Faculty of Health Sciences

Nursing department

Course book & Lecture Notes

Nursing Ethics
For the first year students
2018 – 2019
Prepared by
Assist. Prof. Dr. Hoshyar Amin Ahmed

[Type text] Page 0

 ISHIK UNIVERSITY
FACULTY OF HEALTH SCIENCES
Department of NURSING,
2018-2019 Fall
Course Information for NSNG NURSING ETHICS
Course Name: NURSING ETHICS

Code Course type Regular Semester Theoretical Practical Credits ECTS

DENT 197 2 1 2 - 2 2
Name of Lecturer(s)-
Dr Hoshyar Amin Ahmed - PhD
Academic Title:
Teaching Assistant:
Course Language: English
Course Type: Basic
Office Hours 2
Contact Email: [email protected]
Tel:07504478527
Teacher's academic
Assistant Professor, PhD in Community Health Nursing, MSc in Community Health Nursing.
profile:
Course Objectives: At the end of the course the students will be able to define the term ethics, identify types of
ethics, differentiate common ethical theories, identify principles and rules of health care ethics,
recognize the ethical dilemma and ethical decision making in nursing, including common
models for decision making, describe general legal concepts as they apply in Nursing,
describe ways standards of care affecting nursing practice, identify nursing code of ethics at
the International and the national level, identify areas of potential liabilities in nursing, describe
the purpose and essential elements of informed consent, recognize the importance of record
keeping, list information that needs to be included in incident report and nursing
communication and interpersonal relationships.

Course Description This course provides a broad overview of Ethico-legal aspects to nursing and Communication
(Course overview):
and interpersonal relationships in nursing, through understanding the concept of nursing ethics
and communication techniques in nursing.

COURSE CONTENT
Week Hour Date Topic
1 2 25-29/11/2018 Ethico-legal aspects to nursing
2 2 02-06/12/2018
3 2 09-13/12/2018
4 2 16-20/12/2018
5 2 23-27/12/2018
6 2 30/12/2018-3/1/2019
7 2 6-10/1/2019
8 2 13-17/1/2019

[Type text] Page 1

 9 2 20-24/1/2019 Communication and interpersonal relationships in nursing
10 2 27-31/1/2019
11 2 3-7/2/2019
12 2 10-14/2/2019
13 2 17-21/2/2019
14 2 24-28/2/2019
15 2 3-7/3/2019
16 2 10-14/3/2019 Final Examination
COURSE/STUDENT LEARNING OUTCOMES
1 Ethico-legal aspects of nursing ethics
2 Nursing communication skills

Student's obligation You will be asked to fill out course evaluations before each of the two tests and before the final
(Special Requirements): exam. We are always open to feedback.
Course Book/Textbook:
Other Course
Handout texts, reports, presentations, and notes in the classroom
Materials/References:
Teaching Methods
Lectures, Exercises, Presentation, Assignments, Case Studies
(Forms of Teaching):
COURSE EVALUATION CRITERIA
Method Quantity Percentage (%)
Participation 1 10
Quiz 1 10
Homework 1 10
Midterm Exam(s) 1 30
Final Exam 1 40
Total 100

Examinations: Essay Questions, Multiple Choices, Short Answers

ECTS (ALLOCATED BASED ON STUDENT) WORKLOAD
Duration Total Work
Activities Quantity
(Hour) Load
Course Duration (Including the exam week: 16x Total course hours) 2 32 64
Hours for off-the-classroom study (Pre-study, practice) 16 16 256
Assignments Mid-terms 1 2 2
Final examination 1 2 2
Other 0
Total Workload 324
ECTS Credit (Total workload/25) 12.96

Peer review

Signature: Signature: Signature:

Name: Name: Name:
Head of
Lecturer De
Department

[Type text] Page 2

 Nursing Ethics

PREFACE

Nurses at present are facing various personal, interpersonal, professional,

institutional and socio cultural challenges in their professional performance.
Dealing with these issues may not be always clear. The lack of one correct
approach in addressing different contextual issues may lead to ethical dilemmas.
Responding to this complex issues demand nurses to acquire comprehensive
ethical knowledge and skills in various decision making process. Although
teaching materials have a pivotal role to play in helping nurses in this endeavor,
comprehensive books inclusive of all the topics in the curriculum is scarce.
Therefore, this lecture note is prepared to overcome the acute shortage of reference
materials reflecting the national context and be used as a teaching material for
nurses at various levels. The lecture note is divided in to two units. Unit one of
this lecture note deals with the Ethico-legal aspects to nursing, and unit two
communication and interpersonal relationships in nursing.

[Type text] Page 3

 TABLE OF CONTENTS

Contents Page
Table of contents 4
UNIT ONE: Ethico-legal aspects to nursing 5
Understanding the concept of Ethics 6
Ethics versus Morality 6
Common Ethical theories 7
Ethical Principles 8
Ethical Dilemmas and ethical decision making in nursing 17
Legal concepts in nursing 21
General legal concepts 21
Legal issues in nursing 23
Nursing code of Ethics 26
Responsibilities of nurses for specific ethical issues 27
Areas of potential liability in nursing 38
Potential malpractice situation in nursing 39
Record Keeping 42
UNIT TWO: Communication and interpersonal relationships in nursing 46
Communication 46
Types of Communication 47
Levels of Communication 47
Communication Model 49
Basic Characteristics of Communication 52
Communication Techniques in Nursing 53
Conversation Skills 53
Listening Skills 54
Interviewing techniques 55
Interpersonal Skills in Nursing 56
Communication and the Nursing Process 56
Helping Relationship 57
Reference 59

[Type text] Page 4

 UNIT ONE: ETHICO-LEGAL ASPECT OF NURSING

Learning objectives:

At the end of the lesson the learners should be able to:

1. Define the term ethics

2. Identify types of ethics

3. Differentiate common ethical theories

4. Identify principles and rules of health care ethics

5. Recognize the ethical dilemma and ethical decision making in nursing,

including common models for decision making.

6. Describe general legal concepts as they apply in Nursing.

7. Describe ways standards of care affecting nursing practice

8. Identify nursing code of ethics at the International and the national level

9. Identify areas of potential liabilities in nursing

10. Describe the purpose and essential elements of informed consent.

11. Recognize the importance of record keeping

12. List information that needs to be included in incident report.

[Type text] Page 5

 1. Understanding the concept of Ethics

1.1. Ethics versus Morality

Ethics is derived from the Greek word ethos, meaning custom or character. Ethics
can be defined as the branch of philosophy dealing with standards of conduct and
moral judgment. It refers to a method of inquiry that assists people to understand
the morality of human behavior. (i.e. it is the study of morality). When used in this
sense, ethics is an activity; it is a way of looking at or investigating certain issues
about human behavior. Ethics refers to the practices or beliefs of a certain group
(i.e. Nursing ethics, Physicians' ethics). It also refers to the expected standards as
described in the group's code of professional conduct. Ethics is concerned what
ought to be, what is right, or wrong, good or bad. It is the base on moral reasoning
and reflects set of values. It is a formal reasoning process used to determine right
conduct. It is professionally and publicly stated. Inquiry or study of principles and
values. It is process of questioning, and perhaps changing, one's morals.

Moral: Are principles and rules of right conduct. It is private or personal.

Commitment to principles and values are usually defended in daily life

Types of Ethics

1. Descriptive: It is the description of the values and beliefs of various

cultural, religious or social groups about health and illness.
2. Normative: a study of human activities in a broad sense in an attempt to
identify human actions that are right or wrong and good and bad qualities. In
nursing, normative ethics addresses: scope of practice of different categories
of nurses and, level of competence expected.
3. Analytical: analyzes the meaning of moral terms. It seeks the reasons why
these actions or attitudes are either wrong or right.
[Type text] Page 6
1.2. Common Ethical theories

Ethical theories may be compared to lenses that help us to view an ethical

problem. Different theories can be useful because they allow us to bring
different perspectives in to our ethical discussions or deliberations.

There are four ethical theories:

1. Deontology

2. Teleology

3. Intuitionism

4. The ethic of caring

1. Deontology (Duty or rule-Based theory)

This theory proposes that the rightness or wrongness of an action
depends on the nature of the act rather than its consequences. This theory
holds that you are acting rightly when you act according to duties and
rights. Responsibility arises from these moral facts of life. The theory
denotes that duties and rights are the correct measuring rods for
evaluating action. One place where such factors are presented is in codes
of professional ethics. E.g. informed consent, respect of patient…
2. Teleology (utilitarian or end based theory)
This theory looks to the consequences of an action in judging whether
that action is right or wrong. According to the utilitarian school of
thought right action is that which has greatest utility or usefulness.
Utilitarian hold that no action in itself is good or bad, the only factors that
make actions good or bad are the outcomes, or end results that are
derived from them.

[Type text] Page 7

Types of Utilitarian Theories
1. Act utilitarianism: suggests that people choose actions that will in any
given circumstances increase the over all-good.
2. Rule utilitarianism: suggests that people choose rules that when
followed consistently will maximize the overall good
3. Intuitions:
The notion that people inherently know what is right or wrong;
determining what is not a matter of rational thought or learning. For
example, nurse inherently known it is wrong to strike a client, this does
not need to be taught or reasoned out.
4. The ethic of caring (case based theory)

Unlike the preceding theories which are based on the concept of fairness
(justice) an ethical caring is based on relationships. It stresses courage,
generosity, commitment, and responsibility. Caring is a force for protecting
and enhancing client dignity.

1.3. Ethical Principles

Principles are basic ideas that are starting points for understanding and working
through a problem. Ethical principles presuppose that nurses should respect the
value and uniqueness of persons and consider others to be worthy of high regard.
These principles are tents that are important to uphold in all situations.

The major principles of nursing ethics are:

1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Justice
[Type text] Page 8
1. Autonomy
Autonomy is the promotion of independent choice, self-determination and
freedom of action. Autonomy means independence and ability to be self-
directed in healthcare. Autonomy is the basis for the client's right to self-
determination. It means clients are entitled to make decision about what will
happen to their body.
The term autonomy implies for basic elements which are:
a. The autonomous person is respected
b. The autonomous person must be able to determine personal goals. The
goals may be explicit or may be less well defined
c. The autonomous person has the capacity to decide on a plan of action.
The person must be able to understand the meaning of the choice to be
made and deliberate on the various options, while understanding the
implications of possible outcomes.
d. The autonomous person has the freedom to act upon the choices.

Competent adult clients have the right to consent or refuse treatment even
if health care providers do not agree with clients' decisions; their wishes
must be respected. However, in most instances patients are expected to
be dependent upon the health care provider. Often times health care
professionals are insensitive to ways by which they dehumanize and
erode the autonomy of consumers. For example:

• Right after admission patients are asked about personal and private
matters

• Workers who are new to patients may freely enter and leave the
patients‟ room making privacy impossible.

[Type text] Page 9

Four factors for violations of patient autonomy

1. Nurses may assume that patients have the same values and goals as themselves
2. Failure to recognize that individuals‟ thought processes are different
3. Assumptions about patients‟ knowledge base
4. Focus on work rather than caring

Infants, young children, mentally handicapped or incapacitated people, or

comatose patient do not have the capacity to participate in decision making about
their health care. If the client becomes unable to make decisions for himself/
herself, this “surrogate decision maker” would act on the client's behalf. Autonomy
of clients is more discussed in terms of larger issues such as: informed consent,
paternalism, compliance and self-determination.

Informed consent: is a process by which patients are informed of the possible

outcomes, alternative s and risks of treatments and are required to give their
consent freely. It assures the legal protection of a patient‟s right to personal
autonomy in regard to specific treatments and procedures. Informed consent will
be discussed in detail in selected legal facts of nursing practice.

Paternalism: Restricting others autonomy to protect from perceived or anticipated

harm. The intentional limitation of another‟s autonomy justified by the needs of
another. Thus, the prevention of any evil or harm is greater than any potential evils
caused by the interference of the individual‟s autonomy or liberty. Paternalism is
appropriate when the patient is judged to be incompetent or to have diminished
decision-making capacity.

Non-compliance: Unwillingness of the patient to participate in health care

activities. Lack of participation in a regimen that has been planned by the health

[Type text] Page 10

care professionals to be carried out by the client. Noncompliance may result from
two factors:

1. When plans seem unreasonable to the patient

2. Patients may be unable to comply with plans for a variety of reasons
including resources, lack of knowledge, psychological and cultural factors
that are not consistent with the proposed plan of care
2. Beneficence
Beneficence is doing or promoting good. This principle is the basis for all
health care providers. Nurses take beneficent actions when they administer
pain medication, perform a dressing to promote wound healing or providing
emotional support to a client who is anxious or depressed.

This principle provides nursing‟s context and justification. It lays the

groundwork for the trust that society places in the nursing profession and the
trust that individuals place in particular nurses or health care agencies.

The principle of beneficence has three components:

1. Promote good
2. Prevent harm
3. Remove evil or harm
3. Nonmaleficience

Nonmaleficence is the converse of beneficence. It means to avoid doing harm.

When working with clients, health care workers must not cause injury or suffering
to clients. It is to avoid causing deliberate harm, risk of harm and harm that occurs
during the performance of beneficial acts. E.g. Experimental research that have
negative consequences on the client.

[Type text] Page 11

Nonmaleficence also means avoiding harm as a consequence of good. In that cases
the harm must be weighed against the expected benefit

4. Justice

Justice is fair, equitable and appropriate treatment. It is the basis for the obligation
to treat all clients in an equal and fair way. Just decision is based on client need
and fair distribution resources. It would be unjust to make such decision based on
how much he or she likes each client.

5. Veracity

Veracity means telling the truth, which is essential to the integrity of the client-
provider relationship

• Health care providers obliged to be honest with clients

• The right to self-determination becomes meaningless if the client does not receive
accurate, unbiased, and understandable information

6. Fidelity

Fidelity means being faithful to one's commitments and promises.

• Nurses‟ commitments to clients include providing safe care and maintaining

competence in nursing practice.

• In some instances, a promise is made to a client in an over way

• Nurse must use good judgment when making promises to client. Fidelity means
not only keeping commitment but also keeping or maintaining our obligation.

[Type text] Page 12

7. Confidentiality

Confidentiality comes from Latin fide: trust.

• confide as to “show trust by imparting secrets”; “tell in assurance of secrecy”;

“entrust; commit to the charge, knowledge or good faith of another”; while

• confidential or in confidence is “a secret or private matter not to be divulged to

others”

Confidentiality in the health care context is the requirement of health professionals

(HPs) to keep information obtained in the course of their work private.

Professional codes of ethics (and conduct) will often have statements about
professions maintaining confidentiality, but confidentiality is often qualified.
Confidentiality is non-disclosure of private or secret information with which one is
entrusted. Legally, this requirement applies to HPs and others, who have access to
information about patients, and continues after the patient‟s death

Nurses hold in confidence any information obtained in a professional capacity, and

use professional judgment in sharing such information. Each nurse will treat as
confidential personal information obtained in a professional capacity. The nurse
uses professional judgment regarding the necessity to disclose particular details,
giving due consideration to the interests, wellbeing and safety of the patient and
recognizing that the nurse is required by law to disclose certain information.

Ethical Arguments for Maintaining Patient Confidentiality

1. Utilitarian argument
Patients‟ assurance of confidentiality helps ensure they will seek treatment (e.g.,
for complaints that may be personally embarrassing, or related to socially

[Type text] Page 13

 denigrated, or illegal activities, etc.). This helps to ensure that patients will be
properly diagnosed and treated. This in turn helps to minimize harm, and
maximize good.
2. Respect for autonomy (may be a deontological or utilitarian justification)
Respect for autonomy requires allowing individuals to control any disclosure of
information about them. Such control is essential for personal freedom (e.g.,
from coercion, or to pursue one‟s goals/values).
3. Promise keeping
There is an implicit promise between HPs and patients that information will not
be disclosed to third parties. Hence, breach of confidentiality breaks a promise.

The notion of confidentiality draws upon the principle of privacy, which may
derive from the concept of autonomy or be conceptually separate.

Privacy

(1) Bodily privacy

An ethical concept of bodily privacy can be derived from respect for autonomy,
where autonomy includes the freedom to decide what happens to one‟s body.
Bodily privacy is recognized in law: actions in assault, battery and false
imprisonment may be available to the person who does not consent to health care.
(2) Decisional privacy
Decisional privacy is distinguished as control over the intimate decisions one
makes (e.g., about contraception, abortion, and perhaps health care at the end of
one‟s life).
(3) Informational privacy
This type of privacy underlies the notion of confidentiality.

[Type text] Page 14

Arguments for respecting privacy

1. Privacy and property

Personal information is regarded as a kind of property, something one owns.
2. Privacy and social relationships
Privacy is a necessary condition for the development and maintenance of
relationships, including those between HPs and patients.
3. Privacy and the sense of self
The notion that one is a separate self includes the concept of one‟s body and
experiences as one‟s own. Privacy is to be valued for its role in developing and
maintaining our sense of individuation.

Limits of confidentiality

Should the principles of confidentiality be honored in all instances? There are

arguments that favor questioning the absolute obligation of confidentiality in
certain situations. These arguments include theories related to the principles of
harm and vulnerability. The harm principle can be applied when the nurse or other
professional recognizes that maintaining confidentiality will result in preventable
wrongful harm to innocent others.

Foresee ability is an important consideration in situations in which confidentiality

conflicts with the duty to warn. The nurse or other health care professional should
be able to reasonably foresee harm or injury to an innocent other in order to violate
the principle of confidentiality in favor of a duty to warn.

The harm principle is strengthened when one considers the vulnerability of the
innocent. The duty to protect others from harm is stronger when the third party is
dependent on others or in some way especially vulnerable. This duty is called the

[Type text] Page 15

vulnerability principle. Vulnerability implies risk or susceptibility to harm when
vulnerable individuals have a relative inability to protect themselves.

Actions that are considered ethical are not always found to be legal. Though there
is an ethical basis for subsuming the principle of confidentiality in special
circumstances, and there is some legal precedent for doing so, there is legal risk to
disclosing sensitive information. There is dynamic tension between the patient‟s
right to confidentiality and the duty to warn innocent others. Nurses need to
recognize that careful consideration of the ethical implications of actions will not
always be supported in legal systems.

Can Nurses Violate Confidentiality?

Think About the two given scenarios and discuss about it

1. If a relative contracted HIV from a source who the nurse knew was infected, and
had reason to believe would infect others, but neglected to warn. What do you do?
2. If a person is HIV infected and the health provider violated his right to
confidentiality. What do you think about the act?

Disclosure of Information

• Disclosure of information is not necessarily an actionable breach of confidence.

Disclosure may be allowed, under certain circumstances, when it is requested by:
the patient, and where it applies, freedom of information can be used by patients to
obtain health care information;

• Other health practitioners (with the patient‟s consent, and where the
information is relevant to the patient‟s care);

[Type text] Page 16

• Relatives in limited circumstances (e.g., parents when it is in the interests of the
child);

• Researchers with ethics committee approval (and where the approved process is
followed);

• The court;

• The media, if the patient has consented; and

• The police, when the HP has a duty to provide the information.

Unless there is a warrant or a serious crime has been committed, the information
provided to the police is normally limited to the patient‟s identity, general
condition and an outline of injuries. If in doubt, refer the issue to management
and/or seek legal advice. When a patient has consented to the release of
information to the media, management authorization is usually required.

Confidentiality is the ethical principle that requires non disclosure of private or

secret information with which one is interested.

8. Rules The principles of health care ethics must be upheld in all situations.
Rules are guidelines for the relationship between clients and health care
Providers. They are the foundations for the ethical rules veracity, fidelity and
confidentiality

1.4. Ethical Dilemmas & ethical decision making in Nursing

A dilemma is a situation in which two or more choices are available; it is difficult

to determine which choice is best and the needs of all these involved cannot be
solved by the available alternatives. The alternatives in a dilemma may have
favorable and unfavorable features. Ethical dilemmas in health care involve issues

[Type text] Page 17

surrounding professional actions and client care decisions. They can lead to
discomfort and conflict among the members of the health care team or between the
providers and the client and family,

Models for Ethical decision-making

Ethical issues are real life issues. There is no one way of resolving such situations.
Each situation will be different, depending on the people involved and the context.
However, ethical decision-making models provide mechanisms or structures that
help you think through or clarify an ethical issue. There are a number of models
from which to choose from, but there is no one best way to approach ethical
decision-making. Ethical decision making models are not formulas and they do not
ensure that the decision you take will be the right one.

Model 1: A guide to moral decision-making

It outlines a step-by step process that considers the many aspects of ethical
decision-making:

1. Recognizing the moral dimension

• Is recognizing the decision as one that has moral importance

• Important clues include conflicts between two or more values or ideals

• Consider here the levels of ethical guidance of the code of Ethics for registered
nurses.

2. Who are the interested parties? What are their relationships?

• Carefully Identify who has a stake in the decision in this regard, be

imaginative and sympathetic

[Type text] Page 18

 • Often there are more parties whose interests should be taken in to
consideration than is immediately obvious.

• Look at the relationships between the parties look at their relationship with
yourself and with each other, and with relevant institutions

3. What values are involved?

• Think through the shared values that are at stake in making this decision.
• Is there a question of trust? Is personal autonomy a consideration? Is there a
question of fairness? Is anyone harmed or helped?
• Consider your own and others personal values & ethical principles
4. Weight the benefits and burdens
• Benefits might include such things as the production of goods (physical,
emotional, financial, and social, etc) for various parties, the satisfaction of
preferences and acting in accordance with various relevant valves (such as
fairness).
• Burdens might include causing physical or emotional pain to various parties
imposing financial costs and ignoring relevant values.
5. Look for analogous cases
• Can you think of similar decisions? What course of action was taken? Was it a
good one? How is the present case like that one? How is it different?
6. Discuss with relevant other
• The merit of discussion should not be underestimated. Time permitting discusses
your decision with as many people as have a take in it.
• Gather opinions and ask for the reasons behind those opinions.
6. Does this decision according with legal and organizational rules.
• Some decisions are appropriately based on legal considerations. If an option is
illegal, one should think very carefully before thanking that option

[Type text] Page 19

 • Discussion may also be affected by organizations of which we are members.
For example, the nursing profession has a code of ethics and professional
standards that are intended to guide individual decision-making. Institutions
may also have policies that limit the options available.
7. Am I comfortable with this decision? Question to reflect up on include:
• If I Cary out this decision, would I be comfortable telling my family about it?
My clergy? My mentors?
• Would I want my children to take my behavior as an example?
• Is this decision one that a wise, informed, virtuous person would make?
• Can I live with this decision?

Model 2: Clinical Ethics grid system

This grid system helps construct a summary of the facts that must be considered
along with ethical principles to guide ethical decisions in a clinical setting out lined
as follows.

1. Medical indications:
• What is the patient medical problem? History? Diagnosis?

• Is the problem acute? Chronic? Critical? Emergent? Reversible?

• What are the goals of treatment etc?

2. Patient preference:
• What has the patient experienced about preferences for treatment?
• Has the patient been informed of benefits and risk, understood, and given
consent? etc.

[Type text] Page 20

3. Quality of life:
• What are the prospects with or without treatment, for a return to the patient's
normal life?
• Are there biases that might prejudice the provider's evaluation of a patient's
quality of life etc?
4. Contextual factors:
• Are there family issues that might influence treatment decisions?

1.2. Legal Concepts in Nursing

1.2.1. General Legal Concepts

Law can be defined as those rules made by humans who regulated social conduct
in a formally prescribed and legally binding manner. Laws are based upon
concerns for fairness and justice.

Functions of Law in Nursing

The law serves a number of functions in nursing:

1. It provides a framework for establishing which nursing actions in the care of

client are legal.
2. It differentiates the nurse's responsibilities from those of other health
professional.
3. It helps establish the boundaries of independent nursing action.
4. It assists in maintaining a standard of nursing practice by making nurses
accountable under the law.

[Type text] Page 21

1.2.2. Types of law

Law governs the relationship of private individuals with government and with each
other.

1. Public Law: refers to the body of law that deals with relationships between
individuals and governmental agencies. An important segment of public law is
criminal law which deals with actions against the safety and welfare of public.
Example, theft, homicide.
2. Private Law or Criminal: is the body of law that deals with relationships,
between individuals. It is categorized as contract law and tort law.
3. Contract Law: involves the enforcement of agreements among private
individuals or the payment of compensation for failure to fulfill the agreements.
4. Tort Law: the word tort means 'wrong " or "bad" in Latin. It defines and
enforces duties and rights among private individuals that are not based on
contractual agreements. Example of Tort law applicable to nursing
1. Negligence and malpractice
2. Invasion of privacy and assault.

1.2.3. Kinds of Legal Actions

There are two kinds of legal actions:

1. Civil or private action.

2. Criminal action

1. Civil or private actions: Deals with the relationships between individuals in a

society. Example, a man may file a suit against a person who he believes cheated
him.

[Type text] Page 22

2. Criminal actions: Deals with disputes between an individual and the society as
a whole. Example if a man shoots a person, society brings him to trial.

1.2.4. Legal issues in nursing

Nursing Practice Act: Nursing practice act or act for professional Nursing
practice regulate the practice of nursing. Legally define and describe the scope of
nursing practice, which the law seeks to regulate, thereby protecting the public as
well. It protects the use's professional capacity. Each country may have different
acts but they all have common purpose: to protect the public. It grants the public a
mechanism to ensure minimum standards for entry in to the profession and to
distinguish the unqualified.

Standard of Practice: A standard of practice is a means which attempts to ensure

that its practitioners are competent and safe to practice through the establishment
of standard practice. Establishing and implementing standards of practice are major
functions of a professional organization. The profession's responsibilities inherent
in establishing and implementing standards of practice include:

1. To establish, maintain, and improve standards

2. To hold members accountable for using standards.

3. To educate the public to appreciate the standard

4. To protect the public from individual who have not attended the standards or
will fully do not follow them and

5. To safeguard individual members of the profession.

[Type text] Page 23

Standard of nursing practice requires:

 The helping relationship be the nature of client nurse interaction

 Nurse to fulfill professional responsibilities
 Effective use of nursing process

Standards of nursing practice are to describe the responsibilities for which

nurses are accountable. The standards have the following advantages:

1. Reflect the values and practices of the nursing profession

2. Provide direction for professional nursing practice.
3. Provide a frame work for the evaluation of nursing practice
4. Defines the profession‟s accountability to the public and the client outcomes
for which nurses are responsible.

Nursing standard clearly reflect the specific functions and activities that nurses
provide, as opposed to the functions of other health workers.

When standards of professional practice are implemented, they serve as yardsticks

for the measurements used in licensure, certification, accreditations, quality
assurance, peer review, and public policy.

The profession maintains standards in practice in part through appropriate entry.

Credentialing: Credentialing is the process of determining and maintaining

competence-nursing practice. Credentials includes:

a. Licensure

b. Registration

c. Certification

[Type text] Page 24

d. Accreditation

Licensure: It is legal permit a government agency grants to individuals to engage

in the practice of a profession and to use particular title. It generally meets three
criteria:

 There is a need to protect the public's safety or welfare.

 The occupation is clearly delineated with a separate, distinct area of work
 There is a proper authority to assume the obligation of the licensing process.

Registration: Is listing of an individual's name and other information on the

official roster of a governmental agency. Nurses who are registered are permitted
to use the title “Registered Nurses"

Certification: is the voluntary practice of validating that an individual nurses met

minimum standards of nursing competence in specialty areas such as pediatrics,
mental health, gerontology and school health Nursing.

Accreditation: is a process by which a voluntary organization or governmental

agency appraises and grants accredited status to institutions and/or programs.

The purpose of accreditation of programs in nursing is:

 To foster the continuous development and improvement in quality of

education in nursing
 To evaluate nursing programs in relation to the stated physiology and
outcomes and to the established criteria for accreditation.
 To bring together practitioners, administrators, faculty, and students in an
activity directed towards improving educational preparation for nursing
practice.
 To provide an external peer review process.

[Type text] Page 25

1.2.5. Nursing Code of Ethics.

Code of ethics is formal statement of a group‟s ideas and values that serve as a
standards and guidelines for the groups‟ professional actions and informs the
public of its commitment.

Codes of ethics are usually higher than legal standards, and they can never be less
than legal standards of the profession.

Purposes of code of ethics

Nursing code of ethics has the following purposes:

 To inform the public about the minimum standards of profession and to help
them understand professional nursing conduct.
 To provide a sign of the profession‟s commitments to the public it serves.
 To outline the major ethical considerations of the profession.
 To provide general guidelines for professional behavior.
 To guide the profession in self-regulation.
 To remind nurses of the special responsibility they assume when caring for
the sick.

1.3.1. International Council of Nurses (ICN) CODE OF ETHICS

The need for nursing is Universal. Inherent in nursing is respect for life, dignity,
and rights of man. It is unrestricted by considerations of nationality, race, creed,
color, age, sex, politics or social status.

Nurses render health services to the individual, the family, and the community
and coordinate their services with those of related groups.

[Type text] Page 26

Responsibility & accountability:

1. The fundamental responsibility of the nurse is fourfold: to promote health,

prevent illness, restore health and to alleviate suffering
2. Nurses act in a manner consistent with their professional responsibilities and
standards of practice
3. Nurses advocate practice environment conducive to safe, Competent and ethical
care
4. Nurses work in accordance with dependent, interdependent and collaborative
functions of nursing
5. Nurses carefully handle nursing practice on specific ethical issue and resolve
the ethical problems systematically.
6. Nurses are accountable for their professional judgment and action

Nurses and people

The nurse‟s primary responsibility is to those people who require nursing care

The nurse, in producing care, promotes an environment in which the values,

customs and spiritual beliefs of the individual are respected.

The nurse holds in confidence personal information and uses judgment in sharing
this information.

Nurses and Practice

The nurse caries responsibility for nursing practice and for maintaining
competence by continual learning. The nurse maintains the highest standards of
nursing care possible within the reality of a specific situation.

[Type text] Page 27

The nurse uses judgment in relation to individual competence when accepting and
delegating responsibilities. The nurses when acting in a professional capacity
should at all times maintain standards of personal conduct which reflect credit
upon the profession.

Nurse and Society

The nurse shares with other citizens the responsibility for initiating and supporting
actions to meet the health and social needs of the public.

Nurse and Co-workers

The nurse sustains a cooperative relationship with coworkers in nursing and other
fields. The nurse takes appropriate action to safeguard the individual when his care
is endangered by a co-worker or any other health personnel.

Nurse and the Profession

The nurse plays the major role in determining and implementing desirable
standards of nursing practice and nursing education.

The nurse is active n developing a core of professional knowledge. The nurse,

acting through the professional organization, participates in establishing and
maintaining equitable social and economic working condition in nursing.

1.3.2. National Nursing Code of Ethics

The National Nurses Association (NNA) code of ethics for registered nurses in
most countries comprises key elements of the code. It includes values,
responsibility statements, and levels of guidance or actions.

[Type text] Page 28

1. Accountability and responsibility
 The fundamental responsibility of the nurse is fourfold: to promote health,
prevent illness, restore health and to alleviate suffering
 Nurses act in a manner consistent with their professional responsibilities and
standards of practice
 Nurses advocate practice environment conducive to safe, Competent and
ethical care
 Nurses work in accordance with dependent, interdependent and collaborative
functions of nursing
 Nurses carefully handle nursing practice on specific ethical issue and resolve
the ethical problems systematically.
 Nurses are accountable for their professional judgment and action
2. Respect right and dignity
• The nurse in providing care, unrestricted by consideration of nationality, race,
creed, color, age, sex, politics, religion or social statues.
• The nurse respects the value, customs and spiritual beliefs of individual.
• The nurse identifies health needs of the client, helps them to express their
concern and obtains appropriate information and service.
• Nurses apply and promote principles of equity and fairness to assist clients in
receiving a biased treatment and share of health services and resources
proportional to their needs
3. Confidentiality
• Nurses safeguard the trust of the clients that information and health records in
the context of professional relationship is shared outside the health care team
only with the clients permission or as legally required
• Nurses maintain privacy during therapeutic and diagnostic procedures.

[Type text] Page 29

4. Advocacy:
• Nurses sustain a cooperative relationship with other health workers in the
team work.
• Nurses value health and well-being and assist persons to achieve their
optimum level of health in situation of normal health, illness, injury or in the
process of dying.
• Nurses promote safety prevent intentional or unintentional harm and take
appropriate action to safeguard the individuals when his care is endangered by a
coworker or any other person.
• The Nurse respects acceptance or refusal right of the patient during
therapeutic and diagnostic procedures or research and learning situation up on
clients.
5. Professional development
• The nurse plays the major role in determining and implementing desirable
Standards of nursing practice and nursing education.
• The nurse should develop professionally through formal and non- formal
continuing education
• The nurse should participate in professional organizations and advocates
equitable social and economic working conditions.

1.3.3. Responsibilities of nurses for specific ethical issues

Patient’s bill of rights

Statement on a patient‟s bill of rights was approved by the House of Delegates in

February 6, 1973. The American Hospital association presents a patient‟s bill of
rights with the expectation that observance of these rights will contribute to more

[Type text] Page 30

effective patient care and greater satisfaction for the patients, and the hospital
organization. The traditional physician- patient relationship takes a new dimension
when care is rendered within an organizational structure. Legal precedent has
established that the institution itself also has responsibility to the patient. It is in
recognition of these factors that these rights are affirmed.

The patient’s rights are as follows:

1. The patient has a right to considerate and respect full care.

2. The patient has a right to obtain from his physician complete current
information concerning his diagnosis, treatment and prognosis in terms the
patient can be reasonably expected to understand. When it is not medically
advisable to give such information to the patient, the information should be
made available to an appropriate person on his behalf. He has the right to know
by name the physician responsible for coordinating his care.
3. The patient has the right to receive from his physician information necessary to
give informed consent prior to the start of any procedure and / or treatment.
Except in emergencies, such information for informed consent should include
but not necessary are limited to the specific procedure and/ or treatment, the
medically significant risks involved, and the probable duration of
incapacitation. Where medically significant alternatives for care or treatment
exist, or when the patient requests information concerning medical alternatives,
the patient has the right to such information. The patient also has the right to
know the name of the person responsible for the procedures and /or treatment.
4. The patient has the right to refuse treatment to the extent permitted by Law and
to be informed of the medical consequences of his action.
5. The patient has the right to every consideration of his privacy concerning his
own medical care program. Case dissociation, consultation, examination, and

[Type text] Page 31

 treatment are confidential and should be conducted discreetly. Those not
directly involved in his care must have the permission of the patient to be
present.
6. The patient has the right to expect that all communications and records
pertaining to his care should be treated as confidential.
7. The patient has the right to expect that within its capacity a hospital must make
reasonable response to the request of a patient for their services. The hospital
must provide evaluation, service, and/ or referral as indicated by the urgency of
the case. When medically permissible a patient may be transferred to another
facility only after he has received complete information and explanation
concerning the needs for and alternatives to such a transfer. The institution to
which the patient is to be transferred must first have accepted the patent for
transfer.
8. The patent has a right to obtain information as to any relationship of his hospital
to other health care and educational institutions as far as his care is concerned.
The patient has the right to obtain information as to the existence of any
professional relationships among individuals, by name, which is treating him.
9. The patient has the right to be advised if the hospital proposes to engage in or
perform human experimentation affecting his care or treatment. The patient has
the right to refuse to participate in such research projects.
10. The patient has the right to expect reasonable continuity of care. He has the
right to know in advance what appointment times and physicians are available
and where. The patient has the right to expect that the hospital will provide a
mechanism whereby he is informed by his physician or a delegate of the
physician of the patient‟s continuing health care requirements following
discharge.

[Type text] Page 32

11. The patient has the right to examine and receive an explanation of his bill
regardless of the source of payment.
12. The patient has the right to know what hospital rules and regulations apply to
his conduct as a patient.

Ethical issues related to patients’ rights.

1. Right to truth

The right of patients to know the truth about their condition, prognosis, and
treatment is an issue between the physician and the patient. The current trend is
toward more frankness on the part of physicians. In the past, the moral obligation
to disclose the truth-because the patient has the right to know and adjust to was
often overcome by the professional need to protect the patient from potential
physical or emotional harm that could be caused by knowledge of a critical or
terminal condition. Because of their extended contacts with patients, nurses often
find it difficult to accept a physician‟s decision not to tell a patient the truth about
his or her condition.

Because of the conflict between physicians‟ decisions and nurses‟ personal

feelings, it may be advisable for the health care team to meat in order to resolve the
problem and to devise a consistent approach to the patient.

2. Right to refuse treatment

For reasons that are sometimes known only to themselves patient may refuse
treatment even though lack of treatment may result in their death. The question
of refusal of treatment may have to be decided in court. Many times, the courts
rule that patients cannot be forced to accept treatment. In the case of minor
child, however, the courts are likely to rule that parents cannot withhold

[Type text] Page 33

 treatment from a child for any reason. The child is usually made a temporary
ward of the court and treatment is allowed to begin.

A patient‟s decision to die rather than to accept treatment may be difficult for a
nurse to understand. Nurses must recognize a patients‟ right to individual and
personal attitudes and beliefs, however, and must not allow personal feelings to
interfere with patient care. If nurses cannot reconcile their ethical values with
those of patients, they should ask to be taken off the case in the interest of the
patient.

3. Informed consent
The issue of informed consent applies to many health care institutions in both
legal and ethical ways. Patients have the right to be given accurate and
sufficient information about procedures, both major and minor, so that their
consent to undergo those procedures is based on realistic expectations.

The responsibility for imparting information about major surgery or

complicated medical procedures lies with medical professionals. Nurses should
inform their patients; in terms the patients can understand, about even simple
nursing procedures before the procedures are started. This includes answering
questions that patients may have. Failure to obtain informed, written consent to
perform a procedure could involve nurses and other health care professional in
legal action or subject to disciplinary action by state regulatory agencies.
Because nurses spend considerable periods of time with patients, they are likely
to be most aware of their patients‟ questions and concerns. Many times, these
concerns should be brought to the attention of attending physicians who,
because they see the patients‟ lass frequently, may be unaware of the problems.

[Type text] Page 34

4. Human experimentation
Research and human experimentation are primarily concerns of the scientific
and medical professionals. However, if nursing care is required for the subjects
involved for such experimental projects, then nurses became involved. In these
cases, nurses‟ responsibilities and ethical decisions are related to making sure
that informed consent is given for participation in the research experiments and
that the safety of their patients is protected.

The nurses‟ role, along considered to be that of patient advocate, may, in these
situations, place them in direct conflict with research staffs and sponsoring
agencies as well as human subjects research committees.

5. Behavior control
The issue of informed consent is critical question in any form of behavioral
control; the use of drugs or psychosurgery further complicates a highly complex
topic.
Controversy persists over the rights of society to decide what is or is not
desirable or acceptable behavior. The issue involves both personal and public
behavior. Moreover, it also concerns whether individuals have the right to
decide for themselves what suitable personal behavior is, or whether others can
decide for them based on some other concept of suitable personal behavior.
In this regard, one of the ethical questions that may be confronted by nurses
involves informed consent for treatments that are intended to control behavior.
Nurses may question whether involves who are candidates for drug therapy or
psychotherapy are able and competent to give informed consent, and whether
these patients, too, have the right to refuse treatment

[Type text] Page 35

 1.4.1. Health related Legal issues

Along with the patients‟ bill of rights, below are certain health related issues
commonly seen in most countries:

1. Abortion

• The nurse shall assist the physician if she/he is sure that an abortion is
performed for the purpose of saving the endangered life or health of women.

• The nurse shall not attempt or carry out abortion

• It is mandatory for the nurse to treat a patient who is suffering from the effect
of a criminal abortion induced by another provided there is no physician in the
health institution.

• The nurse shall report to the concerned authorities of criminal abortion in the
absence of physician.

• The nurse has all the right not to participate in all procedures of criminal
abortion

2. Euthanasia

• The nurse shall never assist; collaborate in taking life as an act of mercy even
at the direct request of the patient or patient's relatives.

3. Death

• The nurse shall note the exact cessation of vital signs and notify the attending
physician to pronounce death.

• The nurse shall give due respect to the deceased taking in to consideration
religion and cultural aspects.

[Type text] Page 36

 • A nurse shall participate in or assist a medical team in taking out organ from a
cadaver provided there is written consent of a patient or relatives.

4. Suicide

• A nurse who is taking care of a patient with a suicidal tendency shall remove
all items that facilitate suicide such as sharp instruments, ropes, belts, drugs and
make sure that the outlets are graded.

• The nurse should not leave a suicidal patient alone.

5. Organ Transplantation

• The nurse shall involve in any organ transplantation procedure provided that
the donor and recipient have clear written agreement, the donor gives informed
consent and he/she is not mentally ill at the time of consent.

• The nurse shall advocate the declaration of human rights in the organ
transplantation procedure.

• The nurse shall have moral and professional rights to make ethical decisions
to resolve the dilemma that arises from the procedure.

6. Fertility Matter

• The nurse shall respect autonomy of the client for contraception and other
fertility matter including artificial fertilization.

• The nurse shall have moral and professional right to make ethical decision in a
situation of dilemma for the same.

• The nurse shall have responsibility to give information about the case.

[Type text] Page 37

1.4.2. Areas of potential liabilities in nursing

Crimes and torts

A crime is an act committed in violation of public (criminal) law and punishable

by a fine and/ or imprisonment. A crime does not have to be intended in order to be
a crime. For example, a nurse may accidentally give a client an additional and
lethal dose of narcotic to relive discomfort.

Crimes could be felonies and / or misdemeanors.

1. Felonies: a crime of a serious nature such as murder, armed robbery, second

degree murder. A crime is punished through criminal action by the state.

2. A misdemeanor: is an offense of a less serious nature and is usually punished a

fine or short term jail sentence or both. For example, a nurse who slaps a client‟s
face could be charged with a misdemeanor.

A TORT is a civil wrong committed against a person or a person‟s property. Torts

are usually litigated in court by civil action between individuals.

Tort may be classified as intentional or unintentional:

1. Intentional tort includes fraud, invasion of privacy, libel and slander assault
and battery and false imprisonment.

Fraud: false presentation of some fact with the intention that it will be acted up
on by another person. Example, it is fraud for a nurse applying to a hospital for
employment to fail to list two past employers for deceptive reasons when asked
for five previous employers.

[Type text] Page 38

 False imprisonment: is “unlawful restraint or detention of another person
against his or her wishes”

* Assault -verbal or offensive contact i.e. threaten to give injection w/o consent.
* Battery -any intentional touching w/o consent i.e. actually give injection.
* Invasion of Privacy
* Intrusion on seclusion
* Appropriation of name
* Publication of private or embarrassing facts
* Publicly placing one in a false light
* Defamation of Character -publication of false statements that result on
damage to a person‟s reputation.
* Malice -person knows information is false and still publishes it.
* Slander -if statement is ORAL.
* Libel -if statement is WRITTEN

2. Unintentional tort is negligence or malpractice.

Negligence - conduct falls below standard of care i.e. taking a stop sign.
Malpractice - is negligence committed by a professional such as a nurse or
physician.

1.4.3. Potential Malpractice Situation in Nursing

To avoid charges of malpractice, nurses need to recognize those nursing situation

in which negligent actions are most likely to occur and to take measures to prevent
them.

[Type text] Page 39

The most common malpractice situations are:

1. Medication error: which is resulted from:

 Failing to read the medication label.
 Misunderstanding or incorrectly calculating the dose.
 Failing to identify the client correctly.
 Preparing the wrong concentration or
 Administration by wrong route (e.g. intravenously instead of
intramuscularly). Some errors are serious and can result in death. For
example, administration of Warfarin (Anticoagulant) to a client recently
returned from surgery could cause the client to have hemorrhage.

2. Sponges or other small items can be left inside a client during an operation.

3. Burning a client: May be caused by hot water bottle, heating pads, and
solutions that are too hot for applications.

4. Clients often fall accidentally: As a result that a nurse leaves the rails down or
leaves a baby unattended on a bath table.

5. Ignoring a client’s complaints

6. Incorrectly identifying clients

7. Loss of client’s property: jewelry, money, eye glasses and dentures.

MEASURES TO PREVENT THE ABOVE MALPRACTICE SITUATIONS

• A nurse always needs to check and recheck medications very carefully before
administering a drug.

• The surgical team should count correctly before the surgeon closes the incision

[Type text] Page 40

Reporting crimes, torts and unsafe practice

A nurse may need to report nursing colleagues or other health professionals for
practices that endanger the health and safety of a client. For example, Alcohol and
drug use theft from a client or agency, and unsafe nursing practice.

Guidelines for reporting a crime, tort or unsafe practices:

1. Write a clear description of a situation you believe you should report.

2. Make sure that your statements are accurate
3. Make sure you are credible
4. Obtain support from at least one trust worth person before filing the report
5. Report the matter starting at the lowest possible level in the agency
hierarchy
6. Assume responsibility for reporting the individual by being open about it,
sign your name to the letter.
7. See the problem through once you have reported it.
1.4.4. Record Keeping

Reporting and Documenting

Reporting: oral or written account of patient status; between members of health

care team. Report should be clear, concise, and comprehensive.

Documenting: patient record/chart provides written documentation of patient‟s

status and treatment

Purpose: continuity of care, legal document, research, statistics, education,

audits

[Type text] Page 41

 What to document: assessment, plan of care, nursing interventions (care,
teaching, safety measures), outcome of care, change in status, health care
team communication,

Characteristics of documentation: brief, concise, comprehensive, factual,

descriptive, objective, relevant/appropriate, legally prudent

Record keeping

 Health records are the means by which information is communicated about

clients and means of ensuring continuity of care.
 The clients medical record is legal document and can be produced in a court
as evidence.
 Records are used as risk management tools and for research purpose.
 Often the record is used to remind a witness of events surrounding a lawsuit,
because several months or years usually elapse before the suit goes to trial.
 The effectiveness of record depends up on accuracy and completeness of the
record.
 Nurses need to keep accurate and complete records of nursing care provided
to clients.

Insufficient or inaccurate documentation:

 Can constitute negligence and be the basis for tort liability.

 Hinder proper diagnosis and treatment and result injury to the client.

Accurate Record keeping

• Routine nursing assessment and intervention should be documented properly.

• Use pen rather than pencil during documentation.

[Type text] Page 42

• When making correction do not raise the previous draw one line on an old and
add correction so the previous remained legible because correction is not for
changing.

• Write legibly.

• Document all information.

• Add time, date, name and other important information.

• Document all medically related conditions.

• Use specific terms. • Statements should not be biased.

THE INCIDENT REPORT

An incident report is an agency record of an accident or incident. Whenever a

patient is injured or has a potential injury there exist a possibility of a lawsuit, such
a report must be recorded.

An incidental report may be written for situations involving a patient, visitors, or

employee. The incident report used to:

1. To make all the facts about an accident available to personnel

2. To contribute to statistical data about accidents or incidents.
3. To help health personnel to prevent future accidents.

N.B. the reports should be completed as soon as possible i.e., Within 24 hours of
the incident and filed according to agencies policy.

Information to include in incident report

1. Identify the client by name and hospitals

2. Give date and time of the incident.

[Type text] Page 43

 3. Avoid any conclusions or blame.
4. Describe the incident as you saw it even if you your impressions differ from
those of others
5. Identify all witnesses to incident
6. Identify any equipment by number and any medication by name and
number.
7. Document any circumstance surrounding the incident. For example, that
another client is experiencing cardiac arrest.

WILLS

A will is a declaration by a person about how the person„s property or cash is to be

disposed/ distributed after death.

In order for a will to be valid the following conditions must be met:

1. The person making the will should be mentally conscious

2. The person should not be unduly influenced by any one else.

A nurse may be required to witness a will. A will must be signed in the presence of
two witnesses.

When witnessing a will, the nurse

 Attests that the client signed a document that is stated to be the client‟s last
will.
 Attests that the client appears to be mentally sound and appreciates the
significance of their action.

If a nurse witnesses a will, the nurse should record on clients card that the will was
made and patients physical and mental condition.

[Type text] Page 44

Use of recording:

 Provides accurate information for later use.

 May be use full if the will is contested

N.B. if a nurse does not wish to act as a witness. For example, if a nurse‟s opinion
undue influence has been brought on the client- then it is nurse‟s right to refuse to
act in this capacity.

EUTHANASIA

It is the act of pennilessly putting to death persons suffering from incurable or

distressing diseases. It is commonly referred as “mercy killing”

Types of euthanasia

1. Active euthanasia: Is a deliberate attempt to end life. e.g., deprivation of

oxygen supply, administering an agent that would result in death.

2. Passive euthanasia: allowing death by withdrawing or withholding treatment.

No special attempt will be made to revive the patient

All forms of euthanasia are illegal except in countries where right to die status and
living will exist.

Review questions about Ethics

1. Define ethics and identify its relation and difference with that of morality
2. What are the common principles of ethics and their similarity and deference?
3. What is nursing practice act, standard of practice, and code of ethics?
4. When and how nurses hold in confidence and in private any information
obtained during their professional performance

[Type text] Page 45

 5. What is the basic characteristics and advantage of documentation?

UNIT TWO: COMMUNICATION AND INTERPERSONAL

RELATIONSHIPS IN NURSING

Learning Objectives

Upon completion of this unit, the student will be able to:

1. Define communication

2. List the purpose and levels of communication

3. Discuss the types of communication

4. Explain the model of communication

5. Discuss the relationship of language and experience to the communication

process.

6. State the basic characteristics of communication

7. Identify the techniques of effective communication

8. Explain the helping relationship

9. Discuss confidentiality and privacy

10. List the basic characteristics of documentation

2.1. Communication

Communication is a complex process of sending and receiving verbal and

Nonverbal messages which allows for exchange of information, feelings, needs,
and preferences

[Type text] Page 46

It is the process of creating common understanding

It is the process of sharing information

It is the process of generating and transmitting meanings

Purposes of communication

1. Information
2. Education
3. Persuasion
4. Entertainment

Goals of communication: Shared Meaning

1. Mutual understanding of the meaning of the message.

2. Feedback/response indicates if the meaning of the message was communicated

as intended

2.1.1. Types of Communication

People Communicate in a variety of ways.

1. Verbal Communication- is an exchange of information using words and

includes both the spoken and the written word. Verbal communication depends on
language. Language is a prescribed way of using words so that people can share
information effectively. Both spoken and written communication reveal a great
deal about a person. Conscious use of spoken or written word. Choice of words can
reflect age, education, developmental level, and culture. Feelings can be expressed
through tone, pace, etc The verbal form of communication is used extensively by
nurses when speaking with clients, giving oral reports to other nurses, writing care
plans and recording in nursing progress reports.
[Type text] Page 47
 Characteristics of reports:

Reports must be simple, brief, clear, well timed, relevant, adaptable, credible

2. Nonverbal communication- is the exchange of information without the use of

words. It is communication through gestures, facial expressions, posture, body
movement, voice tone, rate of speech, eye contact. It is generally accepted that
non-verbal communication expresses more of true meaning of a message than dose
verbal communication. Therefore, nurses must be aware of both the nonverbal
messages they send and receive from clients. Nonverbal is less conscious than
verbal, requires systematic observation and valid interpretation.

3. Metacommunication- is a message about a message. It includes anything that is

taken into account when interpreting what is happening, such as the role of the
communicator, the non-verbal messages sent and the context of the
communication-taking place.

Relationship between verbal and non-verbal communication

Congruency: Are verbal and non-verbal messages consistent?

Nurse states observations and validates the communication.

2.1.2. Levels of Communication

● Intrapersonal

● Interpersonal

● Public

[Type text] Page 48

2.1.3. Communication Model

A conceptual model makes the abstraction of communication more concrete. A

model provides form and utility through which nursing knowledge can be iterated.
Models add concreteness to a concept in addition to having a form and utility of
their own.

Elements of the communication model:

1. The referent

2. The source-encoder

3. The message

4. The channel

5. The receiver-decoder

6. Feedback

Every encounter we have with another person, whether spontaneous or deliberate,

begins with an idea-a reason for engaging in a verbal exchange. Our model must
begin with what idea, referent. A referent may be one of “a wide range of objects,
situations ideas, or experiences” Any one of these items or a combination of them
prompts the source- encoder to initiate action in order to convey the message
engendered by the referent.

The source-encoder is a term that describes one person who communicates with
another. Our ability to form, use and understand the messages we transmit is
continually influenced by numerous factors, it include our communication skills,
our attitudes, our levels of knowledge, and our sociocultural system. These factors
are never static; indeed they are always changing, always being modified as we
[Type text] Page 49
change and are modified by the events that surround us. Whenever we act in the
role of the source-encoder we must consider these influences in order to
understand not only our own communication, but also the communicative behavior
of others.

Our ability to transmit the experiences we encounter is limited if we do not poses

the ability to encode them in a form recognizable by others. The vocal mechanisms
used in speech, the motor skills used in writing, and the language peculiar to a
specific culture are encoding skills possessed to some degree by every human
being. Similarly, the use of gestures and other nonverbal behaviors is an encoding
ability that often bridges the verbal gaps encountered by people who speak
different languages.

The ideas and experiences we have, as the source encoder is, at this stage, still
intangible. To make them come alive we must change that intangible invention into
an actual physical product, which in the communication model is labeled the
message. Regardless of the physical product be it a sketch, a letter, or a
conversation of our ideas and our experiences.

All of us are aware that a message does not just appear. Every day we deliver
messages of varying kinds and lengths as if we actually knew what operations were
involved.

In order to convey a message, we must arrange it so that it has some resemblance

of recognizable order. In the English language, this requirement is filled by the
sentence because it is a series of words in connected speech or writing forming the
grammatically complete expression of a single thought. The order established
through sentences is the message code. Whatever the code is – a sentence, picture
or music – its expression becomes the message content. Finally, a message can be

[Type text] Page 50

sent unless consideration is given to the manner in which we convey the desired
message treatment. Message treatment is the decision made in selecting and
arranging both codes and content.

Once decisions have been made on the codes and contents of message, we must
route the message across a channel. Because the cannel in the model involves the
senses of hearing, seeing, touching, smelling and tasting, the sensory channel
selected must be appropriate to the message we wish to convey.

The receiver-decoder is one of the last links in our communication model. Behind
this label is the person to whom the message is directed, that other individual who
has been influenced by the same factors of communication, knowledge, attitudes,
and sociocultural systems as we have been. Since no two people perceive an event
or share their perceptions of that event in the same way, it is crucial to any verbal
interaction that the receiver-decoder understands what we mean to convey. Our
intent is not enough. We must aim for precision in our communication. The
success with which we convey our thoughts determines how they will be absorbed
and translated by the receiver – decoder.

Then the receiver provides some form of feedback, which allows us to determine
the success or failure of our communication efforts.

Importance of language and experience in the communication process

Language distinguishes humans from other animals. It is used not only to

communicate but also to develop the person‟s view of life and the world. Thus,
language and experiences are closely related. A person‟s view of the world is
developed through several kinds of filters. Such filters consist of the sight, hearing,
touch, taste and smell. Stimuli processed through these receptor systems enable the
person to experience the outside world and through language such experiences can
[Type text] Page 51
be compared with others‟ experiences. Another filter through which a person
experiences the world is the particular language system into which the person is
socialized. Words and sentences give meaning to things and events. Language
allows us to conceptualize the world.

A third filter through which a person experiences the world is his or her unique
personal history. Every human has a set of experiences that are unique. Cultural
background, personal history, family relationships, the person‟s place in the sibling
ranking, the type of parenting received, the genetic makeup of the person, and
other factors.

Both nurse and clients bring language and personal experiences into the
communication that occurs between them. The interaction between a nurse and
clients is productive when a method of communication is at work that identifies
and uses common meanings. Developing a common understanding is the
underlying aim of communication.

Two over riding principles that guide communication

1. Clarity-words and sentences used to clarify events when they occur within the
frame of reference and common experience of both nurse and clients.

2. Clarity-in communication occurs when language is used as a tool for the

promotion of coherence or connections of ideas expressed.

2.1.3. Basic Characteristics of communication

1. Communication is a reciprocal process in which both the sender and receiver

of messages participate simultaneously
2. Communication is a continuous and reciprocal process

[Type text] Page 52

 3. Communicating person receives and sends messages through verbal and
nonverbal means.
4. Verbal and nonverbal communication occurs simultaneously.
5. Nonverbal communication is more likely to be involuntary. It intends to be
less under control of the person sending the message than verbal
communication. Nonverbal communication is considered as being a more
accurate expression of true feelings. Non-verbal communication often helps
a person understand subtle and hidden meanings in what is being said
verbally. There is a proverb that says" Action speaks more than thousand
words.
6. Communicating persons respond to messages they receive. This form of
feedback is especially important to validate information in order to learn
whether the message was received accurately.
7. The message cannot always be assumed to mean what the receiver believes
it to mean or what the sender intended to mean. Validation is necessary to
determine the accuracy of not only the message but also the meanings of the
message.
8. Exchanging message requires knowledge
9. Past experiences influence messages, sent and interpretation
10. Communication is influenced by the way people feel at the moment or
about the subject

2.2. Communication Techniques in Nursing

2.2.1. Conversation skills

 Control the tone of your voice so that you are conveying exactly what you
mean to say.

[Type text] Page 53

  be knowledgably about the topic of conversation and have accurate
information
 Be flexible
 Be clear and concise
 Avoid words that may be interpreted differently
 Be truthful
 Keep an open mind

Take advantage of available opportunities

2.2.2. Listening Skills- is a skill that involves both hearing and interpreting what is
said. It requires attention and concentration to sort out, evaluate, and validate clues
so that one understands the true meanings in what is being said. Listening requires
concentrating on the client and what is being said.

Techniques to improve listening skills

 Whenever possible sit when communicating with a client

 Be alert but relaxed and take sufficient time so that the client feels at ease
during the conversation
 If culturally appropriate maintain eye contact with the client
 Indicate that you are paying attention to what the client is saying
 Think before responding to the client
 Listen for themes in the client's comments.

● Use of silence-The nurse can use silence appropriately by taking the time to wait
for the client to initiate or continue speaking. During period of silence, the nurse
has the opportunity to observe the clients verbal and nonverbal messages
simultaneously. Periods of silence during communication demonstrate comfort and
contentment in the nurse-client relationship.
[Type text] Page 54
Factors that influence communication

1. Perceptions

2. Values

3. Background

4. Knowledge

5. Roles and relationships

6. Environmental setting

2.2.3. Interviewing Techniques

Interview is a major tool in nursing for the collection of data during the assessment
step of the nursing process.

Purpose: to obtain accurate and thorough information

Techniques

1. Open-ended question

2. Closed question

3. Validation question

4. Clarifying question

5. Reflective question

6. Sequencing question

7. Directing question

[Type text] Page 55

2.3. Interpersonal Skills in Nursing

Interpersonal skills are communication skills required for positive relationships

between persons. These skills are essential for a nurse to establish and promote
good nurse client relationship.

Some of the interpersonal skills are

1. Warmth and friendliness

2. Openness

3. Empathy

4. Competence

5. Consideration of client variable

Factors facilitating positive interaction

1. Have a purpose for interaction

2. Choose a comfortable environment

3. Provide privacy

4. Confidentiality

5. Client focus

2.3.1. Communication and the Nursing process

Communication is one of the instruments of data collection and implementation in

the nursing process.

[Type text] Page 56

The steps of the nursing process can also be applied in the process of
communication.

2.3.2. Helping Relationship

The helping relationship is sometimes called therapeutic or client nurse

relationship.

The goals of a helping relationship between a nurse and a client are determined
cooperatively and are defined in terms of the client‟s needs.

The common goals of helping relationship might include:

1. Increased independence,
2. Greater feelings of worth and
3. Improved physical well being

Basic Characteristics of a Helping Relationship

1. Dynamic
2. Purposeful and time limited
3. The person providing the assistance in a helping relationship assumes the
dominant role

Phases of a helping relationship

 Orientation phase

The assessment phase of the nursing process, during this phase

o The roles of both persons in the relationship are clarified

o An agreement about the relationship is established. The agreement is
usually a simple verbal exchange or, occasionally, a written document

[Type text] Page 57

 o An orientation to health agency, its facilities and administration routines
 Working phase
o Client and nurse work together the needs of the client identified during
the orientation phase
o Interaction is the essence of the working phase
o The nurse as caregiver, teacher and counselor provides whatever the
assistance needed to achieve the mutually agreed goal
 Termination phase
o Happen at change of shift time
o When the client is discharged
o When the nurse leaves for vacation

Review questions about Communication

1. What is communication?
2. List the purpose and levels of communication
3. Discuss the types of communication.
4. What are the components of the model of communication and discuss each of
them
5. What is the relationship of language and experience to the communication
process?
6. Explain the basic characteristics of communication
7. How do nurses make communication effective?
8. What is a helping relationship?

[Type text] Page 58

REFERENCE

1. Burkhardt A, and Nathaniel A., Ethical issues in contemporary nursing. 2nd

edition, 2002, Delmar publishers, USA.
2. Canadian nursing Association, Every day ethics: Putting the code in to practice,
1997, Ottawa, Canada.
3. Ethiopian Nurses association, Standard of Nursing in Ethiopia, 2002 (Draft
Document).
4. Ethiopian Nurses association, Code of Ethics Nursing in Ethiopia, 2002 (Draft
Document).
5. Gloria M., Nursing perspectives and issues, 3rd edition, 1986 Delmar publishers
Inc.
6. Jorge Grimes and Elizabeth, Health assessment in nursing practice, 4th edition,
1996, Little, Brown and Company, Boston.
7. Hein C. Communication in nursing practice, 1990, Little, Brown and company
8. Kozier, B. ERB, G., Blais, K., Wilkinson. J., Leuven, K., Fundamentals of
Nursing: Concepts, processes and practices, 5th edition, 1998, Addison Weskley
Longman, Inc, California.
9. Kay Kittrell Chitty, Professional Nursing: Concepts and challenges, 2nd edition,
1993, W.B. Sounders company Philadelphia. Ministry of Health, Ethiopia,
10. Purtilo and Cassel., Ethical Dimensions in the health professions, 1st edition
W.B. Sounders company, Philadelphia,
11. Tayler C. Carol Lillis and Priscilla L., Fundamentals of nursing the art and
science of nursing, 1999, care.J.b. Lippincott Company.

[Type text] Page 59