain, and intractable cancer pain. The so-called
needed. As a result, there may be an increase in fall risk
walking epidurals used for women in labour are typically
for some clients who develop muscular weakness in their
PCEA devices that are programmed in the bolus mode
legs or orthostatic hypotension in response to the local
without a continuous infusion (basal rate) set.
anesthetic.
Intraspinal analgesia can be administered by three The needle is inserted into the intrathecal or epi-
modes of operation: dural space (typically in the lumbar region), and a
catheter is threaded through the needle to the desired
1. Bolus: A single dose, or repeated bolus doses, can be
level. The catheter is connected to tubing that is then
provided. When clients have spinal anesthesia (e.g.,
positioned along the spine and over the client’s shoulder
during a cesarean section), a bolus of 1 mg intrathecal
for the nurse to access. The entire catheter and tubing
morphine can provide significant pain control for up
are taped securely to prevent dislodgement. Often, an
to 24 hours. For shorter-acting medications, an epi-
occlusive transparent dressing is placed over the inser-
dural catheter may be intact and accessed by a quali-
tion site for easy identification of catheter displacement
fied health care professional (e.g., anesthesiologist) to
or local inflammation. Temporary catheters, used for
M30_KOZI2703_04_SE_C30.indd 697 27/02/17 1:38 PM

short-term acute pain management, are usually placed

at the lumbar or thoracic vertebral level and often
removed after 2 to 4 days. For clients with chronic
pain, permanent catheters may be tunnelled subcutane- Primary
ously through the skin and exit at the client’s side or (maintenance)
IV fluid
be connected to a pump implanted in the abdomen.
Tunnelling of the catheter reduces the risk of infection
and displacement of the catheter. After the catheter
is inserted, the nurse is responsible for monitoring the
infusion and assessing the client per institutional policy. PCA pump
Nursing care of clients with intraspinal infusions is sum-
marized in Table 30.9.
There are misconceptions that either overstate or
ignore the risks of spinal analgesia. This, in part, results Y-connector site
from the considerable variations among the profession- for PCA tubing
als in the technique of inserting the catheter. In general, and primary line
clients receiving epidural analgesia do not need to be
monitored in an intensive care setting, but they do need
vigilant assessment of their pain, neurological and respi-
FIGURE 30.7 PCA line introduced into the injection port of a
ratory status, and the insertion site frequently during the primary IV line.
course of therapy.
PATIENT-CONTROLLED ANALGESIA Patient-controlled via the intravenous, subcutaneous, or epidural route
analgesia (PCA) is an interactive method of pain con- (Figure 30.7). A programmable lockout interval (usually
trol that permits clients to treat their pain by self-admin- 10 to 15 minutes) follows the dose, when an additional
istering doses of analgesia. PCA involves an infusion dose cannot be given even if the client activates the but-
system with a pump and dose control button that the ton. It is also possible to program the maximum dose
client pushes to release a set amount of opioid by bolus that can be delivered over a period of hours (usually
TABLE 30.9 Nursing Interventions for Clients Receiving Analgesics through an Epidural Catheter
Nursing Goals Interventions

Maintain client safety Label the tubing, the infusion bag, and the front of the pump with tape marked EPIDURAL
to prevent confusion with similar-looking IV lines.
Post a sign above the client’s bed indicating that the epidural is in place.
Secure all connections with tape.
If there is no continuous infusion, apply tape over all injection ports on the epidural line
to avoid the injection of substances intended for IV administration into the epidural
catheter.
Do not use alcohol in any care of catheter or insertion site, as it can be neurotoxic.
Maintain catheter placement Secure temporary catheters with tape.
When bolus doses are used, gently aspirate before medication administration to determine
that the catheter has not migrated into the subarachnoid space. (Expect <1 mL of fluid
return in the syringe.)
Assist client with repositioning or moving out of bed.
Assess insertion site for leakage with each bolus dose or at least every 8 to 12 hours.
Prevent infection Use strict aseptic techniques with all epidural-related procedures.
Maintain a sterile occlusive dressing over the insertion site.
Assess the insertion site for signs of infection (e.g., redness, discoloration, secretions at the
site, swelling, pain or fever [sign of a systemic infection]).
Maintain client’s urinary and bowel Monitor intake and output. Assess for bowel and bladder distension.
functions
Prevent respiratory depression Assess sedation level and respiratory status q1h (every 1 hour) for the first 24 hours and
q4h (every 4 hours) thereafter.
Do not administer other opioids or CNS depressants, unless ordered.
Keep a 0.4-mg ampule of naloxone hydrochloride (Narcan) at the client’s bedside.
Notify the clinician in charge if the respiratory rate falls below 10 per minute or if the client is
difficult to rouse.
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4 hours). Many pumps are capable of delivering a low Nonopioid Analgesics

continuous infusion, or basal rate, to provide sustained
analgesia during times of rest and sleep. Older children NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Non-
can be taught to use PCAs. steroidal anti-inflammatory drugs (NSAIDs),
People using PCA tend to take less total analgesia sometimes referred to as nonopioids, include drugs from
than those receiving intermittent injections (Pasero & the following categories: (a) first-generation (cyclooxygen-
McCaffery, 2011). PCA is used for the management of ase 1 [COX-1] and COX-2 inhibitors, e.g., Aspirin, ibu-
postoperative pain and for other types of acute pain, profen, naproxen, ketorolac) and (b) second-generation
such as sickle-cell crisis, and for cancer pain. Whether (COX-2 inhibitors, e.g., celecoxib). These medications
in an acute care hospital setting, an ambulatory clinic, have anti-inflammatory, analgesic, and antipyretic effects.
or home care, the nurse is responsible for the initial They relieve pain mainly by blocking the action of COX
instruction regarding the use of the PCA and for the (which has two forms: COX-1 and COX-2), the enzyme
ongoing monitoring of the therapy (see the Teaching: necessary for the synthesis of prostaglandins that sensi-
Clinical box). The client’s pain must be assessed at tize nerve endings and trigger pain at the periphery (i.e.,
regular intervals and analgesic use documented in the transduction). The inhibition of COX-1 is responsible
client’s record. Client concerns about addiction and for many of the side effects, such as gastric ulceration,
adverse effects also need to be assessed and addressed. bleeding resulting from platelet inhibition, and acute
If the PCA pump is used for a child, the nurse must renal failure. In contrast, the inhibition of COX-2 is
engage in interactive teaching with the child and par- responsible for the suppression of pain and inflammation
ents. Additionally, the child’s ability to use the PCA cli- (Lehne, 2016). The use of medication that is a combina-
ent control button must be assessed. Older adults may tion of an NSAID and an opioid is indicated for clients
have more comorbidities and need to be monitored with acute musculoskeletal and soft tissue inflammation.
for medication side effects as well as impaired renal Individual drugs in this category vary widely in their
and pulmonary functions. Older adults must also be analgesic properties, metabolism, excretion, and adverse
assessed for cognitive and physical ability to push the effects. In addition, the analgesic activity of these drugs
client control button. has a ceiling effect. Not all clients are candidates for
NSAIDs because of side effects. Caution is advised with
older adults or clients with renal impairment because of
slower clearance rates in these individuals.
The most common adverse effect of NSAIDs is dys-
pepsia, which can be minimized by taking the medication
TEACHING CLINICAL with food. Stomach ulcers and gastric bleeding have also
been reported; those on longer-term NSAID therapy
Client Self-Management of Pain may be prescribed proton-pump inhibitors to preserve
the gastric mucosa. NSAIDs may be contraindicated
by Using a Patient-Controlled for those with impaired blood clotting, gastrointestinal
Analgesia Pump bleeding or ulcer risk, renal disease, thrombocytopenia
(low platelet levels), Aspirin triad (i.e., bronchial asthma,
• Choose a time to teach the client about pain man- Aspirin intolerance, and rhinitis), and possible infection.
agement when the pain is controlled so that the
client is able to focus on the teaching. Many NSAIDs require a prescription, and all have a
• Teaching the client about self-management of pain maximum daily dose limit. Clients and nurses should
can include the following: be aware that dark tarry stools may indicate gastroin-
• Demonstrate the operation of the patient-con- testinal bleeding, one of the more dangerous effects of
trolled analgesia (PCA) pump and explain that the NSAIDs. Depending on the nature of the pain problem,
client can safely push the button without fear of NSAIDs may be prescribed in combination with opioids
overmedicating. Sometimes it helps clients who
are reluctant to repeatedly push the button to or coanalgesics. It is also common for an NSAID, such as
know that they must dose themselves (i.e., push ibuprofen, to be prescribed together with acetaminophen
the button) 5 to 10 times to receive the same (Tylenol) to achieve more efficient analgesia.
amount of medication (10 mg morphine equiva-
lent) they would receive in a standard injection. ACETAMINOPHEN Acetaminophen (Tylenol) has a dif-
• Describe the use of the pain scale and encourage ferent mechanism of action and side effect, or toxicity
the client to respond to demonstrate understanding. profile, from that of NSAIDs. It does not affect plate-
• Explore a variety of nondrug pain relief techniques let function and rarely causes gastrointestinal distress,
that the client is willing to learn and use to pro- ulcers, skin, or cardiovascular problems. Hepatotoxicity,
mote pain relief and optimize functioning.
and possibly renal toxicity, does occur with higher doses
• Explain to the client the need to notify staff when
ambulation is desired (e.g., for bathroom use), if
or with long-term use. Generally, 10 g of acetaminophen
applicable. is considered a lethal dose, with 6 g per day causing mea-
surable liver damage. It is recommended that otherwise
M30_KOZI2703_04_SE_C30.indd 699 03/03/17 10:37 AM

young and healthy people limit acetaminophen con- mind, spirit, and social interactions (Table 30.10).
sumption to less than 4 g/day, with susceptible individu- Physical modalities include cutaneous stimulation,
als (e.g., older adults, those with a history of alcoholism, immobilization or therapeutic exercises, transcutane-
those with liver disease) limiting their consumption to ous electrical nerve stimulation (TENS), and acupunc-
2.4 g/day or less (Pasero & McCaffery, 2011). ture. Mind–body (cognitive–behavioural) interventions
include distracting activities, relaxation techniques,
imagery, meditation, biofeedback, hypnosis, cogni-
Coanalgesics tive reframing, emotional counselling, and spiritually
directed approaches, such as therapeutic touch or reiki.
A coanalgesic agent (formerly known as an adjuvant) is
Lifestyle management approaches include symptom
a medication that is not classified as a pain medication
monitoring, stress management, exercise, nutrition,
but that has properties that can reduce pain, alone or in
pacing activities, disability management, and other
combination with other analgesics; relieve other discom-
approaches used by many clients with persistent pain
forts; potentiate the effect of pain medications; or reduce
that has caused a drastic change in their lives. Detailed
the pain medication’s side effects. Examples of coanal-
information on selected mind–body interventions is
gesics are antidepressants, anticonvulsants, and others.
provided in Chapter 16. The discussion here is lim-
Tricyclic antidepressants, such as amitriptyline (Elavil)
ited to selected physical and cognitive–behavioural
or nortriptyline (Aventyl), interfere with the reuptake of
epinephrine and serotonin in the CNS, leading to reduced interventions.
pain perception when given in low doses. Anticonvul-
sants, such as carbamazepine (Tegretol), stabilize nerve
membranes, reducing excitability and spontaneous fir- Physical Interventions
ing. Gabapentin (Neurontin) and pregabaline (Lyrica) are
The goals of physical intervention include providing
thought to modulate the electrical activity of the brain by
comfort, altering physiological responses to reduce pain
modulating the release of excitatory neurotransmitters
perception, and optimizing functioning.
(Pasero & McCaffery, 2011). These agents appear to be
particularly beneficial in the management of neuropathic Cutaneous Stimulation Cutaneous stimulation
pain. Anxiolytics, sedatives, and antispasmodics are exam- can provide effective temporary pain relief. It distracts
ples of medicines that relieve other discomforts but do not the client and focuses attention on the tactile stimuli,
alleviate pain and thus should be used in addition to, rather away from the painful sensations, thus reducing pain
than instead of analgesics. Examples of medications used perception. Cutaneous stimulation is also believed to
to reduce the side effects of analgesics include stimulants, create the release of endorphins that block pain stim-
laxatives, and antiemetics. uli transmission and stimulate large-diameter A-beta
sensory nerve fibres, thus decreasing the transmission
of pain impulses through the smaller A-delta and C
Placebo Response fibres. Cutaneous stimulation techniques include the
following:
The placebo response occurs when people experience
pain relief from an intervention that may not be directly • Massage
related to the actual pain relief method employed. Health
• Application of heat or cold
care professionals can cause a positive placebo response
by the ways they interact with clients. The nurse’s • Acupressure
empathic approach toward the client, such as listening • Contralateral stimulation
without judgment, giving opportunities to express pain
Cutaneous stimulation can be applied directly to
and permission to do so, and recognizing the person’s
the painful area, proximal to the pain, distal to the pain
unique responses, help to facilitate pain relief. Medication
(along the nerve path or dermatome), and contralateral
placebos, such as giving a saline injection instead of an
(exact location, opposite side of the body) to the pain.
opioid, are unethical and must not be used in practice.
Cutaneous stimulation is contraindicated in areas of skin
breakdown and for those clients with impaired neuro-
logical functioning.
Nonpharmacological Pain Massage Massage is a comfort measure that can aid

relaxation and decrease muscle tension as well as ease
Management anxiety as the physical contact communicates caring.
Massage can also decrease pain intensity by increas-
Nonpharmacological pain management consists of a ing superficial circulation to the area. Massage can
variety of physical, cognitive–behavioural, and life- involve the back and neck, hands and arms, or feet. (See
style pain management strategies that target the body, Chapter 38.)
M30_KOZI2703_04_SE_C30.indd 700 27/02/17 1:38 PM

Table 30.10 Nonpharmacological Interventions for Pain Control
Target Domain
Intervention Pain Pathway Implicated
of Pain Control
Body Reducing pain triggers, promoting comfort May involve various pain pathways
Massage Perception (see GCT)
Applying heat or ice Transmission, transduction, perception
Electric stimulation (TENS) Perception, ascending modulation
Positioning, bracing (selective immobilization) Transduction, transmission
Acupressure Ascending modulation, perception
Invasive interventions (e.g., blocks) Transmissions and other processes
Sleep hygiene Perception and modulation
Diet, nutritional supplements, exercise May involve multiple pain pathways
Mind Relaxation, imagery Mind activities primarily involve perception and
Self-hypnosis modulation
Distracting attention
Pain diary, journal writing
Repatterning thinking
Attitude adjustment
Reducing fear, anxiety, stress
Reducing sadness, helplessness
Information about pain
Music therapy
Spirit Prayer, meditation Spirit pain intervention domains involve perception
Self-reflection about life and pain and modulation but may evolve to implicate
Meaningful rituals other pain pathways
Energy work (e.g., therapeutic touch, reiki)
Spiritual healing
Social interactions Functional restoration May implicate various pain pathways
Improved communication
Family therapy
Problem solving
Vocational training
Volunteering
Support groups
Heat and Cold Applications A warm bath, warm pads, painful area cannot be touched because it is hypersen-
ice bags, ice massage, warm or cold compresses, and sitive, when it is inaccessible by a cast or bandages, or
warm or cold sitz baths, in general, relieve pain and when the pain is felt in a missing part (phantom pain).
promote healing of injured tissues (see Chapter 35).
Immobilization and Bracing Immobilizing or
These are modalities of pain management that are not
restricting the movement of a painful body part (e.g.,
time consuming and are easily obtained in any setting;
arthritic joint, traumatized limb) may help to manage
they should not be overlooked by clinicians as a comple-
episodes of acute pain. Splints or supportive devices
mentary strategy for the standard pain management
should hold joints in the position of optimal function and
techniques. Application of heat should, however, be used
should be removed regularly in accordance with agency
with caution, especially in the emergency department
protocol to provide range-of-motion (ROM) exercises,
setting.
if not contraindicated. Prolonged immobilization can
Acupressure Acupressure developed from the ancient result in joint contracture, muscle atrophy, and cardio-
Chinese healing system of acupuncture. The therapist vascular problems. Therefore, clients should be encour-
applies finger pressure to points that correspond to many aged to participate in self-care activities and remain as
of the points used in acupuncture (see Chapter 16). active as possible, with frequent ROM exercises.
Contralateral Stimulation Contralateral stimulation Transcutaneous Electrical Nerve Stimula-
can be accomplished by stimulating the skin in an area tion Transcutaneous electrical nerve stimu-
opposite to the painful area (e.g., stimulating the left lation (TENS) is a method of applying low-voltage
knee if the pain is in the right knee). The contralateral electrical stimulation directly over identified pain areas,
area may be scratched for itching, massaged for cramps, at an acupressure point, along peripheral nerve areas
if appropriate, or treated with cold packs or analgesic that innervate the pain area, or along the spinal column.
ointments. This method is particularly useful when the The TENS unit consists of a portable, battery-operated
M30_KOZI2703_04_SE_C30.indd 701 27/02/17 1:38 PM

a pet or a toy), and intellectual distraction (crossword

puzzles, Sudoku number puzzles, card games, hobbies).
Elicitation of The Relaxation Response Stress
increases pain, in part by increasing muscle tension,
activating the sympathetic nervous system, and putting
the client at risk for stress-related types of pain (e.g.,
tension headaches). The relaxation response decreases
and counteracts the harmful effects of stress, including
the effect it has on physical, cognitive, and emotional
functioning. Eliciting this response requires more than
simply helping a person to relax; rather, it involves a
Hilary Morgan/Alamy Stock Photo
structured technique designed to focus the mind and

relax muscle groups. Basic techniques with helpful scripts
are detailed by Pasero and McCaffery (2011), with com-
mon techniques including progressive relaxation, breath-
focus relaxation, and meditation. The nurse can coach
the client, urge self-directed meditation, or provide an
audiotaped guide to help elicit the relaxation response.
Many clients can achieve the desired state after a few
Figure 30.8 A transcutaneous electrical nerve stimulator.
attempts, but mastery of this skill requires daily practice
over a few weeks. In general, relaxation techniques by
themselves do not have distinct pain-relieving proper-
device with lead wire and electrode pads that are applied
ties; however, they can reduce pain that may have been
to the chosen area of skin (Figure 30.8). Cutaneous
exacerbated by stress. Some clients may become more
stimulation from the TENS unit is thought to activate
consciously aware of their pain while practising relax-
large-diameter fibres that modulate the transmission of
ation techniques before they have mastered controlling
the nociceptive impulse in the peripheral nervous system
mind chatter and remaining mentally focused.
and CNS (closing the pain gate), resulting in pain relief.
This stimulation may also cause a release of endorphins Psychoeducation Once the client has mastered the
from the CNS centres. The use of TENS is contraindi- basic skills for eliciting the relaxation response, tech-
cated in clients with pacemakers or arrhythmias, or in niques of imagery or self-hypnosis can be considered.
areas of skin breakdown. It is generally not used on the Both imagery and hypnosis begin with attaining a deep
head or over the chest. state of relaxation and are capable of altering the experi-
ence of pain, for example, by having the client replace
Acupuncture Acupuncture, a form of traditional
their pain with a feeling of pleasant numbness (Arnstein,
Chinese medicine, involves the insertion of thin sterile
2004). Additional posthypnotic suggestions can then be
needles into specific points of the skin with the goal of
made, linking these pleasant numb sensations to coping
relieving pain (see Chapter 16).
efforts used during the day (e.g., “Every time you stop to
take a slow, deep, diaphragmatic breath, you will feel this
Cognitive–Behavioural Interventions pleasant numbness instead of pain”).
Psychoeducation is increasingly being used as an
The goals of cognitive–behavioural interventions include adjunctive means of managing the impact of chronic
providing comfort, altering psychological responses to pain on health-related quality of life and disability
reduce pain perception, and optimizing functioning. (McGillion, Watt-Watson, Kim, & Graham, 2004;
Selected cognitive–behavioural interventions include McGillion et al., 2007). Psychoeducational interven-
distraction, elicitation of the relaxation response, and tions are group self-management education programs
psychoeducation. delivered by a trained facilitator; clients can be accom-
Distraction Distraction draws the person’s attention panied by family members or friends if they want to
away from the pain and lessens the perception of pain. In be. The focus is to provide participants with an oppor-
some instances, distraction can make a client completely tunity to enhance their skills for self-care. Through
unaware of pain. For example, a client recovering from rehearsal and application of various cognitive and
surgery may feel no pain while watching a football game behavioural self-management techniques, participants
on television, yet feel pain again when the game is over. learn to set realistic self-management goals in relation
Different types of distraction include visual distraction to their chronic pain. The goal-setting process allows
(reading or watching TV, guided imagery), auditory dis- for the self-attribution of success, thereby improving
traction (listening to music, humour), tactile distraction perceived self-efficacy in managing symptoms. Nurses
(slow rhythmic breathing, massage, holding and stroking facilitating psychoeducation programs require expertise
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in psychoeducational techniques, group process, and To assist in the evaluation process, a flowsheet or a
assessment of participants’ readiness to engage in client diary may be helpful. Columns for day, time, onset
self-management. of pain, activity before pain, pain-relief measure, and
See the Lifespan Considerations box for age-specific duration of pain can be devised to help the client and
ways to manage pain. nurse determine the effectiveness of pain-relief strategies.
If desired health outcomes are not achieved, the
nurse and the client need to explore the reasons before
Evaluating modifying the care plan. The following are some ques-
tions the nurse might consider:
By using the desired outcomes established during the • Is adequate analgesic being given? Would the client
planning stage as a guide, the nurse and the client benefit from a change in dose or in the time interval
determine whether client goals and outcomes have been between doses?
achieved. Examples of client goals and related outcomes • Were the client’s beliefs and values about pain therapy
are shown in Table 30.11. considered?
• Children can use their imagination during guided imag-

Pain Management ery. To use the pain switch, ask the child to imagine a
pain switch (even give it a colour) and tell him or her
Infants to visualize turning the switch off in the area where he
• Giving an infant, particularly a very low-birth-weight infant, or she has pain. A “magic glove” or “magic blanket”
is an imaginary object that the child applies on areas
a water and sucrose solution administered through a paci-
of the body (e.g., hand, thigh, back, hip) to lessen
fier provides some evidence of pain reduction during proce- discomfort.
dures that may be painful, but it should not be a substitute
for anesthetic or analgesic medications.
Older Adults
Children • Promote the client’s use of pain-control measures that
• Distract the child with toys, books, or pictures. have worked in the past.
• Hold the child to console him or her and provide comfort. • Spend time with the client, and listen carefully to what they
say.
• Explore misbeliefs about pain, and correct them in under-
standable, concrete terms. Be aware of how your explana- • Clarify misbeliefs. Encourage independence, whenever
tions may be misunderstood. For example, telling a child possible.
that surgery will not hurt because he or she will be “put to • Carefully review the treatment plan to avoid drug–drug,
sleep” will be very upsetting to a child who knows of an food–drug, or disease–drug interactions.
animal that was “put to sleep.”
Table 30.11 Evaluation Goals and Outcomes: Pain
Goal Examples of Desired Health Outcomes

Modify or minimize pain to enable partial or com- Reports pain relief at level of (specify) or less, on a scale of 0 to 10; or
plete resumption of daily activities expresses feelings of reasonable comfort
Reports decreased frequency and length of pain episodes or decreased
fear and anxiety
Absence of nonverbal pain responses, such as restlessness, muscle ten-
sion, protective body position, facial grimacing (specify)
Reports increase in mobility and physical activity, in hours of uninter-
rupted sleep at night, and in quality of life
Enhance abilities to control pain Identifies factors that precipitate or intensify the pain experience
Identifies pharmacological and nonpharmacological pain management
techniques
Demonstrate actions to control pain and associated Reduces or eliminates factors that precipitate or intensify the pain
symptoms experience
Uses a pain diary to monitor pain pattern and effectiveness of pain measures
Uses nonpharmacological pain relief measures (specify)
Uses analgesics appropriately
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• Did the client understate the pain experience for some • Is the client receiving adequate support from his or
reason? her significant others?
• Were appropriate instructions provided to allay mis- • Has the client’s physical condition changed, necessi-
beliefs about pain management? tating modifications in interventions?
• Did the client and support people understand the • Should selected intervention strategies be re-evaluated?
instructions about pain management techniques?
Case Study 30
Mrs. Lundahl, 45 years old, underwent an emergency anterior
2. What type of pain is Mrs. Lundahl experiencing?
bowel resection approximately 6 hours ago. She has a 15-cm
midline incision that is covered with a dry and intact surgical 3. What interventions, in addition to pain medication, may
dressing. On assessing Mrs. Lundahl, you note be useful in reducing Mrs. Lundahl’s pain?
that she is perspiring, lying in a rigid position, 4. How will you know if your interventions have been effec-
holding her abdomen, and grimacing. Her blood tive in reducing Mrs. Lundahl’s pain?
pressure is 150/90; heart rate, 100; and respira-
tory rate, 32. She rates her pain as 8 on a scale Visit MyNursingLab for answers and explanations.
of 0 to 10.
1. What conclusions, if any, can be drawn about

Mrs. Lundahl’s pain status?
KE Y TERM S
acute pain p. 672 full agonist p. 692 pain threshold p. 672 referred pain p. 681
addiction p. 695 hyperalgesia p. 671 pain tolerance p. 673 sensitization p. 676
agonist–antagonist hyperexcitability p. 671 partial agonist p. 692 somatic pain p. 670
analgesic drug p. 692 intractable pain p. 672 patient-controlled tolerance p. 693
allodynia p. 671 modulation p. 675 analgesia (PCA) p. 698 transcutaneous
cancer pain p. 672 nervous system perception p. 674 electrical nerve
ceiling dose p. 692 plasticity p. 676 peripheral neuropathic stimulation
ceiling effect p. 692 neuropathic pain p. 670 pain p. 671 (TENS) p. 701
central disinhibition p. 672 neuroplasticity p. 671 peripheral sensitiza- transduction p. 673
central neuropathic nociception p. 673 tion p. 676 transmission p. 674
pain p. 671 nociceptive pain p. 670 persistent (chronic) visceral pain p. 670
central sensitization p. 676 nociceptors p. 670 pain p. 672 wind-up p. 676
coanalgesic p. 700 nonsteroidal physical
complex regional pain anti-inflammatory dependence p. 693
syndrome p. 672 drug (NSAID) p. 699 placebo response p. 700
equianalgesia p. 695 pain p. 668 preemptive
equianalgesic dose p. 695 pain management p. 689 analgesia p. 691
CH APTER HIGHLIG HTS

• Pain is a subjective, multidimensional experience with • Unrelieved pain has multiple serious consequences and
sensory–discriminative, cognitive–evaluative, and can prolong recovery from surgery, disease, and trauma.
motivational–affective components; many clients need • Pain can be categorized according to its origin (e.g.,
encouragement or help to clearly communicate their pain somatic, visceral, neuropathic) or according to its dura-
experience, particularly with respect to its intensity, duration (e.g., acute pain, chronic pain).
tion, qualities, and related individual responses.
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• Pain threshold is relatively similar in all people and nonpharmacological interventions. Selecting several strat-
changes little in the same individual over time; conversely, egies from both broad categories is usually most effective.
pain tolerance and response vary considerably from per- • Scheduling measures to prevent pain is far more support-
son to person and in the same person at different times ive of the client than trying to deal with pain once it is
and in different circumstances. established.
• For pain to be experienced, primary afferent nocicep- • Pain management includes two basic types of nursing
tors must be stimulated. Three types of pain stimuli are interventions: pharmacological and nonpharmacological.
mechanical, thermal, and chemical.
• Major nursing functions for all clients are to acknowl-
• The pain process is complex and involves transduction, edge and convey belief in the client’s pain, assist support
transmission, perception, and modulation. people, reduce misbeliefs about pain, and reduce fear and
• Endogenous opioids, critical to pain modulation, include anxiety associated with the pain.
enkephalins, endorphins, and dynorphins. • Pharmacological interventions include the use of opioids,
• Gate control theory is the basis of many pain-interven- nonopioids or NSAIDs, and coanalgesics.
tion strategies and explains the multidimensional nature • The nurse assesses the client’s pain needs, administers the
of pain; yet, it is a theory of acute pain, and it cannot prescribed analgesics, and evaluates the client’s response
account for nervous system plasticity. to analgesics provided.
• Numerous factors influence a person’s perception and • Analgesic medication can be delivered through a variety
reaction to pain: ethnic and cultural values, develop- of routes and methods to meet the specific needs of the
mental stage, environment and support people, past pain client. These routes include oral, subcutaneous with a
experiences, and meaning of pain. continuous infusion, intravenous, transnasal, transdermal
• Pain is subjective, and the most reliable indicator of the or topical, rectal, and intraspinal.
presence or intensity of pain is the client’s self-report. • Patient-controlled analgesia (PCA) enables the client to
Assessment of a client who is experiencing pain should exercise control and minimize feelings of helplessness.
include a comprehensive pain history. Clients who can-
not self-report (e.g., comatose clients) require specialized • Nonpharmacological pain interventions include cutane-
assessment techniques. ous stimulation, such as warm and cold applications,
massage, acupressure, and contralateral stimulation;
• Multiple nursing diagnoses related to pain can be formu- transcutaneous electrical nerve stimulation (TENS); and
lated; many also relate to the consequences of the pain immobilization or bracing.
experience (e.g., social isolation).
• Examples of cognitive–behavioural interventions include
• Overall client goals include preventing, modifying, or distraction techniques and psychoeducation.
eliminating pain so that the client is able to partially or
completely resume usual daily activities and to cope more • Evaluation of the client’s pain therapy includes the
effectively with the pain experience. response of the client, the changes in the pain, and the
client’s perceptions of the effectiveness of the therapy.
• When planning, nurses need to choose pain-relief Ongoing verbal or written feedback from the client and
measures appropriate for the client. Nursing interven- family is integral to this process.
tions should include a variety of pharmacological and
Nclex- St yle Pr actic e Qui z

1. Which term refers to the process when an excited d. A middle-aged client with metastatic prostate cancer
nociceptor converts a noxious stimulus into an action having his fentanyl (Duragesic) transdermal patch
potential? titrated
a. Modulation
b. Perception 3. A client has had significant pain for the last 2 years as
a result of metastatic breast cancer. She manages her
c. Transduction pain using a transdermal patch and oral opioids for
d. Transmission breakthrough pain. The client has been referred to
the pain clinic nurse for teaching and management of
2. Which client is at the greatest risk for respiratory opioid-induced constipation (OIC). Which of the fol-
depression while receiving opioids for pain? lowing recommendations by the nurse is best option for
a. A client with an addiction to opioids receiving mor- managing OIC?
phine for surgical pain a. Eating more dietary fibre by increasing the amount
b. An 80-year-old client on a continuous epidural fen- fresh fruits and vegetables at each meal
tanyl infusion running at 3 cc/h b. Taking psyllium (Metamucil), a bulk-forming laxative
c. A 10-year-old with cystic fibrosis started on the anti- and increase fluid intake
tussive, codeine, for the first time c. Incorporating more activity into the day by walking
d. Taking docusate sodium (Colace), a stool softener
with a mild laxative, such as bisacodyl (Dulcolax)
M30_KOZI2703_04_SE_C30.indd 705 27/02/17 1:38 PM

4. A client who is receiving treatment for unmanaged from the sleeve of his shirt. During the admission his-
chronic pain is prescribed morphine and nortripty- tory taking, the nurse asks the client about how he feels
line, an antidepressant. The client states, “I’m here while putting on clothes, and the client states, “I have
for pain, not depression! Give me the morphine, but I intense pain when anything light touches my arm.”
refuse the other pill!” Which of the following is the best What term should the nurse use to accurately document
response by the nurse to the client’s comment about the the client situation?
antidepressant? a. Hyperalgesia
a. “This pill is meant to prevent you from getting b. Neuritis
depressed because of the pain you have been
experiencing.” c. Paraesthesia
b. “This pill will help reduce any inflammation that you d. Allodynia
might have.”
8. Which of the following is the rationale to support the
c. “This pill will help your nervous system by increasing continued use of an opioid to prevent the symptoms of
your body’s own pain-reducing substances.” withdrawal?
d. “This pill helps to block the pain signals from going a. A psychological response
up your spinal cord.”
b. A physiological response
5. A client recovering from a surgical intervention requires c. A threshold response
increasing doses of analgesia in the postoperative period d. An addictive response
to control pain. Which of the following statements best
explains this pattern of pain? 9. A client, 45 years old, has acute pain following a frac-
a. Tolerance to the analgesia has occurred. tured ankle. The physician’s order is acetaminophen
b. Physical dependence on the analgesia has occurred. (Tylenol #3) with 30 mg of codeine one to two tablets,
q3–4h prn. Although the client had taken two tablets 1
c. Addiction to the analgesia has occurred. hour ago, she reports having severe pain. What nursing
d. Compulsive drug abuse has been established. action is most appropriate?
a. Consult the nurse-in-charge
6. The client is prescribed morphine 2.5 to 5 mg IV every
4 hours. He received 2.5 mg IV 4 hours ago for pain b. Reassess the client’s pain in 15 minutes
rated at 3 on a scale of 0 to 10. He is now watching c. Notify the physician of the client’s pain level
television, and his family members are visiting with him. d. Administer an additional dose while awaiting a new
When asked about his pain, he rates it as a 5. His vital order
signs are stable. What nursing intervention is the most
appropriate? 10. A client who has been receiving 100 mg IV morphine
a. Give morphine 3.5 mg IV and inform him to con- per day is now being prescribed oral hydromorphone
tinue watching television because it is a distraction (Dilaudid). The equianalgesia chart indicates that 10 mg
from the pain IV morphine is equivalent to 7.5 mg oral hydromor-
b. Give 2.5 mg of morphine IV to avoid the client phone. How many milligrams of hydromorphone will
becoming addicted this client receive daily that is equivalent to the IV dos-
age of morphine?
c. Give nothing at this time because he is not exhibiting
any signs of pain a. 0.75 mg oral hydromorphone (Dilaudid) per day
d. Give morphine 5 mg IV and reassess in 20 minutes b. 7.5 mg oral hydromorphone (Dilaudid) per day
c. 75 mg oral hydromorphone (Dilaudid) per day
7. A client with complex regional pain syndrome (CRPS) d. 750 mg oral hydromorphone (Dilaudid) per day
arrives at the pain clinic with his left arm bare and free
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Chapter 31
Hygiene*
Updated by
Madeleine Buck, BSc(N), MSc(A)
H
LEARNING OUTCOMES
After studying this chapter, you will be able to ygiene is the science of
1. Explain the main purpose of hygiene. health and its mainte-

nance. It is a highly per-
2. Relate determinants of health to the practice of personal hygiene.
sonal matter determined by individual
3. Discuss comprehensive assessment related to hygiene.
values and practices. It involves the
4. Discuss common conditions affecting clients’ hygiene needs. care of skin, hair, nails, teeth, oral
5. Apply the nursing process to care for common hygiene problems and nasal cavities, eyes, and ears,
related to skin, feet, nails, the mouth, hair, eyes, ears, and the as well as perineal and genital care.
nose.
Personal hygiene is hygiene self-
6. Describe hygiene care for various types of baths. care that includes bathing, toileting,
7. Verbalize the steps used in providing perineal–genital, foot, oral, general body cleaning, and groom-
and hair hygiene care, as well as care related to contact lenses ing. Individuals engage in personal
and hearing aids.
hygiene activities to fulfill the need
8. Identify safety and comfort measures underlying bed-making for physical, social, and emotional
procedures.
comfort, as well as for safety. It is a
highly personal matter determined by
individual values and practices. (See
Table 31.1 for selected factors influ-
encing individual hygiene practices.) c
*Hand hygiene is an essential component of “hygiene.” This practice is discussed in

great detail in Chapter 34.
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Chapter 31 Hygiene 711
c Nurses frequently encounter people who require varying degrees of assistance, from minimal
intervention to complete care, to attain their optimal hygiene needs. Responsibility for assisting clients
to meet their hygiene needs encompasses not only the activities related to hygiene but also compre-
hensive assessment, mutual goal setting and planning, interventions, and evaluation of the extent to
which the hygiene needs are met.
TABLE 31.1 Factors Influencing Individual H

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KOZIER ERB BERMAN SNYDER FRANDSEN

BUCK FERGUSON YIU STAMLER

A01_KOZI2703_04_SE_FM.indd 1 03/03/17 3:30 PM

Glenora Erb, BScN, RN

Audrey Berman, PhD, RN

Shirlee J. Snyder, EdD, RN

Geralyn Frandsen, EdD, RN

Madeleine Buck, RN, BScN, MSc(A)

Linda Ferguson, RN, BSN, MN, PhD

Lucia Yiu, RN, BSc, BA, MScN

Lynnette Leeseberg Stamler, PhD, RN, FAAN

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Originally published under title: Fundamentals of nursing, the

RT41.K69 2017 610.73 C2016-904384-3

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Canadian Reviewers xviii

Chapter 1 Chapter 4 Chapter 6

Chapter 7 Chapter 8 The Nurse’s Role in Health

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Chapter 17 Preschoolers (4 to 5 Years) 318 Moral Development 355

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UNIT 4 INTEGRAL ASPECTS OF NURSING 364

Chapter 21 Chapter 23 Computer Technology and Informatics

Chapter 28 Male Genitals and Inguinal Area 621 Implementing 689

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Chapter 32 Chapter 34 Chapter 35

Chapter 37 Chapter 39 Vegetarian Diets 1143

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Physiology of the Respiratory

Chapter 45 Spiritual, Religious, and Faith Coping 1443

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Lynnette Leeseberg Stamler

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Linda Ferguson dedicates this edition to those nurses in professional practice

Lynnette Leeseberg Stamler dedicates this edition to the many

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Resources and Supplements

Online Resources Learning Catalytics

MyNursingLab Learning Catalytics is a “bring your own device” assessment

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Chapter The Foundation of

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to these questions are contingent on who was available

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Library and Archives Canada

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General Hospital in Halifax (Nursing Education in Nova

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Victorian Order of Nurses Canada

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FIGURE 1.8 Red Cross Nurse Gertrude Leroy Miller discharg-

colonel. Initially, nursing sisters were the only women to

soldiers under their care than less-trained personnel

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During the 1930s, the private duty market for nurses

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Professional nursing associations have also examined Recipients of Nursing

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