The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Doctors are perceived—by patients and clinicians—as being the captain of the health care team, with good reason. But, physicians may spend only 30 to 45 minutes a day with even a critically ill hospitalized patient, whereas nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families, and all other members of the health care team. Of all the members of the health care team, nurses therefore play a critically important role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing countless other tasks to ensure patients receive high-quality care.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

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Nurse staffing and patient safety
Nurses’ vigilance at the bedside is essential to their ability to ensure patient safety. It is logical, therefore, that assigning increasing numbers of patients eventually compromises nurses’ ability to provide safe care. Several seminal studies have demonstrated the link between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity, and even mortality as the number of patients per nurse increases. The strength of these data has led several states, beginning with California in 2004, to establish legislatively mandated minimum nurse-to-patient ratios; in California, acute medical–surgical inpatient units may assign no more than five patients to each registered nurse.

The nurse-to-patient ratio is only one aspect of the relationship between nursing workload and patient safety. Overall nursing workload is likely linked to patient outcomes as well. A sophisticated 2011 study showed that increased patient turnover was also associated with increased mortality risk, even when overall nurse staffing was considered adequate. Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis, and requires close coordination between management and nursing based on patient acuity and turnover, availability of support staff and skill mix, and many other factors. The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in detail in an AHRQ WebM&M commentary.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Nursing skill mix and training may also be linked to patient outcomes. One classic study showed lower inpatient mortality rates for a variety of surgical patients in hospitals with more highly educated nurses. This finding has resulted in calls for all nurses to have at least a baccalaureate education. Irrespective of educational level, the quality of nurses’ on-the-job training may also play a role in patient outcomes. As discussed in an AHRQ WebM&M commentary, nurses do not currently have a standardized transition to independent practice training requirement (analogous to medical residency training). Less experienced nurses may therefore lack mentorship and training in dealing with systems issues and complex clinical scenarios.

Nurses’ working conditions and patient safety
The causal relationship between nurse-to-patient ratios and patient outcomes likely is accounted for by both increased workload and increased stress and risk of burnout for nurses. Missed nursing care—a type of error of omission in which required care elements are not completed—is relatively common on inpatient wards. In one British study, missed nursing care episodes were strongly associated with a higher numbers of patients per nurse. Burnout among clinicians (both nurses and physicians) has consistently been linked to patient safety risks, and some studies show that higher numbers of patients per nurse is correlated with increased risk of burnout among nurses.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

The high-intensity nature of nurses’ work means that nurses themselves are at risk of committing errors while providing routine care. Human factors engineering principles hold that when an individual is attempting a complex task, such as administering medications to a hospitalized patient, the work environment should be as conducive as possible for carrying out the task. However, operational failures such as interruptions or equipment failures may interfere with nurses’ ability to perform such tasks; several studies have shown that interruptions are virtually a routine part of nurses’ jobs. These interruptions have been tied to an increased risk of errors, particularly medication administration errors. While some interruptions are likely important for patient care, the link between interruptions and errors is one example of how deficiencies in the day-to-day work environment for nurses is directly linked to patient safety.

Longer shifts and working overtime have also been linked to increased risk of error, including in one high-profile case where an error committed by a nurse working a double shift resulted in the nurse being criminally prosecuted. Nurses who commit errors are at risk of becoming second victims of the error, a well-documented phenomenon that is associated with an increased risk of self-reported error and leaving the nursing profession. In their daily work, nurses are also frequently exposed to disruptive or unprofessional behavior by physicians and other health care personnel, and such exposure has been demonstrated to be a key factor in nursing burnout and in nurses leaving their job or the profession entirely.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

All of these factors—the high-risk nature of the work, increased stress caused by workload and interruptions, and the risk of burnout due to involvement in errors or exposure to disruptive behavior—likely combine with unsafe conditions precipitated by low nurse-to-patient ratios to increase the risk of adverse events. Using a systems analysis perspective, active errors made by individual nurses likely combine with these aligned holes in the “Swiss Cheese Model of Medical Errors” to result in preventable harm.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Abstract
Nurses are critical in the delivery of essential health services and are core in strengthening the health system. They bring people-centred care closer to the communities where they are needed most, thereby helping improve health outcomes and the overall cost-effectiveness of services. Nurses usually act as first responders to complex humanitarian crises and disasters; protectors and advocates for the community and communicators and co-ordinators within teams. Communication is a core component of sound relationships, collaboration and co-operation, which in turn are essential aspects of professional practice. The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. Increases in nursing communication can lessen medical errors and make a difference in positive patient outcomes. This chapter explores how effective communication and interpersonal skills can enhance professional nursing practice and nursing relationships with various stakeholders. It explains principles of communication, communication process, purpose of communication, types of communication, barriers to effective communication, models of communication and strategies of improving communication and guidelines for successful therapeutic interactions.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Nurses are critical in the delivery of essential health services and are core in strengthening the health system [1, 2]. They bring people-centred care closer to the communities where they are needed most, thereby helping improve health outcomes and the overall cost-effectiveness of services [3]. Nurses usually act as first responders to complex humanitarian crises and disasters; protectors and advocates for the community and communicators and co-ordinators within teams. Communication skills for nurses are essential but may be difficult to master. Communication is the exchange of information between people by sending and receiving it through speaking, writing or by using any other medium. Clear communication means that information is conveyed effectively between people. To be a successful nurse, excellent communication skills are required [4]. Nurses speak to people of varying educational, cultural and social backgrounds and must do so in an effective, caring and professional manner, especially when communicating with patients and their families [5]. The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. This influence can play a very important role in areas such as patient health, education and adherence [6]. Good communication plays an important role in the organization’s effective functioning [7, 8, 9]. A nurse must therefore, continuously try to improve his/her communication skills as poor communication can be dangerous and lead to confusion.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

2. Principles of communication

Principles of communication can be summarized as follows:

Communication is a process;

Communication is not linear, but circular;

Communication is complex;

Communication is irreversible; and

Communication involves the total personality [5].

3. Communication process

Interaction between people is cyclic, which means that what one person says and does evokes a reaction from the other person, and this reaction again stimulates another reaction from the first person [10, 11]. Three things are needed for successful communication. They are:The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

A sender;

A clear message; and

A receiver [12].

4. Purpose of communication
The purpose of communication is to inquire, inform, persuade, entertain, request and investigate. A single message can have one or more of the following purposes:

To convey information/opinion, for example, “I have headache” or “I am here to give you medication”.

To request information/opinion/behavior, for example, “Are you allergic to penicillin?” or “Tell me more about the injury”.

To give social acknowledgement, for example, “Hello” or “Good morning”.

These three primary types of messages can be combined in many ways so that they form an interaction (conversation). The goals of the interaction can be comprehensive. Nurses strive to make all their communication with patients therapeutic, that is, their communication is purposefully and consciously planned to promote the patient’s health and wellbeing.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

5. Types of communication

Verbal and non-verbal communications are the two main types of communication used by human beings.

5.1. Verbal communication
Verbal communication is associated with spoken words and is vitally important in the healthcare context. Members of the multi-disciplinary healthcare team communicate verbally with one another and with patients as well as family members.

5.2. Verbal communication
Non-verbal communication is not reliant on words. It is sent through the use of one’s body rather than through speech or writing. This kind of communication, called body language, can tell a great deal or can totally the wrong impression. It is worth noting that body language may indicate a different meaning to what is spoken. As approximately 60% of communication is non-verbal, non-verbal skills are essential for effective communication [8]. Often non-verbal messages send stronger signals than verbal messages. Non-verbal communication is made up of:The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Accent

Bodily contact

Direction of gaze

Emotive tone in speech

Facial and gestural movements

Physical appearance

Posture

Proximity

Speech errors

Timing of speech [5, 8, 9, 10].

6. Communication process

The communication process may be explained by means of a linear model of communication, interactive model of communication or transactional model of communication [11].

6.1. Linear model of communication
Linear model of communication entails a sender, a message, a receiver and noise (Figure 1).The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Figure 1.
Linear model of communication.
6.2. Interactive model of communication
Interactive model of communication gives a slightly more complex explanation of the communication process. Communication is seen as a process in which the listener gives feedback or responds to a message after a process of interpretation. A communicator creates and interprets a message with a personal field of expertise and/or a frame of reference

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Figure 2.
Interactive model of communication.
6.3. Transactional model of communication
Transactional model of communication acknowledges and gives emphasis to the dynamic nature of interpersonal communication and the multiple roles of the communicators. Features such as time, messages, noise, fields of experience, frames of reference, meanings, shared systems of communicators and personal systems all pay a role in the process of communication. Communicators often participate simultaneously (sending, receiving and interpreting). The unique interpretive and perceptual processes of individuals thus play an essential role in the communication process.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

7. Barriers to effective communication

Effective communication skills and strategies are important for nurses. Clear communication means that information is conveyed effectively between the nurse, patients, family members and colleagues. However, it is recognized that such skills are not always evident and nurses do not always communicate well with patients, family members and colleagues. The message sent may not be the message received. The meaning of a message depends on its literal meaning, the non-verbal indicators accompanying it and the context in which it is delivered. It is therefore, easy to misinterpret the message, or to interpret it correctly, but to decide not to pursue its hidden meaning this leads to obstruction to communication. Continuous barriers to effective communication brings about a gradual breakdown in relationships. The barriers to effective communication outlined below will help nurses to understand the challenges [8].The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

7.1. Language barrier
Language differences between the patient and the nurse are another preventive factor in effective communication. When the nurse and the patient do not share a common language, interaction between them is strained and very limited [9, 10, 11]. Consequently, a patient may fail to understand the instructions from a nurse regarding the frequency of taking medication at home.

7.2. Cultural differences
Culture is another hindrance. The patient’s culture may block effective nurse–patient interactions because perceptions on health and death are different between patients [12, 13, 14]. The nurse needs to be sensitive when dealing with a patient from a different culture [9, 15, 16]. What is acceptable for one patient may not be acceptable for another. Given the complexity of culture, no one can possibly know the health beliefs and practices of every culture. The nurse needs check with the patient whether he/she prefers to be addressed by first name or surname. The use of eye contact, touching and personal space is different in various cultures and rules about eye contact are usually complex, varying according to race, social status and gender. Physical contact between sexes is strictly forbidden in some cultures and can include handshakes, hugging or placing a hand on the arm or shoulder. A ‘yes’ does not always mean ‘yes’. A smile does not indicate happiness, recognition or agreement. The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay Whenever people communicate, there is a tendency to make value judgements regarding those perceived as being different. Past experiences can change the meaning of the message. Culture, background and bias can be good if they allow one to use past experiences to understand something new; it is when they change meaning of the message that they interfere with the communication process [12]. It is important for nurses to think about their own experiences when considering cultural differences in communication and how these can challenge health professionals and service users.

7.3. Conflict
Conflict is a common effect of two or more parties not sharing common ground. Conflict can be healthy in that it offers alternative views and values. However, it becomes a barrier to communication when the emotional ‘noise’ detracts from the task or purpose. Nurses aim for collaborative relationships with patients, families and colleagues.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

7.4. Setting in which care is provided
The factors in care setting may lead to reduction in quality of nurse–patient communication. Increased workload and time constraints restrict nurses from discussing their patients concerns effectively [16]. Nurses work in busy environments where they are expected to complete a specific amount of work in a day and work with a variety of other professionals, patients and their families. The roles are hard, challenging and tiring. There is a culture to get the work done. Some nurses may consider colleagues who spend time talking with patients to be avowing the ‘real’ work and lazy. Nurses who might have been confident in spending time with patients in an area where this was valued, when faced with a task-orientated culture have the dilemma of fitting into the group or being outside the group and spending time engaging with patients. Lack of collaboration between the nurses and the doctors in information sharing also hinder effective communication. This leads to inconsistencies in the information given to patients making comprehension difficult for the patient and their families.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

7.5. Internal noise, mental/emotional distress
Internal noise has an impact on the communication process. Fear and anxiety can affect the person’s ability to listen to what the nurse is saying. People with feelings of fear and anger can find it difficult to hear. Illness and distress can alter a person’s thought processes. Reducing the cause of anxiety, distress, and anger would be the first step to improving communication.

7.6. Perception
If a healthcare professional feels that the person is talking too fast, not fluently, or does not articulate clearly etc., he/she may dismiss the person. Our preconceived attitudes affect our ability to listen. People tend to listen uncritically to people of high status and dismiss those of low status.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

7.7. Difficulty with speech and hearing
People can experience difficulty in speech and hearing following conditions like stroke or brain injury. Stroke or trauma may affect brain areas that normally enable the individual to comprehend and produce speech, or the physiology that produces sound. These will present barriers to effective communication.

7.8. Medication
Medication can have a significant effect on communication for example it may cause dry mouth or excess salivation, nausea and indigestion, all of which influence the person’s ability and motivation to engage in conversation. If patients are embarrassed or concerned that they will not be able to speak properly or control their mouth, they could be reluctant to speak.

7.9. Noise
Equipment or environmental noise impedes clear communication. The sender and the receiver must both be able to concentrate on the messages they send to each other without any distraction.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

8. Improving communication

Some ways of improving communication are as follows:

Listen without interrupting the sender.

Show empathy at all times and try to understand.

Try to stay focused on the conversation. Do not however, force the patient to continue if he/she becomes anxious or seems to wish to change the subject.

Use the body language that indicates your interest and concern. Touch the patient if it seems appropriate. Lean forward, listen intently and maintain eye contact if it culturally acceptable.

Offer factual information. This relieves anxiety. Do not offer your personal opinion. Assure the patient that you have professional discretion.

Try to reflect the feelings and thoughts the patient is expressing by rephrasing questions and comments using their own words.

Avoid unclear or misleading messages.

Avoid giving long explanations.

Give your co-workers your full attention when communicating with them.

Ask questions to clarify unclear messages.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Do not interrupt until the sender has completed the message.

Provide a quiet environment without distractions.

Be convincing wen communicating [17].

9. Communicating with patients

There are several points to be kept in mind when communicating with patients. The first point is that you are there to provide care and support to the patient.

Be open, respectful and gracious in all your interactions with the patient and keep his/her cultural preferences in mind.

Answer nurses’ bells promptly.

Make sure you have the patients’ attention when communicating.

Use words that are non-threatening – explain what you would like to do and do not give orders to the patient.

Use simple, understandable phrases, not medical terms as most patients do not understand these terms.

Speak clearly and courteously.

Use a pleasant and normal tone of voice to the hard of hearing.

Always stand so that the patient can see the nurse’s face when communicating, as lip reading is part of all normal hearing.

Use body language that is appropriate.

Explain facts and procedures before donning a mask that covers the wearer’s mouth and lower face.

Be alert to the patient’s needs. Allow time for answers to your requests and to answer patient’s questions [17].

10. Communicating by phone

Nurses often communicate over the phone with patients, family members and colleagues and this can lead to misunderstandings. The way in which the pone is answered and a message is interpreted needs special skills because the body language of the person at the other end of the phone line cannot be seen. When answering the phone or making a call:The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Always speak clearly into the mouthpiece of the phone.

Offer a greeting for example, good morning or good afternoon.

Identify the unit or place of work.

Identify yourself by indicating who you are and where you are phoning from.

Identify the person to whom you are speaking.

Politely listen to the message and make notes if you think you may not remember all the information.

If you are asked to call another person, note the date, time, caller’s name and telephone number together with the message.

Date and sign the message [17].

11. Assertive communication
The skill of assertiveness is important to nurses. Nurses are expected to be the patients’ advocates. So, they need to have the assertive communication skills in order to be able to be patients’ advocates. Assertiveness enables a person to be honest with him/herself and in relationships with others. Assertiveness helps to enhance relationships, avoid power games and is a vehicle for clear outcomes. Hargis as cited by van Niekerk identifies four elements of assertive communication [8]:

Content – where the rights of the people involved are embedded gently in the statement. This could be done by using an explanation, empathy for the listener, and praise for the listener, an apology for the consequence for the listener or a compromise that is favorable to both people.

Covert elements – where the speaker is able to recognize their rights and the rights of the listener in the communication process. These include respect, expressing feelings, having your own priorities, being able to say ‘no’, being able to make mistakes and choosing to say nothing.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Process – concerned with how people express themselves assertively. Is their body language, intonation and choice of language reflective of a confident assertive person? Are the processes that make up communication congruent, in keeping with what is being said? The process also involves managing the setting so that people are not embarrassed, or the noise levels are kept to a minimum. Increasing the likelihood of assertive communication happening again involves feedback to the listener to show that their accomplishment is appreciated.

Non-verbal cues – gesture, touch, proxemics and posture – also need to reflect confidence, regard and respect for self and others.

12. Therapeutic interactions
Therapeutic interactions are purposeful as opposed to social. Social interaction entertains the participants, but in a professional situation, the nurse usually has a clinical objective that he/she wants to achieve with communication. The nurses therefore, decides on the purpose of the interaction before or shortly after it begins. The following purposes are common in nursing:

Assess a patient: The nurse wants to know more about a patient to identify his/her problems. This type of conversation can be a structured interview using an interview schedule. The purpose of this conversation is always a better understanding of the patient.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Instruct a patient: Patient instruction may vary from an informal conversation during which few facts are conveyed to an elaborate instruction session.

Problem solving: If a patient discuss his/her problems with a nurse, the nurse helps the patient to analyze the problem, consider possible alternative ways of handling it and how to decide which way is the best. Problem solving is done with the patients and not for them.

Give emotional support: The presence of an empathetic nurse, that is, one who can enter into the patient’s shoes and understand the patient’s experience, is immensely supportive of the patient. Emotional support alleviates the loneliness of the patient’s experience of illness and increases his/her dignity [17].

13. Guidelines for successful therapeutic interactions
After the purpose of the therapeutic interaction has been established, the following guidelines assist in conducting a successful interaction:

13.1. Maintaining a low-authority profile
The nurse must strive to maintain a low-authority profile at the beginning of the conversation. As the conversation progresses, the nurse can use more directive techniques to find out specific information. There are usually differences in age, sex, occupation, cultural background, moral and religious convictions between the nurse and the patient. These differences make it impossible for the nurse to fully understand the patient’s behavior and reactions. It is therefore, important for the nurse to understand and accept differences in patients’ cultures and beliefs. When in doubt, check with the patient. If trust is established, patient will be willing to teach the nurse.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

13.2. Use of understandable language
The nurse should determine the patient’s level of understanding and if necessary change the use of language, comments and questions. Using the terminology which the patient does not understand can also frighten the patient and make him/her think that he/she has a more serious problem than he/she originally wanted help for. At the same time, the patient could give incorrect information because due to confusion, he/she may give affirmative answers to questions about symptoms that he/she has not actually experienced [18]. Nurses should share their aims with patients before expecting them to participate in the interaction. They should understand that there is a mutual understanding of each other’s point of departure. In an assessment interview, the nurse can, for instance, say: “Mr Jones, I would like to give you information on how to lose weight so as to bring down you high blood pressure, but I first need to find out what you already know about the condition”. It is not only important that the patients understand what nurses expect from the conversation; it is also essential that nurses understand the patients and convey this understanding before they participate in the conversation. When providing emotional support, this understanding is often all that is necessary. For nurses to understand patients, they must encourage them to talk – not just about facts, but also about their feelings. The nurse must listen more than speak, both to what the patient is saying verbally and what is being said non-verbally. Having listened carefully, the nurse then concentrates and responds empathetically to the patients’ feelings. Only when the nurse has a reasonably complete understanding of the patient’s situation and has communicated this understanding, can she proceed to interventions, such as giving information or solving a problem.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

13.3. Tailor the message to the totality of the person
Saying something does not necessary mean that the message has been received and understood. It is the responsibility of the nurse to ensure that the person with whom he/she is conversing understands the message. To ensure this, the message has to be adapted to the language, culture and socio-economic status of the patient. The emotional or physical condition of patients may also make it difficult for them to receive long of complicated messages or even any message. There may also be other disturbances in the immediate environment for example, noise that can make the patient not to hear or understand the message. The message must also be adapted to the age of the patient [10].

13.4. Validate the interpretation with the patient
Validation means that you ask the patient whether your interpretation is correct or not. You therefore, ask him/her to confirm your understanding of what he/she said. Many misunderstandings arise because people interpret other people’s words without checking their interpretation. The nurse should try to eliminate misunderstandings in the conversations by checking meaning with the patient.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

13.5. Active listening
Active listening means concentrating all your senses and thoughts on the speaker. One can usually deduce whether a person is listening actively by looking at the following non-verbal indicators:

Is the eye contact maintained with the person who is speaking?

Are the body and face turned towards the speaker?

It is, of course, also clear from the verbal responses:

Are there regular verbal responses, even if these consist only of encouraging sounds?

Does the response indicate understanding, not only of the facts, but also of the feelings and the implications of the facts?

It is much easier to speak than to listen. Nurses are, in general, very active people, who want help b acting quickly. To ‘just listen’ without expressing opinions or offering advice is therefore, often not in their nature. Active listening is a valuable skill to acquire [10, 17, 18].

13.6. Evaluate own communication
In the interest of nurse–patient relationship, it is essential that they ascertain whether their communication has been successful. The following criteria can be used:

Simplicity: Say what you want to say concisely and without using difficult or unfamiliar terms.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Clarity: Say precisely what you want to say without digressing, and support your verbal message with non-verbal indicators.

Relevance: Make sure that your message suits the situation, the time and the person you are speaking to.

Adaptability: Adapt your response to the clues the patient that the patient gives you.

Respect: Always show respect for the individuality and dignity of the person you are speaking to [17].

14. Therapeutic communication techniques
Table 1 gives an overview of therapeutic communication techniques and provides examples of each technique [10, 13].

General area of issue Therapeutic communication techniques Rationale Examples
To obtain information Make broad opening remarks This gives the patient the freedom to choose what he/she wishes to talk about “Please tell me more about yourself”
Use open-ended questions This type of question allows the patient to talk about his/her views about the subject. In this way, what the patient sees as important, what his/her intellectual capacity is and how well-orientated he/she is, becomes clear. This encourages the patient to say more and does not limit answers to a ‘yes’ or ‘no’ “How did you experience the pain?”The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay
“You say you felt dizzy, and then…”
“Tell me more about that”
Share observations and thoughts This shows that you are aware of what is happening to the patient and encourages him/her to talk about it “You seem to be upset”
Confrontation This entails confronting the patient with an observation you have made and assess his/her reaction to it. This technique is useful when verbal and non-verbal communication do not match “You say that your ankle is very painful, but you do not react when I bend the ankle. How is it possible?”
Reflection This means that you repeat what the patient said in the same or different words. This shows you are involved in what the patient is saying and that he/she should talk more about a specific point, or explain further Patient: “It is sore”.
Nurse: “Very painful?”
Encourage description This is used to obtain more information about patient’s views and feelings “Tell me how it happened”
Validate what is being said This is to make sure that you understand the patient correctly “Do I understand you correctly when you say…”
Offer your presence The nurse offers his/her attention and interest without making demands “I will be with you until they come to fetch you for the operation in theater”
Summarizing By organizing and checking what the patient has said, especially after a detailed discussion. This technique is used to indicate that a specific part of the discussion is coming to an end and that if the patient wishes to say any more, she should do so “You went for a walk and then you felt the sharp chest pains, which radiated down your arm”The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay
Use of interpretation Draw a conclusion from the information you have gathered and discuss it with your patient to see whether it is true. The patient can then disagree with it, or confirm that your conclusions are true “You must have been exhausted after walking a long distance from home to the hospital”
To give support Supportive remarks Make supportive remarks to encourage the patient to participate in the conversation. Show that you are listening “Yes….”
“Mmmm…”
“Go on, I am listening”
Appropriately touch the patient Touch can assure the patient that the nurse cares and is present Hold his/her hand. Consider the cultural belief and comfort of the patient before touching
Paraphrasing This conveys understanding of the patient’s basic message “It sounds as though the most important problem is the diet”
To assist in analysis and problem solving Acknowledge the person This promotes a sense of dignity “Good morning Mr. Jones”
Sequencing This helps the patient to see the connection between the parts of an occurrence. To effectively assess the patient’s needs, the nurse often needs to know the time frame within which symptom sand /or problems developed or occurred “Did you experience this sharp pain before or after eating?”The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay
Ask for clarification This helps the nurse to understand and the patient to communicate more clearly “What do you mean by everybody?”
Ask for alternatives This stimulates creative thought and promotes finding solutions “What else can you try?”
Use of transition This is used to guide the conversation to another subject, without losing the continuity of the conversation “It seems to me that you have solved the problem of poor appetite, but I would like to hear more about your diabetes. How long have you been aware of this illness?”
Comparison Use of examples and comparisons to concrete objects. In this way, a vague or abstract concept can be more easily explained “Does the pain feel like a sharp or a blunt object that hits you?”
Use silence This gives the patient the chance to think, and/or to his/her organize thoughts. Silence also give a nurse an opportunity to observe the patient. However, the nurse should avoid silences that last too long because they can make the patient anxious
To instruct the patient Give information This explains information and puts it at the patient’s disposal “After the operation, you will have a drainage tube”The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay
Orientate the patient towards reality When the patient interprets something incorrectly, the nurse draws his/her attention to reality “I am not your daughter, I am Nurse Jones”
Query what the patient says The patient’s observation is called into question without belittling him/her, or arguing about it Are you sure about that?”
Withhold social reward Do not give social approval to wrong behavior so as not to encourage a repeat of the wrong behavior Do not smile, nod or agree when the patient jeopardizes his/her recovery with wrong behavior
Give social reward Reward behavior that promotes health to encourage a repeat of the correct behavior Nod is approval at a patient with a weight problem who declines to eat a heavy meal
Table 1.
Therapeutic communication techniques.

15. Counter-productive communication techniques
There are certain counter-productive communication techniques that the nurse should avoid as they do not assist in the recovery of the patient and do not have any therapeutic value. Table 2 shows counter-productive communication techniques, explains why these should be avoided and gives examples [10, 18].The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Non-therapeutic techniques Rationale Examples
Inappropriate reassurance The nurse attempts to brush aside the patient’s aside the patient’s worry by acting as though it is unnecessary or inappropriate. Reassurance is not based on fact or real certainty. This helps the nurse more than it helps the patient “Do not worry; everything will be fine”
Passing judgment The nurse passes judgment on the patient’s behavior, thoughts or feelings and in doing so, places herself in the position of an adversary or a person who knows better and more “As a Christian, I do not think you should terminate this pregnancy”
Giving advice The nurse tells the patient how he/she ought to feel, think or act. This implies that she has the correct information and knows better than the patient. This is particularly problematic when the advice is based on limited assessment and knowledge of the patient and the situation “I think you must…”
Closed questions These questions require only a single word as an answer when specific information is needed. If this type of question is used often, the patient are less inclined to give the information and may be interpreted as an interrogation “Do you feel any pain in your arm?”
‘Why’ questions These questions demand that the patient explains behavior, feelings or thoughts that he/she often does not understand himself or herself. These questions are often asked early in a conversation when the nurse cannot even be certain that the patient wants to explain himself of herself to the nurse “Why are you upset?”
Offering platitudes This is stereotyped expression of something the patient is in any case aware of and which, therefore, helps little. This is similar to giving advice “Everybody goes through this in life”
Defensiveness The nurse tries to defend someone or something the patient criticized. This places the nurse and the patient on opposite sides and does not promote further openness on the part of the patient “We are very short-staffed; so we cannot help everyone at the same time”The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay
Table 2.
Non-therapeutic communication techniques that should be avoided.

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16. Conclusion
Promoting effective communication in health care is demanding and challenging because of the nature of the work environment. Nurses who have received training in communication skills communicate effectively and show increased confidence in communicating with patients. Many nurses choose to work in other countries, providing an opportunity to broaden their experience and knowledge. However, it is important that nurses who have the opportunity to work in other countries develop communication skills, cultural awareness and sensitivity before arriving. For example, in China talking about death is taboo [19]. In South Africa, maintaining eye during communication may be regarded as being disrespectful by Black people [11]. This article provides a reflective account of the experiences of one of the authors of working overseas. This chapter provides the effective communication and interpersonal skills that enhance professional nursing practice and nursing relationships by explaining principles of communication, communication process, purpose of communication, types of communication, barriers to effective communication, models of communication and strategies of improving communication and guidelines for successful therapeutic interactions.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Acknowledgments
The author wishes to acknowledge the Durban University of Technology for funding this book chapter.

Conflict of interest
The author declares that there is no conflict of interest in this chapter.

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In today’s healthcare system, information technology is the foundation of the future. Healthcare modernization is best visualized if we compare how we were thirty years ago and where we are today. The need for improvement was the driving force behind the evolution of computers in healthcare. The majority of the past thirty years of technological expansion was spent on computer programs for administrative purposes while the past decade has seen as emphasis on the clinical process. Patient care has become a primary focus in the development of new concepts and knowledge in healthcare technology. Technological development in clinical applications is the current trend in healthcare and it will continue to play a major role for years to come.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

This article will describe the participation of nurse informatics specialists in adopting the right balance between the electronic documentation in nursing workflow and quality of patient care.

Healthcare information technology began with the computer in the early 1970s and did not see a broad acceptance until individual computers were made available at the end of the decade. In spite of the advancement of the computer, actual clinical patient care was never a consideration until well after the turn of the 21st century. Cross over from administration to clinical applications started with individual departments that needed to speed up the process in order to provide better outcomes. Some of the automated systems began with radiology, pharmacy, and laboratory. This beginning then began to be adopted in other clinical departments. Information technology is quickly changing in all areas worldwide, creating new challenges and opportunities for different industries every day, including healthcare.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

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The healthcare industry recognizing the need for communication between information technology personnel and healthcare practitioners in order to address the issues of patient care, created nurse informatics specialist positions. Nurse informatics specialists are an integral part of the healthcare delivery process and a deciding factor in the selection, implementation and evaluation of healthcare, which supports safe, high-quality and patient-centered care (Elkind, 2009). The American Nurses Association (2008) defined Nursing informatics as “A specialty that integrates nursing science and computer science to manage and communicate data, information and knowledge in nursing practice (p. 1). Nursing informatics can also be defined as any use of information technology by nurses for the purpose of enhanced patient outcomes, the management of healthcare facilities, nurse education and nursing research.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Many healthcare individuals associate the field of nurse informatics as having two types of roles, the clinician who uses the health information technology and the specialist, who creates, facilitates, tests, and implements new information technology. Healthcare settings now integrate electronic medication prescribing, tele-health, online appointment scheduling and mobile laboratories where informatics nurses are essential in guaranteeing that the computerized solutions interface with each other (HIMSS, 2011). In order to accomplish information related activities, informatics nurses must synchronize and exchange significant clinical and technical information with the goal of supporting and coordinating safe, effective patient care and assuring an efficient workflow.

A vital element of healthcare information is nursing documentation. Information systems are designed for nurses where documentation can be best utilized to expand their knowledge of quality of care. The evolution of knowing has been exponential in the past forty years due to the new ways of learning that have been discovered. Nursing in particular has benefitted from these new concepts and continues to find newer and better methods to improve patient care. Nurses bring to their practice a personal history that develops the way their nursing care is performed. Nursing theory, standards of practice, legal and ethical obligations must be understood and utilized to enhance the quality of nursing care.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

The electronic patient record has become an important aspect in the information workflow, and using information technology will result in improving patient outcome quality and efficiency. Patient documentation is a vital skill in communicating the patient’s condition and organizing their care according to the patient’s needs. Nursing practice is primarily guided by patients’ needs and depending on those needs and their environments, different theories can be applied for individualized care. The application of individual nursing practice is based on an combination of medical, philosophical, psychological and other nursing theories.

Barbara Carper, a professor at the College of Nursing at Texas Woman’s University, wrote an essay in 1978 titled the “Fundamental Patterns of Knowing in Nursing,” that has identified four ways of knowing that nurses apply to meet patients’ needs. Today many universities and nursing colleges are using her fundamental patterns to help nursing students gain a more universal approach to assessing, understanding and treating patients. One of Carper’s patterns is the empirical knowing that is based on the result of the most relevant and supported evidence derived from research. This includes research related to nursing informatics and the use of technology in healthcare.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Before the digital age, nurses were utilizing paper forms to document important patient information. A significant factor in the nursing profession and healthcare systems is the transition to electronic documentation. Electronic documentation contains flow sheets that help in assembling information about the patient’s needs, improve the patient’s information accuracy, and enhance the quality of patient care. A well designed information system can facilitate and provide an easier and faster information flow that is needed for efficient documentation processing. Nurses play an essential role in patient’s safety where the quality of the nursing environment and electronic documentation has a positive influence on patients. The electronic documentation method has evolved to provide a plan of care for patients, efficient communication between clinicians, and direct patient care processes. Nurses are very diligent in coordinating, monitoring and delivering patient care to guarantee effective documentation flow. Nursing computer based software allows nurses to collect, store, recover data and integrate clinical data with nursing management resources.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Among multiple healthcare organizations, nurses represent the largest technology user group. In the beginning nurses believed that electronic documentation and information systems were an interruption to their daily workflow and a disruption from bedside care (Lee, 2004). Over the years however, nurses have become more accustomed to the technology, which is positive since their acceptance of it is imperative to successful system implementation. Today, nurses are more proficient in all aspects of information technology while maintaining superior levels of patient care.

Most nurses now have a positive attitude related to the improved quality of electronic documentation and a new appreciation of the decreased workload afforded when using a well- designed system. However, despite the benefits of electronic documentation for nursing workflow, there are barriers that can obstruct the utilization of computerized documentation systems. Some of these barriers can result from behavioral issues in regards to perception and satisfaction toward information technology and the time spent documenting the patient information. The challenge comes when some nurses (i.e. older nurses) have doubts about working in a nursing environment filled with technology. Even though they are provided with reference guides, screen shots, and cheat sheets that are helpful, some nurses still have a hard time adjusting to electronic charting. Some of them have a fear of clicking in the wrong place as they work with computerized charts and they become aggravated when they cannot perform their electronic tasks.

With electronic charting, nurses have the capability of accessing information quickly and efficiently and are able to use information to improve the quality of nursing workflow. In most of these situations, nurse informatics specialists play a pivotal role in assisting nurses in identifying and addressing these challenges. Many nursing theories have been developed to promote nursing practice efficiency. For an informatics nurse, change theory is the most integrated theory in their practice. Nurse informatics specialists apply theories in directing patient care, while providing guidance and technical assistance for staff nurse workflow as well as providing leadership for system change.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Kurt Lewin’s theory of change offers a tactical approach that can help informatics nurses in implementing and evaluating the projected changes in the system processes. An interesting article was written by Polly Ryan in 2009 where she stated that: “the integrated theory of health behavior change suggests that health behavior change can be enhanced by fostering knowledge and beliefs, increasing self-regulation skills and abilities, and enhancing social facilitation” (p. 161). Informatics nurses motivate and encourage nurses to use innovative problem-solving methods by providing them with support.

The informatics nurse is part of the delivery of care, the building of knowledge, skills, and the experience in the use of information technology. They often lead clinical informatics committee meetings that have a major influence for nurses in assisting them to coordinate all the multifaceted technology activities in regards to patient care, documentation and safety. Informatics committees provide continuing guidance in the development and implementation of information technology and digital solutions for nursing practice and patient care. The significance of developing and maintaining positive attitudes and computer-use acceptance among nursing staff have been discovered in multiple literature reviews. For a successful implementation of an electronic documentation system, it is important to understand the various levels of computer familiarity, and acknowledge nurses’ computer use needs, attitudes, skills, beliefs and readiness to learn. An informatics committee also provides structure, support and staff development to nurses from different departments who interface with or are impacted by information technology.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Informatics and nurses support for ongoing professional development that implements the work knowledge of nurses leads to high quality care and patient satisfaction. Research reveals the importance of nurse’s involvement in informatics committee meetings where they can participate in system design, redesigning workflow, and improving interdisciplinary communication (Lee, 2007). Many nurses are professionally and ethically motivated to contribute to new knowledge, high quality improvement, and innovation through evidence based decision making.

Evidence-based practice and decision-making began with Florence Nightingale in the 1850s during the Crimean War. She realized a correlation between poor sanitary situations in the hospitals and rising death rates among wounded soldiers. Her consequent efforts to keep the hospitals disinfected in order to save soldiers resulted in a remarkable drop in patient mortality (Alligood, 2014). Since Nightingale’s work in improving healthcare conditions, the progress of evidence based practice has evolved over time. Effective nursing care relies on the gathering and use of nursing evidence. The pattern of empirical knowledge is founded in evidence-based research and objective experience, and has been identified as the most prevalent in nursing practice. Evidence based practice functions as the key standard for quality in nursing practice by enhancing patient satisfaction. Evidence-based quality improvement was redesigned to transform healthcare into an environment of care that is effective, safe, and efficient. Research is being used progressively as the basis for clinical decisions in many organizations. The stream of information through the increase of technology, has transformed the decision-making process for clinicians. Research authenticates, enhances and creates a scientific base for nursing practice and is facilitated and disseminated through the use of information technology and nursing informatics. The nurse’s ultimate goal through the use of information technology is patient education, while providing high quality care and most importantly patient safety.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

It has been observed that patient education has slowly become a major concern and that hospitals want to get involved in implementing better education for patients and their families. The importance of patient education is an example of critical study and evidence based practice by nurses that has shown that knowledge, on the part of patients and their families, can reduce re-admission rates, decrease healing time, improve mental discomfort, and produce better patient results. Today, patients are educated with the help of technology including modern televisions, I-pads and other sophisticated electronic devices where the patient can watch, learn and explore their illnesses and care. Partnership with team members and families is essential to optimal treatment. The application of individual nursing practice is based on an arrangement of the clinician and the patient. Traditional patient education relied on written material about disease processes, medication, medical management, and self-care instruction guidelines. Today, patients benefit from many forms of education and with all these forms of education nurses can provide patients with knowledge that enables them to understand the disease process and make important decisions about their health. Nursing interventions in proper patient education improves patient self-care, satisfaction, moral support, coping skills and mental stability. Addressing improvement in nursing workflow is essential to the improvement of patient stability and safety.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Healthcare outcomes including quality of life measures are the result of a multifaceted relationship between the patient, the nurse, the treatment and the information healthcare system. A strong foundation for addressing the challenges of electronic documentation is the informatics nurse’s capability to understand and direct the balance of patient care with the technology systems and organizational structure that supports this balance. In order to guarantee a successful implementation of a computer system while managing patient care it is important to integrate nurses’ perceptions, beliefs, and knowledge in the use of new technology and how nurses implement this technology into their daily nursing practice. Finding the right balance of information science in conjunction with nursing science is a continuing process that will rely on the forward thinking and perseverance of today’s modern nurse and the support of nursing informatics specialists.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

Current context
The National Quality Forum endorsed voluntary consensus standards for nursing-sensitive care in 2004. These included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the quality of the nursing practice environment (which includes staffing ratios), and nursing turnover. These measures are intended to illustrate both the quality of nursing care and the degree to which the working environment at an institution supports nurses in their patient safety efforts.The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay

The Magnet Hospital Recognition Program, administered by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association), seeks to recognize hospitals that deliver superior patient care and, partly on this basis, attract and retain high-quality nurses. The program has its genesis in a 1983 study that sought to identify hospitals that retained nurses for longer than average periods of time. The study identified institutional characteristics correlated with high retention rates, an important finding in light of a major nursing shortage at the time. These findings led 10 years later to the formal Magnet Program.

As of September 2015, 14 states have enacted legislation or adopted regulations around nurse staffing ratios. Mandatory overtime for nurses is also restricted in 16 states. The Role of Nurses in the Delivery and Monitoring of Quality of Care to Patients Essay