N302 Test II Lecture Notes

DEATH AND DYING Objectives: Discuss communication goals with dying patients and their families, Describe stages of Grief/Bereavement, Discuss Patient Self Determination Act/ Advanced Directives, Define Palliative Care Death is often referred to as the final stage of growth. Life is a moving process, it begins at birth, but when does it end? The style in which a person dies is very individual; just as their life was. Death is individual. A Cultural Perspective: It is unfamiliar, causes great fear in many people, the younger you are the more abstract the concept of death, it is hard to imagine oneself not being part of this world. A Nursing Perspective: As nurses we are committed to life and health. Dying is a contradiction to a nurses commitment. This can be seen by some nurses as a failure in their care, or their skills. Your feelings will provide the foundation, driving the way you deliver care.

Comfort at End of life: The nurse helps or soothes the dying patient. The key is respecting the dying persons wishes. What is a good death? Is it peaceful, quick, slow, etc.? The Dying person may be uncomfortable because of: Pain, Breathing problems, Skin irritation, Digestive problems, Temperature sensitivity, Fatigue, etc. Focus on how these states can impact the nurses communication with the patient. Loss: A universal experience, Part of the life process, Involves emotional pain, Requires adjustment, *May result in personal growth End of Life Losses - Multiple Losses (for the patient): Loss of physical functioning Loss of social functioning Loss of role Loss of cognitive acuity

What patients fear Patients fear the dying process more than they fear death itself. Fear being in pain, being left alone, being avoided by others who are uncomfortable with the idea of dying.

Stages of Death and Dying (70s) Denial-no, not me. Anger-why me? Bargaining-yes, but Depression-yes me

Acceptance-withdrawal

Elizabeth Kubler-Ross (1971):

Communication at the End of Life: Crucial to convey: o Seriousness of illness o Expected course of illness o Treatment options and benefits o Empathy, support, and caring Help in decision-making o advance care planning Alleviate pain Provide appropriate hope

What patients want: Honest answers Symptom management

What families want: Frequent updates on the patients condition To be told when there are changes in the patients condition Understandable explanations

Nurses non-therapeutic communication to a dying patient: Blocking behavior i.e. Aww, dont say that Avoiding intimate conversation by changing the subject Ignoring cues Making jokes Nurses tend to avoid using the words death and dying.

How do we start the conversation? o We want to make certain that the care we provide is the type of care and treatment that you want. o Is there anything that you would like to share with us about your treatment preferences? o In the event that you become too sick to talk and make treatment decisions, do you have a document (advance directives, living will, durable power of attorney for healthcare) that you would tell us who you want to make decisions for you? What to say when the patient asks if he/she is going to die? Talk to me a bit about why you are asking me this. What are your concerns right now? Most of the time patients arent wanting a simple yes or no answer.

Patient Self Determination Act 1991-Federal Law Health care institutions must inform patients on admission on their right to an advanced directive

Advanced Directives Living Will: Indicates choices regarding end of life care such as code status, extent of heroics, etc Durable Power of Attorney (DPOA): Patient gives medical decision making power to another person in the event the patient cannot make decisions for him/herself. Benefits of Advance Directives: o Preserves autonomy after incompetency o Reduces anxiety for the patient, the family, and healthcare providers o Increases a patients self-respect and dignity o Honors a patients moral beliefs o Saves public resources How do we help patients decide advance care planning? o Does your patient have a medical directive?

o Ask about life support preferences. o Talk about scenarios o What are their personal values? What does your patient need to create an Advance Directive? o Decision making capacity o Needs to not be impaired by anything that would interfere with an autonomous choice o Is able to receive information about the risks and benefits for optional care o Has the opportunity to question and receive answers regarding any decisions

Living Will vs. Power of Attorney

Palliative Care Palliative Care: Begins at time of diagnosis Is designed to maximize quality of life through effective symptom management As active treatment plans fail, comfort care increases.

Anticipatory Grief: Emotional response that occurs before the actual loss. Grief and Bereavement: Emotional response to the event of loss. It is a highly individualized experience Multidimensional response (physical, emotional, cognitive) Bereave Be deprived of a loved one through a profound absence.

Dr. Eric Lindemann in the 1940s studied grief over time: Dr. Eric Lindemann, a Boston psychiatrist, studied survivors and their relatives and published what has become a classic paper, Symptomatology and Management of Acute Grief, May 1944 considered to have laid the foundation for research in this area.

492 killed in nightclub fire

Dr. George Engels Stages of Grief (1960s): 1) Shock and disbelief 2) Developing Awareness 3) Restitution Complicated Grief (presented when): Death following suicide, homicide Death following botched care Death of a child Pre-existing mental illness of bereaved-esp. depression Death of a spouse Disenfranchised grief Stigmatized death

Nursing Interventions should be specific to the stage of grief: Shock and disbelief (approximately 6 weeks following death)- arrange for the bereaved to be cared for Anger/hostility (2-6 months)- avoid becoming defensive, allow bereaved to de-brief Depression (up to 2 years or more)-refer to support groups

Avoid Euphemisms! Shes not suffering anymore. Shes in a better place. Time will be the best healer. He wouldnt have wanted to live like that any longer.

Instead say I am so sorry for your loss. I wish things could have gone differently. I feel privileged that I got to care for him/her. Communicating with Colleagues

Objectives: Discuss the connection between communication and medical errors. Describe standards of effective communication. Identify the steps in using the SBAR method of information exchange. Importance of Communication Among the Healthcare Team: Ineffective communication is a root cause for greater than two-thirds of all sentinel events reported. Source: The Joint Commissions Root Causes and Percentages for Sentinel Events (All Categories) January1995December 2008 44,000-98,000 people die each year due to medical errors (IOM, 2000)

Health care involves complex interdependencies of personnel Teams that do not communicate effectively are merely groups of people working side by side. Examples of Interdependence: Multiple Care Transitions: For every 1,000 persons aged 65: 400 ambulance rides 300 visits to Emergency Rooms 200 hospital admissions 46 SNF admits 106 home care visits Multiple patient Hand-offs

Factors Impacting Communication: Multiple variables influence how the healthcare team communicates. Mistakes occur because people abuse their authority. Factors: Power, Status, Gender, Age, Education, Salary, Seniority, Responsibility, Ambiguities. Some things to consider: Audience How might your interaction about a medication with a pharmacy tech differ from your interaction about the same issue with a physician? Mode of Communication How might your face to face request to a physician for more pain medication for your patient differ from the same request over email? Standards for communication: Avoiding do not use abbreviations. Verbal clarification for non-verbal responses: non-verbal communication can be a powerful tool for therapeutic communication, but is not acceptable for transmitting patient care information. Reading back verbal orders Timeliness of reporting critical lab results

Disruptive Behavior http://www.youtube.com/watch?v=Z8g_fkQb2F8 (Summary: Disruptive behavior breaks down the dynamics of teamwork) Disruptive behavior: Any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment.

Silence Kills (2005 study AACN/VitalSmarts) Surveyed 1700 nurses, doctors, administrators 84% observed colleagues making dangerous shortcuts Less than 10% confronted their colleagues about it

Silent Treatment- follow-up study in 2010 Dangerous shortcuts: unchanged from previous study Incompetence: 82% say that 10% of their colleagues are missing basic skills Disrespect: 85% say 10% of their colleagues undermine their ability to share concerns or speak up by being disrespectful

The Joint Commission (Sentinel Event Alert #40) Disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to patient care. Leaders must address disruptive behavior of individuals working at all levels of the organization, including management, clinical and administrative staff, licensed independent practitioners, and governing body members.

Disruptive Behavior (Nadzam, 2009): Fosters medical errors Results in patient dissatisfaction Increases cost of care Leads to staff turnover Causes preventable adverse outcomes

Code of Conduct: Zero tolerance policy for disruptive behavior 60% of nurses new to the nursing practice, leave their first position in 6 months because of some form of hostility directed to them by another nurse.

AACN Standards for Establishing and Sustaining a Healthy Work Environment (2005) First standard is skilled communication

Nurses must be as proficient in communication skills as they are in clinical skills.

Standards of Effective Communication Complete: include relevant information, avoid unnecessary details Clear: use common or standard terminology Brief: be concise Timely: avoid delays in relaying information that could place a patient in danger

SBAR Standardized framework for members of the health care team to communicate about the patients condition. S ituation B ackground A ssessment R ecomendation

History of SBAR Developed by the United States Navy Works well in stressful, time-critical, emergency situations

Communication Styles: Training approaches differ between physicians and nurses: Nurses tend to be descriptive and narrative. Physicians tend to want just the facts and arrive quickly at conclusions. Frustration: physicians keep waiting for the punch line. Nurses feel pressed and interrupted. Embedded SBAR Slides: How does SBAR help? SBAR provides a framework for organizing information.

Bridges gaps between varying communication styles. Calls for you to share your assessment and recommendation.

Tips before talking: Before calling a physician be ready with the following information: o Check to make sure you are calling the right physician. o Know the admitting diagnosis. o Assess the patient and have recent VS, lab work, and test results. o Know the I/O status, allergies, medications, and IV fluids. o Read the most recent progress notes and prior shift nursing assessment and notes. Physicians have three main questions: What is the problem? What do you need me to do? When do I have to respond? (Is this just an update or does this need immediate attention)

S Situation The situation is described by stating the problem. It is a to-the-point punch-line done in 5-10 seconds to get the attention of the receiver. The situation includes: o Identification of yourself (name and unit). o Patients name, physician, and room number o Brief and to-the-point statement of your concern B Background A brief history of the situation is provided to further describe the problem. The background may include: o Admission diagnosis o Pertinent medical history o Brief summary of the current treatment o Clinical assessment (including VS) o Recent interventions given and effectiveness o Abnormal lab or imaging tests

Background Tips: o Prior to speaking with the other person: Anticipate what information the receiving person needs. Have all of the relevant information in front of you. Have the medical record and electronic record open to that patient. Using SBAR notepad, write down all information. Practice conversation if uncomfortable with the situation.

A- Assessement An assessment of the situation is made. o What you think is going on with the patient. o What you think the problem is. At times, you may not be able to make an interpretation of the problem. If so, it is OK to report this. For example: o I am not sure what the problem is, but the patient is deteriorating. o The patient seems to be unstable and may get worse, I think we need to do something. R- Recommendation Based on the situation, background, and assessment of the case, state what you think needs to be done. Some staff find this step of SBAR is intimidating. Staff may feel that they are not qualified to make a recommendation or worry that their recommendation is incorrect. It is important to remember that you are not making the final decision The purpose of the recommendation is to outline your thoughts. If you are not sure what needs to be done, simply stating, It is important for you to check on the patient now, is an appropriate recommendation. Recommendation Tips: o Using critical words can increase the intensity of your message (it conveys a sense of urgency) o Ex: The patient needs meds now. I need you to check on the patient immediately. C.U.S. C.U.S. is an assertion tool to help formulation tool to help formulate your recommendation. o I am Concerned for my patients condition. o I am Uncomfortable with my patients condition.

o The Safety of my patient is at risk. Supervising Unlicensed Assistive Personnel: o Refer to state nurse practice act for legal issues surrounding delegation. o Although tasks can legally be delegated, the responsibility for the patient rests with the nurse. Giving Constructive Criticism o Offer criticism privately o Make comments soon after you observe the problem action o Focus on behaviors (not- I dont appreciate your attitude.) o Apply the hamburger method o Compliment (Bun) o Criticism (Burger)

o Compliment (Bun) Receiving Constructive Criticism o Shut up and listen o Ask clarifying questions o Refer back to the goals o Ask what changes could be made to satisfy the criticism.

Networking

effective networking is all about creating and fostering relationships

Thought for today: Three types of people in the world: Those who make it happen Those who watch it happen Those who wonder what happened Networking people make things happen.

Networking is: Sharing knowledge and contacts. Getting the help you need when you need it from those from whom you need it. Getting more done with less effort. Building relationships before you need them. Helping others

Networking is not: Selling anything Getting a job Receiving a donation Securing funding

Networking is about building relationships before you need them! Then when you need them, you know whom to call and he or she will want to help you.

A Professional Network: Do not wait until your career is in crisis to start building and maintaining a network. Building a network is the life blood of a strong and stable career. Networking is often the most neglected aspect of professional development. It begins now when you are a student!

Words to the wise: Start a card file with a note on the back about how you met the person. This becomes your list of professional contacts and you should establish ways to cultivate and maintain regular correspondence.

Networking skills: A key is to remember that networking is making professional connections and using them wisely. Networking should be systematic You should seek out and become acquainted with people to accomplish your professional goals. People who dont network are less likely to succeed! Networking is not a substitute for doing quality work.

It takes a village And you need to create your own!

Why is networking important? It makes you known It makes your work known It is a source of new clinical practice ideas It provides you feedback It is a source of collaborators. It may give you an edge in getting a job and building your professional career.

Who should you network with? Everyone! Cast your net widely!

Kinds of networking Informal At conferences Correspondence including emails.

Informal networking Serendipity happens: talk to people you meet by chance. Dont only be focused on your world but show excitement about their work. Talk about their lives as well as their work. Ask for help when you need it.

Things to do at conferences: Dont just stand there, speak! If you are a speaker, hang around afterwards. Talk to the person you are sitting next to you. Do lunch! Participate in hall talk. Get people to introduce you to others. Move out of your comfort zone.

Networking at conferences: follow-up!

Get back to people (tell them it was nice meeting them or give them what you might have promised) If you find something the people you meet may need send it.

Networking at conferences: Dont: Dont hang around with your friends. Dont be overly negative or critical. Dont get discouraged.

Intercultural Communication

Objectives: Define culture and related terminology. Discuss the concept of intercultural communication. Apply the nursing process to the care of culturally diverse clients. Demographic Breakdown San Diego SANDAG, 2009

By 2050, more than half of U.S. population will be minorities Indigenous Peoples of California In California, we have over one hundred recognized American Indian Tribes. With this number, we have the largest Native American population and the largest number of distinct tribes than any other US state. Cultural Competency Practice cultural, humility, which consists of recognizing the differences and limitations of ones own culture when working with people of other cultures. o Overcome cultural biases and barriers. o Reduce authoritative communication. Cultural Competence Requires that you understand your own world views and those of the patient.

Avoid stereotyping. It is about cultural awareness, so you can see the entire picture and improve the quality of care and health outcomes. The attitudes, knowledge and skills necessary for providing quality care to diverse populations Not letting ones personal beliefs have an undo influence on those whose worldview is different from ones own.

Cultural Competence Means: Obtaining cultural information and then applying that knowledge. To provide culturally appropriate care means you need to know and understand culturally influenced health behaviors.

Transcultural Nursing Transcultural Nursing: A humanistic and scientific area of formal study and practice in nursing, which is focused upon differences and similarities among cultures with respect to human care, health, and illness. This is based upon the peoples cultural values, beliefs, and practices, and the fact that nurses should use this knowledge to provide cultural specific or culturally congruent nursing care to people... (Leininger) Culture: The norms of behavior and shared values among a particular group of people. The nurse needs to be non-judgmental and open to different practices. Elephant Dung Tea Thailand drinks it as a medicinal drink. All of us like to eat! But some like to drink poo and eat bugs.

Where is culture learned Family Geographic context Religious institutions Schools Community

Illness is culture bound The culture defines what is considered illness o Example: there is no word for Depression in Chinese Illness trends vary by culture o Example: Eating disorders are a western phenomena

Some illnesses have a genetic component and therefore tend to run in closed cultural groups

What people do when they are sick For example, chicken noodle soup vs. seeing a medicine man

Who do you seek care from? Traditional Healer Services o Traditional Healers play a significant role in a health care system. o They are usually informal, unrecognized by government, and do not interact with the rest of the health care system. o Traditional healer services: the application of knowledge skills, and practices based on the experiences indigenous to different cultures. o These services are directed towards the maintenance of health, as well as the prevention, diagnosis, and improvement of physical and mental illness. Western Medicine o Prescription medications and diagnosis by a doctor. o The MAGIC PILL! A Pill for Everything: the American Way. o Over the last 10 years, the percentage of Americans who took at least one prescription drug in the past month increased from 44% to 48%. The use of two or more drugs increased from 25% to 31%. The use of five or more drugs increased from 6% to 11%.

Herbs Herb Cautions: May be contaminated with heavy metals. i.e. lead & arsenic. Hard to calculate dosage. Not much research focus on herbs. Who would not want us to know more about herbs as an option? Big pharma.

WHO: Traditional Medicine (2003) Traditional Healers are significant providers in developing countries because they are more accessible and affordable. They are also seen as more socially accepted. In Africa, up to 80% of the population uses traditional medicine. In China, traditional medicine accounts for about 40% of all health care delivered. In USA, the number who use traditional medicine is unknown.

These providers are especially influential in reaching and changing behavior of low-status, stigmatized patients who often avoid public providers or those who are neglected.

How to focus your communication on traditional treatment modalities? Do you or your family members use anything to stay healthy or things to prevent you from becoming ill? Dont ridicule or discount the patients use of traditional medicine.

Hospital Room and Hospital Chapel (I forgot what he was getting at with this example) Acculturation/Assimilation A socialization process in which a person from a different cultural group learns the dominant culture. Language is a good indicator of acculturation

(Immigrants should speak English vs. Racism, conversation) Ethnicity vs. Race Ethnicity refers to shared racial, religious, and historical culture Race is a biological concept

Ethnocentrism: Belief that ones own culture is superior to others Why is all of this important to nurses? Minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer compared with whites. Patients of lower socioeconomic position are less likely to receive recommended diabetic services and more likely to be hospitalized for diabetes and its complications. When hospitalized for acute myocardial infarction, Hispanics are less likely to receive optimal care. Many racial and ethnic minorities and persons of lower socioeconomic position are more likely to die from HIV. Minorities also account for a disproportionate share of new AIDS cases. The use of physical restraints in nursing homes is higher among Hispanics and Asian/Pacific Islanders compared with non-Hispanic whites. Blacks and poorer patients have higher rates of avoidable hospital admission (i.e. hospitalizations for heath conditions that in the presence of comprehensive primary care, rarely require hospitalization).

Health Disparities: Differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the U.S. How do we best communicate with people from another culture? Learn another language

Say back method Body language Avoid gestures that might be misunderstood Find common ground Strength based Build on cultural healthy practices

Cultural Assessment: Birthplace of parents, grandparents Age at immigration Presence of extended family in home; within 10 mile radius Religious preference Consumption of ethnic foods Language spoken

Cultural Intervention: Interpreters o Children should not be used o Protection of privacy must be maintained Learning health practices specific to cultures o Travel o Read fiction from the perspective of an author from another culture than your own o Watch films that depict other cultures

Communicating with Clients Experiencing Communication Deficits

Objectives: Describe nursing strategies for working with clients experiencing various forms of communication deficits. Communication Difficulty Communication difficulty can be due to impaired functioning of one or more of the five senses or due to impaired cognitive functioning. Examples:

o Hearing loss o Blindness o Aphasia o Mental disorders A communication deficit: simply means insufficient communication, often combined with misunderstandings. Effective communication is the cornerstone of a strong, healthy nurse patient relationship. It involves talking, listening and understanding. General Strategies for Effective Communication: Say the persons name before beginning a conversation (this lets them focus their attention). Acquaint the listener with the general topic of the conversation. (avoid sudden changes in topic). Have the person repeat specifics back to you. Provide pertinent information in writing.

Hearing Loss Demographics According to the Centers for Disease Control and Prevention, more than 34 million Americans were hearing impaired as of 1997. About 50% are men and 33% of women 65 years of age and older have some degree of hearing loss. Hearing loss is more common in men than in women, and in whites more than African-Americans or Hispanics.

Three Major Types of Hearing Impairment: Conductive Hearing Loss: A reduction in the ability of sound to be transmitted (conducted) to the middle ear. (It can be caused by ear wax and infection) Sensorineural Hearing Loss: results from damage to any part of the inner ear or the neural pathway to the brain. (It can result from genetic causes or from systemic disease and things like-prolonged loud noise and medications.) Mixed Hearing Loss: A combination of conductive and sensorineural impairment. Presbycusis A form of sensorineural hearing loss associated with aging. Most common type of hearing loss in the USA. Typically progressive, gradual, bilateral, and characterized by high-frequency hearing loss. o Consonants such as T, P and S are high frequency. Hearing Deficits

Please remember that when patients are being anesthetized, or are heavily medicated, hearing is considered to be the last sense to go. So dont say things that you wouldnt say to the patient when in the presence of the patient. Should this kind of comment be made in front of the patient? Get a body bag for this one.

Strategies to use when your patient has hearing loss: Speak slowly Lower your pitch Face the person so they can read your expression and your lips Keep your hands away from your face Reduce other background noise (TV) Talk into their good ear Avoid shouting (actually can hinder hearing d/t high pitch) Keep a pad and pen at bedside

Hearing Aids May need to assist patient with putting hearing aid in ear (Arthritis, etc.) Make sure patient has hearing aid batteries (ask family members to help out) Decrease background noise as all sound is amplified. Expensive and not always covered by insurance Hearing aids have changed significantly over the last decade, and many can now be programmed to closely address specific needs. A good fit is essential. Prices range from a few hundred to several thousand dollars per unit. Batteries can be expensive and need to be changed every one to two weeks.

Thoughts about hearing devices: Belief that the problem can be overcome with greater amplification by using a device. o They help, but cannot replicate the natural ability to tolerate both soft and loud noises. o The device amplifies all noises o Distortion of sounds in the device hinders hearing ability. How does a person compensate for hearing loss?

70% of spoken sounds look the same on the lips. This makes lip reading very difficult and often inadequate when a patient wants precise information. The individual also may read facial expressions and body language to understand communication.

Suggestions for the Nurse: Use a little ingenuity Combine patience and empathy The patient may deny the problem and you must look, see, and listen. If you suspect hearing loss, try a simple test: o Turn away from the patient and ask a question in a normal voice. Present your finding and reassure him and let him know you want to help! Avoid: Shouting Speaking to fast Exaggerated enunciation Repeating using the same words Try to make the environment more conducive to communication.

Remember: Hearing-impaired individuals are as intellectually capable and deserving of respect as any other patient. Ear Wax Excessive cerumen may impede the passage of sound in the ear canal, causing conductive hearing loss. Estimated to be the cause of 6080% of hearing aid faults. Fear, stress and anxiety may increase production of ear wax

Mandatory Newborn Hearing Screening 3 out of every 1000 newborns are deaf or have hearing loss. Newborn hearing is now tested in the nursery

Vision Loss 10 million Americans are blind or have poor vision Vision loss occurs across a continuum, most patients will have some sight As vision loss increases, patient is unable to interpret non-verbal communication

o Every seven minutes someone in America becomes visually impaired. Causes of Vision Loss: Glaucoma Cataracts Diabetic retinopathy Macular degeneration

Presbyopia Diminished ability to focus on near objects with age. Presbyopia's exact mechanisms are believed to be caused by a loss of elasticity of the crystalline lens. The only treatment is corrective lenses which need to be re-checked every 2 years.

Macular Degeneration Age related macular degeneration is a medical condition which usually affects older adults that results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. Macular degeneration develops as part of the body's natural aging process. Etiology is unknown No treatment has been uniformly effective. It occurs in dry and wet forms. Extra info: Wet is most severe, but more treatable. It is a major cause of visual impairment in older adults (>50 years). Macular degeneration can make it difficult or impossible to read or recognize faces, although enough peripheral vision remains to allow other activities of daily life. Leading Cause of Vision Loss in Caucasians >65

What can you do? When you work with a patient whos visually impaired, its important that the patient feels involved in their care and that you feel comfortable caring for them.

Suggestions: Knock on the door and enter the room addressing him by name. Introduce yourself each time you enter the room. At your initial assessment, ask the patient how he performs activities living at home and how he is functioning in the hospital.

Strategies to Improve Communication with Vision Loss Encourage use of eyeglasses Use large print when possible

Make sure there is plenty of light Read instructions out loud to patient and ask for repeat back

Communicating Effectively with someone Blind or Vision Impaired: Identify yourself: dont assume the person will recognize you by your voice. Tone of your voice is very important. Never channel conversation through a third person. Never leave a conversation without saying so. Relax and be yourself.

Assistive devices for the visually impaired Magnifying glasses. Large print devices Pre-filled syringes

How can you communicate with the patient with Aphasia? Aphasia: any neurological linguistic deficit. There may be no cognitive impairment, but the client may need more think time for cognitive processing during a conversation. Aphasia: Expressive, Receptive, Global

o Expressive aphasia (Brocas aphasia): Patient can usually understand what you say, but cant form sentences to respond. Also called non-fluent aphasia.

o Receptive Aphasia (Wernickes aphasia): AKA Fluent Aphasia: Patient cannot understand what you are saying. Patient may be able to speak, but sentences and words are gibberish. Sometimes patients can sing fine, but not generate coherent sentences.

o Global Aphasia: Patient cannot understand what is being said and cannot form words. Patient may also not be able to write or understand writing. Global aphasia is usually caused by stroke. Global aphasia usually gets better after cerebral edema has decreased. Communication Strategies with Aphasic Patients Dont pretend you understand what they are saying when you dont. Dont use baby talk!

Write down key words. Speak slowly, remain relaxed. Have pictures of common objects available. Give the patient a Yes/No card. Give the person at least 5 seconds to respond

Communication Boards: Examples of communication boards on slides Sensory Loss, Depression, and Isolation People with sensory loss are often depressed and isolated. New Technologies (computers, PDAs, etc) are helping patients with communication deficits live more independently. These devices are not used much in hospitals. Nurses are the communication partners for these patients.

Patients on Ventilators Many report being very frightened. Dont say anything you wouldnt want to hear your patient repeat. Use communication boards. Explain all procedures to patient.

Interpersonal Conflict

Objectives: Discriminate among passive, assertive, and aggressive responses to conflict situations. Specify the characteristics of assertive communication. Identify different approaches to conflict management. Conflict is like the Air we Breathe! As we lead busy and challenging lives, we experience conflict daily if not hourly. o We need to understand sources of conflict and how to manage it when it occurs. Conflict is neither GOOD nor BAD, it just IS! Dispute, Arguments and Disagreements are a normal and necessary part of life.

Conflict

Conflict Tension arising from incompatible needs in which the actions of one frustrate the ability of another to achieve a goal. Causes of conflict: misunderstanding, poor communication, differences in values/goals, personality clashes, and stress.

Reasons for Conflicts: Differing values Competition over scarce resources Miscommunication or lack of information Relationship breakdown

Types of Interpersonal Conflict Nurse-patient Nurse-physician Nurse-ancillary staff Nurse-nursing management

Conflict is inevitable in human interaction. Unless you want to live the life of a hermit, you will need to find ways to effectively handle conflict. Healthcare and Conflict Conflict is complex and generates errors. What in Healthcare Creates Conflict: o Misunderstanding at multiple levels. o Disparity of knowledge, power and control. o It is about people interacting. o Diversity. Common sources of conflict inherent in Nurses Work Stressful work environment Scheduling Patient assignment Visiting hours Limited resources Management styles

Differences in work goals

Why is there so much conflict with patients? Emotions run high during illness. The complexity of caring for the sick results in frequent misunderstandings The stakes are high for patients. The ethnic diversity of patients and providers can result in conflict because of value differences, religious differences, etc.

Behaviors that may create conflict: Speaking in an accusatory or blaming tone. Offering false sympathy. Minimizing someone Reluctance to see the problem from another viewpoint. Using an authoritarian tone of voice (some of us have this naturally and have to correct for it).

Five Approaches to Conflict: 1. Avoidance: most overused technique and very common approach used by nurses (not very effective) 2. Accommodation: cooperative (but non-assertive) 3. Competition: one party exercises power over another 4. Compromise: (can create a lose-lose situation!) 5. Collaboration: cooperative style of problem solving. Avoidance Delaying or avoiding responding, withdrawing, or being inaccessible Avoidance is good when: You dont care that much about the outcome You are very angry and need time to cool down You are in a dangerous situation and you need to remove yourself from the conflict

Avoidance is bad when: You do care about the outcome, but dont want to speak up You keep being bothered by the same conflict and it isnt going away

Accommodation Accepting anothers point of view and letting the other point of view prevail Accommodating is good when:

You are or were wrong about something You care more about the other person being satisfied than you care about the issue (really?)

Accommodating is bad when: It happens a lot and you wish you could speak up more often An important outcome isnt achieved

Competition Controlling the outcome, insisting on one view, and discouraging disagreement Competition is a good conflict management strategy when: You need to move quickly to achieve an outcome There is a safety issue at hand Your expertise dictates the direction to take

Competition is a bad conflict management strategy when: You use it often There are alternative solutions that are satisfactory

Collaboration Asserting your own views while inviting other points of view. Collaboration is good when: You have time to work something out that satisfies everyone You want widespread agreement so that there is long term adherence to the solution

Collaboration is bad when: You dont care much about the outcome Quick action is needed

No one conflict management strategy is better than another. They all have their place. When we learn to manage conflict: Our health improves Our job satisfaction improves We become more effective with patients We learn about ourselves

Influence of Gender on Conflict Socialization of women in handling conflict often involves smoothing things over. (Avoidance/Accomodation)

Men more often use collaboration or competition.

Influence of Culture on Conflict Management U.S. society values individualism and competition (basis of capitalism) Other societies value collectivism (basis of socialism)

Assertiveness A learned behavior to stand up for oneself without suppressing the rights of others. Requires practice. Body language and tone of voice play a role.

Power Continuum:

Responding Assertively: o Be conscious of your body language Use I statements o You- is accusatory o We- is condescending Make statements (avoid why questions) Modulate pitch and tone Focus on the present Demonstrate respect

The Difficult Patient We cant change or reform our patients. We can only change or reform how we respond to them. If you are unable to work with a patient, ask for help. If no help is offered, refuse to accept the assignment.

Dealing with Angry Patients Anger is a stress response. It is a secondary emotion with root causes being: o Perceived hurt o Unmet needs/expectations

o Violation of rights/injustice o Attack on self esteem Angry patient management tips: Listen to the patients complaint completely without interrupting or reacting. Dont tell patient to calm down, model calmness Dont avoid the patient even if you might want to. Use disarming statements: agree with something the patient says: o Ex: You are right. You shouldnt have had to wait this long. I hear you and agree with you, we have got to find a better way to manage this pain.

o Pause for the patient to be able to react. Anger Ask the patient what they really want. What do you see as the best outcome for this situation? Be alert to the potential for violence o Most common in emergency rooms and mental health units o Emergency Nurses Association reports over half of all Emergency Room nurses surveyed reported having experienced violence from patients Conflict is Inevitable and Can Enhance Learning Conflict is a natural consequence of human diversity. Conflict can result in: o Interpersonal gain o Incentive for creativity o Motivation for change o Scholarly discussion

Generational Differences

We all know the person who is always happy, the greedy person, the loud mouth, the busy body, the expert. Astrological Sign: Do you remember when the question was to ask when meeting someone new: What is your Sign? What Characteristics are associated with Zodiac Signs? In the News: The Bad Cheerleaders AKA The Fab Five

Felt they could get away with almost anything and refused to bend to authority. Used their cellular phones during class and wouldnt stop when asked to do so. Insulted teachers They regularly skipped classes and cheated on tests. They pushed other students around They used MySpace to post sexually suggestive pictures. The parents they had were very supportive

For the first time in our history, we have FIVE separate generations. It is important that anyone who works with people looks beyond their own perspectives to understand events, conditions, values, and behaviors that make each generation unique!

Key Things to Remember: There is no magic birth date to define the members of a generation. The characteristics associated with generations should serve only as guidelines not as stereotypes. o The only way to build bridges is not to stereotype. There will always be generation gaps, and while they may seem to grow larger each passing year, we can still try and bridge the gaps. The essence of this bridge is communication. o Communication bridges generational gaps. The human spirit: is neither good nor bad. Each person is unique. It is essential to respect each individuals uniqueness.

The Four Major Generations:

A New Generation Category: Generation Z (2003-Present) Highly connected. Has had lifelong use of worldwide web, instant messaging, and texting. Considered to be Digital Natives Images of fear and violence they frequently see on TV makes them feel that the USA is unsafe. They have mistrust in the political system. They are concerned about financial stability.

Military Recruitment Differences through Generations: Traditionalist (1900-1946): Focus was on masculinity, patriotism, and pride. Baby Boomers (1946-1964): Personified the military as a new more permissive and congenial military. Generation X (1965 1982): Conveyed the military as a way of developing ones self (Be all that you can be). Millennials (1982 2002): You as an individual can make a difference in direction (The power of one).

Highlights and Summary of the Generations: Traditionalist (1900-1946): Loyalty o The Two Commandments:

Save for a rainy day Waste not, want not In other words, they are frugal people.

o Put aside your needs and work toward a common good. o Traditionalists have faith in institutions. o They want to build a legacy. o Their goal is to build a lifetime career. o They are satisfied with a job well done o When it comes to feedback: No news is good news.

Baby Boomers (1946-1964): Optimism o Desire life in a prosperous society o The baby boomer believes that anything is possible. o They want to fix what is wrong! o It is a me generation and they are compelled to challenge authority. o They are considered workaholics. They want to build a stellar career and it is important to excel. They often stay on their job because they love it. They are satisfied with recognition, money, and title. (Anything to get ahead of the pack)

Generation X (1965 1982): Skepticism o They are often seen as the most misunderstood generation. o They tend to put faith in themselves and less in institutions. o They dislike red tape (excessive regulation and conformity to formal rules). o Extremely resourceful and independent. o They Rely on Self. o Work and Life balance is very important. o They like their freedom. o Feedback is important. Sorry to Interrupt, but how am I doing?

Millennials (1982 2002): Realism o Places are both virtual and tangible. o Personal safety is an issue (disregard for safety). o They are more close to technology than people. o They appreciate diversity. o Key to getting things done is through collaboration. o This generation focuses on building parallel careers. o They are truly multi-taskers. o They become bored very easy. o They look for work that has meaning for them. o They aim to please. o They tend to be overachieving and over-managed. o They want to be #1 and the best. o They have always won the prize or trophy and every one is above average. o The most watched over generation ever. o They cant think long range and everything has to be immediate like a video game. o They expect a lot of feedback on daily basis, they want it at a push of a button. o They are generation of critical thinkers because they have the tools to question, challenge and disagree.

CUSPERS Cusper Someone who is born between two generations. These individuals may take on the characteristics of one generation or both. These are persons who are naturals at mediating, translating and mentoring among the different generations

The Characteristics of Todays Generation (Generation Z): Special Sheltered

Confident Team-oriented Achieving Pressured Immediacy

The Characteristic of Being SPECIAL: The individuals have been told throughout their life that they are Special. They view themselves as the center of the universe.

The Characteristic of Being SHELTERED: Baby-on-Board signs. Used to structured lives, with less free time than other generations. They are extensively involved with parents, the term helicopter parent was developed. High ambition without clear long-term goals. Sense of wanting to be successful, but not knowing why. Desire for performance can blur boundaries (e.g. cheating and plagiarism)

The Characteristic of Being CONFIDENT: Have generally a positive outlook. Dedication to community serviceas long as it comes with recognition They have access to knowledge and resources at their fingertips. They have gotten rewards and awards without necessarily comparable output. (Everyone wins!)

The Characteristic of Being TEAM-ORIENTED: Enjoy being in groups, cooperative, teamwork. Structured lives lead to desire for compliance (verses risk taking) It has been suggested that when they do encounter difficult people, they become uncomfortable and expect those in authority to protect them (Lancaster and Stillman, 2002). Respect diversity, some say because they have been told to do so.

The Characteristic of ACHIEVING: Comfortable with, and expect, accountability. Invest in education as long as others invest in them.

Expect high grades as a reward for compliance to academic standards (DeBard, 2004).

The Characteristic of IMMEDIACY: View the world as 24-7, everything has an instant version. They have an emotional and intellectual openness. Speedy communication, via web, email and text messaging. New Speed Language to Communicate They use a short hand communication that may seem like hieroglyphics. 143 404 (I love you!) (I dont know)

PCM PDQ (Please call me, Pretty dam quick)

The Characteristic of Being PRESSURED: These individuals feel pressure to perform. They need clarity frequently. They need to be told what is important. Connects to reliance on structure.

The Characteristic of IMMEDACY: I WANT IT AND I WANT IT NOW! T_T

Possible Conflicts for Generation Z: Todays new nurse will change careers at least four times and have at least six jobs. Todays new nurse is a multi-tasker and we may have to accept their attention span (can you tolerate them writing a term paper during lecture or reading emails?) Current research indicates that 43% of todays high-school/college students identify their mother as their best friend. High level of competence with technology, remember this group of students have been on the web before they were ten years old.

Students define the special teacher or boss as one who has a sense of: Fairness, Honesty, Ethics, and Respect. Safety and Quality of Care

This lecture is dedicated to Kim Hiatt, RN.

A nurse, who had been practicing as an RN for 27 years, committed suicide after she had given an unintended overdose to an infant heart patient. The medical error was said to have contributed to the childs death days later. She had given this drug hundreds of times in her career. This life-changing error caused the death of her patient, she was suspended, then fired from a profession she loved, and then she committed suicide. The Institute of Medicine (IOM): considers patient safety indistinguishable from the delivery of quality healthcare. Many view quality health care as the overarching umbrella under which the patient safety resides. Quality care is: safe, effective, patient centered, timely, efficient, and equitable. People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected). Improving safety requires respecting human abilities by designing processes that recognize human strengths and weaknesses. What is Quality? The IOM has attempted to define quality of health care in terms of standards. The IOM definition of Quality: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality has been defined according to quality indicators which are expressed as outcomes.

To Err Is Human (1999) Safety In Healthcare Delivery: The IOM report on safety opened the door to acknowledge that there is a healthcare safety crisis. Data indicated in 1999: Approximately 44,000 to nearly 100,000 patients die annually in U.S. hospitals due to error. What is Patient Safety? The IOM definition of Patient Safety: The prevention of harm to patients. Emphasis is placed on the system of care delivery that: 1) Prevents errors 2) Learns from the errors that do occur and patients. 3) Is built on a culture of safety that involves health care professionals, organizations, and patients. Technology and Safety There are many patient safety practices that utilize technology such as: use of simulators, bar coding, computerized physician order entry, etc. A MAJOR GOAL is to Standardize a Patient Safety Taxonomy

What are the Risks in Reporting an Error? The problem is that We ALL want to be PERFECT! FEARS if you Report an Error: 1) As a student, failing a course or being dismissed from the program for unsafe practice.

2) Administrative blame 3) As a RN being terminated from a job. 4) As a RN being sued. 5) As a RN loss of your RN licensure. Outcomes: the Person Becomes: a. Irresponsible b. a Quitter c. Reliant on Others d. Disturbed e. Unhappy What is it going to take to improve the Safety and Quality of Health Care Quality? The right work environment. Patient-centered care (patient has an important active role). Teamwork and Collaboration. Evidence-based practice. A Culture of Safety (Individual and Group Value). The Challenge of Change. f. Hopeless g. Angry h. Irrational i. Depressed

Strategies to improve Care Quality: 1) Preventing errors 2) Recognizing 3) Mitigating harm from errors Communication Lapses and Safety A major role of nursing is being a prime communication link in all health care settings. The root causes of Errors: 1) Failure to follow standard operating procedures. 2) Poor leadership. 3) Breakdowns in communication or teamwork. 4) Overlooking or ignoring individual fallibility. 5) Losing track of objectives.

How to Take Responsibility for Your Actions? Realize that you cannot place the blame on others for the choices you make. Be fair in your dealings. Understand that its OK to make mistakes. No one will think less of you. On the contrary, you will earn the respect of others for admitting your errors. Seek to improve your self-esteem. Build your self-confidence. Let go of feeling of victimization.

Statistics A study found that errors affect 1 in 3 hospital patients. Researchers have found that errors may be 10 times more common than experts had previously thought.

Common Errors Statistics Medication Errors: o Very common and the largest source of errors. 1.5 million each year in U.S alone. Results in $3.5 billion extra medical costs. Health Care-Acquired Infections (HAI): o In the US, 1 out of 20 hospitalized patients contact a HAI. Common types: 1. Catheter 2. Pneumonia (some with patients on a ventilator). 3. Surgical-site infection. Falls: o 500,000 falls happen in US hospitals each year. These falls result in 150,000 injuries. The Numbers are NOT Accurate: The United States does not have a consistent system for reporting all health care safety problems. Some hospitals and health care groups have stepped up research and surveillance in the last decade. Factors affecting error statistics: o Underreporting. o Failure to recognize an error. o Lack of patient harm. o Differences in definitions of reporting errors. Two Major Nursing Examples: Avoiding medication errors and Preventing patient falls.

Factors Leading to Medication Errors:

Blame The IOM report caused health care agencies to be put on the defensive. Why is so difficult for us to accept responsibility for our actions? Two children who attended 5 schools before 10th grade all within 20 mile radius because the parents claimed the schools were horrible and the teachers showed favoritism. At what point would these parents accept responsibility for their childrens involvement in the problems they experienced?

Taking Responsibility for Your Own Actions! The inability to accept responsibility for our actions and behaviors is a result of insecurity. If you accept responsibility you are admitting to being weak, powerless and you may lose the respect of others. You may feel you lose your sense of value and importance. Accepting responsibility is a sign of personal growth and maturity. It is definitely not a sign of weakness.

Difficulty in Taking Responsibility 1) You may frequently feel insecure. 2) Triggers doubt about your own abilities. 3) Undermines your self-confidence. 4) You may become defensive about every action right or wrong. What are some Medical Errors? 1) Medication errors 2) Hospital-acquired infections 3) Pressure ulcers (bedsores) 4) Medical device failures

5) Patient falls 6) Blood clots 7) Others Error Occurrence Situations: 1) No one knows and finds out. 2) An error occurs and the person making it did not know, but others found it. 3) The person making the error and knows they made it and didnt report the error. 4) The person making the error knows and reports it. Key Concepts: Safety: Freedom from accidental injury. Error: Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

Types of Errors: Diagnostic Treatment Preventive Other Many errors go undocumented or are not reported due to: Staff fear of reprisal, lack of adequate systems to report the error, limited staff education about safety and report process, and lack of computerized surveillance systems.

Near-Misses or Good Catches Errors of commission or omission that could harm or adverse consequences a patient but did not. Think about the times that you almost made an error. We all have these experiences. What do you do to learn from these experiences?

Provision 4: ANA Code of Ethics for Nurses With Interpretive Statements The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care. 4.1 Acceptance of accountability and responsibility The nurse bears primary responsibility for the nursing care that their patients receive and individually responsible for their own practice. Nursing practice includes direct care activities, acts of delegation, and other responsibilities such as teaching, research, and administration. 4.2 Accountability for nursing judgment and action. Accountability means answerable to oneself and others for ones own actions. Your actions are grounded in the moral principles of fidelity and respect for the dignity, worth, and self-determination of patients.

4.3 Responsibility for nursing judgment and action 4.4 Delegation of nursing activities

Communication during Stressful Situations

Today is about the need to take care of yourself if you are committed to take care of others.

Objectives: Define stress. Identify coping mechanisms used by clients and family members in stress situations. Identify communication strategies clients and families in crisis. Describe the diversion Program for Nurses

Stress as a Concept: Stress is an unavoidable part of our everyday lives. Stress affects our bodies, behaviors, and minds in many different ways! Stress is a personalized physical, psychological, and spiritual response to the presence of a stressor.

Stress in America More than half of all Americans report feelings of high stress in a typical day. Up to 75% to 90% of all visits to the doctor are stress-related. (Harvards Mind/Body Medical Institute) 40% of worker turnover is due to job stress.

What Causes One to be Stressed? One can put themselves into circumstances that can cause stress. Some people like a life of crisis and stress. A little stress is good for learning.

Stressors A Stressor is any demand, situation, internal stimulus or circumstance that threatens a persons personal security or self-integrity. Common Stressors: Family Job Environment Lifestyle

Body image changes situation role change

Theories on Stress: Homeostasis (Canon) General Adaption Syndrome (Selye) Social Readjustment Rating Scale (Holmes and Rahe) Transactional model (Lazarus and Folkmann) Allostatic Load (McEwen and Stellar)

Characteristics of Stress: Headache Sleep problems, fatigue, and irritability. Restlessness, rapid speech, and movement. Gastric upset. Tachycardia, palpitations, and hot flashes. Frequent urination and dry mouth. Crying. Use of alcohol or drugs. Withdrawal from friends and family

Physical effects of stress Skeletomuscular: Back aches, arthritis, accidents. Immune: Infections, allergies, skin eruptions, autoimmunity, cancers. Cardiovascular: Heart attacks, angina, hypertension, migraines, dysrhythmias, CVAs. Digestive: Ulcers, colitis, constipation, diarrhea.

You are all aware that Stress is linked to the leading causes of death: Heart disease, cancer, respiratory conditions, accidents, depression and suicide and immune systems conditions. Other health conditions associated with stress include: sleep disorders, ulcers, migraines and tension headaches The Cost of Stress: It is estimated that stress will cost more than $300 billion annually because of lost hours due to absenteeism, increased worker compensation costs, and reduced productivity.

An estimated 1 million workers are absent every day due to stress

The Goal of Stress Management: To restore balance and feel calm and centered. Strategies to Manage Stress: Eat for the long run. choose nurturing and sustaining food instead of quick pick-ups. Decrease sleep deficit. Laugh, its a natural stress buster. Choose your music with care.

Other Strategies: Help others. Be truthful to yourself. Breathe. Take a walk.

More Strategies: Notice something about nature every day. Count ten things you are grateful for every day. Focus on chewing your food. Meditate or pray daily. Clear up unresolved relationships. Laugh and breathe deep. Hug someone. Its Sauna Time or whatever relaxes you!

Stress has been declared a Work Place Hazard B U R N O U T Syndrome Burnout has a negative connotation and instead some experts refer to this concept as work disengagement or emotional exhaustion According to Wikipedia, Burnout is a psychological term for the experience of long-term exhaustion and diminished interest (usually in the work context). Burnout is physical, emotional, and spiritual exhaustion Nurses are at high risk!

o We care o We have high expectations of ourselves o Our jobs are HARD! Characteristics of Burnout: Emotional Exhaustion Depersonalization, inability to become involved with others. Decreased effectiveness. Stress-related behavior becomes a persistent problem. Usual coping strategies are ineffective. Person feels overwhelmed and helpless. o The person becomes at risk for physical or mental illness. Burnout Affects Many In the USA it is estimated that 68% of workers indicated that they feel burned out and that job stress is the cause of their frequent health problems, in addition to making them less productive.

Why Burnout? Major threat in nursing due to the large amounts of physical, emotional, and mental stressors that can easily arise and accumulate in a single 8 or 12 hour shift Past personal experience Unhealthy hospital cultures are one of the primary reasons nurses have burnout and leave their work.

Symptoms of Burnout: Begins with a difficulty focusing on key tasks and maintaining a possible attitude about work. High blood pressure. Insomnia. Depression. Addiction.

The Defining Attributes of Burnout: Emotional exhaustion Cynicism Depersonalization

Lack of personal accomplishment Inefficacy

Elements Contributing to Burnout for Nurses: Heavy physical demands. Heavy psychological demands. Vigorous schedule (12 hour shifts and working a schedule with different shifts). Unhealthy hospital cultures. Overwhelming technology. Potential for making errors. The nursing shortage. Lack of confidence and respect for nursing leadership.

Compassion Fatigue Syndrome: A physical, emotional and spiritual fatigue or exhaustion that takes over a person and causes a decline in their ability to experience joy or feel and care for others. The emotional residual (side effect) from exposure to working with individuals suffering from the consequences of traumatic events in their lives. Compassion Fatigue Syndrome is a form of Burnout, a kind of secondary victimization that is transmitted by clients to workers through empathetic listening. Phases of Compassion Fatigue: 1) Idealist Phase 2) Irritability Phase 3) Withdrawal Phase 4) Zombie Phase Idealist Phase: Motivated by idealism Ready to serve & problem solve Desires to contribute & make a difference. Volunteers to help & assist Full of energy & enthusiasm

Irritability Phase:

Cuts corners Avoids client contact Mocks peers & clients Underestimates own efforts of wellness Loss of concentration & focus Distances oneself from others

Withdrawal Phase: Loses patience with clients Becomes defensive Neglects self & others Chronically fatigued Loses hope Views oneself as a victim & isolates oneself

Zombie Phase: Views others as ignorant or incompetent Loses patience, sense of humor, and zest for life Dislikes others Becomes easily enraged

Why is it important to recognize Compassion Fatigue? There are many human costs associated with compassion fatigue.

The negative effects include: 1. Diminished job Performance 2. Increased tardiness & absenteeism 3. Declining physical health 4. Poor morale 5. Low energy 6. Stressed personal relationships 7. Increased substance abuse

8. Depression & irritability Emotional Exhaustion As their emotional resources are depleted, workers feel they can no longer give of themselves at a psychological level (Toscano & Ponterdolph, 1998, p. 32N). People who are exhausted feel drained and unable to unwind and have the feeling of being overextended emotionally (Angerer, 2003, p. 100 - 101). Breakdown of energy resources and adaptability (Buhler & Land, 2003, p. 5).

Cynicism People take on a cold attitude toward work and their coworkers in order to protect themselves [from further] exhaustion and disappointment (Angerer, 2003, p. 101). Negative, cynical attitudes about ones clients (Toscano & Ponterdolph, 1998, p. 32N).

Depersonalization Social withdrawal (Lederer et al., 2006, p. 58). Indifferent towards other people, having difficulties in empathizing, being neither very helpful nor considerate resulting in fewer friends (Buhler & Land, 2003, p. 11.) An inability to perceive that other people have similar feelings, impulses, and thoughts as oneself is caused by a basic inability to love (Buhler & Land, 2003, p. 11).

Lack of Personal Accomplishment Feel useless, pointless, & dissatisfied With low morale and feelings of reduced effectiveness, the individual believes that his/her actions no longer make a difference (Lederer et al., 2006, p. 62).

Inefficacy If one feels inadequate, accomplishments seem trivial and projects seem overwhelming (Angerer, 2003, p. 101). Tendency to evaluate oneself negatively, particularly with regard to ones work with clients (Toscano & Ponterdolph, 1998, p. 32N). Inefficiency and diminished competence (Lederer et al., 2006, p. 58).

What can Nurses Do to Re-energize themselves? Strive to work in an environment that is less stressful and more productive. Be creative in making your job easier and more rewarding. Overwork and being overtired should not be a job expectation. Playing is not only for children, learn how to play as an adult. HAVE FUN!

Rubber Band Man A rubber band stretched beyond its capacity, resulting in a snap, is similar to burnout.