2.1 assignment nursing education

Nursing Fundamentals

(8 reviews)

Kimberly Ernstmeyer, Chippewa Valley Technical College

Elizabeth Christman, Chippewa Valley Technical College

Copyright Year: 2020

ISBN 13: 9781734914146

Publisher: WI Technical Colleges Open Press

Language: English

Formats Available

Conditions of use.

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Reviewed by Sophan Theam, Assistant Professor, North Shore Community College on 5/25/24

The Nursing Fundamentals OER surprisingly has every component and topic that is covered in the current textbook used at my college which students are required to purchase. Not only does it cover all of the necessary subjects related to Nursing... read more

Comprehensiveness rating: 5 see less

The Nursing Fundamentals OER surprisingly has every component and topic that is covered in the current textbook used at my college which students are required to purchase. Not only does it cover all of the necessary subjects related to Nursing Fundamentals, but it also elaborates on application of the nursing process within each component.

Content Accuracy rating: 5

The information is accurate and reflective on what is lectured in Nursing Fundamentals.

Relevance/Longevity rating: 5

I was impressed about the learning activity at the end of the chapters which had very relevant and practical case studies and Q&A's.

Clarity rating: 5

The information is portrayed in very clear and concise formatting including tables and images. Links to additional resources within the text were also easy to navigate.

Consistency rating: 5

The formatting was very consistent and clearly portrayed. Ease of reading and consistent framework are evident throughout the OER.

Modularity rating: 5

Modules are clearly labeled and defined which would make assignments clear and easy for students.

Organization/Structure/Flow rating: 5

Topics and modules within the index are easy to navigate to and organized in a very simple format. It is easy to click and read topics chosen.

Interface rating: 5

I did not come across any broken links or disruptions throughout the OER.

Grammatical Errors rating: 5

There were no issues with grammar or punctuation throughout the OER.

Cultural Relevance rating: 5

There was an entire chapter on Cultural Competency which is a significant subject in nursing. Spirituality was also referenced and is a large topic to cover.

Overall, this OER was impressive. I didn't expect much prior to reviewing it but once I did, I can see the benefits of using this OER for my course.

Reviewed by Jennifer Riggs, Professional Specialist, Saint Mary's College on 12/12/23

The book covers a large amount of relevant content and nearly all of the theory content that I typically cover in my fundamentals course. It does not, however, cover the nursing skills that I review in lecture and that students practice in the lab... read more

Comprehensiveness rating: 4 see less

The book covers a large amount of relevant content and nearly all of the theory content that I typically cover in my fundamentals course. It does not, however, cover the nursing skills that I review in lecture and that students practice in the lab portion of the course. Yet, the same editors (Ernstmeyer & Christman) also provide a separate OER entitled Nursing Skills which covers everything that Nursing Fundamentals does not. So, I have named both books (Nursing Fundamentals AND Nursing Skills) as required resources for the course. Nursing Skills contains the skill checklists and videos, as well as sample documentation, that are associated with the theory content. One topic not covered in Nursing Fundamentals is medication administration. For the 2-3 weeks that we spend on this topic, students will use primarily the Nursing Skills OER.

Additionally, in the past, students have purchased a textbook package that also includes digital quizzing and virtual simulations. Both Nursing Fundamentals and Nursing Skills have sections titled “Learning Activities” which include interactive case studies, quizzes and simulations that incorporate NGN NCLEX-style questions. I plan to use these activities during class. I would like to be able to assign these activities but, as far as I can tell, there is no way to view student performance and ensure that they are being completed.

Finally, LibreText ADAPT is a test bank of quiz and exam questions that faculty can draw from. It feels good to have this support, but I will continue to use the exams that I have created in the past for now. Any supplementation to the course will be minor and well worth the hundreds of dollars in savings to students.

Content is accurate and aligns with what is being taught in nursing fundamentals courses. The material perfectly compliments my lecture PowerPoints as they are. I will not need to change anything and can simply assign readings and activities from the book. I have not encountered any errors.

Content is up-to-date. Sources are current and at most, only a few years old. Sources are evidence-based and reliable. They are cited at the bottom of each individual content page and are hyperlinked for easy access.

The text is clear and concise. The headings are helpful for organizing information and key terms are bolded. The presentation is visually appealing and easy to understand. The pages are easy to navigate. I believe that students will appreciate the simplicity and clarity of the pages.

Each book section and page is formatted in the same way. Students will know what to expect as they access each new chapter. Quality and quantity of information is also consistent across the book.

This is my favorite feature of this book. I believe that students will greatly appreciate and benefit from the concise reading sections. It seems to me that this generation of students does not like to read and that that they do not learn best by reading. Yet, they need and want a place where they can go for clarification or an alternate explanation of a topic. With the short readings, they can find answers to their questions quickly. Also, the pictures and video links are visually appealing and attractive to students. Additionally, I like how I can easily link relevant sections and assignments directly in the syllabus, course calendar and online learning platform. I can have the confidence that students are getting reliable information and students can directly access information in a way that better agrees with their preferred learning style.

Each chapter begins with an introduction and then presents related topics in a logical order. Chapters contain 6-12 topics, and topics are appropriately separated. The last section in each chapter is titled “Putting it all Together” and includes a relevant patient scenario and application of the nursing process.

I have not experienced any interface issues in the several months that I have been using this book. LibreText provides options for "Readability." Students can adjust text and margin size, as well as color gradients that allow for ease and efficiency of reading. There is also a "Reader Mode" that eliminates the website navigation information and decreases distractions while reading. Additionally, there is a scientific calculator in the "Tools" section. This is helpful for this course, because students must often complete medication math problems. I like the accessibility options included in this program.

I have not noticed any grammatical errors.

The end-of-chapter patient scenarios include a variety of patient types. Chapter 3 is titled ‘Diverse Patients’ and includes information on health disparities as well as how to perform an appropriate cultural assessment and provide culturally competent care. Additionally, the content can be translated into 133 different languages with Google Translate. In some cases, Google Translate can use “conversation mode” to provide an audio version of the content.

In addition to being able to access a free digital copy of the book, students can also download a FREE pdf version of this book and/or purchase a copy of the book at the following prices: Paperback: Grayscale ($40.47) Full Color ($55.48); Hardcover: Grayscale ($50.70) Full Color ($65.78).

LibreText offers the following tips for working with a PDF: “Encourage students to use a program like Adobe Reader, iBooks, or Notability to download, read, and annotate the PDF. These tools allow for highlighting, commenting, bookmarking, etc, that will make interacting with the file easier than reading it in the web browser. Here is a list of 15 free PDF readers Links to an external site.(though not all of them support highlighting and annotating). This resource from Reed CollegeLinks to an external site. It provides helpful tips for using Adobe Reader and Preview for Mac. Students can use Ctrl-F (the command for "find"), which helps find a particular point in a long PDF document.”

Reviewed by Eileen Weatherby, Nursing Instructor (PhD, MS, MBA, CNE), Normandale Community College on 5/20/23

Overall, the book covers topics expected of nursing fundamentals textbooks. Some topics are developed very well such as therapeutic communication strategies, writing SMART outcomes, and highlighting Watson's caring theory. Other topics would... read more

Overall, the book covers topics expected of nursing fundamentals textbooks. Some topics are developed very well such as therapeutic communication strategies, writing SMART outcomes, and highlighting Watson's caring theory. Other topics would benefit from futher development such as the role of the nurse as the teacher applying learning theory principles to patient education. The text does a good job introducing the challenges faced by older adults, and would benefit readers by expanding on the developmental stages of other age groups. Only cursory references are made to theorists Piaget and Erikson.

No errors noted with the information. The authors successfully impart unbiased content with the exception of predominantly Caucasian images and models. Up to date information addresses the social determinants of health and health care disparities.

The electronic nature of this textbook allows for updating ease. The use of and emphasis on nursing diagnoses seems to be waning and this topic may be one of the areas of the textbook that will require modification.

Sections are succinct and easily readable. The glossaries and flash cards assist with mastering common medical terminology.

Each section is set up similarly. The reader can anticipate the review exercises at the conclusion of each section.

Each unit presents small "chunks" of information appropriately. The reader is not overwhelmed with a very large section under a single heading. I antipcate that learners would be more adherent with reading assignments using this format.

The arrangement of topics is done very well starting with a "big picture" of the nursing profession then gradually narrowing down to very specific topics.

The electronic version worked well for jumping from link to link. Some images had such high definition that every pore and blackhead was visible on the model's face. The learning activities also worked well. The pdf version contains many blank pages and more effort is required of the reader to try the links and explore the learning activities.

No grammar errors encountered.

Cultural Relevance rating: 4

The proportion of images and models that represent people of color is small. This could be shored up.

Nurse educators often classify teaching content as, "Need to know, nice to know, or nuts to know". This textbook exemplifies the "need to know" & has eliminated the superfluous and/or detailed content. Overall, I believe nursing students would be more likely to complete reading assignments from this textbook as it is succinct and provides activities that help solidify concepts.

Reviewed by Bailey Kuhlman, Instructor, Pittsburg State University on 1/9/23

The comprehensiveness of the text is sufficient. It includes all subjects our current text has. A benefit of the text is the instructor resources being readily available. Particularly, the NextGen instructor resources will be helpful. read more

The comprehensiveness of the text is sufficient. It includes all subjects our current text has. A benefit of the text is the instructor resources being readily available. Particularly, the NextGen instructor resources will be helpful.

The book is accurate and up to date with EBP.

The texts longevity and relevance are beneficial to the subject of nursing fundamentals.

The text is clear and concise.

The text is consistent with EBP.

The setup is beneficial to the user.

The organization of the text is easy to follow.

Easy to follow and no problems experienced with technology.

No grammatical errors discovered in the text.

No cultural insensitivities were found.

This is a great text for nursing fundamentals students. The readily available instructor resources are a plus, especially when helping students prepare for NextGen. The online text is user friendly and up to date with EBP. There is no cost to the student which is a massive benefit.

Reviewed by Carol Blanchard, Instructor, North Shore Community College on 11/9/22

This text covers all the subjects of our current text with the additional easily available instructor resources. The topics were covered well and included activities that were very well laid out, including relevant case studies that will help with... read more

This text covers all the subjects of our current text with the additional easily available instructor resources. The topics were covered well and included activities that were very well laid out, including relevant case studies that will help with our Next Generation questions.

Content Accuracy rating: 4

The book is accurate and covers all of the most updated evidenced based best practices.

Relevance/Longevity rating: 4

Because of this format, updates are easy to add, a real plus for Nursing and it's frequent updates.

Although the text is sometimes dry, it is very clear and understandable to a student.

The framework and terminology within the text is consistent.

The Module setup is very user friendly, and easy to access.

The topics are organized in such a way that is consistent with how most schools approach Nursing Fundamentals as a course.

No problems were encountered with navigating throughout the text. The charts and activities were clear as well as the instructor resources and answer keys.

No grammatical errors were encountered.

This text is an excellent resource for Nursing students. The many activities and resources woven within each chapter makes this an excellent products for all types of learners. Additionally, because Nursing texts are often updated to reflect best practices, an online text is much easier to update with little to no expense for the student.

Reviewed by Bonnie Wilkinson, Primary Faculty, Nursing Assistant, Clackamas Community College on 12/29/21

Great introductory exploration of concepts and topics germane to nursing students. Can be adapted to meet the needs for education of nursing assistants as well as those pursuing practical/vocational licensure or registered nurse read more

Great introductory exploration of concepts and topics germane to nursing students. Can be adapted to meet the needs for education of nursing assistants as well as those pursuing practical/vocational licensure or registered nurse

Includes multiple recent and relevant sources with the ability to review or further explore the resources.

Includes links to resources that are frequently updated, rather than including the current standard at the time of publication which may change over time.

Written to meet the needs of a student unfamiliar with the subject with multiple clarifications of terms that can be referenced directly in the text. Each chapter included a glossary at the conclusion, which could be accessed prior to reading the subchapters if desired. Chapters divided into digestible sections that build upon the previous subchapter.

Each chapter arranged in a consistent pattern. Includes a summary subchapter as well as glossary of terms covered in the chapter. Each chapter has a learning assessment which includes critical thinking scenarios, flashcards with information, and an interactive quiz with immediate feedback function.

Chapters divided into digestible sections that build into a cohesive overview of the subject. Works well with supplemental texts by same group on Nursing Skills and Pharmacology.

Information presented from a global perspective followed by specific information and a summary section in each chapter. Chapters arranged with foundational information (scope of practice, communication, diverse populations, nursing process) at the beginning, followed by more specific subject areas.

Links embedded in the text upload smoothly and images and charts placed in appropriate places to accent the subject being discussed. Additional information can be accessed easily by either clicking on the web addresses of the references or imbedded in boxes within the section

Clear and inclusive text

Full section on cultural issues plus references throughout the rest of the text

The authors have allowed access to further modify the publication to meet the needs of individuals pursuing nursing education outside the Wisconsin area. It is available for purchase in a print format, as referenced data showed students prefer a print text over 50% of the time. Has a companion publications for nursing skills and pharmacology.

Reviewed by Janelle Patterson, Professor of Nursing, Des Moines Area Community College on 11/23/21

Includes all topics covered in our fundamentals nursing curriculum. The two topics not included in detail in this textbook are nursing skills and nursing assessments, but these resources are included via hyperlinks to other texts covering this... read more

Includes all topics covered in our fundamentals nursing curriculum. The two topics not included in detail in this textbook are nursing skills and nursing assessments, but these resources are included via hyperlinks to other texts covering this content within this fundamentals textbook.

The text contains accurate photos, tables, and figures to help visual learners and depict current equipment.

Most fundamental topics are straightforward and universal. Some content that may be outdated are the NANDA-I diagnoses since these are no longer included on the NCLEX-RN. Nursing problems terminology have now replaced NANDA-I.

There is a glossary included at the end of each chapter to review unfamiliar bold-faced terms within the text. This book is written at a nursing fundamentals student level. Nursing interventions are explained in simple terms and include photos and tables to depict details further.

Each chapter follows the same sequence (nursing process) and ends with application exercises including "Putting it all Together" and "Learning Activities."

Text is very organized, predictable, and divisible.

Text is very organized, systematic, and logical.

Excellent and thorough use of hyperlinks to additional references, evidence-based practice, national organizations, assessment steps, and skill steps.

Minimal grammatical errors

A variety of examples are included.

Reviewed by Tabatha Morgan, Assistant Professor, Emporia State University on 11/2/21

There were some errors noted within the context. There are also many blank pages between information and the labeling for the tables are on separate pages, which may be very confusing to a reader. read more

Comprehensiveness rating: 3 see less

There were some errors noted within the context. There are also many blank pages between information and the labeling for the tables are on separate pages, which may be very confusing to a reader.

Content Accuracy rating: 3

There was some information that could be correct, such as the ISBARR examples. I believe the information listed under the situation, background, and assessment needs to be under the correct title. In the nursing diagnosis examples, there is conflicting information regarding the risk for nursing diagnosis. When it's potential, there are two parts of the nursing diagnosis: the problem and the related factors due to there is no evidence since it has not happened. The text states to include the problem and as evidence for a risk for diagnosis. When also stating if a goal has been met with evaluating a patient for their plan of care, it's best to list it as "Goal met, Goal partially met, or Goal met." The mnemonic for pain is "OLD CARTS," not "OLDCARTES," which I had looked up within other resources to see if there is an update, and every resource I found still states "OLD CARTS."

Relevance/Longevity rating: 3

The accuracy of the information that is stated needs to be updated in areas. Please review the information listed under accuracy.

Information is clear and explained in layman's terms.

Consistency rating: 3

Please refer to the comment under accuracy.

Modularity rating: 4

There are many blank pages noted between each section of information while reading the information.

Organization/Structure/Flow rating: 3

The information flows well, except there are many blank pages noted between each information section while reading the information.

Interface rating: 3

The labeling for the tables doesn't always go with the information, and we cannot view some information. For example, in table 3.2b, part of the table is cut off over cultural concepts and cannot view information. Now, if this is a hard copy, some of the links would not be clicked on, making this textbook an ebook only.

No grammatical errors noted.

This textbook was not insensitive or offensive in any way to any culture.

By reviewing the textbook and changing the information provided, I believe this would be a great textbook. This textbook appears to be more at an Associate degree level for nursing students than a Bachelor in Science of Nursing degree.

Table of Contents

• I. Scope of Practice
• II. Communication
• III. Diverse Patients
• IV. Nursing Process
• VI. Cognitive Impairments
• VII. Sensory Impairments
• VIII. Oxygenation
• IX. Infection
• X. Integumentary
• XI. Comfort
• XII. Sleep and Rest
• XIII. Mobility
• XIV. Nutrition
• XV. Fluids and Electrolytes
• XVI. Elimination
• XVII. Grief and Loss
• XVIII. Spirituality
• XIX. Care of the Older Adult
• XX. Answer Key

Ancillary Material

About the book.

This Nursing Fundamentals textbook is an open educational resource with CC-BY licensing developed for entry-level nursing students. Content is based on the Wisconsin Technical College System (WTCS) statewide nursing curriculum for the Nursing Fundamentals course (543-101), the 2019 NCLEX-RN Test Plan, the 2020 NCLEX-PN Test Plan, and the Wisconsin Nurse Practice Act.

This book introduces the entry-level nursing student to the scope of nursing practice, various communication techniques, and caring for diverse patients. The nursing process is used as a framework for providing patient care based on the following nursing concepts: safety, oxygenation, comfort, spiritual well-being, grief and loss, sleep and rest, mobility, nutrition, fluid and electrolyte imbalance, and elimination. Care for patients with integumentary disorders and cognitive or sensory impairments is also discussed. Learning activities have been incorporated into each chapter to encourage students to use critical thinking while applying content to patient care situations.

About the Contributors

Kimberly Ernstmeyer,  Chippewa Valley Technical College

Dr. Elizabeth Christman,  Chippewa Valley Technical College

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2.1 Prioritization Introduction

Learning objectives.

• Prioritize nursing care based on patient acuity
• Use principles of time management to organize work
• Analyze effectiveness of time management strategies
• Use critical thinking to prioritize nursing care for patients
• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands. [1] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role. [2] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

• Rochefort, C. M., Abrahamowicz, M., Biron, A., Bourgault, P., Gaboury, I., Haggerty, J., & McCusker, J. (2021). Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient‐level longitudinal study. Journal of Advanced Nursing, 77 (3), 1567-1577. https://doi.org/10.1111/jan.14710 ↵
• Hoeve, Y. T., Brouwer, J., Roodbol, P. F., & Kunnen, S. (2018). The importance of contextual, relational and cognitive factors for novice nurses' emotional state and affective commitment to the profession. A multilevel study. Journal of Advanced Nursing, 74 (9), 2082-2093. https://doi.org/10.1111/jan.13709 ↵

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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4.1 Leadership & Management Introduction

Learning objectives.

• Compare and contrast the role of a leader and a manager
• Examine the roles of team members
• Identify the activities managers perform
• Describe the role of the RN as a leader and change agent
• Evaluate the effects of power, empowerment, and motivation in leading and managing a nursing team
• Recognize limitations of self and others and utilize resources

As a nursing student preparing to graduate, you have spent countless hours on developing clinical skills, analyzing disease processes, creating care plans, and applying clinical judgment. In comparison, you have likely spent much less time on developing management and leadership skills. Yet, soon after beginning your first job as a registered nurse, you will become involved in numerous situations requiring nursing leadership and management skills. Some of these situations include the following:

• Prioritizing care for a group of assigned clients
• Collaborating with the interprofessional team regarding client care
• Participating in an interdisciplinary team conference
• Acting as a liaison when establishing community resources for a patient being discharged home
• Serving on a unit committee
• Investigating and implementing a new evidence-based best practice
• Mentoring nursing students

Delivering safe, quality client care often requires registered nurses (RN) to manage care provided by the nursing team. Making assignments, delegating tasks, and supervising nursing team members are essential managerial components of an entry-level staff RN role. Nursing team members include registered nurses (RN), licensed practical/vocational nurses (LPN/VN), assistive personnel (AP) such as certified nursing assistants (CNA), client care technicians (PCT), certified medical assistants (CMA), certified medication aides, and home health aides. [1]

Read more about assigning, delegating, and supervising in the “ Delegation and Supervision ” chapter.

The professional nurse is expected to demonstrate leadership and management skills in many other facets of the role. Nurses manage care for high-acuity patients as they are admitted, transferred, and discharged; coordinate care from a variety of diverse health professionals; advocate for clients’ needs; and manage limited resources with shrinking budgets. [2]

Read more about collaborating and communicating with the interprofessional team; advocating for clients; and admitting, transferring, and discharging clients in the “ Collaboration Within the Interprofessional Team ” chapter.

An article in the Online Journal of Issues in Nursing by the American Nurses Association (ANA) states, “With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important…The next generation of nurses will play key roles in partnering with other healthcare professionals to lead  the improvement and design of the health system and practice environments. To meet these challenges, we need emerging leaders in nursing who are both interested in leadership and well-prepared to assume the role.” [3] This chapter will explore leadership and management responsibilities of a registered nurse. Leadership styles are introduced and change theories are explored as a means for implementing change in the health care system.

• American Nurses Association & NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• Cherry, B., & Jacob, S. R. (2017). Nursing leadership and management. In Cherry, B. & Jacob, S. (Eds.), Contemporary nursing: Issues, trends, and management (8th ed.). Elsevier, pp. 294-314. ↵
• Dyess, S. M., Sherman, R. O., Pratt, B. A., & Chiang-Hanisko, L. (2016). Growing nurse leaders: Their perspectives on nursing leadership and today’s practice environment. OJIN: The Online Journal of Issues in Nursing, 21 (1). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-21-2016/No1-Jan-2016/Articles-Previous-Topics/Growing-Nurse-Leaders.html ↵

Leadership and Management of Nursing Care Copyright © 2022 by Kim Belcik and Open Resources for Nursing is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Chapter 2 Communication

2.1. communication introduction, learning objectives.

• Assess one’s own communication skills and effectiveness [ 1 ]
• Demonstrate cultural humility, professionalism, and respect when communicating [ 2 ]
• Use communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust [ 3 ]
• Maintain communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery [ 4 ]
• Use therapeutic communication techniques
• Confirm the recipient of the communication heard and understands the message [ 5 ]
• Apply principles of distance and space
• Discuss strategies for maintaining confidentiality
• Use technology to access current and reliable information
• Use correct medical terminology and abbreviations
• Report significant patient information verbally and in writing
• Document according to legal guidelines

Strong communication skills are essential to provide safe, quality, patient-centered care. Nurses develop therapeutic relationships with patients and family members each day to ensure that health care concerns and needs are addressed. If communication breaks down, information exchange stops and needs go unidentified. Nurses optimize communication channels with patients and families by establishing trust and actively listening to health care concerns. Additionally, the nurse is vital for ensuring that information transfer occurs within the multidisciplinary team. Communication with other health care team members is professional, organized, accurate, complete, and concise. This chapter will review methods for establishing good communication.

Before getting started, view the following video and reflect on the often invisible needs of those around us and the difference we can make by creating caring human connections.

View the video:  Empathy: The Human Connection to Patient Care . [ 6 ]

2.2. basic communication concepts.

Effective communication is one of the Standards of Professional Performance established by the American Nurses Association. The standard states, “The registered nurse communicates effectively in all areas of practice.” [ 1 ]  There are several concepts related to effective communication such as demonstrating appropriate verbal and nonverbal communication, using assertive communication, being aware of personal space, and overcoming common barriers to effective communication.

Types of Communication

Verbal communication.

Effective communication requires each interaction to include a sender of the message, a clear and concise message, and a receiver who can decode and interpret that message. The receiver also provides a feedback message back to the sender in response to the received message. See Figure 2.1 [ 2 ]  for an image of effective communication between a sender and receiver.

Effective Communication

Nurses assist patients and their family members to understand health care needs and treatments by using verbal, nonverbal, and written communication. Verbal communication is more than just talking. Effective  verbal communication  is defined as an exchange of information using words understood by the receiver in a way that conveys professional caring and respect. [ 3 ]  Nurses who speak using extensive medical jargon or slang may create an unintended barrier to their own verbal communication processes. When communicating with others, it is important for the nurse to assess the receiver’s preferred method of communication and individual receiver characteristics that might influence communication, and subsequently adapt communication to meet the receiver’s needs. For example, the nurse may adapt postsurgical verbal instruction for a pediatric versus an adult patient. Although the information requirements regarding signs of infection, pain management, etc., might be similar, the way in which information is provided may be quite different based on developmental level. Regardless of the individual adaptations that are made, the nurse must be sure to always verify patient understanding.

Nonverbal Communication

In addition to communicating verbally, the nurse must also be aware of messages sent by  nonverbal communication . Nonverbal communication can have a tremendous impact on the communication experience and may be much more powerful than the verbal message itself. You may have previously learned that 80% of communication is nonverbal communication (see Figure 2.2 [ 4 ] ). The importance of nonverbal communication during communication has also been described in percentages of 55, 38, and 7, meaning 55% of communication is body language, 38% is tone of voice, and 7% is the actual words spoken. [ 5 ]

Nonverbal communication includes body language and facial expressions, tone of voice, and pace of the conversation. For example, compare the nonverbal communication messages in Figures 2.3 [ 6 ]  and 2.4 . [ 7 ]  What nonverbal cues do you notice about both toddlers?

Toddler’s Nonverbal Communication

Nurses should be attentive to their nonverbal communication cues and the messages they provide to patients and their families. Nurses should be purposeful in their use of nonverbal communication that conveys a feeling of caring. [ 8 ]  What nonverbal cues do you notice about the nurse in Figure 2.5 [ 9 ]  that provide a perception of professional caring?

Nurse’s Nonverbal Communication

Nurses use nonverbal communication such as directly facing patients at eye level, leaning slightly forward, and making eye contact to communicate they care about what the person is telling them and they have their full attention. [ 10 ]

It is common for health care team members in an acute care setting to enter a patient’s room and begin interacting with a patient who is seated or lying in bed. However, it is important to remember that initial or sensitive communication exchanges are best received by the patient if the nurse and patient are at eye level. Bringing a chair to the patient’s bedside can help to facilitate engagement in the communication exchange. SOLER is common mnemonic used to facilitate nonverbal communication (sit with open posture and lean in with good eye contact in a relaxed manner).

Communication styles.

In addition to verbal and nonverbal communication, people communicate with others using three styles. A passive communicator puts the rights of others before their own. Passive communicators tend to be apologetic or sound tentative when they speak and often do not speak up if they feel as if they are being wronged. Aggressive communicators, on the other hand, come across as advocating for their own rights despite possibly violating the rights of others. They tend to communicate in a way that tells others their feelings don’t matter. However, assertive communicators respect the rights of others while also standing up for their own ideas and rights when communicating. An assertive person is direct, but not insulting or offensive. [ 11 ]   Assertive communication  refers to a way of conveying information that describes the facts and the sender’s feelings without disrespecting the receiver’s feelings. Using “I” messages such as, “I feel…,” “I understand…,” or “Help me to understand…” are strategies for assertive communication. This method of communicating is different from aggressive communication that uses “you” messages and can feel as if the sender is verbally attacking the receiver rather than dealing with the issue at hand. For example, instead of saying to a coworker, “Why is it always so messy in your patients’ rooms? I dread following you on the next shift!,” an assertive communicator would use “I” messages to say, “I feel frustrated spending the first part of my shift decluttering our patients’ rooms. Help me understand why it is a challenge to keep things organized during your shift?”

Using assertive communication is an effective way to solve problems with patients, coworkers, and health care team members.

View this humorous video demonstrating assertive communication techniques being used by the actors on a TV show: Everybody Loves Raymond Uses Active Listening – from Parent Effectiveness Training.

Personal space.

While being aware of verbal and nonverbal messages and communicating assertively, it is also important to be aware of others’ personal space. Proxemics is the study of personal space and provides guidelines for professional communication. The public zone is over 10 feet of distance between people and generally avoids physical contact. The social zone is four to 10 feet of distance between people. It is used during social interactions and business settings. The personal zone is 18 inches to four feet of space and is generally reserved for friends and family. Less than 18 inches is reserved for close relationships but may be invaded when in crowds or playing sports. [ 12 ]  Nurses usually communicate within the social zone to maintain professional boundaries. However, when assessing patients and performing procedures, nurses often move into a patient’s personal zone. Nurses must be aware of patients’ feelings of psychological discomfort that can occur when invading this zone. Additionally, cultural considerations may impact the appropriateness of personal space when providing patient care. See Figure 2.6 for example of personal space zones. [ 13 ]

Personal Space Zones

Overcoming Common Barriers to Communication

It is important for you to reflect on personal factors that influence your ability to communicate effectively. There are many factors that can cause the message you are trying to communicate to become distorted and not perceived by the receiver in the way you intended. It is important to seek feedback that your message is clearly understood. Nurses must be aware of these potential barriers and try to reduce their impact by continually seeking feedback and checking understanding. [ 14 ]

Common barriers to communication in health care and strategies to overcome them are described in the following box. [ 15 ]

Common Barriers to Communication in Health Care

• Jargon:  Avoid using medical terminology, complicated, or unfamiliar words. When communicating with patients, explain information in plain language that is easy to understand by those without a medical or nursing background.
• Lack of attention:  Nurses are typically very busy with several tasks to complete for multiple patients. It is easy to become focused on the tasks instead of the patient. When entering a patient’s room, it is helpful to pause, take a deep breath, and mindfully focus on the patient in front of you to give them your full attention. Patients should feel as if they are the center of your attention when you are with them, no matter how many other things you have going on.
• Noise and other distractions:  Health care environments can be very noisy with people talking in the room or hallway, the TV blaring, alarms beeping, and pages occurring overhead. Create a calm, quiet environment when communicating with patients by closing doors to the hallway, reducing the volume of the TV, or moving to a quieter area, if possible.
• Light:  A room that is too dark or too light can create communication barriers. Ensure the lighting is appropriate according to the patient’s preference.
• Hearing and speech problems:  If your patient has hearing or speech problems, implement strategies to enhance communication. See the “Adapting Your Communication” section below for strategies to address hearing and speech problems.
• Language differences:  If English is not your patient’s primary language, it is important to seek a medical interpreter and to also provide written handouts in the patient’s preferred language when possible. Most agencies have access to an interpreter service available by phone if they are not available on-site.
• Differences in cultural beliefs:  The norms of social interaction vary greatly in different cultures, as well as the ways that emotions are expressed. For example, the concept of personal space varies among cultures, and some patients are stoic about pain whereas others are more verbally expressive. Read more about caring for diverse patients in the “ Diversity ” chapter.
• Psychological barriers:  Psychological states of the sender and the receiver affect how the message is sent, received, and perceived. For example, if nurses are feeling stressed and overwhelmed with required tasks, the nonverbal communication associated with their messages such as lack of eye contact, a hurried pace, or a short tone can affect how the patient perceives the message. If a patient is feeling stressed, they may not be able to “hear” the message or they may perceive it differently than it was intended. It is important to be aware of signs of the stress response in ourselves and our patients and implement appropriate strategies to manage the stress response. See the box below for more information about strategies to manage the stress response.
• Physiological barriers:  It is important to be aware of patients’ potential physiological barriers when communicating. For example, if a patient is in pain, they are less likely to hear and remember what was said, so pain relief should be provided as needed before providing patient education. However, it is also important to remember that sedatives and certain types of pain medications often impair the patient’s ability to receive and perceive messages so health care documents cannot be signed by a patient after receiving these types of medications.
• Physical barriers for nonverbal communication:  Providing information via e-mail or text is often less effective than face-to-face communication. The inability to view the nonverbal communication associated with a message such as tone of voice, facial expressions, and general body language often causes misinterpretation of the message by the receiver. When possible, it is best to deliver important information to others using face-to-face communication so that nonverbal communication is included with the message.
• Differences in perception and viewpoints:  Everyone has their own beliefs and perspectives and wants to feel “heard.” When patients feel their beliefs or perspectives are not valued, they often become disengaged from the conversation or the plan of care. Nurses should provide health care information in a nonjudgmental manner, even if the patient’s perspectives, viewpoints, and beliefs are different from their own.

Read more about  Barriers to Effective Communication.

Managing the Stress Response [ 16 ]

The stress response is a common psychological barrier to effective communication. It can affect the message sent by the sender or how it is received by the receiver. The stress response is a common reaction to life events, such as a nurse feeling stressed by being overwhelmed with tasks to complete for multiple patients, or a patient feeling stressed when admitted to a hospital or receiving a new diagnosis. Symptoms of the stress response include irritability, sweaty palms, a racing heart, difficulty concentrating, and impaired sleep. It is important to recognize symptoms of the stress response in ourselves and our patients and use strategies to manage the stress response when communicating. Strategies to manage the stress response are as follows:

Use  relaxation breathing . Become aware of your breathing. Take a deep breath in your nose and blow it out through your mouth. Repeat this process at least three times in succession and then as often as needed throughout the day.

Make healthy diet choices. Avoid caffeine, nicotine, and junk food because these items can increase feelings of anxiety or being on edge.

Make time for exercise. Exercise stimulates the release of natural endorphins that reduce the body’s stress response and also helps to improve sleep.

Get enough sleep. Set aside at least 30 minutes before going to bed to wind down from the busyness of the day. Avoid using electronic devices like cell phones before bedtime because the backlight can affect sleep.

Use  progressive relaxation . There are several types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. Progressive relaxation generally includes the following steps:

• Start by lying down somewhere comfortable and firm, like a rug or mat on the floor. Get yourself comfortable.
• Relax and try to let your mind go blank. Breathe slowly, deeply, and comfortably, while gradually and consciously relaxing all your muscles, one by one.
• Work around the body one main muscle area at a time, breathing deeply, calmly, and evenly. For each muscle group, clench the muscles tightly and hold for a few seconds, and then relax them completely. Repeat the process, noticing how it feels. Do this for each of your feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, and face.

2.3. COMMUNICATING WITH PATIENTS

Therapeutic communication is a type of professional communication used by nurses with patients and defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.” [ 1 ]  Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. [ 2 ]  Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

An Example of Nursing Student Using Therapeutic Communication

Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [ 3 ] , [ 4 ]

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During  active listening , we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening. [ 5 ]

Touch  is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 2.7 [ 6 ]  for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Using Touch as Therapeutic Communication

Therapeutic Techniques

Therapeutic communication techniques  are specific methods used to provide patients with support and information while focusing on their concerns. Nurses assist patients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using  therapeutic communication , nurses often ask open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. [ 7 ]   Table 2.3a describes a variety of therapeutic communication techniques. [ 8 ]

Therapeutic Communication Techniques

In addition to the therapeutic techniques listed in Table 2.3a , nurses and nursing students should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. [ 9 ]  Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors. [ 10 ]

Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several  nontherapeutic responses  to avoid. These responses often block the patient’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses. [ 11 ]

Nontherapeutic Responses

Strategies for Effective Communication

In addition to using therapeutic communication techniques, avoiding nontherapeutic responses, and overcoming common barriers to communication, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like? [ 12 ]

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized patients include the following:

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the patient’s treatment plan and progress. This information helps you to provide safe patient care as changes occur and also to accurately answer the patient’s questions.
• Review information periodically with the patient to improve understanding.
• Use patient communication boards in their room to set goals and communicate important reminders with the patient, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives patients and families the feeling that they always know the current plan of care. However, keep patient confidentiality in mind regarding information to publicly share on the board that visitors may see.
• Provide printed information on medical procedures, conditions, and medications. It helps patients and family members to have multiple ways to provide information. [ 13 ]

Adapting Your Communication

When communicating with patients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to the patient’s age and developmental level includes the following strategies:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with patients who have impaired hearing and vision. [ 14 ]

Strategies for Communicating with Patients with Impaired Hearing and Vision

Impaired Hearing

• Gain the patient’s attention before speaking (e.g., through touch)
• Minimize background noise
• Position yourself 2-3 feet away from the patient
• Facilitate lip-reading by facing the patient directly in a well-lit environment
• Use gestures, when necessary
• Listen attentively, allowing the patient adequate time to process communication and respond
• Refrain from shouting at the patient
• Ask the patient to suggest strategies for improved communication (e.g., speaking toward better ear and moving to well-lit area)
• Face the patient directly, establish eye contact, and avoid turning away mid sentence
• Simplify language (i.e., do not use slang but do use short, simple sentences), as appropriate
• Note and document the patient’s preferred method of communication (e.g., verbal, written, lip-reading, or American Sign Language) in plan of care
• Assist the patient in acquiring a hearing aid or assistive listening device
• Refer to the primary care provider or specialist for evaluation, treatment, and hearing rehabilitation [ 15 ]

Impaired Vision

• Identify yourself when entering the patient’s space
• Ensure the patient’s eyeglasses or contact lenses have current prescription, are cleaned, and stored properly when not in use
• Provide adequate room lighting
• Minimize glare (i.e., offer sunglasses or draw window covering)
• Provide educational materials in large print
• Apply labels to frequently used items (i.e., mark medication bottles using high-contrasting colors)
• Read pertinent information to the patient
• Provide magnifying devices
• Provide referral for supportive services (e.g., social, occupational, and psychological) [ 16 ]

Patients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to portions of the brain that are responsible for language.  Aphasia  usually occurs suddenly, often following a stroke or head injury, and impairs the patient’s expression and understanding of language.  Global aphasia  is caused by injuries to multiple language-processing areas of the brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly important for understanding spoken language, accessing vocabulary, using grammar, and producing words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. [ 17 ]

The most common type of aphasia is  Broca's aphasia . People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. They are often aware of their difficulties and can become easily frustrated. See the hyperlink in the box below for evidence-based strategies to enhance communication with a person with impaired speech. [ 18 ]

Read more about  aphasia .

Strategies to improve communication with patients with impaired speech.

• Modify the environment to minimize excess noise and decrease emotional distress
• Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect
• Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
• Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, and computer)
• Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit family’s assistance in understanding the patient’s speech)
• Ensure the call light is within reach and central call light system is marked to indicate the patient has difficulty with speech
• Repeat what the patient said to ensure accuracy
• Instruct the patient to speak slowly
• Collaborate with the family and a speech therapist to develop a plan for effective communication [ 19 ]

Maintaining Patient Confidentiality

When communicating with patients, their friends, their family members, and other members of the health care team, it is vital for the nurse to maintain patient confidentiality. The  Health Insurance Portability and Accountability Act (HIPAA)  provides standards for ensuring privacy of patient information that are enforceable by law. Nurses must always be aware of where and with whom they share patient information. For example, information related to patient care should not be discussed in public areas, paper charts must be kept in secure areas, computers must be logged off when walked away from, and patient information should only be shared with those directly involved in patient care. For more information about patient confidentiality, see the “ Legal Considerations & Ethics ” section in the “Scope of Practice” chapter.

Read more information about the  Health Insurance Portability and Accountability Act of 1996 (HIPAA) .

2.4. communicating with health care team members.

Professional communication with other members of the health care team is an important component of every nurse’s job. See Figure 2.8 [ 1 ]  for an image illustrating communication between health care team members. Common types of professional interactions include reports to health care team members, handoff reports, and transfer reports.

Interprofessional Communication

Reports to Health Care Team Members

Nurses routinely report information to other health care team members, as well as urgently contact health care providers to report changes in patient status.

Standardized methods of communication have been developed to ensure that information is exchanged between health care team members in a structured, concise, and accurate manner to ensure safe patient care. One common format used by health care team members to exchange patient information is  ISBARR , a mnemonic for the components of  I ntroduction,  S ituation,  B ackground,  A ssessment,  R equest/Recommendations, and  R epeat back.

• Introduction:  Introduce your name, role, and the agency from which you are calling.
• Situation:  Provide the patient’s name and location, why you are calling, recent vital signs, and the status of the patient.
• Background:  Provide pertinent background information about the patient such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
• Assessment:  Share abnormal assessment findings and your evaluation of the current patient situation.
• Request/Recommendations:  State what you would like the provider to do, such as reassess the patient, order a lab/diagnostic test, prescribe/change medication, etc.
• Repeat back:  If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the patient’s chart.

Read an example of an ISBARR report in the following box. A hyperlink is provided to a printable ISBARR reference card.

Sample ISBARR Report From a Nurse to a Health Care Provider

I: “Hello Dr. Smith, this is Jane White, RN from the Med Surg unit.”

S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96%, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”

B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”

A: “I just assessed the surgical site and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Otherwise, her lungs are clear and her heart rate is regular.”

R: “I am calling to request an order for a CBC and increased dose of pain medication.”

R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”

View or print an  ISBARR reference card

Handoff Reports

Handoff reports  are defined by The Joint Commission as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the patient’s care.” [ 2 ]  In 2017, The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in patient harm such as wrong-site surgeries, delays in treatment, falls, and medication errors. Strategies for improving handoff communication have been implemented at agencies across the country.

Although many types of nursing shift-to-shift handoff reports have been used over the years, evidence strongly supports that  bedside handoff reports  increase patient safety, as well as patient and nurse satisfaction, by effectively communicating current, accurate patient information in real time. [ 3 ]  See Figure 2.9 [ 4 ]  for an image illustrating two nurses participating in a handoff report. Bedside reports typically occur in hospitals and include the patient, along with the off-going and the oncoming nurses in a face-to-face handoff report conducted at the patient’s bedside. HIPAA rules must be kept in mind if visitors are present or the room is not a private room. Family members may be included with the patient’s permission. See a sample checklist for a bedside handoff report from the Agency for Healthcare Research and Quality in Figure 2.10 . [ 5 ]  Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts. For example, the “assessment” portion of the bedside handoff report includes detailed pertinent data the oncoming nurse needs to know, such as current head-to-toe assessment findings to establish a baseline; information about equipment such as IVs, catheters, and drainage tubes; and recent changes in medications, lab results, diagnostic tests, and treatments.

Bedside Handoff Report

Figure 2.10

Bedside Handoff Report Checklist

Print a copy of the  AHRQ Bedside Shift Report Checklist. View  Sample Information to Include in a Shift Report.

View a video on creating shift reports. [ 6 ].

Transfer Reports

Transfer reports are provided by nurses when transferring a patient to another unit or to another agency. Transfer reports contain similar information as bedside handoff reports, but are even more detailed when the patient is being transferred to another agency. Checklists are often provided by agencies to ensure accurate, complete information is shared.

2.5. DOCUMENTATION

Using technology to access information.

Most patient information in acute care, long-term care, and other clinical settings is now electronic and uses intranet technology for secure access by providers, nurses, and other health care team members to maintain patient confidentiality. Intranet refers to a private computer network within an institution. An  electronic health record (EHR)  is a real-time, patient-centered record that makes information available instantly and securely to authorized users. [ 1 ]  Computers used to access an EHR can be found in patient rooms, on wheeled carts, in workstations, or even on handheld devices. See Figure 2.11 [ 2 ]  for an image of a nurse documenting in an EHR.

Figure 2.11

Nurse Documenting in EHR

The EHR for each patient contains a great deal of information. The most frequent pieces of information that nurses access include the following:

• History and Physical (H&P):  A history and physical (H&P) is a specific type of documentation created by the health care provider when the patient is admitted to the facility. An H&P includes important information about the patient’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
• Provider orders:  This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
• Medication Administration Records (MARs):  Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
• Treatment Administration Records (TARs):  In many facilities, treatments are documented on a treatment administration record.
• Laboratory results:  This section includes results from blood work and other tests performed in the lab.
• Diagnostic test results:  This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
• Progress notes:  This section contains notes created by nurses and other health care providers regarding patient care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.

View a video of how to read a patient’s chart. [ 3 ]

Legal Documentation

Nurses and health care team members are legally required to document care provided to patients. In a court of law, the rule of thumb used is, “If it wasn’t documented, it wasn’t done.” Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. All types of documentation must include the date, time, and signature of the person documenting. Any type of documentation in the EHR is considered a legal document and must be completed in an accurate and timely manner. Abbreviations should be avoided in legal documentation.

Documentation is used for many purposes. It is used to ensure continuity of care across health care team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.

Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the “Planning” section of the “ Nursing Process ” chapter.

Common Types of Documentation

Common formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.

Charting by Exception

Charting by exception (CBE)  documentation was designed to decrease the amount of time required to document care. CBE contains a list of normal findings. After performing an assessment, nurses confirm normal findings on the list found on assessment and write only brief progress notes for abnormal findings or to document communication with other team members.

Focused DAR Notes

Focused DAR notes are a type of progress note that are commonly used in combination with charting by exception documentation.  DAR  stands for  D ata,  A ction, and  R esponse. Focused DAR notes are brief. Each note is focused on one patient problem for efficiency in documenting and reading.

• Data:  This section contains information collected during the patient assessment, including vital signs and physical examination findings found during the “Assessment” phase of the nursing process. The Assessment phase is further discussed in the “ Nursing Process ” chapter.
• Action:  This section contains the nursing actions that are planned and implemented for the patient’s focused problem. This section correlates to the “Planning” and “Implementation” phases of the nursing process and are further discussed in the “ Nursing Process ” chapter.
• Response:  This section contains information about the patient’s response to the nursing actions and evaluates if the planned care was effective. This section correlates to the “Evaluation” phase of the nursing process that is further discussed in the “ Nursing Process ” chapter.

View sample charting by exception  paper documentation  with associated DAR notes for abnormal findings.

For more information about writing dar notes, visit  what is f-dar charting, view a video explaining f-dar charting. [ 4 ].

Narrative Notes

Narrative notes  are a type of progress note that chronicles assessment findings and nursing activities for the patient that occurred throughout the entire shift or visit. View sample narrative note documentation according to body system in each assessment chapter of the  Open RN   Nursing Skills  textbook.

SOAPIE Notes

SOAPIE  is a mnemonic for a type of progress note that is organized by six categories:  S ubjective,  O bjective,  A ssessment,  P lan,  I nterventions, and  E valuation. SOAPIE progress notes are written by nurses, as well as other members of the health care team.

• Subjective:  This section includes what the patient said, such as, “I have a headache.” It can also contain information related to pertinent medical history and why the patient is in need of care.
• Objective:  This section contains the observable and measurable data collected during a patient assessment, such as the vital signs, physical examination findings, and lab/diagnostic test results.
• Assessment:  This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
• Plan:  This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
• Interventions:  This section describes the actions implemented.
• Evaluation:  This section describes the patient response to interventions and if the planned outcomes were met.

Patient Discharge Summary

When a patient is discharged from an agency, a discharge summary is documented in the patient record, along with clear verbal and written patient education and instructions provided to the patient. Discharge summary information is frequently provided in a checklist format to ensure accuracy and includes the following:

• Time of departure and method of transportation out of the hospital (e.g., wheelchair)
• Name and relationship of person accompanying the patient at discharge
• Condition of the patient at discharge
• Patient education completed and associated educational materials or other information provided to the patient
• Discharge instructions on medications, treatments, diet, and activity
• Follow-up appointments or referrals given

See Figure 2.12 [ 5 ]  for an image of a nurse providing discharge instructions to a patient. Discharge teaching typically starts at admission and continues throughout the patient’s stay.

Figure 2.12

Discharge Teaching

Minimum Data Set (MDS) Charting

In long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument  Minimum Data Set (MDS)  is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life. [ 6 ]  This tool also guides nursing care plan development.

Read more details about MDS charting in the  Long-Term Care Facility Resident Assessment User Manual  established by the Centers for Medicare and Medicaid Services (CMS).

2.6. putting it all together.

Patient Scenario

Mr. Hernandez is a 47-year-old patient admitted to the neurological trauma floor as the result of a motor vehicle accident two days ago. The patient sustained significant facial trauma in the accident and his jaw is wired shut. His left eye is currently swollen, and he had significant bruising to the left side of his face. The nurse completes a visual assessment and notes that the patient has normal extraocular movement, peripheral vision, and pupillary constriction bilaterally. Additional assessment reveals that Mr. Hernandez also sustained a fracture of the left arm and wrist during the accident. His left arm is currently in a cast and sling. He has normal movement and sensation with his right hand. Mrs. Hernandez is present at the patient’s bedside and has provided additional information about the patient. She reports that Mr. Hernandez’s primary language is Spanish but that he understands English well. He has a bachelor’s degree in accounting and owns his own accounting firm. He has a history of elevated blood pressure, but is otherwise healthy.

The nurse notes that the patient’s jaw is wired and he is unable to offer a verbal response. He does understand English well, has appropriate visual acuity, and is able to move his right hand and arm.

Based on the assessment information that has been gathered, the nurse plans several actions to enhance communication. Adaptive communication devices such as communication boards, symbol cards, or electronic messaging systems will be provided. The nurse will eliminate distractions such as television and hallway noise to decrease sources of additional stimuli in the communication experience.

Sample Documentation

Mr. Hernandez has impaired verbal communication due to facial fracture and inability to enunciate words around his wired jaw. He understands both verbal and written communication. Mr. Hernandez has left sided facial swelling, but no visual impairment. He has a left arm fracture but is able to move and write with his right hand. The patient is supplied with communication cards and marker board. He responds appropriately with written communication and is able to signal his needs.

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Practice what you have learned in this chapter by completing these learning activities. When accessing the online activities that contain videos, it is best to use Google Chrome or Firefox browsers.

To test understanding of these terms, try an online quiz: Therapeutic Communication Techniques vs. Non-therapeutic Communication Techniques Quizlet

Consider the following scenario and describe actions that you might take to facilitate the patient communication experience.

You are caring for Mr. Curtis, an 87-year-old patient newly admitted to the medical surgical floor with a hip fracture. You are preparing to complete his admission history and need to collect relevant health information and complete a physical exam. You approach the room, knock at the door, complete hand hygiene, and enter. Upon entry, you see Mr. Curtis is in bed surrounded by multiple family members. The television is on in the background and you also note the sound of meal trays being delivered in the hallway.

Based on the described scenario, what actions might be implemented to aid in your communication with Mr. Curtis?

• II GLOSSARY

A communication disorder that results from damage to portions of the brain that are responsible for language.

A way to convey information that describes the facts, the sender’s feelings, and explanations without disrespecting the receiver’s feelings. This communication is often described as using “I” messages: “I feel…,” “I understand…,” or “Help me to understand…”

A handoff report in hospitals that involves patients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the patient’s bedside.

A type of aphasia where patients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca’s aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated.

A type of documentation where a list of “normal findings” is provided and nurses document assessment findings by confirming normal findings and writing brief documentation notes for any abnormal findings.

A type of documentation often used in combination with charting by exception. DAR stands for Data, Action, and Response. Focused DAR notes are brief, and each note is focused on one patient problem for efficiency in documenting, as well as for reading.

A digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.

A process of exchanging vital patient information, responsibility, and accountability between the off-going and incoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices.

A mnemonic for the format of professional communication among health care team members that includes Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

A federally mandated assessment tool used in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life.

A type of documentation that chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift.

Responses to patients that block communication, expression of emotion, or problem-solving.

Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness.

A breathing technique used to reduce anxiety and control the stress response.

A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.

The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.

Techniques that encourage patients to explore feelings, problem solve, and cope with responses to medical conditions and life events.

Exchange of information using words understood by the receiver.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 2 Communication.
• PDF version of this title (216M)

In this Page

• COMMUNICATION INTRODUCTION
• BASIC COMMUNICATION CONCEPTS
• COMMUNICATING WITH PATIENTS
• COMMUNICATING WITH HEALTH CARE TEAM MEMBERS
• DOCUMENTATION
• PUTTING IT ALL TOGETHER
• LEARNING ACTIVITIES

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