Medical Surgical

Huntington’s Disease

Huntington;s disease is a chronic, hereditary disease of the nervous system that results in progressive involuntary choreiform (dance-like) movements and dementia.  Researchers believe that glutamine abnormally collects in certain brain cell nuclei, causing cell death.  Huntington’s disease affects men and women of all races. It is transmitted as an autosomal dominant genetic disorder. Each child of a parent with Huntington’s has a 50% risk of inheriting the illness. Onset usually occurs between 35 and 45 years of age.


  • The most prominent clinical features are abnormal involuntary movements (chorea), intellectual decline, ans emotional disturbance.
  • Constant writhing, twisting and uncontrollable movements of the entire body as the disease progresses.
  • Facial movements produce tics and grimaces; speech becomes slurred, hesitant, often explosive, and then eventually unintelligible.
  • Chewing and swallowing are difficult, and aspiration and choking are dangers.
  • Gait becomes disorganized, and ambulation is eventually impossible; patient is eventually confined to a wheelchair.
  • Bowel and bladder control is lost.
  • Progressive intellectual impairment occurs with eventual dementia.
  • Uncontrollable emotional changes occur but become less acute as the disease progresses. Patient may be nervous, irritable, impatient. During the early stages of illness: uncontrollable fits of anger; profound , often suicidal depression; apathy; or euphoria.
  • Hallucinations, delusions, and paranoid thinking may precede appearance of disjointed movements.
  • Patient dies in 10 to 15 years from heart failure, pneumonia, or infection or as a result of a fall or choking.


  • Diagnosis is made on the basis of clinical presentation, positive family history, and exclusion of other causes.
  • Imaging studies, such as computed tomography (CT), and magnetic resonance imaging (MRI), may show atrophy of striatum.
  • A genetic marker for Huntington;s disease has been located. It offers no hope pf cure or even specific determination of onset.


No treatment stops or reverse the process; palliative care is given.

  • Medications such as phenothiazines (haloperidol), butyrophenones, and thioxanthenes, which block dopamine receptors, and reserpine  and tetrabenazine. Anti-parkinsonism therapy (L-dopa) may improve chorea and temporarily decrease rigidity in some patients.
  • Motor signs are continually assessed and evaluated. Akathisia (motor restlessness) in the overmedicated patient is dangerous and should be reported.
  • Psychotherapy aimed at allaying anxiety and reducung stress may be beneficial; antidepressants are given for depression or suicidal ideation.
  • Patients needs and abilities are the focus of treatment.


  • Reinforcing understanding that Huntington;s disease takes emotions, physical, social and financial tolls on every member of the patients family.
  • Encourage genetic counseling, long-term psychological counseling, marriage counseling, and financial and legal support.
  • Teach patient and family about medications, including signs indicating need for change in dosage and medication.
  • Address strategies to manage symptoms (chorea, swallowing problems, ambulation problems, or altered bowel or bladder function).
  • Arrange for consultation with a speech therapist, if needed.
  • emphasize the need for regular follow-up.
  • Refer for home care nursing assistance, respite care, day care centers, and eventually skilled long-term care to assist patient and family to cope.
  • Provide information about the Huntington’s Disease Foundation of America, which gives information, referrals, education, and support for research.



Handbook for brunner & Suddarth’s textbook in Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.450-452

Medical Surgical

Hodgkin’s Disease

Hodgkin’s disease is a rare cancer of unknown cause that is unicentric in origin and spreads along the lymphatic system. There is a familial pattern associated with Hodkin’s as well as an association with the Epstein-Barr virus (found 40% to 50% of patients). It is more common in men and tends to peak in the early 20s and after 50 years of age.  The Reed-Sternberg cell, a gigantic morphologically unique tumor cell that is thought to be  of immature lymphoid origin, is the pathologic hallmark and essential diagnostic criterion of Hodgkin’s disease. Most patients with Hodgkin’ disease have the types currently designated “nodular sclerosis” or “mixed cellularity”. The nodular sclerosis type tends to occur more often in young women ans at an earlier stage but has a worse prognosis than the  mixed cellularity subgroup. which occurs more commonly in men and causes more constitutional symptoms but has a better prognosis.


  • Painless enlargement of the lymph nodes on one side of the neck. Individual nodes are firm and painless; common sites are the cervical, supraclavicular, and mediastinal nodes.
  • Mediastinal lymh nodes may be visible on x-ray films and large enough to cause severe pressure symptoms (eg. dyspnea from pressure against the trachea; dysphagia from pressure against the esophagus).
  • Symptoms may result from the tumor compressing other organs, causing cough and pulmonary effusion (from pulmonary infiltrates); jaundice (from hepatic involvement or bile duct obstruction); abdominal pain (from splenomegaly or retroperitoneal adenopathy); or bone pain (due to skeletal involvement).
  • Pruritus is common and can be distressing; unclear etiology Herpes zoster  infection is common.
  • Some patients (20%) experience brief but severe pain after drinking alcohol, usually at the site of the tumor.
  • Mild anemia develops; the white blood cell count may be elevated or decreased; and energy (an absence of or decreased response to skin sensitivity tests such as candidal infection, mumps) may be noted.
  • Constitutional symptoms for prognostic purpose referred to as B symptoms, include fever (without chills), drenching sweats (particularly at night), and unintentional loss of more than 10% of body weight (found in 40% of patients and more common in advanced disease).


Diagnostic depends on identification of characteristic histologic features in an excised lymph node. After the diagnosis is confirmed, the total extent of tumor involvement is assessed and its distribution is defined.

  • Laboratory studies: complete blood count; platelet count, sedimentation rate, liver and renal function studies, RBC sedimentation rate and serum copper levels are used by some clinicians to assess disease activity.
  • Excisional  lymph node biopsy, bone marrow biopsy, characteristic presence of Reed-sternberg cell; staging of node.
  • Chest x-ray and computed tomography (CT) of chest, abdomen, and pelvis; positron emission tomography (PET) to detect residual disease.


Treatment id determined by the stage of the disease instead of the histologic type.

  • Chemotherapy followed by radiation therapy is used in early-stage disease.
  • Combination chemotherapy alone is now the standard treatment for more advanced disease.
  • When Hodgkin;s does recur, the use of high doses of chemotherapeutic medications, followed by autologous bone marrow or stem-cell transplantation, can be very effective.


  • Help patients to cope with undesirable effects of radiation therapy including esophagitis, anorexia, loss of taste, dry mouth, nausea and vomiting, diarrhea, skin reactions, and lethargy.
  • Serve bland, soft foods at mild temperature.
  • Teach patient about proper dental hygiene.
  • Administer antiemetics during peak times of nausea.
  • Teach patient that skin reactions are common; rubbing the area and applying heat, cold or lotion should be avoided.
  • Encourage patient to rest and sleep to maintain a  reasonable energy level; lethargy accompanies radiation.
  • Help patient to prepare for alopecia by encouraging him or her to purchase a wig before hair loss.
  • Encourage patient to report any sign of infection for immediate treatment.
  • Instruct patient to use contraception during chemotherapy to prevent cytotoxic effects on the fetus.
  • Encourage patient to keep all follow-up appointments.



Handbook for Brunner & Suddarth’s textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.447-450




Medical Surgical

Hyperthyroidism (Grave’s disease)

Hyperthyroidism is the second most common endocrine disorder and Grave’s disease is the most common type. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland  by circulating immunoglobulins. Long-acting thyroid stimulator (LATS) is found significant in concentrations in the serum of many of these patients. The disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It may appear after an emotional shock, stress, or infection, but the exact significance of these relationships is not understood. Other common causes include thyroiditis and excessive ingestion of thyroid hormone (eg. from treatment of hypothyroidism)


Hyperthyroidism presents a characteristic  group of signs and symptoms (thyrotoxicosis).

  • Nervousness (emotionally hyperexcitable), irritability, apprehensiveness; inability to sit quietly; palpitations, rapid  pulse on rest and exertion.
  • Poor tolerance of heat; excessive perspiration; skin that is flushed and likely to be warm, soft and moist
  • Dry skin and diffuse pruritus in the elderly
  • Fine tremor of the hands
  • Exophthalmos (bulging eyes) in some patients
  • Increased appetite and dietary intake, progressive loss of weight, abnormal muscle fatigability, weakness, amenorrhea, and changes in bowel function (constipation or diarrhea)
  • Pulse ranges between 90 and 160 beats/min with sinus tachycardia or dysrhythmias; systolic (but not diastolic) blood pressure elevation (increased pulse pressure).
  • Atrial fibrillation; cardiac decompensation in the form of congestive heart failure, especially in the elderly
  • Osteoporosis and fracture
  •  May include remissions and exacerbations, terminating with spontaneous recovery in a few months or years
  • May progress relentlessly; causing emaciation, intense nervousness, delirium, disorientation, and eventually myocardial hypertrophy and heart failure.


  • Thyroid glands is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries
  • Laboratory tests show a decrease in serum TSH, an increase in serum thyroxine (T4) level and an increase in 123I or 125I uptake in excess of 50%.

Gerontologic Considerations

Elderly patients commonly presents with vague and nonspecific signs and symptoms. The major symptoms in the elderly patient may be depression and apathy, accompanied by significant weight loss and constipation in some. The patient may report cardiovascular symptoms and difficulty climbing stairs  or rising from a chair because of muscle weakness; congestive failure may be noted. Elderly patients may experience a single manifestation, such as atrial fibrillation, anorexia, or weight loss.  These general symptoms may mask underlying thyroid disease. Spontaneous remission of hyperthyroidism is rare in the elderly. Measurement of thyroid-stimulating hormone (TSH) uptake is indicated in elderly patients with unexplained physical or mental deterioration . Use of 123I or 131I is generally recommended for treatment of thyrotoxicosis rather than surgery unless an enlarged thyroid gland is pressing on the airway. Thyrotoxicosis must be controlled by antithyroid drugs before 131I is used because radiation may precipitate thyroid storm, which has a high mortality rate in the elderly.  Beta-blockers may be indicated. Use these agents with extreme caution ans monitor closely for granulocytopenia. Modify dosages of other medications because of the altered rate of metabolism in hyperthyroidism.


Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. These forms of treatment are available:

  • Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland.
  • Pharmacotherapy with antithyroid medications.
  • Surgery with the removal of the most of the thyroid gland.

Radioactive Iodine (131 I)

  • 131 I is given to destroy the overactive thyroid cells (most common in the elderly).
  • 131 I is contraindicated in pregnancy and nursing mothers because radioiodine crosses the placenta and is secreted in breast milk.


  • The objective of pharmacotherapy is to inhibit hormone synthesis or release and reduce the amount of thyroid tissue.
  • The most commonly used medicatioins are propylthiouracil (Propacil, PTU) and methimazole (Tapazole) until patient is euthyroid.
  • Maintenance dose is established, followed by gradual withdrawal of the medication over the next several months.
  • Antithyroid drugs are contraindicated in late pregnancy because of the risk for goiter and cretinism in the fetus.
  • Thyroid hormone may be administered to put the thyroid to rest.

Adjunctive Therapy

  • Potassium iodide, Lugol’s solution, and saturated solution of potassium iodide (SSKI) may be added.
  • Beta-adrenergic agents may be used to control the sympathetic nervous system effects that occur in hyperthyroidism; for example; propanolol is used for nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Surgical Intervention

  • Surgical intervention (reserved for special circumstances)removes about five sixths of the thyroid tissue.
  • Before surgery, the patient is given propylthiouracil until signs of hyperthyroidism have disappeared.
  • Iodine is prescribed to reduce the thyroid size and vascularity and blood loss. Patient is monitored carefully for evidence of iodine toxicity (swelling buccal mucosa, excessive salivation, skin eruptions).
  • Risk for relapse and complications necessitates long-term follow-up of patient undergoing treatment of hyperthyroidism.
  • Surgery to treat hyperthyroidism is performed after thyroid function has returned to normal (4 to 6 weeks).



Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams and Wilkins pp.461-464

Medical Surgical

Parkinson’s Disease

Parkinson’s disease is a slowly progressive degenerative  neurologic disorder affecting the brain center that are responsible for control and regulation of movement. The degenerative or idiopathic form of Parkinson’s disease is the most common; there is also a secondary form with a known or suspected cause. The cause of the disease is mostly unknown. The disease usually first appears in the fifth decade of life and is the fourth most common neurodegenerative disease.


Stores of the neuotransmitter dopamine are lost in the substantia nigra ans the corpus striatum because of a degenerative process. The loss pf dopamine stores in this area of the brain results in excitatory neurotransmitter than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement . Other neurotransmitter pathways (responsible for cell metabolism, growth, nutrition, and so forth) may be involved as well. Cellular degeneration causes impairment of the extrapyramidal tracts that control semiautomatic functions and coordinated movements. Regional cerebral blood flow  is reduced, and there is a high prevalence of dementia. Biochemical and pathologic data suggest  that patients with Parkinson’s disease and dementia may have coexistent Alzheimer’s disease.


The three cardinal signs of Parkinson’s disease are tremor, rigidity, and bradykinesia (abnormally slow movements).

  • Impatient movement: bradykinesia includes difficulty in initiating, maintaining, and performing motor activities, muscle stiffness or rigidity
  • Resting tremors: a slow unilateral turning of the forearm and hand and pill-rolling motion of the thumb against the fingers; tremors at rest and increasing with concentration and anxiety
  • Muscle weakness
  • Hypokinesia (abnormally diminished movement), gait disturbances, flexed posture, and postural instability (loss of postural reflexes, and the freezing phenomenon)


Patients tend to develop micrographia (shrinking, slow hand-writing) as dexterity declines. Additional characteristics include:

  • Dysphonia (soft, slurred, low-pitched, and less audible speech)
  • Masklike facial expression
  • Loss of postural reflexes: patients stand with head bent forward and walks with propulsive gait ( shuffling gait); difficulty pivoting and loss of balance, resulting in risk for falls.
  • Depression and psychiatric manifestaitons (personality changes, psychosis, dementia, and confusion)
  • Sleep disorders, uncontrolled sweating, orthostatic hypotension, gastric and urinary retention, and constipation


  • Patient’s history and presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia
  • Positron emission tomography (PET) scanning
  • Neurologic examination and response to pharmacologic management


Goal of treatment is to control symptoms and maintain functional independence; no approach prevents disease progression.

Pharmacologic Therapy

  • Levodopa therapy ( converts to dopamine): most effective agent to relieve symptoms; usually given in combination with carbidopa (Sinemet), which prevents levodopa breakdown.
  • Budipine is a non-dopaminergic, antiparkinson medication that significantly reduce akinesia, rigidity, and tremor.
  • Antihistamine drugs to allay tremors.
  • Dopamine agonists (eg. pergolide [Permax], bromocriptine mesylate [Parlodel], ropinirole, and pramipexole are used to postpone the initiation of carbidopa and levodopa therapy.
  • Anticholinergic therapy to control the tremor and rigidity.
  • Amantadine hydrochloride  (Symmetrel), an antiviral agent, to reduce rigidity, tremor and bradykinesia.
  • Monoamine oxidase inhibitors (MAOI’s) to inhibit dopamine breakdown
  • Anntidepressant drugs
  • Trials of catechol-O-methyltransferase (COMT) inhibitors.

Surgical Management

  • Surgery to destory a part of the thalamus (stereotactic thalamotomy and pallidotomy) to interrupt nerve pathways and alleviate tremor or rigidity.
  • Transplantation of neural cells from fetal tissue of human or animal source to reestablish normal dopamine release.
  • Deep brain stimulation with pacemaker-like brain implants shows promise but is waiting for FDA approval.




Handbook for Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp. 594-596

Medical Surgical

Cancer of the Cervix


Cancer of the cervix is predominantly (90%) squamous cell cancer and can include adenocarcinomas. It is less common than it once was because of early detection by the Pap test, but it remains the third most common reproductive cancer in women. it occurs most commonly between the ages of 35 and 45 years but can occur in women as young as 18 years. Risk factors vary from multiple sex partners to smoking to chronic cervical infection (exposure to HP virus).



  • Cervical cancer is most often asymptomatic. When discharge, irregular bleeding, or bleeding after sexual intercourse occurs, the disease may be advanced.
  • Vaginal discharge gradually increases in amount, becomes watery, and finally is dark ans foul-smelling because of necrosis of the tumor mass.
  • Bleeding occurs at irregular intervals between periods or after menopause, may be slight (enough to spot the undergarment), and is usually noted after mild trauma (intercourse, douching, or defecation). As disease continues, bleeding may persist and increase.
  • Nerve involvement, producing excruciating pain the back and legs, occurs as cancer advances and tissues outside the cervix are invaded, including the fundus and lymph glands anterior to the sacrum.
  • Extreme emaciation and anemia, often with fever due to secondary infection and abscesses in the ulcerating mass, and fistula formation may occur in the final stage.


  • Pap smear and biopsy results show severe dysplasia, HGSIL, or carcinoma in situ.
  • Abnormal Pap test may be followed by biopsy, dilation and curettage (D & C), computed tomography (CT), magnetic resonance imaging (MRI), intravenous utrography (IVU), cystogram and barium radiopgraphs.


Disease may be staged based on the International Classification staging system or TNM classification to determine treatment as well as progress of the cancer.

  • Conservative treatments include cryotherapy (freezing with nitrous oxide), laser therapy, loop electrosurgical excision procedure (LEEP), or conization (removing a cone shaped portion of the cervix).
  • Simle hysterectomy if invasion is less than 3 mm. Radical trachelectomy is an alternative to hysterectomy.
  • For invasive cancer , radical hysterectomy, radiation (external-beam or brachetherapy), or chemotherapy (cisplatin, carboplatin, and paclitaxel [Taxol] or a combination of these approaches may be used.
  • For recurrent cancer, pelvic exenteration is considered.


Chapter 1:

Health Promotion and Disease Prevention


1.The nurse explains that the belief advancing the idea that disease is a result of an organically caused disorder is the

a.    biomedical model.

b.    biopsychosocial theory.

c.    Dunn’s high-level wellness model.

d.    Travis’ health model.

Answer:    A

The biomedical model describes disease as an organically caused disorder with consistent clinical manifestations. The biopsychosocial theory claims that disease is caused by the interaction of environmental, physical, and social factors. Dunn wrote about high-level wellness. The model by Travis emphasizes that wellness requires work and attention.

2. The nurse explains that the client’s ability to cope with stress dynamically will play a significant role in the client attaining maximum potential. This approach is most consistent with the model of

a. King

b. Leninger

c. Levine

d. Neuman

Answer: A

King’s theory suggets that continous adjustment to stressors, both internal and external, with the use of one’s resources allows the person to attain maximum potential.

3.When the nurse encourages a Native American to seek health counsel from the tribe’s shaman, the nurse is following the tenets of:

a. King

b. Leninger

c. Pender

d. Rogers

Answer: B

Leninger postulates that health refers  to culturally known and utilized practices that maintain personal and group well-being.

4. The nurse using the World Health Organization (WHO) description of health bases care on the premise that health is

a.    a gift from a higher being.

b.    any disease-free condition.

c.    complete mental, physical, and social well-being.

d.    high-level functioning despite illness.

Answer: C

The most widely accepted definition is the classic 1947 WHO description of health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”

5. The nurse planning a health promotion program with clients in the community will focus least on

a.    assisting the clients to make informed decisions.

b.    organizing methods to achieve optimal mental health.

c.    providing information and skills to maintain lifestyle changes.

d.    reducing genetic risk factors for illness.

Answer: D

Health promotion programs are designed to improve the health and well-being of individuals and communities by providing people with information, skills, services, and support they need to undertake and maintain positive lifestyle changes. Genetic risks for illness cannot be controlled to promote health.

6.    A holistic belief system by the nurse would be most evident if the nurse

a.    accepts death as an outcome of life.

b.    encourages behavior modification programs.

c.    incorporates client perceptions of health when planning care.

d.    supports goal-directed learning to improve health.

Answer: C

The theories of Orem, Rogers, and Roy focus on the holistic view, which takes the client and the client’s beliefs, values, and culture as necessary considerations to comprehensive care.

7.    The nurse understands that the document he/she can use to plan community teaching projects addressing the federal population-based health objectives is

a.    Healthy People 2010.

b.    Nursing’s Agenda for Healthcare.

c.    the federal Medicare/Medicaid Acts.

d.    the Goldmark Report.

Answer:    A Healthy People2010 contains federal population-based health objectives and identifies leading indicators of health that apply to adults.

8.    The nurse recognizes the activity that reflects primary prevention is

a.    a self-initiated walking regimen.

b.    collaboration with a physical therapist.

c.    physician-prescribed exercise after a heart attack.

d.    tuberculosis screening.

Answer:    A

Primary prevention is an activity that is done before any illness, but as a preventive effort to avoid illness. Collaboration with a physical therapist and physician-prescribed exercise after a heart attack are both tertiary prevention: measures intended to reduce the effects of an established health problem. Screening activities, designed for early detection, are secondary prevention.

9.    The nurse is planning a community STD (sexually transmitted disease) screening fair. This activity would be considered

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer: C

Secondary prevention activities are those that include screening and early diagnosis.

10.The nurse is developing a teaching plan for a 60-year-old man who experienced a cerebrovascular accident (CVA). The nurse works with the client to prevent aspiration when eating. This is an example of

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer:    D

Tertiary prevention is directed toward rehabilitation after a disorder already exists. The interventions are directed toward minimizing disability and improving quality of life.

11. The nurse is counseling an overweight young man on entry into a weight reduction and exercise program. The nurse is aware that the client is most likely to begin and maintain the program if he

a.    can envision himself as thinner.

b.    feels competent about making the change.

c.    has read about the program.

d.    is aware of being overweight.

Answer:    B

Clients are more likely to be motivated to change if they feel competent to do it and have social support.

12.    The nurse is caring for a 35-year-old client at risk for cardiovascular disease. The client states he is aware that he must “maintain a low-fat diet.” Using the Transtheoretical Model and Stage of Change, the nurse assesses that this client is at the stage of

a.    action.

b.    contemplation.

c.    maintenance.

d.    pre-contemplation.

Answer:    B

The contemplation phase describes the client as seriously thinking about a change. In the action phase, the client is implementing the behavior change; in the maintenance phase the client continues to move forward with the change, and in the pre-contemplation phase the client has not yet thought about changing his behavior.

13.The nurse can “empower” a client in adjusting to the changes associated with the chronic effects of non–insulin-dependent diabetes mellitus by

a.    explaining that concerns about vision changes are premature at this point.

b.    explaining the pathophysiology of the disease.

c.    informing the client about the different types of insulin.

d.    teaching the client how to minimize complications.

Answer:    D

Empowering gives the client information, skills, and contact with services available to deal with the client’s disease.

14.Suggestions that a home health nurse could make to an elderly client with cataracts to reduce the risk of falls in his home would include

a.    arranging scatter rugs to prevent slipping on the hardwood floor.

b.    using lower-illumination bulbs to prevent eyestrain.

c.    using night lights in every room.

d.    wearing soft-soled house shoes indoors.

Answer:    C

The visual impairment requires increased illumination and an uncluttered environment. Soft-soled shoes enhance the fall potential as do scatter (or “throw”) rugs.

15.During a nursing history before a physical exam, a nurse identifies a client as being in a violent relationship. The most important intervention by the nurse at this time is to

a.    ask the physician to order a series of x-rays to look for old broken bones.

b.    call the police if the abusive partner is in the waiting room.

c.    help the woman develop an individual plan to diminish future abuse.

d.    refer her to the local battered women’s shelter.

Answer:    C

The priority intervention at this time is to help the woman develop an individualized plan to avoid future abuse. The emphasis must be on safety because the woman has a high risk for significant injury or death. Part of the safety plan can include information on shelters available in the local area, but referral to a shelter does not diminish the nurse’s responsibility to help the woman remain safe.

16.A client is having a physical examination and asks the nurse if his father, age 76, should have the same prostate cancer screening that he is having. The nurse bases her answer on knowledge that

a.    a simple blood test is all that is required for prostate cancer screening.

b.    all men, regardless of age, need routine prostate cancer screening.

c.    men over age 70 generally do not need routine prostate screening.

d.    only members of certain high-risk ethnic groups need regular screening.

Answer:    C

Generally, men over the age of 70 or who have a significant illness that will probably result in a life span of less than 10 more years are not routinely screened for prostate cancer. Screening should start at age 50 or earlier for high-risk ethnic groups and consists of a prostate-specific antigen test and digital rectal examination.

17.A nurse is teaching women breast self-examination (BSE). When designing a teaching program, the nurse is aware that the biggest barrier to women doing BSE is

a.    better screening tools like mammograms.

b.    discomfort and pain when doing the exam.

c.    lack of confidence when performing the exam.

d.    realization that breast cancer is not a leading cause of cancer death in women.

Answer:    C

A major barrier to BSE is a lack of confidence. Breast cancer is the second leading cause of cancer death in women. While mammogram is a more sensitive tool, it is costly and is only recommended every 1 to 2 years, while BSE is recommended monthly. A BSE is not uncomfortable.

18.     A nurse is presenting information at a community forum related to pneumonia. The nurse informs the audience that people who should receive the pneumococcal vaccine include those who (select all that apply).

a.    are over age 65 and had a vaccination more than 5 years ago.

b.    are under age 65 and are alcoholics.

c.    are under age 65 with chronic illnesses.

d.    are over age 65 and have never had pneumococcal pneumonia before. e.    are over the age of 65.

Answer:    A, B, C, D

All adults over age 65 should have a pneumococcal pneumonia vaccination and they should be re-vaccinated if it has been more than 5 years since their previous vaccination. Individuals younger than 65 are considered high risk and should have the vaccination if they are alcoholics, have chronic illnesses, are members of certain high-risk ethnic and social groups, or have sickle cell anemia or have had their spleen removed.

19. Place the steps for breast self-examination (BSE) in the order a nurse should teach a client to do them (select all that apply).

a.    Feel both breasts while lying down.

b.    Feel both breasts while sitting or standing.

c.    Gently squeeze each nipple to look for discharge.

d.    Look at your breasts in the mirror with your arms on your hips.

e.    Look at your breasts in the mirror with your arms raised.

Answer:    A, B, C, D, E

This is the proper sequence for BSE. BSE should be done at the end of the menses in women who still menstruate, and on the same day of each month in post-menopausal women.

20. Strategies a nurse should use when teaching a client include (select all that apply)

a.    using plain, lay language.

.    providing comprehensive information at each session.

c.    having the client “teach back” what has been taught.

d.    using written material written at a low literacy level.

Answer:    A, C, D

Strategies for teaching include (1) using plain, lay language; (2) limiting the amount of information given at any one time; (3) using teach-back techniques; (4) using diagrams; and (5) using written material that is at a low literacy level. Estimates are that one third to one half of people in the United States experience low health literacy.

21. A nurse teaching a client using self-management support strategies would include measures to help the client increase his/her (select all that apply)

a.    compliance with recommendations.

b.    decision-making abilities.

c.    health literacy.

d.    problem-solving skills.

e.    resource utilization

Answer:    B, C, D, E

The five self-management skills that form the core of Loring’s self-management support program are problem-solving, decision-making, resource utilization, empowered client role, and health literacy.

Chapter 2: Health Assessment

1.A nurse is collecting a health history from a client and feels the client is not reliable. One recommended way to verify some of the client data is to

a.    ask the client the same questions but in a different manner.

b.    confront the client with your suspicions.

c.    find and question a secondary source.

d.    have another nurse try to get data from the client

ANS:    C

Clients may be poor historians and unable to provide accurate data. If there is a secondary source such as a significant other or family member available, ask them some of the health history questions. A client who is confused will not be able to answer accurately even if you ask questions in different ways. Confrontation can lead to alienation. Having another nurse question an unreliable client is unlikely to garner valid data.

2.The nurse is collecting a health history on a middle-aged African American male. The nurse asks about past blood pressure screening because the incidence of hypertension is higher in this ethnic group than in others. This is an example of

a.a generalization based on the nurse’s limited experience with African Americans.

b.bias, and the nurse should not question the client about blood pressure screening.

c.stereotyping the client based on the client’s ethnic/racial group.

d.using valid research data to focus questions on the client’s specific risks.

ANS:    D

Reliable research finding concerning group characteristics or similarities may be applied to a specific client who belongs to that group. Generalizations, stereotypes, and biases have no place in nursing care.

3.A client had surgery yesterday and is complaining of pain. The best action by the nurse is to

a.ask the patient which pain medication she/he took last. a complete assessment of the pain.

c.prepare to administer the ordered pain medication.

d.record the client’s complaints thoroughly and get the pain medication.

ANS:    B

This is an example of symptom analysis. Nurses should use a recognized approach to fully assess each client complaint, such as the OLDCART or PQRST method. It is best to understand the source of a complaint before treating it. In this case, the postoperative client could be having a nonrelated problem such as angina. Without a further assessment, the nurse would administer the postoperative pain medication, which might mask the new symptoms or delay diagnosis and treatment.

4.A client is being admitted to the hospital and the nurse has the client’s electronic record, including past medical history. What should the nurse do with this information?

a.Copy the information from the electronic database to the admission database.

b.Not use it because it is preferred to ask clients about past history at each encounter.

c.Save time and skip this part of the history-taking because the record is electronic.

d.Verify with the client that the list is current, complete, and correct.

ANS:    D

A previously recorded past health history is useful to have, but the nurse must verify its accuracy with the client. Diagnoses may change because of second opinions, because they have been cured, or because they have been surgically corrected.

5.To assess precipitating factors, the nurse interviewer would ask

a.“Do you remember the first time you had this problem?”

b.“How many times has the problem been related to activity?”

c.“What measures relieve this problem for you?”

d.“What were you doing when you first noticed the problem?”

ANS:    D

To ask what the client was doing and where he was at the time the manifestation was noticed is an abbreviated way to obtain information as to cause or environmental precipitators. The other options are related to timing, aggravating factors, and remedy.

6.Because the psychosocial assessment includes many more personal aspects of the client’s history, the most significant variable that may affect the quality and usefulness of the collected data is the

a.nurse’s ability to establish a therapeutic relationship.

b.nurse’s difficulty in differentiating normal from abnormal.

c.reluctance of most clients to share information with health care providers.

d.value the client places on the health interview.

ANS:    A

The client must feel comfortable to share some of the information assessed in the psychosocial portion; therefore the nurse’s ability to establish a therapeutic relationship is the major element in securing accurate data.

7.In the preparation of a nursing care plan relative to the client’s mental status, the least helpful data would be those resulting from

a.client’s overall response to the interview.

b.formal psychological tests.

c.notation of appropriateness of affect.

d.observation of nonverbal behavior.

ANS:    B

Mental status assessment consists of evaluation of verbal and nonverbal responses to the individualized questions, as well as evaluation of mood and affect. Psychological tests cannot measure these factors.

8. A client is brought to the emergency department in serious condition and needs an operation within the next hour. Which of the following principles does the nurse use to guide the health history? (Select all that apply.)

a.Assess the client’s current health status.

b.Collect data pertinent to the immediate problem.

c.Strive to collect only pertinent data while being thorough.

d.Update the database when the client’s condition allows.

e.Use a systematic approach to gather the client’s entire health history.

ANS:    A, B, C, D

Many factors influence the depth of health history the nurse should obtain. In this case, the client is in an emergent situation that does not warrant gathering information on the client’s entire history. However, for client safety, the nurse must assess the client’s current health status, collect data relevant to the current situation, and strive to be as thorough as possible within these limitations. When the client is more stable, more data can be collected.

9. The nurse collecting data on a client’s social history asks questions regarding the client’s (select all that apply)

a.exposure to communicable diseases.

b.home life.

c.immunization history. roles.

ANS:    A, B, D, E

Immunization history, while an important component of health history, is not included in social history.

10. Which principles of assessment does the nurse use when working with hospitalized clients? (Select all that apply.)

a.Assess each client at the beginning of each shift.

b.Base the frequency of assessment on client condition.

c.Begin with the most seriously ill client.

d.Record findings as they are assessed, not later.

e.Wait for physician orders to determine the frequency of assessments.

ANS:    A, B, C, D

These answers are all good principles on which to base nursing assessments. Assessing a client is an independent nursing function. While the physician may write for assessments to be done at a specified minimum time frame, nurses use their own professional judgment to obtain client assessments as appropriate.

Chapter 3: Critical Thinking

1. The process by which a nurse uses purposeful thinking, informed reasoning, reflections, and thinking about thinking in clinical situations is called a.    clinical judgment.

b.    critical thinking.

c.    decision making.

d.    problem solving.

ANS:    B

Critical thinking is a process of thinking that ensures conclusions are self-correctable, reasonable, informed, and precise. This is done through informed reasoning, purposeful thinking, reflecting on situations, and thinking about one’s thinking. Clinical judgment uses experience to guide assessments and decision making. Decision making involves using the scientific process to identify a specific problem, assess and weigh all options, test possibilities, and consider the consequences of the choice of action. Problem solving is more focused with the selection of only pertinent information about the problem and evaluating the solution over time. All are part of critical thinking but none are as broad.

2.It is crucial for the nurse to be able to make sound decisions using critical thinking because is the most efficient use of the nurse’s time and resources. uses previously learned knowledge in predictable situations.

c.most clients have problems for which there are no textbook answers.

d.nurses can recognize problems rapidly and provide speedy responses to situations.

ANS:    C

Most client care situations are unique—not predictable—and nurses must adapt previously learned knowledge to new circumstances, drawing from multiple sources of information. It may well be more efficient and rapid, but that is not the primary reason critical thinking is valuable.

3.A nurse with 6 year’s labor and delivery experience is floated to the intensive care unit. In this situation, the nurse would most likely function at the level of

a.    advanced beginner.

b.    competent.

c.    novice.

d.    proficient.

ANS:    C

According to Benner’s Five Levels of Competency in Nurses, a novice is one who has no experience in situations in which they are expected to perform. This nurse would need specific rules to guide action. An advanced beginner has seen enough real situations to note recurring and meaningful components of the situation. A competent nurse has been on the job or in similar situations for 2-3 years. A proficient nurse has a great deal of situational perception as the result of 3-5 years of experience.

4.A nurse is working in the intensive care unit. When assessing the clients, the nurse notes one of them, who was scheduled to transfer to a step-down unit as soon as a bed becomes available, has a respiratory rate change from 18 to 20 breaths/min and an oxygen saturation (O2 sat) of 92%, when earlier it was 93%. The client denies complaints. The nurse calls the physician and requests a chest x-ray and arterial blood gases (ABGs). This nurse is working at which Benner Level of Competency in Nurses?

a.    Advanced beginner

b.    Competent

c.    Expert

d.    Proficient

ANS:    C

The expert nurse is able to grasp the important components of a situation intuitively, noticing subtle changes, and zeroing in on the problem immediately. This nurse is also flexible. The advanced beginner is not flexible, is slow to act, and still needs rules to guide practice. The competent nurse is beginning to be able to master many situations in nursing but is still somewhat slow. The proficient nurse is perceptive and sees subtle changes rapidly, but would not be able to zero in on the problem as rapidly as the expert nurse.

5.A nurse is confused about the best way to confirm placement of a small flexible feeding tube before giving a bolus feeding. Colleagues on the unit suggest several different methods. The best process by which to determine a policy outlining the appropriate course of action is

a.    critical reasoning.

b.    evidence-based practice.

c.    problem solving.

d.    professional judgment.

ANS:    B

Evidence-based practice (EBP) is a process by which nurses make clinical decisions using the best available research evidence, clinical expertise, and client preferences to guide actions. There are several steps necessary to solve problems using this method. None of the other options provides as broad a foundation for a practice change as EBP, which utilizes research in the literature to inform practice changes, which are then evaluated for institutional fit and feasibility.

6.A nurse who is alert to changes, confident, open-minded, proactive, and questioning is displaying which characteristics?

a.Alfaro’s Attitudes and Characteristics of a Critical Thinker

b.Benner’s Five Levels of Competency in Nurses

c.Hawk’s Model of Critical Thinking in Registered Nurses

d.Universal Intellectual Standards

ANS:    A

There are 29 attitudes and characteristics of a critical thinker listed in Box 3-1, 5 of which are listed here. Benner’s model has 5 levels of nursing competency: novice, advanced beginner, competent, proficient, and expert. The Universal Intellectual Standards encourage thoughtful examination of clinical problems. There is no Hawk’s Model of Critical Thinking in Registered Nurses.

7. A nurse brings a client a medication that is scheduled once daily with food. The medication administration record lists it as being due at 9:00 AM. The client refuses the medication, asking to take it later. The nurse replies “That’s OK. I can give it to you with your lunch if you like.” Which statement about the nurse is correct? The nurse

a.    is being flexible and logical.

b.    just made a medication error.

c.    needs to call the doctor.

d.    should tell the patient to take the medication now

. ANS:    A

Flexible and logical are two attitudes and characteristics of a critical thinker. Hospital pharmacies often schedule once-a-day medications at 9:00 AM. The important aspect of this medication is that it is indeed given once a day and with food. The time of day does not matter as long as it is consistent. The nurse could call the pharmacy and ask them to change the time on the medication administration record. The other three options all demonstrate inflexibility and rule-bound behavior.

8. At the beginning of the shift a student nurse is meeting with the registered nurse (RN) assigned to the student’s client. The student nurse should provide the RN with which information? (Select all that apply.)

a.Assessments the student will make

b.Documentation the student will complete

c.Medications the student will administer

d.Treatments the student can perform

e.What time the student is going to lunch

ANS:    A, B, C, D

These are all important components of the student’s report to the RN. The time the student will take lunch is not crucial to discuss at this time and may well change depending on client status and needs at lunchtime.

Chapter 4: Complementary and Alternative Therapies

1. According to the National Center for Complementary and Alternative Medicine, complementary medicine is

a.prescribed and overseen by a medical physician.

b.treatment of a physical illness by a spiritual intervention.

c.used in place of conventional medicine.

d.used together with conventional medicine.


Complementary medicine is used together with conventional medicine, such as using aromatherapy to help reduce discomfort after surgery.

2.Of the many complementary and alternative medicine (CAM) modalities available in the United States, the most rapidly growing area is



c.dietary supplementation.



Dietary supplementation is currently the most rapidly growing CAM modality in the United States.

3.A nurse taking the history of a client with rheumatoid arthritis might be alerted to the client’s use of CAM when the client says

a.“A bunch of nuts believe that putting nice smells in the air cures arthritis.”

b.“Doctors don’t know everything, you know.”

c.“I’ve heard something about alternative medicine. What is that?”

d.“What do you think about biofeedback?”


The most “nondisclosing” client remark is asking the nurse about a specific alternative modality and “testing the waters” relative to the nurse’s response to that specific modality.

4.When the client asks the nurse about the use of therapeutic herbs, the nurse’s most instructional response would be

a.“Herbs are not regulated and may pose health risks if used with prescribed drugs.”

b.“Herbs have many qualities; some effects are good, and some are not.”

c.“I have heard many people have used some herbal remedies and had good results.”

d.“If you are getting relief from some herbal remedy, there is probably no harm in it.”


Herbs are not regulated, and some herbs can interfere with the therapeutic effects of some drugs and can react unfavorably with anesthesia and surgical intervention.

5.The nurse reminds a client that the Dietary Supplement and Health Act of 1994 prevented manufacturers of dietary supplements from

a.making specific therapeutic claims for the product on their labels.

b.manufacturing products that are not tested or proven.

c.offering products for sale except through pharmacies.

d.publishing outrageous claims for the product on promotional materials.


This act forbids claims for specific results from being placed on the label, although outrageous claims may be made on websites and in promotional materials.

6.When the client asks the nurse what “placebo effect” means, the nurse includes in the response that the placebo effect describes a

a.deterioration of the product to the point that it renders the product incapable of offering any therapeutic benefit.

b.phenomenon of a person taking the placebo and claiming positive effects because of psychological factors unrelated to the product.

c.practice of manufacturers to make hugely inflated claims to induce the potential user to believe in the worth of the product.

d.product that, although producing therapeutic effects for many users, has no effect on others.


Placebo effect is the phenomenon of persons given the placebo in testing and then claiming positive benefits from the product based on psychological factors unrelated to the product.

7.A nurse understands that many conventional drugs are derived from plants, such as

a.meperidine (Demerol).





Quinine is derived from cinchona. The other options are manufactured from chemical compounds or derived from hormones.

8.The nurse cautions that, when consumed in large quantities, antioxidants can become pro-oxidants, which

a.absorb large quantities of free radicals.

b.can produce free radicals.

c.create a free radical “shield.”

d.enhance the immune system.


Pro-oxidants, which can develop from the concentrated use of large amounts of antioxidants, can produce millions of free radicals. They do not absorb free radicals, create a free radical shield, or enhance the immune system.

9.A young Hispanic woman tells the nurse that she is going to have a healing ritual to center her spirit after the recent death of her husband. The nurse recognizes the alternative medicine system of




d.Tai Chi.


Curanderismo is the practice prevalent in the Hispanic culture of spiritual rites and rituals to promote healing. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Reiki is the Japanese health belief that when spiritual energy is channeled through a Reiki practitioner, the client’s spirit is healed, subsequently healing the physical body. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being.

10.An elderly Chinese woman tells the nurse that she must improve the flow of her Qi. The nurse asks the client how long she has been using



c.Tai Chi.


Acupuncture is an ancient Oriental practice of placing needles in certain points of the body to improve the energy flow of Qi throughout the body to improve health. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being. Yoga is an exercise that teaches specific postures and breathing exercises. It has been shown to reduce stress levels and improve relaxation.

Chapter 5: Ambulatory Health Care

1. Ambulatory care nursing is an emerging field of nursing practice in which the nurse

a. deals with clients who are ambulatory and able to walk into the clinic.
b. is part of an interdisciplinary team offering primary, secondary, and tertiary care.
c. offers an integrated system of care to persons within walking distance of the clinic.
d. works only with clients who are not acutely ill.

Answer: B
The ambulatory nurse takes care of clients who are healthy, acutely ill, and chronically ill. Ambulatory nurses function as a member of an interdisciplinary team.

2. Ambulatory care centers include available 24 hours a day, 7 days a week. for short-term medical-surgical procedures. for those unable to provide self-care after a procedure.
d.sleeping accommodations for a family member.

Answer: B
Technological advances allow treatment in a short-term facility that previously required a hospital stay. Ambulatory care centers meet the needs of these clients and avoid a costly inpatient stay. They may or may not be open 24 hours, 7 days a week. A person who needed help with self-care would probably need in-home or hospital care. And since care duration is less than 24 hours, sleeping accommodations are not provided as part of ambulatory care centers.

3. The nurse manager of an ambulatory care center assesses the center for environmental hazards to comply with guidelines of both the local state health department and the

a.Ambulatory Care Nursing Administration and Practice.
b.American Nurse’s Credentialing Center.
c.Nurse Practice Act.
d.Occupational Safety and Health Administration.

Answer: D
The Occupational Safety and Health Administration (OSHA) and the state health department oversee environmental factors. The other three options address professional practice and credentials.

4. The facility that could best represent an ambulatory care center is a

a.home health care agency. with less than 50 beds.
c.rehabilitation center.
d.student health center.

Answer: D
The student health center is an ambulatory care center. The other options provide care to clients in their home, to inpatients, or as a prescribed follow-up service.

5. In comparing the ambulatory care setting to an inpatient hospital setting, the nurse- instructor is correct in stating that the ambulatory care setting

a.has had so many cost increases that a visit is just as costly as the hospital. already in decline and offers limited employment opportunities.
c.may create a feeling of greater stress to the client than a hospital setting.
d.provides an environment where the client is less at risk for nosocomial infection.

Answer: D
The client using an ambulatory care center is exposed less to nosocomial infection and other hazards of hospitalization. Care is much more cost-efficient in ambulatory care centers. Employment opportunities are increasing in ambulatory care. Ambulatory care centers often are less stressful than hospitals for clients.

6.A nurse working in an ambulatory care setting would provide secondary prevention activities such as

a.carrying out hypertension screening. instructions after minor surgery.
c.providing cardiac rehabilitation.
d.teaching young adults the benefits of good nutrition.

Answer: A
Screening activities are secondary prevention. Teaching nutrition and giving instructions to prevent complications after minor surgery are both primary prevention. Cardiac rehabilitation is an example of tertiary prevention.

7.The nurse instructor describes an integrated delivery system and cites the example of

a.a hospital’s alignment with several physician groups to increase hospital referral. outpatient clinic in the hospital.
c.enrollees of the system being “locked” into the system of care for services.
d.providers concerned about generating revenue.

Answer: A
Hospitals have aligned themselves with groups of physicians to increase hospital referral and provide greater coordination of care.

8.A health care service that provides a defined population with a stated range of services through prepayment of an annual or monthly capitation fee is a(n) maintenance organization (HMO).
b.nurse-managed ambulatory center.
c.outpatient service of a community hospital.
d.preferred provider organization (PPO).

Answer: A
An HMO provides services to members for an annual or monthly capitation fee. Physicians who contract with a preferred provider organization get paid at a reduced rate for each service they provide.

9.The facility least suited to the provision of primary health care is a(n)

a.ambulatory care center.
b.emergency department.
c.HMO. outpatient clinic.

Answer: B
Emergency departments (EDs) are organized according to the clinical model and are essentially dedicated to meet acute care needs. Providing primary care is a basic function of the ambulatory care center. An HMO is an organization with which physicians contract to receive payment for caring for enrollees. Primary health care could be provided at a hospital outpatient clinic.

10.The nurse-manager explains to a new nurse at the ambulatory clinic that the service for which the telephone nursing practice is not feasible is

a.assessing a client’s needs based on the nurse’s perception.
b.developing a collaborative plan of care with a client.
c.evaluating outcomes of practice and care.
d.prioritizing the urgency of a client’s needs.

Answer: A
To assess a client’s needs based on a nurse’s perceptions, the nurse would need to be able to assess the nonverbal responses, which usually are not available on a phone. All other options are feasible by phone.

11. The nurse contacts a client by follow-up telephone call after the client’s visit to an ambulatory care center. The client who would benefit most from this intervention

a.has undergone cast removal.
b.has undergone same-day surgery. having blood pressure monitored. having blood sugar monitored.

Answer: B
Telephone follow-up calls are used for clients who have had ambulatory surgery or for those subject to daily changes in condition.

12. The nurse who is seeking legal guidance in delegating assignments to assist workers in an ambulatory care setting would best consult protocols.
b.recently published texts.
c.the agency’s legal counsel.
d.the state nurse practice act.

Answer: D
Nurse practice acts (NPAs) for each state define legal delegation guidelines. Agency protocols cannot override the NPA; the legal counsel would certainly reference the NPA; and texts cannot address each state’s NPA.

13. The purpose of the mutual recognition model (MRM), implemented through an interstate contract, is to

a.ensure an increasing supply of nurses entering the work force.
b.monitor the number of nurses working in more than one field of specialty.
c.provide educational incentives for nurses to continue working full-time.
d.reduce barriers to interstate nursing practice.

Answer: D
The MRM allows nurses to communicate and recommend health practices to persons out of state, thus reducing the barriers to interstate nursing practice, especially as it applies to telehealth services.

14. One challenge for nurses working in ambulatory care centers is

a.clients give overall responsibility for self-care to the center.
b.duties are rigidly defined within the interdisciplinary team.
c.length of client visit is short, reducing assessment time.
d.use of telephones and computers eases assessment potential.

Answer: C
The short time of the ambulatory care visit makes assessment difficult and makes omissions in the assessment almost impossible to correct.

15. When considering culture as the nurse is designing health plans for clients, the ambulatory care center nurse will consider least the cultural concept of

a.making food modifications culturally appropriate.
b.recognizing that cultural family roles may be rigidly defined.
c.reflecting on research data describing culturally motivated responses.
d.understanding that some cultures reject female authority.

Answer: C
Although all options are significant, options a, b, and d are considerations for client welfare and, consequently, are more important.

16. In a telephone consultation, the ambulatory care center nurse may

a.assess cardiac or fetal monitoring.
b.decide how soon the client should be seen at the center.
c.give advice based on the nurse’s phone assessment.
d.teach a specific procedure based on approved protocols.

Answer: D
The telephone consult is designed for teaching or advising the client based on prescribed protocols, not on phone assessment (option c). Triage (option b) and surveillance (option d) are not considered within the definition of “consult.”

17. After each telehealth communication the nurse should

a.immediately document the content of the call in the client’s record.
b.inform the physician of the information or teaching given.
c.schedule a later call to check on the client’s progress.
d.send the client a written form of the pertinent information.

Answer: A
All information pertinent to the call should be recorded in the client record.

18. An ambulatory care center nurse who is counseling a young client with sickle cell anemia can best access evidence-based practice (EBP) guidelines from current nursing texts or journals.
b.integrated hospital care plans and protocols.
c.the Occupational Safety and Health Administration (OSHA).
d.the Agency for Healthcare Research and Quality (AHRQ).

Answer: D
AHRQ has evidence-based guidelines for many common problems, including sickle cell anemia, and would be the best source of up-to-date evidence-based practice guidelines. “Current” textbooks are written approximately 2 years before publication. Journals have up-to-date information but might not have the subject matter needed. Hospital care plans and protocols should be based on current EBP practice, but are often outdated and based on what has always been done. OSHA’s role has nothing to do with EBP.

19. The ambulatory care center nurse assures a dubious client that she has been certified as an ambulatory nurse by

a.application to the Accreditation Association for Ambulatory Health Care.
b.membership in the National Committee for Quality Assurance.
c.passing a specialized examination.
d.working as an ambulatory care nurse for 5 years.

Answer: C
Ambulatory care nurses may be certified by passing a practice-specific examination. To qualify for the examination, nurses must have worked in ambulatory care for a certain minimum number of hours. The first two options involve agency-accrediting organizations.

20. The nurse explains that to work at an independent, nurse-supervised ambulatory care center, there is a minimum requirement of a(n)

a.associate degree.
b.bachelor’s degree.
d.master’s degree.

Answer: B
A bachelor’s degree is the minimum requirement for a nurse to work at an independent ambulatory care center.

Chapter 6: Acute Health Care

1.The prepayment plan developed in 1929 is

a.Blue Cross Health Insurance.
b.Medicare Insurance.
c.Medicaid Insurance.
d.Health Maintenance Organization.

Answer: A
The 1929 Blue Cross Plan offered a form of prepayment insurance. Medicare and Medicaid are government entitlement programs. Health maintenance organizations arose as cost-containment measures, and physicians are reimbursed at a fixed rate for each person enrolled.

2.A hospital staff nurse is collaborating with a nurse case manager in planning the care of a client with a below-the-knee amputation. The primary role of the case manager is

a.client education on specialized care.
b.coordination of care for the client. care of the client’s medical problems. of the staff nurse.

Answer: B
Case managers are nurses who coordinate the care of a group of clients, monitor the implementation of interdisciplinary care plans, and maintain communication with third-party payers and referral sources.

3.A registered nurse (RN) seeking work in a voluntary health agency would choose a hospital.
b.proprietary hospital.
c.state university hospital.
d.veterans administration (VA) hospital.

Answer: A
Voluntary agencies are not-for-profit, tax-exempt organizations designed to meet health care needs of the public.

4.A client experiences chest pain with electrocardiographic changes during an appointment with the primary care physician, and the physician orders hospital admission for cardiac monitoring. This type of admission is a(n)

a.elective admission.
b.emergency admission. admission.
d.scheduled admission.

Answer: C
A direct admission is the process followed when a client is determined to need hospital or nursing care while in a physician’s office.

5.A client for whom the nurse would provide post–acute care is the

a.38-year-old following cesarean birth.
b.40-year-old recovering from kidney stone removal.
c.60-year-old receiving a regulated regimen of anti-hypertensive medication.
d.76-year-old needing rehabilitation after cardiac surgery.

Answer: D
Post–acute care areas are designed for clients who are out of the fragile phase of their illness and need routine monitoring and rehabilitation. After childbirth and kidney stone removal, the client would most likely need inpatient care at a hospital. A client receiving anti-hypertensive medications would most likely be followed in an ambulatory care setting.

6.While administering an antibiotic to a client with an infection, the nurse explains the importance of completing the full course of antibiotic therapy. This is an example of

a.formal education. advice.
c.informal education.
d.setting an example.

Answer: C
Informal education continues throughout the course of nursing care in the form of directions and explanations. Formal education is a formal presentation.

7.When unit staffing includes unlicensed assistive personnel, the nurse is aware that

a.delegating tasks to unlicensed assistive personnel is not in the scope of RN practice.
b.licensed personnel are accountable for the tasks delegated to the unlicensed personnel.
c.unlicensed assistive personnel do not have clinical duties on a client care unit.
d.unlicensed assistive personnel have formal training and function independently.

Answer: B
Nurses remain accountable for client outcomes whether or not the specific tasks are performed by nurses or by nurse extenders.

8.When a nurse is able to work effectively in more than one care area (e.g., general medical-surgical, and cardiac care unit), the nurse is said to be

b.flexibly assigned.
c.nursing intense.
d.skill mixed.

Answer: A
In an attempt the make the most effective use of available personnel, nurses may be cross-trained to work skillfully in two or more specialty care areas. A skill mix is the ratio of RNs to LPNs and assistive personnel to deliver the highest quality care while controlling cost.

9.An applicant was denied employment with a health care agency because she is a recovering alcoholic. This action by the agency violates the

a.Age Discrimination and Employment Act.
b.Americans with Disabilities Act.
c.Civil Rights Act.
d.Occupational Safety and Health Act.

Answer: B
In 1990 the Americans with Disabilities Act was passed to eliminate discrimination against persons with physical or mental disabilities. The Age Discrimination and Employment Act protects individuals over the age of 65. The Civil Rights Act protects individuals from employment discrimination on the basis of qualifications unrelated to job performance (such as race) and promotes employment based on ability and merit. The Occupational Safety and Health Act requires places of employment to be free of hazards and requires they write and enact safety policies.

10.A planned program of loss prevention and liability control best defines

a.client satisfaction.
b.clinical pathway.
c.quality assurance.
d.risk management.

Answer: D
Risk management is a planned program of loss prevention to identify and analyze risks in an effort to reduce accidents and injuries. Client satisfaction data are usually collected after a client is discharged from a hospital or other care setting. Quality assurance is a multi-leveled plan with components such as strategic planning, budgeting, performance improvement, and other elements. A clinical pathway is a plan that directs client care and recovery from predictable problems.

Chapter 7: Critical Care

1.The population that is increasingly using critical care units and needing specialized nursing care is the population of

b.middle-age adults.
c.underserved pregnant women.

Answer: A
Clients needing critical care do span the life span; however, those ages 65 and older comprise an increasing number of such clients. Of all hospital beds, more than 50% are filled with the elderly. The physiologic changes that accompany aging, plus chronic conditions seen in this age group, lead to an increased need for critical care beds.

2.The ICU nurse planning care for a critically ill client tries to arrange care to minimize the most disruptive stressor for the client, which is

a.alteration in sleep.
b.fear of the unknown.
c.persistent pain.
d.sense of isolation.

Answer: A
There are many stressors to the ICU client, but alteration in sleep patterns supercedes all the other options.

3.Critical care units (CCUs) have been developed in almost all hospitals because such units

a.allow for concentration of expert personnel.
b.can offer special services to the family.
c.contain costs.
d.separate the seriously ill from the other clients.

Answer: A
The CCU offers a space in which a concentration of expert personnel can be assigned to monitor and apply highly technological machines such as ventilators. The concentration of personnel does not reduce cost.

4.The nurse admitting clients to the critical care unit understands that priority clients for this area are those who need

a.a cleaner environment to prevent nosocomial infections.
b.continuous physiologic monitoring.
c.frequent vital sign checks.
d.private rooms conducive to rest and sleep.

Answer: B

5. The nurse admitting clients to an intensive care unit understands that research demonstrates best client outcomes when clients

a.are in an area that allows liberal family visitation.
b.have consistent nurses caring for them.
c.have state of the art physiologic monitoring.
d.receive multidisciplinary care led by an intensivist.

Answer: D
Studies showed a 30% reduction in intensive care unit stay when care was delivered by an intensivist-lead multidisciplinary team as opposed to an attending physician.

6.A nurse who is acting in a manner that respects and supports the client’s and family’s basic rights, values, and beliefs is functioning in which professional role?

c.Critical thinker

Answer: A
See Box 7-3 for more description of advocacy in critical care. A nurse functioning in the caregiver role provides bedside care. A critical thinker evaluates all options and chooses the best response when faced with a dilemma. A manager coordinates care.

7.A nurse working in critical care would plan interactions with clients’ families based on the understanding that families most need

d.spiritual support.

Answer: A
Studies consistently show that the family’s need for knowledge is consistent. While all options are valid, need-to-know is most important. Nurses tend to greatly underestimate their role in keeping families’ needs satisfied. Providing information from one consistent nurse is very valuable and helpful to most families.

8.A nurse working in the critical care unit would assess the client’s complexity by asking questions related to

a.ability of the client and family to make sound decisions.
b.effect of family, stress, and environmental factors on the client.
c.interplay of multiple medical problems on the current condition.
d.the client’s ability to use compensatory coping mechanisms.

Answer: B
Complexity is a client characteristic that assesses the intricate entanglement of two or more systems, such as physiologic, emotional, family, and environment. Option a refers to participation in decision-making, option c is not a client characteristic, and option d is resiliency.

9.The essential nurse competency that the critical care nurse uses when providing best care practices is

b.clinical inquiry.
c.clinical judgment. thinking.

Answer: B
Advocacy is working on another’s behalf when that person is not capable of advocating for himself/herself. Clinical judgment is the reasoning used by a health care provider when delivering care. Systems thinking is using tools and knowledge to work within the interconnected health care system. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. All are essential nurse competencies for the critical care nurse.

10. A critical care nurse understands that stressors affecting both the client and the client’s family include (Select all that apply)


Answer: A, B, C, D
Clients and their families have multiple stressors in the critical care environment. Lack of privacy is one of them as are the other four options.

Community Health Nursing

VII. Conceptual Approaches to Care


            The term ‘nursing model’ was probably introduced to you in your basic education, and used for assignment work. Nursing models are supposed to be used in practice but in reality they are generally not used well, and appear to serve more as checklists for care plans rather than to inform the direction of nursing care. You may now be questioning the value of models of nursing, if they are simply used as a theoretical exercise in nurse education and a checklist in routine practice, but nursing models can, properly used, facilitate thinking about care and the philosophy that underpins it.

            Most nurses have used one or more nursing models. You are likely to be familiar with the Activities of Living model (Roper, Logan and Tierney 1980, 2000) and the Self Care model (Orem 1971, 1991). There are many models that can inform nursing and health practice. Models are not simple; they have been very rigorously contemplated by experts and each one serves as a representation of nursing. An interesting point about nursing models is the way in which they vary quite considerably, so that the purpose and intention of one, and the way in which it informs nursing, is quite different from these aspects in another model, and each is helpful to different branches of nursing.This will be discussed as the chapter develops.


           It is unlikely that anyone has a blank sheet, mentally, when approaching patient care, and this indicates that professionals take a considered approach in this matter. There are several labels for these general approaches. One approach to nursing is known as task-orientated – referring to the clinical task being carried out in isolation from any other aspects that influence the patient’s condition. Thus the nurse dresses the wound and does not consider other factors that could influence the healing of the wound or the patient’s comfort. Most nurses have heard the term biomedical model, which refers to treating the medical condition of the patient in isolation from the patient as a person. For instance, the patient’s heart condition would be treated but their excess weight and sedentary lifestyle, and the anxiety they might have about their health, would be ignored. Pearson et al. (1996) consider that many nurses still use the biomedical model as the basis for their practice.

            A term that is often used in relation to a general philosophy of care is holistic. The holistic approach takes into account a range of physiological and personal considerations for each individual and also places them in the context of contemporary society and of current health care provision. Holism is concerned with balance, i.e. with balancing the physical, psychosocial, and economic relationships of the person, with the environment in which they live (Aggleton and Chalmers 2000). Some branches of nursing, for example the nursing of those with learning disabilities, are more likely to take a holistic approach, as clients are not perceived in terms of a medical condition.

          The underlying philosophy of our approach to nursing very much reflects our individuality. ‘Philosophy’ refers to the beliefs and values that shape the way each of us thinks and acts. You will certainly have heard the word used in the context of philosophy to life. Some common sayings exemplify such philosophies: Live now pay later; A short life but a good one; You reap what you sow. These sayings demonstrate our use of the term philosophy in this context: how our beliefs and values shape thinking and influence actions. It is to be expected that life experiences, education, professional  socialisation  and professional experience will shape a nurse’s philosophy of care. Thus our underlying philosophy of care says something about us as individuals with unique personal experience.


           Nurse theorists have examined the concept of nursing and have illustrated their ideas through nursing models. The full term is ‘conceptual model’, differentiating this kind of model from the sort that are exact miniatures of real objects – model cars, boats, buildings, for example. Each of these can be perfectly recreated as a working model. Is it possible to build such a model of nursing? The answer is, of course, No; and the reason for this is that nursing is a concept. A concept is a collection of images and ideas that help to classify things and it is not possible to build anything material from images and ideas. The notion of a concept can be explained through something that is familiar, for example the concept of spring. There are certain aspects that embody spring: lambs, daffodils, buds on trees, sunshine and warmer days. Put all these together and a set of images that creates a picture of the season of spring comes to mind. Nursing is a concept that is built around a set of images.

          Your concept may involve images about caring, knowledge about health and illness, prevention of ill  health, rehabilitation and enabling people to help themselves, partnerships with patients and other health workers, the list goes on. When nursing is viewed in this way it is easy to determine why models of nursing are conceptual. It would be impossible to build such a set of images into a visible working model.

       It is possible to see that models may differ quite considerably because nurses think differently and hold divergent views about the concept. The difference in views will also reflect the varied concepts that are embodied in the different specialities of nursing. Take, for example, the conceptual difference between mental health and acute nursing. The concepts that make up the two roles will vary because the nature of nursing is different in each role; mental health nursing treating psychological disorders and imbalances while acute nursing is concerned with physical illness or disability. As conceptual models are developed for the nursing role it is logical that they will differ in accordance with the differences between branches of nursing.

         Fawcett (1984) identified some common ground by analysing four key concepts that are embodied in all nursing models. These are: (1) the person or individual; (2) the environment in which nursing takes place; (3) health; and (4) nursing itself. Whatever other concepts make up a particular model, these four are found in all. Nurse theorists have attempted to build conceptual models that illustrate ‘systematically constructed, scientifically based, and logically related sets of concepts which identify the essential components of nursing practice’ (Riehl and Roy 1980: p. 6).

Building Nursing Models

         Models must be put down in writing/text to enable them to be shared and used by other nurses. It is in this state that you have probably encountered nursing models. You might imagine how difficult it is to represent a complex set of concepts in writing. All models require to be portrayed through the written word and with the use of diagrams.

        Before any model can be effectively used it must be interpreted and understood. It may take time to work through some of the terminology, but this is necessary if the is model to be used as intended. You can see that Orem’s model (1980) is based on the ability of people to care for themselves. The model represents a balance between what people need to be able to do, which Orem refers to as ‘universal self care needs’ and a person’s ability to perform their care, which Orem refers to as ‘self care’. The model also lists areas where, for various reasons, an individual may require nursing intervention and suggests, under methods of helping, the form that such intervention might take.

       The model proposed by Orem has several components that relate to self care, starting with the premise that individuals wish to be independent and listing areas where people normally meet their own self care needs. There are health-related reasons that interfere with people’s ability to be independent and to care for themselves. The model looks at general reasons why a person may need help and makes suggestions about ways in which a nurse may support a patient in their striving for self care. The overall philosophy is to support self care and independence, and this sets the tone of this particular model and the direction that nursing care will take.

       Representing this conceptual model is not easy and Orem supports the concepts embodied in the model with detailed explanatory text. To use any model well, the whole model should be applied, with all concepts captured, in its application to patient care. Nurses tend to take what they consider to be the useful ideas from models and apply them in isolation. A prime example of this is the use of the Activities of Living model (Roper, Logan and Tierney, 1980, 2000), where the list of daily living activities is used as a checklist against which care plans are developed. This action ignores the essence of the model.

       You should now have an understanding of the nature and purpose of a nursing model. One or more models should be used by a care team to guide the process of care, and the model(s) must be supported by all members. The team leader has responsibility to ensure that all team members are sufficiently knowledgeable to be able to use the chosen model(s) competently to follow through the planned programme of care. Effective caring using a nursing model is a team effort.

Models with Differing Philosophies

         You may not feel that a Self Care model is suitable for the patient that you have in mind or for your branch of nursing. There are other options to explore, some similar to the ideas expressed in Orem’s model, others very different. A similar model was developed by Roper, Logan and Tierney (1980, 2000), informed by earlier work from Henderson, who offered a definition of nursing based on 14 activities of daily living (Henderson 1966). The Activities of Living model is well known and much used in the British Isles. It approaches nursing care by considering the activities of living that are common to all people, and how these can be influenced by a range of factors, the origins of which might be physical, psychological, social, cultural, environmental, political or economic. Other aspects that come into the model are the age of the person and the degree to which they are able to lead an independent life. The model focuses strongly on the many factors that influence activities of daily living and requires nurses to take these into consideration in making judgements about nursing care.

          Self care and activities of living tend to be concerned with planning nursing care in order to meet physical health deficits, which is why these two models are widely used to nurse patients with acute and chronic illnesses. They are equally suitable for wider use. Aggleton and Chalmers (2000) illustrate this point by applying the Activities of Living model to bereavement.

        Other models take a very different philosophical approach. Roy (1976) proposed a model based on adaptation. It works from the premise that each person is constantly adapting to an ever-changing environment. Roy suggests that an altered state of health requires a person to adapt to cope with changed circumstances. She sees the role of the nurse as one of facilitating adaptation in the patient by adopting a systematic series of actions, directed towards the goals of adaptation. The role of the nurse in this model is to facilitate the patient to adapt to their altered health circumstances and through adaptation learn to cope with the change. This explanation is much over-simplified but it indicates yet another conceptual approach.

        Neuman’s Systems model (Neuman 1989) takes a very different conceptual approach, based on wellness. It is concerned with the patient’s response to stressors in the environment. Each person develops a range of responses to cope with normal circumstances, with some people appearing to cope better than others with everyday life. There are, however, situations that occur in the lives of all people that deviate from normal and produce stressors that are very difficult to cope with. Neuman defines stressors as inert forces that have the ability to impact on the patient’s steady state (Neuman 1989: pp. 12, 24). Some situations may be positive and enabling whilst others may be detrimental. This model views the nurse’s role as intervening to enable the patient to maintain an optimal state of wellness. There may be opportunities in primary care practice to capitalise on facilitation and enable the patient to manage stressors that face them in order to attain an optimum state of health. Such a model may be well suited for use in school nursing, health visiting and occupational therapy.

     In Peplau’s Interpersonal Relations model (Peplau 1988) the key components are the interpersonal process, nurse, patient and anxiety. Peplau considers that people are motivated towards self-maintenance, reproduction and growth by biological, psychological and social qualities. The model views the interpersonal relationship between nurse and patient as the focal point of interface that will produce benefits for the patient’s health. There are elements of adaptation and coping in this model with the main thrust of nursing intervention coming through the nurse–patient relationship as a therapeutic interpersonal process. A model such as this, based on interpersonal relationships, may be well suited to mental health and learning disability nursing.

        The conceptual models that have been mentioned in this chapter serve to illustrate the wide and varying approaches that contribute to the development of models of nursing. The differing approaches afford choice in decisions that are taken about delivery of care, and consideration should be given by the care team to the most suitable choice of model for the patient. The models are complex and to use any one effectively it will be necessary to refer to texts where the model under consideration is fully examined. It will also be necessary to make sure that others involved in the care know and understand the model in all its aspects.


          The vehicle for implementing a nursing model is the nursing process, a functional approach to the organisation of nursing care. Yura and Walsh (1967) identified a number of stages in nursing care with which all nurses have some familiarity: assess, plan, implement, evaluate. The four stages of the process are used in conjunction with a nursing model and its philosophy. Using Orem’s model as an example, the four stages of the nursing process could be applied as follows.

The assessment stage of the nursing process would take into consideration:

• the philosophy that people are normally self caring

• the ability of people to care for themselves, using universal self-care needs to guide the assessment

• recognition of the reasons an individual may require nursing intervention

• recognition of the way in which lifestyle and the patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meet identified needs in relation to the patient’s normal lifestyle and wishes

• interventions that could be used to achieve self care, whether they are the responsibility of the nurse, the patient or others

• the type of intervention needed: for example, teaching how to carry out care, or giving care, and providing aids to living that enable the patient to regain independence

• ways in which the planned actions would be evaluated.

The planned care would then be given (implemented), bearing in mind that:

• planned care is given according to good practice;

• current knowledge that is evidence-based underpins the care

• lifestyle and the environment are accommodated in the provision of care

• care given is evaluated against changes in the patient’s physical, psychological and socio- economic condition.

Evaluation of care takes place to determine its effectiveness. This is:

• carried out as an ongoing practice at each visit

• includes, at regular predetermined intervals, an objective review of the care with reference to changes in condition, treatment effectiveness,

introduction of new treatments

• leads to an adjustment of the care plan, if necessary, updating it in accordance with the evidence of the review.

     Thus the nursing process, systematically applying a model, connects theory to what is done on a practical level; and the nursing process and model(s) of care offer a care team a more supportive structure than can be provided by a task-oriented approach to nursing. They enable systematic, logical organisation of care to be developed around a philosophical focus.

     Though we are here referring to ‘nursing process’, in fact the four-stage process outlined above can be applied to any situation that requires organizing. It is a tool that can be just as useful for organizing a charity walk or planning a teaching session.

       Through the use of models of nursing and the nursing process there is good support on which to base nursing and health care practice, in a well  planned manner. All nurses must be thoroughly conversant with models and process, but although these provide a philosophy of care and give structure to care, what else is needed to provide sound practice? Evidence from patient surveys suggests that patients would want competent and caring practitioners (Carey and Posovac 1982) and the next part of this chapter is concerned with competent practice.


          You are taught in formal and informal situations. You read professional journals, books, literature from medical suppliers and drug companies. You observe those who you work with, some of whom you admire as role models. As you progress through your career you gain from experience. Many things that you have done have worked well and the patient has had positive outcomes from your care. These positive outcomes are sources of learning: you learned from something that went well. Learning can also take place following a poor experience. If something did not work well or went wrong a great deal can be gained from reflecting on the event, identifying what went wrong and considering measures that could be taken to improve the situation.

Objectivity in Nursing Practice

         Learning takes place in a variety of ways and everyday work provides a mixture of objective and subjective learning experiences. Information that is evidence-based has been based on research studies, and this is objective knowledge, gained from systematically established evidence. Subjective knowledge is gathered from observations made in practice, from conversations with colleagues and sometimes from teaching sessions. The problem with knowledge gained in this way is that it may not be reliable, and could even be unsound and dangerous. It is important that care is planned on the basis of objective evidence, and this means that knowledge that is gained subjectively must be checked to see that it supported by evidence.

     EBP, a key concept in modern health care, is one element of clinical governance (DOH 1999), a framework for the continual improvement of services and quality in the NHS, the purpose of which is to ensure that clinical decisions are based on the most up-to-date evidence and that clear national standards are set to reduce local variations in access to and outcomes of health care. Clinical governance has the following key elements:

• To set national standards for health services through development of national service frameworks and the National Institute for Clinical Excellence (NICE).

• To provide mechanisms for assessing local delivery of high-quality services, reinforced by a new statutory duty to quality.

• To provide support for life-long learning.

• To develop effective systems for monitoring the delivery of quality standards in the form of the Commission for Health Improvement, the NHS Performance Framework and surveys of patient/user experience (DOH 1999).

All health professionals are accountable for their individual practice and are responsible for making sure that their knowledge and skills are current. This implies that any care given is based on the most up-to-date knowledge available.

         EBP forms an essential element in the quality of health care and is directly related to clinical care in that clinically effective practice is based on national standards, frameworks and research.

A Systematic Approach to Acquiring Evidence

        Systematic acquisition of evidence provides the information from which standards and protocols for care are developed. Standards and protocols related to the provision of care are written by employers to guide the process of care. Health trusts use national guidelines based on the work of the National Institute for Clinical Excellence (NICE) and evidence from research as the basis for protocols. Each employee has a duty to keep up-to-date with, and refer to, guidelines that are supplied by their employer to inform their specific area of care, and to work to protocols.

       Research is the means of gathering evidence, and thus the source of guidelines and protocols. Nurses should have a working knowledge of the research process to enable them to appraise and understand the evidence that is presented as the basis for care, and be able to make a judgement on validity.

        McInness et al. (2001) suggest that evidence is not easily integrated into practice. The reasons that they offer for this are that research literature can be poorly organised and not easy to read, making it particularly hard for busy practitioners to access. The same authors also acknowledge the poor quality of some research. These comments make it clear that evidence is not always easy to access/understand, neither is it always sound. Health professionals must be able to interpret the information that is given to them to enable them to question evidence when it is unclear or unconvincing. The application of EBP lies with each health professional who must exercise judgement about the applicability of knowledge, whether it is evidence-based or subjective. Senior members of the team should have sufficient knowledge to support less experienced nurses, but all registered nurses should have a working knowledge that equips them to question the soundness of practice.

     A part of professional life must be the acquisition of knowledge that informs patient/client care. Access to information through electronic journals and websites makes information readily accessible. Most health trusts have access points for internet searches and this makes it so much easier for nurses to keep informed and current in their practice.

Evidence-based care or patient preference?

       There may be some instances where a treatment or practice, even though based on evidence, may not be appropriate for a patient. Thought and consideration are required to be given by practitioners at each care intervention. This makes the argument for evidence-based practice turn on itself. You may reasonably ask why objective evidence cannot be applied in all cases when it is likely to be effective. The response to this rests in the nature of health care practice, which is described by McCormack et al. (2002) as practice that takes place in a variety of settings, communities and cultures. To add to this complexity, there are other relevant influences, for example psychosocial and economic factors. Taking all these factors into account it is reasonable to assume that thought needs to be given to the application of practice. While practice should be based on evidence, it is also important to establish that the patient is suited to this care, and willing to accept the proposed treatment.

Informed decisions and patient choice

       One example of advocated treatment being found unacceptable to the patient, would arise in the case of a family who do not wish to have their child vaccinated with the triple measles, mumps and rubella (MMR) vaccine. The family might hold strong views about the safety of triple vaccine. Here the parents’ wishes might conflict with those of professionals, who have convincing reasons why children should be protected from childhood infections. There are no easy answers to this type of problem, and decisions taken must be carefully considered in the light of evidence that is presented from a range of sources. The patients’, or in this case the parents’, wishes are vital. When decisions about care are to be made the nurse’s role is to provide information that can enable the patient to make an informed decision, but in the end the choice rests with the patient.

     Planning decisions about care are normally considered by the care team, and a long-term treatment plan, though initially developed by one nurse, would not rest with a single individual. The plan would be discussed by the team to ensure that it was suitable and allow all team members to understand the goals and process of care. Daily evaluation of circumstances would, however, rest with an individual and would rely on informed decision making.

      Professional practice relies on nurses being competent in a range of specified outcomes (UKCC 2001), successful achievement of which equips nurses to practice. Practice requires that decisions are made, and that implies that each professional should be knowledgeable in their subject area and have the ability to translate their knowledge to support practice. Knowledge in itself has only limited value if it is used without due consideration of the effect that it might have on a situation. Thus a key aspect of professional practice is the ability to interpret and apply knowledge in widely varying circumstances. It is around the varying circumstances that decisions must be made that assure that care is appropriate and each nurse is accountable for the decisions that they make about patient care (NMC 2002).


       Many of the issues raised in this chapter illustrate the complexity of nursing practice and demonstrate how thinking skills and decision making are essential to good practice. Not only is nursing practice complex it is also dynamic, and changes with developments in health policy and scientific knowledge. For nurses this means that every patient contact is unique and that over a period of time a great deal of experience is generated from nursing practice. Nursing practice, taken in its widest sense, means working with other health and social care practitioners to provide the assessment, organisation and management of holistic care for patients.

     Reflection is a great way to learn. It enables nurses to capitalise on what they do well and see how to improve the aspects of care that did not go so well. Taylor (2000) stresses this by stating how the unconsidered life is transformed, through the process of reflection, into one that is consciously aware, self-potentiating and purposeful. All recently qualified nurses will have been taught to use reflection as a method of learning, for just as EBP is a key concept in current nursing practice, so is reflection. Reflection has particular value to learning in nursing because of the richness of experience in practice and the direct observation that nurses are able to make about how the care that they and the health care team give affects patients.

Reflection and practice

       Reflection can and should take place during the process of practice. Schon (1983) refers to this as ‘reflection in action’. It also takes place after the event, which Schon refers to as ‘reflection on action’. Sometimes reflection is private, at other times it is shared with colleagues or may even form part of a team meeting.

       The exercise that you have undertaken is an illustration of reflecting on practice, learning from it and using the learning to inform and develop future practice. This is why reflection is so beneficial in nursing. In part it is explained because of the uniqueness of each situation demands new thinking and reasoning and this accumulates over time as experience increases.

      Reflecting on action is a deliberate event. It can be a very effective learning experience for the individual nurse or for the team. Each nurse should regularly take time to reflect on their practice, considering their knowledge and skills, the evidence base from which care is given and the many influences that impinge on care.

     Group reflection probably occurs informally in many teams at hand-over meetings when care is discussed. Reflection by the team in a more formal sense provides opportunity for review of patient care on a planned and regular basis. Like the individual nurse, the care team considers their knowledge and skills, the evidence base from which care is given, the influences on care, that are raised in models of nursing, and take a general reflective view of the care provided for each patient. Group thinking can be productive, with each member contributing an individual perspective, and everyone learning from the others in the group. Shaw (1981) suggests that groups make better- quality decisions than individuals, which has particular significance when so much is at stake for patients. However, some caution needs to be exercised when a group reflects, on account of a phenomenon known as groupthink, whereby pressures for conformity and for keeping within the boundaries of accepted practice stifle creative thinking (Robbins 1986).

     Learning often occurs when something happens that is disappointing or does not turn out the right way. It is this type of experience that most frequently makes people think about what they have or have not done and how it could have been more effectively achieved. It is not enough only to reflect and recognise where things went wrong: that is evaluation of the incident. Reflection is more than evaluation – it involves new learning. For learning to occur it is first necessary to identify what, in the case of a negative experience, went wrong. It is then essential to take the necessary steps to remedy the deficit and put it right. It may be as simple as recognising that work has been done without sufficient thought and that corners have been cut. In this instance the practitioner knows what should be done but has failed to do it correctly. The learning will be in the nature of accepting that however great the pressures, sufficient time must be given to each patient and procedure. It may, however, be that new learning needs to take place, perhaps a new skill needs to be learned, maybe from a colleague who has the necessary expertise. Sometimes knowledge is out of date and must be updated by reading or by attending study days. Very often in primary care nurses come across health problems that are new to them and they have to find the information that is needed to enable them to provide effective care. As you can see, learning involves taking some action. The purpose of reflective practice is to actively enable learning so that it becomes integral to routine practice. If a nurse constantly reflects on practice, learns from it and changes practice in response to learning, practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed to help the process of reflection. Many nurses are introduced to reflection by using the staged process advocated by Gibbs (1988). Gibbs’s model offers a cycle to guide nurses through the reflective process:

• describe what happened

• explore the thoughts and feelings that occurred as part of the experience

• evaluate what was good and bad about the experience

• analyse the experience in order to better understand it

• consider what else could have been done, and finally

• make an action plan to determine how the situation would be handled should it occur again.

       This cycle of steps gives an easy-to-follow process, guiding the nurse through reflection. There are other frameworks that facilitate the reflective process, for example Burnard (1991), Boud, Keogh and Walker (1985) and Goodman (1984). Goodman’s approach focuses on levels of reflection, suggesting three levels of increasing complexity. The first level consists of a simple approach that involves considering how the job was done with regard to technical efficiency and effectiveness, and in terms of accountability. The second level takes a wider view, looking at the implications and consequences of the nurse’s actions and beliefs, which includes the underlying rationale for practice. The third, most complex, level draws on all the considerations in levels one and two, and adds ethical and political considerations and developments.

       There are distinct differences between the approaches that are taken by Gibbs and Goodman. Gibbs offers a framework to facilitate structured thinking while Goodman pushes the boundaries of thinking to levels of considerable complexity. Examination of different approaches helps nurses to choose the one most suited to the situation. As with models of nursing the most suitable approach to reflection may vary with differing experiences and so it is beneficial to have a range of approaches to draw upon.


        This chapter has covered some of the key factors that influence and inform professional practice in nursing. This should create awareness of sources of nursing knowledge and reinforce earlier learning that introduced the nature and purpose of nursing models. There is no doubt that practice is complex and nurses can only truly attempt to meet the needs of patients if they are able to understand and manage complexity. The value of models of nursing is that, in representing the complex nature of practice, they act as prompts. Because each model is presented in diagrammatic form it enables the same detailed process of assessment, planning, implementation and evaluation to take place for every patient. Professional skill comes into play as infinitely variable information is analysed and interpreted into personal and individual plans of care that take account of very differing needs. The skill of the nurse is needed to manage patient information and translate it, with the patient’s collaboration, into meaningful and appropriate delivery of care. Nurses must therefore be knowledgeable and skilful. The dynamic nature of health care means that new knowledge is constantly emerging, and health practitioners are obliged to keep up to date with the latest developments.

         Knowledge and the validity of information are requirements for planning effective, economic care. Quality in care is high on the government agenda for improving the National Health Service (DOH 2000). Receiving care that is based on objective information is an essential part of provision; application of care without thought or consideration of the individuality of people would go against the ethos of professional practice (Norman and Cowley 1999). Norman and Cowley state that knowledge based on evidence is valuable and should underpin protocols and guidelines. Information that is collated and current greatly assists practitioners. Blind acceptance of evidence is not, however, consistent with professional practice, one criterion of which is autonomy. Reflective practitioners who are constantly learning on the job are fundamental to the profession – nurses who can plan appropriate care on an individual basis, with the patient, and are able to be justify their decisions.



Community Health Nursing Site news

VI. Working Collaboratively




           The ability to work collaboratively has been highlighted in the professional Code of Conduct (NMC 2002a) as an essential part of a nurse’s role. There is an expectation that a nurse will work co-operatively with other professionals, respecting their skills, expertise and contributions.Additionally, a nurse must communicate effectively to share knowledge, skills and expertise in order to work efficiently with other team members, whilst maintaining high standards of care (NMC 2002a). Nurses who seek to enrich their practice need to have a greater understanding of what it means to work collaboratively, not just with other professionals but primarily with patients and their carers(Fatchett 1996). This active involvement of patients in their care lies at the heart of current government policy (DOH 2001a, 2001b). Whilst the aim of collaborative working is that it should lead either to health gains or improved patient outcomes, it must be noted that there is, according to Ross and Mackenzie (1996), insufficient evidence to date to substantiate this view – an interesting finding given that policy and practice place such emphasis on collaborative working.

          The following case study of a hypothetical family in receipt of primary care will be used to contextualize the issues being discussed.


Elmer King, aged 35 years, is black British of Caribbean origin but grew up in London. He is unemployed, suffering from schizophrenia and carries sickle cell trait. His partner Ann, aged 32 years, is white British. She also carries sickle cell trait. She has a part-time night cleaning job for a large local firm.



Malcolm Roberts, aged 13 years, is the son of Ann’s first partner. He is timid and small for his age. He ‘gets picked on’ by other children at school and has recently been complaining of stomach aches and not wanting to go to school.

Louise King, aged 8 ye

ars, has sickle cell disease and has had a lot of absence from school because of sickle cell crises.

Alice King, aged 11 months, is wheezy and suffers from severe infantile eczema. She was bottle-fed from birth and weaned very early. She has attended for developmental checks. Her hearing and vision are satisfactory but there is concern about delayed motor development.

Ann recently scalded her leg badly. She says she accidentally knocked over a full pot of freshly made tea. She has been self-treating the wound for a few days and has only just visited her general practitioner (GP) as the wound is now ‘rather smelly’ and her leg is very red.

The family live in an urban area of a large city. Their accommodation, which they rent, is a small terraced house with two bedrooms and a small garden at the rear.


In considering issues relating to Elmer, Ann and their family there is the potential for a number of different people to be involved in order to provide the appropriate services to meet the family’s health and social needs.


         Over the past 15 years, government health and social policy has constantly reinforced the need for primary health care and teamwork to meet the challenges of a changing population and of ‘life- style related disease in the community’ (Ross and Mackenzie 1996: p.78). In 1986 the Cumberlege Report (DHSS 1986) noted that numerous health and social care professionals were ‘beating the same pathway’ to patients. The results were confusion for the patients and their carers and duplication of services. It was considered that the service provision was fragmented and the potential for missing health needs was significant. Through a series of government policies (DOH 1987, 1989a, 1989b, 1990, 1996, 1997, 1999a, 1999b), teamwork, collaboration and a partnership approach to care have become central to the provision of care in the community. There is recognition of a need to move away from the traditional boundaries of health and social care towards the development of multi- professional teams working throughout hospital and primary care settings.

        The NHS and Community Care Act 1990 brought together the social services and health services to provide ‘seamless care’ to people in their own homes or in homely settings. The Act provided a ‘planning framework’ to enable different agencies to work together, to consult and collaborate at every level (Audit Commission 1992). This ‘bringing together’ was further strengthened in the subsequent government report, Primary Care-Led NHS (DOH 1996). It was envisaged that multi-disciplinary, multi-professional, inter-agency teams of people would be working together. In a time of diminishing resources and increasing demand they would provide an effective, high-quality care that would be needs led and not merely a blanket provision.

           It was the change of government in 1997 that brought about recent changes of policy in the National Health Service, but the need for partnership and collaborative working has remained a significant feature – in fact has been emphasized more strongly. One of six key underpinning principles outlined in The New NHS: Modern, Dependable (DOH 1997) was to involve the National Health Service in partnership with other agencies in the provision of social and health care, with the needs of the patient at the centre of the care process. The increasing emphasis on the role of primary health care teams has come about as a result of ever-increasing hospital costs alongside government recognition of their importance as gate-keepers to health care (Fatchett 1996). The more recent NHS Plan (DOH 2000) has contributed to this shift in emphasis to a needs-led service – one that encompasses collaboration, joint working and partnership. Fatchett (1996) has attributed the increase in popularity to collaboration to a number of causes.

  • A growth in the complexity of health and welfare services.
  • Expansion of knowledge and subsequent increase in specialization.
  • A perceived need for the rationalisation of resources
  • A need to reduce the duplication of care
  • The provision of a more effective, integrated and supportive service for both users and professionals

           The greater complexity of technology and treatment has placed tremendous pressure upon practitioners to have the necessary knowledge and competencies to meet the needs of patients with complex care needs. There have been a number of recent public inquiries into incidents involving people who have been diagnosed as mentally ill. Government response has been to seek to improve the co-ordination of care for such individuals, with an increased emphasis on the role of the primary health care teams (Secker et al. 2000).


                As highlighted in the previous section, the reasons given for collaborative working would seem to be extensive and significant, but what does it actually mean? The word ‘collaborate’ is derived from the Latin collaborare which means ‘to labour together’. This notion of working together has been highlighted by Ovretveit (1997) in the sense of collaboration between organisations or individuals working together or acting jointly. In addition, the notion of exchange is evident in Armitage’s definition (1983), defining collaboration as being the exchange of information between individuals involved in the delivery of care, which has the potential for action or joint working in the interests of a common purpose.

             This definition would seem to be quite straightforward, but it could also be seen to be referring exclusively to professionals delivering care without reference to the patients and their carers. Interestingly enough, the issue about being professionally driven could be inferred from policy documentation (DOH 1992). Here collaboration is seen as a ‘partnership of individuals and organisations formed to enable people to increase their influence over the factors that affect their health and well being’, a view more recently expressed in The NHS Plan (DOH 2000) and Liberating the Talents (DOH 2002).

              The issue of collaboration having the potential to be professionally driven is of particular importance when considering a partnership approach between practitioners, patients and their carers. Henneman et al. (1995) suggest that when individuals are involved in collaboration their relationship is non- hierarchical. Power is shared on the basis of knowledge and expertise rather than role or title. In other words, collaborative working needs to involve a redistribution of power within the health care team (Soothill et al.1995).


           In considering the needs of Elmer, Ann and their family there will be a need to relate to and work with each member of the family as well as networking with a range of diverse groups, including social services, and voluntary agencies. The interface may be at different levels, according to the actual requirements of care. Armitage (1983) identified a taxonomy of levels of collaboration that moves from a situation where people communicate without meeting to a situation where people work together. For example, issues of child protection and bullying that could be associated with Alice and Malcolm might be dealt with by the health visitor and the school nurse, who might also involve such other agencies as social workers, the police and the judiciary. The GP and the practice nurse may be involved with the care of Ann’s wound and for Elmer’s maintenance medication. In this way referrals from one agency to another regarding the family might occur without any need for a meeting. However, if the care is to be effective it might be that each of the agencies involved would need to come together and meet with the family to resolve difficulties, duplication and problems. Similarly, two agencies might be more involved than others and take the lead in the care whilst informing the remaining agencies of progress.

          A framework for classifying collaboration by Gray (1989, cited in Huxham 1996) suggests that there are two dimensions: factors that motivate people to collaborate and the goal or anticipated outcome of the collaboration. Gray further suggested that there are four types of collaboration: appreciative planning, dialogues, collective strategies and negotiated settlements. Although Gray is concerned specifically with business organisations, her classification of the four types of collaboration could also be applied to health care situations.

            The different types of collaboration as identified by Gray can be seen at a micro level, as in the King family. The exchange of information is one of the key features in the King family’s situation (appreciative planning). Each of the different practitioners involved with Elmer, Ann and the family care need to communicate (dialogues) their knowledge of the situation in order to arrive at a shared vision. They need to provide an arena for exploring solutions to the problems identified by the patients and their carers, resolve difficulties (negotiated settlements) and reach agreement about a plan of care (collective strategies). Thus the collaborative process will pass through three phases: problem solving, direction setting and implementation (Gray 1989, cited in Huxham 1996).

           At a broader macro level, working in partnership and collaborative care means ensuring that the structure of the organisation is sufficiently flexible to support patients and enable them to function. The implementation of health improvement programmes (HIPs) is seen as providing the ‘strategic glue’ that binds the different services together in new working partnerships between users and health service providers, including statutory and non-statutory (Gillam and Irvine 2000). In addressing the needs of local populations through HIPs there is an emphasis upon primary care staff to work across practice and professional boundaries with colleagues in Social Services, Education and Housing. In this way, people with the relevant knowledge and skill, including the patients and their carers, will be able to carry out the appropriate care.


         Previous sections of this chapter have discussed why it is important to work collaboratively, what it means to collaborate and with whom we need to collaborate. This section is about how we collaborate – in particular the skills needed to collaborate effectively. Using the case study of Elmer, Ann and their family, scenarios will be drawn out to demonstrate the range of skills that are fundamental to effective collaboration.

       Hornby and Atkins (2000) are clear in establishing that the sole purpose of collaboration is to provide optimum help. In their discussion on collaborative processes and problems, they identified a range of attitudes and skills necessary for good practice. It is these that will be identified and integrated in an examination of this complex family situation.

         Thompson (1996) states that working with others involves engaging with other people person- to-person. However, before we can do this we have to have a good understanding of ourselves in terms of ‘how we are perceived by other people, our characteristic responses and reaction and our own needs’ (p. 234).

Collaborative Attitudes

Hornby and Atkins (2000) suggest that collaborative attitudes may be clustered under the concepts: reciprocity,flexibility and integrity.

  • Reciprocity is based on respect and concern for individuals and the development of mutual understanding and mutual trust.
  • Flexibility is the readiness to explore new ideas and methods of practice and an open attitude to change. It is about working in partnership with clients and colleagues and not about positions of power.
  • Professional integrity places the client’s needs first and not those of the individual practitioner. Integrity, according to Hornby and Atkins, demands that practitioners examine their own defensive practices and separatist tendencies.

            This scenario highlights the importance of collaborative attitudes. In considering the issues of reciprocity, flexibility and professional integrity, you may have covered the following issues.

            Reciprocity. The practice nurse has shown genuine concern and empathy for Elmer. She has begun to build up a relationship with him during his routine appointments and her knowledge of his condition has led her to feel genuine concern. In the busy schedule demanded by the appointment system at the surgery, it would be easy to label Elmer as a ‘DNA’ (did not attend) and be somewhat dismissive of any follow-up. Mutual trust is beginning to develop between the practice nurse and Elmer and the fact that she has been unable to contact him on the phone, has led her to feel that ‘something is wrong’.

        Flexibility. The practice nurse has shown by her actions that she sees Elmer as an equal partner in his care. Her approach is one of working towards concordance (see DOH 2001a) as opposed to compliance. She would be keen to consider other methods of practice, depending on Elmer’s needs.

             Professional integrity. The practice nurse has demonstrated the importance she places on meeting Elmer’s needs – it would have been easy for her to become irritated by Elmer’s ‘DNA’. In terms of her role within the practice and the other patients she has been more prepared to consider what is wrong with Elmer than her own position at that time. However, she should also realise that she is not alone in being able to provide support for Elmer. She is a member of a wider primary health care team, some of whom might be better placed to follow up Elmer’s situation. In this way she would be demonstrating her awareness of her own role and its boundaries whilst respecting the roles of the others in the team.


Consider what reciprocity, flexibility and professional integrity would mean in relation to the following scenario.

Elmer usually attends the health centre for his regular depot injections from the practice nurse. He has not attended for the second injection and the nurse is very concerned about Elmer. She has tried to contact him by telephone but the number is unobtainable – in fact it has been cut off due to non-payment of bills.

           Elmer’s community mental health nurse would probably be the first colleague to contact regarding his schizophrenia and depot medication. She might also want to discuss the situation with her health visitor colleague, who would know the family because of visiting Ann and baby Alice. Both these colleagues would be able to discuss Elmer’s financial situation with him and seek further support from the social worker, should he wish it. She could also contact the school nurse responsible for the schools that Louise and Malcolm attend just to ensure that the children have the opportunity to share any concerns if they wish and to monitor their situation.

       In summary, this scenario demonstrates how important it is to have a positive attitude to collaboration not only with patients but also with colleagues.

Collaborative Skills

      In addition to collaborative attitudes, Hornby and Atkins (2000) highlight the importance of  collaborative skills and see these as relational, organizing and assessment skills – all essential elements for effective collaborative working.

        Relational skills include open listening, empathy, communicating and a helping manner, in other words putting people at their ease.

      Open listening means hearing without stereotyping, and using direction purely for the purpose of hearing more rather than less. It requires the ability to tolerate distress and anxiety without resorting to coping methods that restrict the client’s communications. It means being alert to the feelings that may be involved when individuals seek and receive help and being aware of the effect on people of finding themselves as a service user. It is about facilitating the expression of relevant emotions and being able to empathise whilst at the same time retaining the necessary objectivity when meeting patients’ needs.

       Empathy, according to Thompson (1996), is the ability to appreciate the feelings and circumstances of others even though we do not necessarily share them. It is about being sensitive to differences and avoiding making stereotypical assumptions. In order to avoid discrimination and disadvantage, it is essential that patients’ differing requirements are met.

       Clements and Spinks (1994) stress the importance of treating others, whether as individuals or in groups, fairly, sensitively and with courtesy, regardless of who they may be. Further, they identify the following skills, knowledge and attitudes, which are applicable to almost any situation:

• empathy

• keeping within the law

• thinking about the consequences

• not believing myths

• a desire to be fair

• openness to different ideas

• reflective thinking

• sensitivity

• using appropriate language

• knowing about the issues

• treating people as individuals

• not seeing alternative cultures as a threat

     Open communicating means conveying what seems to be relevant, including feelings as well as facts and opinions, without becoming defensive. Where trust is lacking, defensive processes and protective devices are likely to come into operation. Open communicating also relates to the need for professional confidentiality (NMC 2002b). For further information about confidentiality see Cornock (2001).

       A helping manner, according to Hornby and Atkins (2000), is the ability to manifest personal concern and professional confidence without superiority, thus enabling patients, carers and practitioners to function at their best in a working relationship. The role of carers should not be taken for granted nor undervalued: the practitioner must be as concerned for their wellbeing as for that of the patient. This feeling of being valued may not automatically result in an increased participation but it can at least bring emotional benefit to both carer and patient. Facilitating patients’ and carers’ expressions of their feelings is a skill which can often increase understanding of a situation, resolve blocks to progress and relieve tension and distress.


In terms of relational skills, for example open listening, communication and a helping manner, what do you feel are some of the issues in the following scenario?

The district nurse has received a referral from the GP regarding visiting Mrs King, who has recently scalded her leg. She has been self-treating the wound for several days and it has now become infected. The district nurse has not had any previous contact with Mrs King.

Mrs King has a night-time cleaning job for a large local supermarket and with her family commitments is not able to attend the health centre. The district nurse knocks hard on the door and eventually Mrs King appears in her nightie, looking cross. She was asleep and Elmer, who should have been looking after baby Alice, has gone out.

          You may have considered some of the following points. At the initial referral it would have been helpful if the GP had indicated that Mrs King worked ‘nights’. Even though she could not confirm her visit by telephone the district nurse should have been able to make a visit at a time more convenient for Mrs King which intruded less on her need to sleep during the day. It might have averted the initial ‘angry’ meeting. However, once in this somewhat confrontational position, the district nurse needs to be able to acknowledge the situation as a whole and her role in it. She needs to be receptive to Mrs King’s irritation and demonstrate her open listening skills. It would be easy to become defensive and use closed questions as a means of restricting Mrs King’s communication. Skills in open communication are essential in order to build a trusting relationship between practitioner and patient. A helping manner is demonstrated by concern for the individual patient within the wider family context. This example shows how important it is for the practitioner to view a situation from a holistic perspective rather than from a limited task viewpoint. In an uncomfortable atmosphere the practitioner could well have undertaken a specific task and then left, limiting her concern solely to Mrs King’s leg.

        Organising skills identified by Hornby and Atkins (2000) are those required to implement the principles of essential collaboration. These include establishing networks, setting up meetings, devising appropriate patient/carer referral systems, and managing changes within the work context. Professional boundaries need to be clearly defined and agreed. Henneman et al. (1995) maintain that collaboration requires individuals to have both a clear understanding of their own role and an understanding and respect for the roles of others.

       When individual team members are clear about their own roles and boundaries and those of others in the team, the most appropriate person can then support Elmer and his family – otherwise gaps in their support could appear. The complex situation presented by Elmer’s family requires an effective application of skills. The family, the GP, practice nurse, receptionist, community mental health nurse, district nurse and school nurse have already been indicated as each having a role to play. Clearly, networking with others in such a situation is crucial. The primary health care team meeting could prove to be a valuable forum where issues would be shared, future support for the family clarified, and the key worker identified. A lack of organisational skills could prevent a full and accurate picture of the family’s needs being completed.

          Assessment skills represent the final element of collaborative skills as identified by Hornby and Atkins (2000). Assessment, according to Thompson (1996), is a complex and multi-faceted process. A high level of interpersonal skills is required when undertaking a holistic assessment, and in complex situations assessment skills involving a range of perspectives may be appropriate. When different agencies have overlapping boundaries sometimes the patient can experience difficulty in finding that which is most suited to meeting his/her needs. At the same time it is not always possible for one practitioner to have sufficient in-depth knowledge of the various contributions of other agencies. Practitioners need to know enough about a range of services to be able to select the most appropriate one for any given situation and also when to refer the patient. Thus, the demands on the practitioner include not only a wide range of knowledge and a high level of assessment skills but also a freedom from defensive or separatist attitudes (Hornby and Atkins 2000). Whilst there is a desire to move towards a single assessment process, currently different professionals have their own methods for documenting assessment (NMC 2002b). It is the pooling of this information that is so important to ensure that all the pieces of information fit together.


The final section of this chapter focuses on interprofessional relationships, thus drawing together some of the wider issues already alluded to.

            Mackay et al. (1995) have asserted that working interprofessionally involves crossing traditional professional boundaries, being prepared to be flexible in considering a range of views and having a willingness to listen to what colleagues from other disciplines are saying. Each group brings different skills and solutions to the health care problem with which they are presented. In some decisions the contribution of one professional group needs to take precedence over others, which underlines the need for flexibility in decision making. Interprofessional working, as mentioned earlier, raises the question of redistribution of power within teams. So many fundamental changes are taking place within primary care that perhaps now is an opportune moment to challenge established and entrenched attitudes.

           Collaboration between professionals and between service agencies is currently regarded as the cornerstone of the development of community care in the UK. However, only recently have mechanisms of collaboration been subject to evaluation as a means of demonstrating effectiveness. Molyneux (2001) attempted to do just this in her study of interprofessional team-working by identifying and evaluating the positive characteristics of team working. Three main themes emerged:

• Motivation and flexibility of staff. Personal qualities of staff such as flexibility, adaptability and lack of professional jealousy enabled team members to work across professional boundaries.

• Communication within the team. Findings identified regular and frequent team meetings and agreement on the communication strategies, for example shared records, within the team as central to effective team working.

• Opportunities for creative development of working frameworks. Encouragement and opportunities need to be provided for staff working together to enable them to develop creative methods of working which meets their patients’ needs.

           It is in the sharing of knowledge and skills in a collaborative way that the common goal of holistic care is more likely to be achieved with ultimate benefits to the patient and family. (Shields et al. 1995). Essential to the success of collaborative working is a defined mechanism for making decisions. Problems can occur where a team does not have a clear and agreed process. Ovretveit (1993) points out that conflict can arise unless differences are aired and worked through in a creative and fair way. Unstructured decision making procedures waste time, cause conflict and resentment and can lead to team break down.

         In summary, collaborative working is an ideal that essentially seeks to ensure that the best interests of the patient are protected. It is a never-ending  process in which the patient, relatives and carers must increasingly be supported to play a central role in making their own contribution to decisions affecting their lives. Collaborative working is, therefore, one step on the way to fully informed decision making in meeting the needs of patients and their carers and delivering effective and efficient community health care.




Community Health Nursing

V. Therapeutic Relationships


           The recognition of the importance of the therapeutic relationship is not a new phenomenon. Peplau’s (1952) theory of nursing is based upon the importance of the relationship between the nurse and the patient, and she asserts this is the way in which all nursing care is delivered. The importance of this relationship has continued to be widely acknowledged and indeed McMahon and Pearson (1998) suggest that it is central to patient health, well-being and recovery. Since a therapeutic relationship is so important, it is essential to consider what features characterise such a relationship. In reviewing various definitions it becomes apparent that the important factors are:

  • appropriate boundaries are maintained
  • meets the needs of the patient
  • promotes patient autonomy
  •  positive experience for the patient

Appropriate boundaries are maintained

      A boundary, as defined in the dictionary (Chamber, 1993) is: ‘a limit, a border, termination or final limit’. Within the therapeutic relationship, boundaries define how far the nurse is willing to go to meet the needs of the patient and his family.

       Therefore it is important that the nurse, patient and family are clear regarding their relationship and what is reasonably expected of each party. This will protect all those involved in the relationship. A publication from the UK Central Council (1999: p.5) on this subject states that: ‘boundaries define the limits of behaviour which allow a client and practitioner to engage safely in a therapeutic, caring relationship’. The practitioner has the responsibility to maintain appropriate professional boundaries at all times (UKCC 1999). However, the process of finding the boundaries of care is far from automatic (Totka 1996), as will be discussed later in this chapter.

Meets the needs of the patient

       The purpose of the relationship between the nurse and patient is to meet the nursing needs of that patient. It is therefore important that the nursing needs of the patient are discussed at the outset of the relationship in order that mutually identified goals can be set and each person within the relationship can be clear as to their role in the achievement of those goals. This might include the nurse, patient, family members, other professionals and carers. This will require expert communication skills on the part of the nurse in order that a relationship of trust can develop. Whilst the relationship exists to meet the needs of the patient it is likely that the nurse will experience satisfaction in helping the patient to meet those needs. This is entirely appropriate. However, it is important that nurses do not allow their personal needs for positive self-esteem, control and belonging to undermine the professional relationship (Jerome and Ferraro- McDuffie 1992). This requires the nurse to be self- aware and open to seeking support from others when the need arises.

Promotes patient autonomy

          Autonomy is the right to self-determination. Self- determination can be defined as an ability to understand one’s own situation, to make plans and choices and to pursue personal goals (McParland et al. 2000). This further supports the need for excellent communication skills on the part of the nurse in order to assist the patient to understand their own situation. Within a relationship that promotes patient autonomy the patient will contribute to the achievement of personal goals and will move towards independence.

Positive experience for the patient

        The experience of participating in a therapeutic relationship will be positive for the patient as nursing needs will be met, in a way that is most appropriate to the patient and their family. Truly therapeutic relationships can empower the patient, the family and the nurse.

  These features are embodied in the Code of Professional Conduct, which states:

             You must at all times, maintain appropriate professional boundaries in the relationships you have with patients and clients. You must ensure that all aspects of the relationship focus exclusively upon the needs of the patient or client. (NMC 2002: Clause 2.3)


          Having considered the features of a professional relationship, some of the challenges of achieving such a relationship in the community setting will be discussed. Professional relationships with the patient are influenced by a number of factors.

          The delivery of care within the home can provide a feeling of security for the patient and his carer/s as they are on familiar territory. This can make it easier to develop a good relationship, such that they are able to share their concerns and worries. It is also probable that patients and carers will be able to learn new skills more readily as they are likely to feel more relaxed within their ‘normal’ environment.

           In this example the benefits of home visiting are apparent. These opportunities could be lost if health visitors change their mode of practice to give more care in clinic settings, as has been reported by Normandale (2001). However, caring in the home environment can leave the nurse feeling vulnerable. A nurse who has recently left a hospital-based job to work in the community can feel very isolated. Despite the use of mobile phones and pagers it is more difficult to seek the advice of a colleague, and help may not be instantly at hand. A nurse who feels vulnerable and isolated will find it more difficult to inspire the confidence of patients.
Working in the relative isolation of the home can provide challenges to nurses in maintaining standards of care. If the relationship is not ‘therapeutic’ it can be difficult for the nurse to identify this herself, particularly if the situation has developed over time. The support and guidance of colleagues is essential, as is the willingness of the nurse to be open to that support. Totka (1996) notes that peers often recognise unhealthy situations before the nurse involved, but find it difficult to discuss the situation with their colleague.
Care given by the nurse within the workplace will also be different from the more traditional hospital setting. The occupational health nurse works within a three-way relationship between the employer, employee and the nurse (Atwell 1996).

        Developing therapeutic relationships may also be affected by a clinic or surgery setting, where the patient may gain the impression of busy workloads inhibiting the time they spend with the nurse. Paterson (2001) identified lack of time as a major inhibitor in developing a participatory relationship between professional and patient, and although the nurse is likely to be as busy, if not more so, when undertaking home visits the interaction may be less distracted than in a busy clinic.

           In other cases the relative anonymity the surgery or clinic provides may be of benefit in facilitating the development of a therapeutic relationship. Initial assessments are often the first point of contact between community nurse and patient and the nurse must develop skills to enable a conducive environment in order to establish the start of a therapeutic relationship (Bryans and McIntosh 1996).

        Working in the community, many nurses find that not wearing a uniform removes an unnecessary barrier, which makes the development of a therapeutic relationship an easier task. It does, however, require skills on the part of the nurse to gain access to the patient’s home, gain the patient’s trust and explain her nursing role, since a symbol, which for many carries some degree of status, has been lost.
For those community nurses who do wear a uniform other challenges arise. Wearing of a uniform can enable almost instant entry to some homes, but may present a barrier to acceptance by some people. This may be especially apparent with children, who have perhaps learnt to associate uniforms with pain and discomfort. In these situations it will take time to address prior conceptions before a therapeutic relationship can be established.
If nurses do not wear a recognised uniform it is particularly important to consider the appropriateness of the clothing that is worn. Entering a home inappropriately dressed may cause offence and prevent establishment of a relationship. Perhaps this might require the nurse to cover her arms and legs if visiting Asian families, or maybe to remove shoes prior to entry into some homes. In order to meet the needs of individual families the nurse must enquire as to family preferences and be willing to adapt behaviours to respect values different from her own, in order to facilitate good relationships.
A final point about dress code: whether wearing uniform or not, it is essential to carry identification at all times in order to protect the wellbeing of patients.

Nature of care

       A key element in the nature of the therapeutic relationship with all patient groups is the duration of the relationship. Morse (1991) describes three appropriate relationships. Firstly, she describes the one-off clinical encounter that, for example, a practice nurse may have with a patient in a travel clinic. There are also encounters that last longer but focus on a specific need, such as maintenance of hormone replacement therapy. Both of these relationships are mutual and appropriate to certain situations but Morse argues that within a much longer-term nurse–patient relationship there should be a different focus, with the development of what Morse terms as a connected relationship. Morse suggests that the key characteristic of a connected relationship is that the nurse views the patient as a person first rather than a patient.

       Whilst for many families and professionals this can only be positive, there is a potential to step over the professional boundary and it is essential to maintain the appropriate balance within the therapeutic relationship. The consequences of not maintaining the balance will be explored later in the chapter.

        In the home environment the patient and his carer could be perceived to have greater control within the relationship. Should the patient decide not to concur with recommended treatment, this may not be immediately evident as the nurse is
spending only a short period of time within the home environment. Parkin (2001) notes that professionals are unable to control the home environment. If, unbeknown to the nurse, the patient has not adhered to the recommended treatment, the therapeutic relationship is threatened, since a relationship based on trust no longer exists. Within a therapeutic relationship the patient should be able to tell the nurse of his intentions. This might allow treatment to be modified such that the patient feels able to follow the regimen, but even if this is not the case at least the nurse is aware of the true situation and can modify her nursing care accordingly.

Patient expectations

         Expectations of the nurse and of the community nursing service may also impact on the relationship between the nurse and adult patient. Over the past 25 years there has been a rapid rise in consumerism (May and Purkis 1997), with a corresponding rise in expectations of the Health Service. In community nursing this can be seen by the use of time bands in allocating home visits and the proliferation of charters and mission statements displayed on clinic and surgery walls.

      Many patients have clear ideas on the service they expect from community nurses with a consequential detrimental effect on the therapeutic relationship when these expectations are either not met or are unrealistic.
However, despite trends in healthy ageing and participation in health care (Lorig et al. 1996), many older adults were bought up in a society where medicine was seen to have all the answers and the public was expected to be the passive recipient of care (Dukes Hess 1996). There is some evidence that not all adult patients wish to be an active partner in the therapeutic relationship (Waterworth and Luker 1990) and there may be a significant number of patients who feel more comfortable with the paternalistic model of care (Roberts 2001). The nurse ‘doing for’ the patient rather than enabling them to self-care contradicts the current trend towards empowerment (Copperman and Morrison 1995), which is a central theme in the National Service Framework for Older People (DOH 2001a). The community nurse may find a challenge in helping some patients in developing the confidence and ability to self care, and again the therapeutic relationship will be focused on trust and the facilitation of realistic independence.

Patient needs

        The main purpose of the nursing or health visiting intervention may also have a significant impact on the therapeutic relationship. The patient within the relationship may have significant physical and emotional needs, such as happens in palliative care. The relationship in such cases may be based on intensive input by the nurse (Goodman et al.1998). In contrast, the practice nurse or occupational health nurse may see a person for health screening with less obvious health needs as the focus of the intervention.
The substantial shift of care from hospitals to the community for those with mental health needs (Brooker and Repper 1998) has resulted in a rapidly developing role for community nurses in supporting this group. With approximately one in six people at any one time suffering from mental illness in the United Kingdom (DOH 1999a) the role is constantly evolving. The National Service Framework for Mental Health (DOH 1999a) is firmly underpinned by a patient focus. However, empowering patients with mental health needs is often challenging, not least because of concerns from society and professionals as to whether some patients have the capability of making decisions over their care and treatment (Feenan 1997).

Table 5.1 Responses to caring role:

Response to caring role – Features of Response

  • Engulfment mode
  1. Cannot articulate needs as a carer
  2. No other occupation
  3. Generally female spouse
  4. Total sense of responsibility and duty
  • The balancing/boundary setting mode
  1. Have a clear picture of themselves as carers (e.g. how they save nation money)
  2. Generally male
  3. Often adopt language of an occupation – treat role as a job
  4. May emotionally detach themselves from recipient
  • Symbiotic mode
  1. Positive gain by caring
  2. Does not want role taken away

            The therapeutic relationship with this group is essential in empowering patients to actively participate in decisions about their care. Peplau’s (1952) developmental model is often used as the framework for developing a therapeutic relationship (Collister 1986) with the assessment (or orientation) phase focusing on the development of mutual trust and regard between nurse and patient, as well as data gathering. Addressing anxiety is the overarching aim of the therapeutic relationship (Aggleton and Chalmers 2000), and the community nurse may take on a number of roles to facilitate this including that of counsellor, resource, teacher, leader or surrogate. All nurses working in the community develop knowledge of local resources and other agencies and facilitating the patient to access these may be the key component within this relationship.

            It should also be acknowledged that the therapeutic relationship in the community setting is not only formed between nurse and patient, but will often encompass an informal carer. In the United Kingdom there are approximately 6 million informal carers who are the primary carers for a range of patients ranging from young people with learning disabilities, to the frail elderly (Bond et al. 1999). The Carers Recognition and Services Act (DOH 1995) and the Carers and Disabled Childrens Act (DOH 2000) enshrined the principle that carers should be assessed and acknowledged as an individual rather than simply an adjunct to the patient. For the community nurse this reinforces that an individual therapeutic relationship must also be developed with the informal carer, but this poses a number of challenges.

            First, a significant number of informal carers are unknown to the community nurse, with Henwood (1998) estimating that only half of all carers receive any support from community nurses. Second, the more an informal carer does for the patient, the less intervention there will be from the community nurse (Pickard et al. 2000). Consequently, the informal carers most likely to benefit from a therapeutic relationship are less likely to be visited by the community nurse. Third, there are often misguided assumptions by many professionals that informal carers should undertake the caring role and that the role is taken on very willingly (Procter et al. 2001).

           Finally, studies have shown that many informal carers have significant health needs of their own which often are unrecognised (Henwood 1998) and undertake very complex and technical tasks (Pickard et al. 2000). All too frequently community nurses first meet an informal carer when there is a crisis and the nursing input is a short-term measure to help the patient and carer over this period. However, the therapeutic relationship with informal carers should ideally be long-term, with the nurse aiming to provide information and acting as a resource (Seddon and Robinson 2001) and responding to the role the carer is happy to undertake.
Twigg and Atkin (1994) describe three different responses by individuals to the informal caring role, given in Table 5.1. It is important for the community nurse to recognise the informal carer’s response to their situation.

          Another frequently met scenario is that of the husband caring for his wife. He has every detail organised and is business-like in his approach to the community nurse. Again, this may hide a number of physical and emotional needs, and the community nurse must develop a therapeutic relationship in order to enable him to express these. The needs of informal carers are only now being recognised and the community nurse must develop a relationship and provide intervention appropriate to both the patient and informal carer as individuals.


          In reality it is hard to learn about boundaries unless one is involved in setting them, and extending beyond the therapeutic boundary may only be apparent once it has been breached.

          It may be that it is in the interests of the patient and his carer to encourage the professional to develop a relationship of friendship since this has the potential to ‘normalise’ the patient, as it is ‘normal’ to have friends who visit. This is perhaps more likely to occur if nurses do not wear uniforms. Families may be keen that friendships do develop since a friend is likely to respond to requests for help, perhaps more swiftly than a detached professional. Therefore nurses must consider their actions carefully in case actions are misinterpreted, as perhaps was the case when Ann attended John’s party.

        Hylton Rushton et al. (1996) describes over- involvement as a lack of separation between the nurse’s own feelings and that of the patient. Typically the nurse may spend off-duty time with the patient (Barnsteiner and Gillis-Donovan 1990), appear territorial over the care (Morse 1991), or treat certain patients with favouritism (Wilson 2001a). Consequences for the patient are an over- dependence on that particular nurse and a lack of support in reaching therapeutic goals. For the community nurse the implications are often significant stress and deterioration in job satisfaction (Hylton Rushton et al. 1996) and an inevitable detrimental effect on team working.

         Of course, the balance in the therapeutic relationship may be tipped the other way. The detached, cold nurse who seems indifferent to her patient’s emotional needs may be familiar to the reader. The results of under-involvement are a lack of understanding by the nurse of the patient’s perspective, conflict, and standardised rather than contextually dependant care (Hylton Rushton et al. 1996). It has been suggested that the overwhelming feelings that a nurse may have for a patient’s situation can lead to dissociation by the nurse within the therapeutic relationship (Crowe 2000). Within the community setting the feelings of being the last resort in care has also been linked to under- involvement within the therapeutic relationship (Wilson 2001a). The consequences of under- involvement for the patient is that the nurse has a lack of insight into the patient’s perspective and is unable to facilitate the patient in meeting therapeutic goals.

          Maintaining a therapeutic relationship is particularly challenging in the community nursing context because of the commonly intense nature of care, duration of contact and the non-clinical environment. Reflection with colleagues and clinical supervision become invaluable tools to facilitate the nurse in developing the appropriate relationship with patients.


          Long-term interventions within the community setting will continue to increase with an ageing population and rise in chronic illness (Kalache 1996; Wellard 1998; DOH 1999b), and this chapter has already explored the impact of duration of care on the therapeutic relationship. One response by policy makers to the rise in long- term conditions is the facilitation of individuals to self-manage their own conditions. The expert patient programme (DOH 2001b) recognises that individuals often have significant expertise about their chronic illness which has developed over years through experience and the aim of the programme is to further develop this expertise in order to promote symptom control, quality of life and effective use of health resources (Wilson 2001b). Within all spheres of community nursing, nurses are now dealing with far more knowledgeable patients not least because of the readily available access to information via the Internet (Timmons 2001). Therapeutic relationships in the current climate must be based on an acknowledgement that the patient may have considerable expertise in their own condition, exceeding that of the nurse. There has been some debate as to how comfortable community nurses are with this (Wilson 2002), but there can be little doubt that a therapeutic relationship that fails to take into account the knowledge that both nurse and patient bring will fail.

         The expert patient programme is one example of a policy that is based on partnership and responsibility (Wilson 2001b). Another example is the move towards concordance (Royal Pharmaceutical Society of Great Britain 1997), where the patient’s views are considered of equal importance in treatment plans.

             Community nurses are required to demonstrate evidence-based practice (Woodward 2001) and the challenge of today’s therapeutic relationship is to balance this with informed choice by the patient (Wilson 2002). There is a balance to be maintained between the rights of the child (dependant on their age and understanding) and rights of the parents in decision-making, against the risks of significant harm that might result from the treatment. The parents in the above scenario should be advised to ensure the advice regarding the complementary treatment comes from a registered practitioner. Community nurses need to assess their own knowledge base regarding complementary therapy and seek specialist advice if necessary. Within a therapeutic relationship the nurse will be aiming to facilitate an atmosphere where the parents feel able to be honest about the treatments the child is currently receiving, and should be able to direct patients and their families to sources of appropriate information.

            A final feature of the current context of care that may have an effect on the therapeutic relationship is the fragmentation of care. In particular the division of health and social care (DOH 1990) means that patients within the community often have to deal with a vast array of professionals, which can inhibit the development of a therapeutic relationship (Hyde and Cotter 2001).


           In this chapter features of a therapeutic relationship have been identified, leading to an exploration of some of the challenges community nurses face in establishing therapeutic relationships. In future community health care provision, challenges will be shaped by an increasingly multi-cultural, ageing and informed population. The growing provision of health care in the community only serves to reinforce the need to establish appropriate relationships with patients, their families and other carers. Current government policy emphasises partnership in care at all levels; the challenge for the community nurse is to develop this opportunity in everyday working practice.



Community Health Nursing

IV. Personal Safety in the Community



          Working in the community provides many challenges and opportunities. When placed in non- hospital settings as a student nurse or embarking upon a career as a community staff nurse, it is timely to reflect upon personal safety. This chapter is not intended to deter nurses from choosing to work in a community setting, but to ensure that practical and reasonable steps are taken to ensure their safety.
The first section of this chapter examines safety relating to the prevention and management of violence and aggression.The second part focuses upon manual handling, as the safety of both nurse and patient may be compromised if careful thought is not given to this issue before home visiting. The principles remain the same wherever the nurse is working, but some consideration needs to be made when moving into community settings. Finally, issues of reporting and bringing incidents to a resolution will be explored.


       The 1974 Health and Safety at Work Act and the 1992 Health and Safety at Work Regulations charge employers and employees with responsibilities in risky situations. Assessment of risk is a requirement to minimise potential harm and community nurses need to consider safety issues from both practical and professional perspectives.
Sadly, violence and aggression are an increasing problem in hospitals around the United Kingdom (Health Services Advisory Committee 1997, Royal College of Nursing 1998, Whittington and Wykes 1996). This is also the case for those nurses working in the community who are often working alone (Jackson, Clare and Mannix 2002) despite the Zero Tolerance Campaign launched in 1999 by the government.
This campaign sought to reduce the incidence of violence against nurses by 20 per cent. It has proved difficult to achieve (RCN 2001). It is very important to spend time considering how to prepare for community work and be aware of potential problems.


          This includes developing knowledge of the area of work, developing self-awareness and understanding why and how aggression can escalate.
First, learn the geography of the area, whether that is a town, clinic or surgery. Become familiar with the layout of rooms and buildings and note the position of exits. Find out what is known about the community. Without falling into the trap of stereotyping people, investigate what reputation the area has, find out about crime rates, for example. Talk to your colleagues about safety. It is strongly recommended (Leiba 1997) that visible security measures, involving personnel and technology, should be evident in health centres and clinics.

         There may be areas within the surrounding locality that are considered to be high risk. Sometimes community staff visit these in pairs. Find out if the remit of the post involves visiting after dark. It is good practice to gather as much information as is possible before setting off to a patient or client’s house.


          This section will focus particularly upon home visits, as there are particular features that could, potentially, compromise personal safety. Bearing this in mind, read carefully any records or notes pertaining to the visit. Talk to colleagues, who may know the situation and should make sure that concerns are shared. Look at the location of the visit – think about how you will get there.
Always remember that home visits, however welcome to the patient or client, are an invasion of that individual’s space. Table 4.4 outlines some of the things that should be considered when arriving at someone’s home.
The community nurse is a visitor in the patient’s home and must wait to be invited in. It is good practice to discourage patients from leaving notes (for example: ‘Please come round to the back – door open’) and hanging keys on strings behind letterboxes. These, obviously, put patients at risk from unscrupulous opportunists. In addition to these measures, the community nurse should offer personal identification.

      When visiting in other people’s homes, self-awareness is crucial. The conditions in which some people live can be upsetting. Monitoring facial expressions and choosing words carefully are a must (Leiba 1997). This may not prove to be easy. If so, take the opportunity to discuss your feelings with other members of the team after visits that leave emotions heightened.
The majority of home visits are very welcome to the patient or client. Relationships between community staff and the people that they care for can be very positive and a rewarding aspect of working in primary care. With thought, observation and self-awareness many potential problems may be avoided.

Table 4.4 :Entering a Patient’s Home

Considerations – Rationale

  • Remember that you are the visitor. – It is the patient’s space that you are invading – it is unknown what is or has recently been happening in that person’s home.
  • State clearly who you are and why you have come. Show your identity badge. – Don’t assume that the person will recognise a uniform (if one is worn) or will be expecting the visit. It is good practice to encourage patients and clients to ask to see identification. This protects them as well as the professional.
  • Wait to be invited into the house and ask in which room the patient or client would like you to carry out the purpose for your visit. – Being pushy can make people irritated and angry. It may not be convenient for the patient or client to allow you into a particular room. This may be for good reason, e.g. if an unpredictable dog is shut in there!
  • Note the layout of the house – exits, telephones.- In case a speedy exit is required.
  • Be careful with people’s property – protect their belongings. – Spillages, breakages or rough treatment of belongings will irritate – remember the visitor status.
  • Be alert – monitor moods and expressions during the visit. – Changes in the demeanour of the patient or client could indicate potential conflict developing.
  • Be self aware – monitor the manner in which information is given and care carried out. Do not react to conditions, which may seem unacceptable – dirty, smelly environments, for example. – The nurse should not provoke feelings of anger. Remember that this is the patient’s home.
  • Trust instinctive feelings. If it feels that leaving quickly is the thing to do – go. – Often assessment of situations takes place on many levels. If uncomfortable feelings are building up don’t wait until there is an incident.
  • If prevented from leaving – try not to panic – see the section relating to interpersonal relationships. – It may be possible for you to de-escalate the situation.


Working in a community setting involves being mobile. In some localities bicycles may be an entirely appropriate way to get around; in busy cities public transport is often the best option. For most community staff, however, it would be impossible to function effectively without a car.
Some practical measures need to be undertaken relating to car safety (Table 4.2). Areas between car parks and clinic/surgery buildings should be well lit.
In addition to the above, it is helpful to plan the route to the destination with care. As the geography of the area becomes more familiar, this will become easier. Try not to give the impression that you are unsure of the way. Some police experts are now recommending that car doors are kept locked whilst driving in more dangerous areas. Good preparation for the journey makes it more likely that the nurse will arrive feeling calm. It is better to avoid road rage – especially if it is your own.
Walking between  car and house, community nurses should appear purposeful, confident and in control. Walk towards the kerb side of the pavement and away from alleyways and hedges. Footwear should be comfortable and allow for speed, if necessary. It is not a good idea to wear jewellery at work for many reasons. Chains may catch or be pulled; rings and wristwatches are a hazard to patients and clients if physical care is needed. In addition to these (well known) considerations, wearing jewellery could catch the attention of muggers.

Table 4.2 Car Safety

Consideration – Rationale

  • It makes sense to ensure the vehicle is well maintained. – Not only is it inconvenient, it may be hazardous to break down in a remote place after dark. Well worth the expense of servicing and looking after the car.
  • Try not to run out of petrol. – The car will not be happy and again this could leave you stranded in remote or unsavoury places.
  • Park with thought. – Look for safe parking places. In the dark it is helpful to find a streetlight to park under. Try to park near to your destination.
  • Take out breakdown cover. – At least someone is coming to assist you. Always state that you are alone and make it clear if you are female.
  • Keep any nursing bags out of view – in addition to any personal valuables. – Some people may believe that nurses carry drugs in their bags – prevent temptation.


In spite of the preparations suggested above, it may be that tensions rise whilst visiting. Confrontation may occur between patient or carer and nurse. Communication skills are crucially important in all fields of nursing; however, some issues need careful thought when visiting patients and clients in their own homes.
Households vary tremendously and staff new to community working may be surprised or shocked by the conditions in which some people live. An open mind needs to be cultivated in terms of the possible relationships that may be encountered – there are many variations of family life. It is necessary to communicate respect for all patients and clients, whatever thoughts may be experienced. Nabb (2000) found many incidences of family and carers assaulting nurses – remember that the giving and receiving of information should always be carried out courteously and sensitively.

Table 4.3 Interpersonal relationships – Non-Confrontational Behaviour

Considerations – Rationale

  • Be aware of how you are feeling and how you may appear to others. – If you appear worried or defensive you may cause worry or fear.
  • Try to look calm and relaxed. – Never try to domineer or act in an arrogant fashion. Attempts to belittle those who are angry are extremely dangerous.
  • Speak clearly and quietly – speak in a low pitch if possible. –
  • Listen to responses. Use non-verbal communication (such as nodding the head) to convey understanding. – This is a two-way process. Demands and commands should not be issued.
  • Try to accept how the other person is feeling. Ask for further clarification. – Even if the issue is difficult to empathize with, people own their feelings. Don’t argue.
  • Be polite in the face of provocation. – Avoid becoming over-emotional. It is better to be brief and professional if tensions are mounting.
  • Try to ensure that the other person has an escape route. – If people are angry and feel crowded or cornered, aggression can be triggered.
  • Stay seated if the other person is seated. – It can be dangerous to tower over others – the aim is not to provoke.
  • Don’t stand too close. – Leave reasonable personal space to avoid crowding.
  • Watch carefully to plan your exit. – Try to close the conversation if possible.

Table 4.3 suggests guidelines for non- confrontational behaviour to minimise the risk of provoking or encouraging aggression or violence. Some of the suggestions may appear to be ‘common sense’. In situations of potential conflict, however, it is easy to feel anxious and behave inappropriately. Try to think carefully about the considerations and rationales before a difficult visit occurs.
Remember that there may be indicators that a person is potentially aggressive, such as using a raised voice, clenching their fists and threatening assault (Leiba 1997).

Aggression has been defined as:
Any incident in which a health professional experiences abuse, threat, fear or the application of force arising out of the course of their work, whether or not they are on duty. (RCN 1998: p.3)

This definition is useful, as actual abuse does not have to occur in order for aggression to be felt. Fear is a powerful enough experience to warrant action. The Royal College of Nursing’s definition also does not differentiate between on- or off-duty situations. It is important to remember that insurance cover from employers relates to the duration of the shift.


              Under the 1974 Health and Safety at Work Act, employers have a duty to provide a safe working environment. Along with the responsibilities for employers there are also requirements, which need to be carried out by employees. Firstly, locate any policies and procedures, which exist locally relating to health and safety (RCN 1994). Study these carefully and note the reporting arrangements that are laid down for staff to follow.
Many primary care trusts (PCTs) offer training in assertiveness and dealing with aggression and violence. The Health and Safety at Work Regulations (1992) charge employers with provision of training in these fields. Take up the opportunities on offer. If there doesn’t seem to be any training available ask if this could be arranged.
It is good practice to contact the work base at the end of the day to let someone know that visits are complete. The team leader will delegate visits to each member of staff and will co-ordinate the team. The order in which visits are carried out may not be predictable, but someone knows where each nurse should be visiting on a daily basis.
Many community nurses have the use of a mobile telephone, which can be useful in difficult situations. It may not be possible, however, to access the phone at the very time that you may need it. Mobile phones do not ensure safety, but they help. The use of personal alarms may be useful, to
frighten, disorientate and debilitate an attacker. The Suzy Lamplugh Trust (see useful addresses) advises holding up the alarm directly to the ear of the attacker and running away as fast as possible.
In addition to all of the above, there is a potential threat (even in a ‘caring profession’), which may not manifest itself in the homes or streets of the community served. Personal safety may be at risk in situations of harassment and bullying. Reported incidents are rising (Jackson, Clare and Mannix 2002; Rippon 2000) and it is important to be aware of ways to deal with bullies.
Bullying has been defined as the misuse of power or position (RCN 2001) and includes aggressive behaviour, ridiculing or humiliation, public criticism and exclusion from opportunities open to others.
Bullying may occur in any NHS setting and is, unfortunately, becoming more prevalent in many societies (Jackson, Clare and Mannix 2002). Many studies have found that aggression between staff is more upsetting and difficult to deal with than assaults from patients (Farrell 1999, 2001).
It is important not to keep bullying quiet – talk to other people (family, friends, trusted colleagues) and document what is happening. Employers are charged with the task of developing a culture of intolerance towards bullying and to deal with incidents effectively (DOH 2002). It is always better to try to address issues informally and directly at first – the person may not realise the effect that they are having. If, however, this does not work, then a formal complaint may be made. It is strongly advised that advice be sought from union representatives if a formal complaint is to be made.
A further requirement of the 1992 Health and Safety at Work Regulations is that of risk assessment in the workplace, which should be followed by planning, organising and monitoring both protective and preventive measures. The Health and Safety Executive (HSE) have issued a five-stage framework for risk assessment. This applies to all situations, which could lead to harm and is used also to evaluate needs relating to manual handling.


          These apply to all situations that have potential for risk. It is the case that many interventions carried out by nurses carry risks of harm to patients, the nurse and the general public. Dale and Woods (2001) state that these risks include clinical issues such as infection control, needlestick injury, inappropriate skill mix and staffing levels. There has been a rise in MRSA (methicillin-resistant Staphylococcus aureus) infections in community settings (Cookson 2000). This is of great concern and should mean that the highest standards are maintained in terms of hygiene.
Measures such as hand cleansing need to be carefully considered, particularly in patient’s homes – not every household will have hot running water and soap, for example. Consult local policies for advice as to how to deal with this problem. There are many solutions for hand cleansing, in addition to traditional soap and water – these should be used as prescribed by the manufacturers. Uniforms and clothes worn for work need to be changed daily and laundered properly (RCN 1999b) to protect nurses and patients alike. Chronic understaffing puts nurses at risk. In addition to personal safety issues, health and safety within clinics and patient’s homes needs consideration.
We shall now look at, each of the five stages of risk assessment and relate them to potentially threatening situations of violence or abuse.

1. Identify the hazards

         This includes reports of threats and abuse, not only of actual physical violence, by patients, carers or others. Remember that this could be whether the nurse is on duty or not. The community staff nurse must report any incidents by following local policies.

2. Identify who is at risk

        Specify who could be harmed by the risk. This could include other members of the nursing team, other professionals and lay people.

3. Evaluate the risk

            Assess the seriousness of the situation. Identify what can be done to minimise or eliminate the risk to protect those who could be harmed. Senior nurses will carry out the assessment of the risk with contributing evidence from the team. However, it is everyone’s responsibility to identify and report potentially hazardous situations.

4. Record the findings

Decisions taken and workable measures to minimise the risk will be documented.This provides a working plan for staff and managers outlining all of the above in addition to steps, which may still need to be taken. Be sure to record events accurately (NMC 2002).
Poor communication of risk can result in misunderstanding and failure to pass on vital information to other colleagues. Documentation needs to be comprehensive and accurate, containing a full account of intervention and assessment of the situation (NMC 2002, Woods 2002). Avoid the use of jargon and abbreviations.

5. Review and revise the assessment

Assessment is a dynamic process. It is important to revisit the document, particularly after incidents are reported. Staff training and communications should also be reviewed. It has been said that a major source of risk is uncertainty by members of staff about what is expected of them, especially in emergency situations (Dale and Woods 2001). Policies and procedures need to be current, available to those who need them, and comprehensive.
In order not to compromise patient care, care plans need to be regularly reviewed and updated so that staff are clear what has been found on assessment and what interventions are required.
The above stages also apply to other areas of practice – in the interests of patients and nurses it is important to think about manual handling situations arising in non-institutional settings.


The potential for safety to be compromised in manual handling situations in patients’/clients’ homes is very real. The inclusion of this issue within this chapter is in recognition of the fact that over 30 per cent of nurses suffer work-related back pain each year (Institute of Employment Studies 1999).
Although the principles of manual handling remain the same wherever the nurse is working, community visiting gives rise to particular issues. By revisiting the five tenets of manual handling some of these are presented.

The task:

There will be manual handling issues in many nursing procedures undertaken in the home (see Table 4. 4). These include moving patients in bed, helping patients get out of bed and standing up. Toileting and dressing should be approached with thought, as should bathing and washing procedures.

The load:

As in many settings, patients can be heavy and unpredictable. Paralysis, confusion or pain may make the patient a particular challenge.
When handling a load it is important to hold that load as close to the trunk as possible. Think about a patient in the middle of a double bed. This bed is low and not very firm. Immediately problems for safety (both for nurse(s) and patient) are apparent.

The environment:

          Nursing patients in their home environment is very different from doing so in a hospital ward. Hazards could include cluttered rooms with little space for manoeuvre, slippery polished floors, loose rugs and poor lighting. These are a problem for both patients and staff. It is important to address these hazardous conditions with tact and sensitivity. When rapport and trust have been developed between patient and nurse, suggestions for improving home safety will be better received.

The worker:

        Nurses come in all shapes and sizes. The same is true of carers, who tend to be more involved in giving direct care in home settings. Older people who are carers may not be in the best of health themselves. It is important not to make assumptions about the abilities of others.

The organization:

      Policies and procedures relating to manual handling must be studied carefully (Chambers 1998). Mandatory updates in PCTs are necessary to ensure the safety of staff and patients. There may be unfamiliar equipment in patients’ homes. Don’t use unknown manual handling aids until training has been carried out.
Inadequate staffing levels can put nurses at risk. The number of staff at any given time will affect directly the workload of each nurse. Tired staff are more vulnerable to injuries, accidents and mistakes (RCN 1996, 1999a).
In addition to the above, keeping fit and healthy can reduce the possibility of back problems developing. By valuing and safeguarding his/her own health the community nurse can contribute to the risk reduction process.

Table 4.4 Occasions when manual handling procedures must be carefully considered:

1. Moving patients in bed

2. Helping them to sit or stand

3. Toileting and dressing

Note the following:

  • A full assessment will be carried out as required according to the Manual Handling Operations Regulations 1992.
  • The sister or charge nurse will assess patients. Measures to reduce the risk of potential injury will be put in place, e.g. a hospital bed may need to be provided.
  • The assessment will be documented in the care plan. Any changes in circumstances must be reported to the team leader.


Nurses are required to report issues relating to safety under the Health and Safety at work Act (1974). If injury occurs as a result of manual handling procedures, then this must be reported. There is evidence that a large majority of nurses believe that a certain level of aggression is part of the job (Leiba 1997, Unison 1997). This acceptance of abuse seems to be particularly widespread amongst older nurses. In their campaign to ‘stamp out violence’, the Nursing Times received 1000 replies to a questionnaire on the subject (Coombes 1998). In nurses aged over 55 years, 92 per cent felt that violence and aggression was part of the nurse’s lot.

Amongst nurses aged between 26 and 34 this view was held by 76 per cent. Undoubtedly this leads to an underreporting of incidents, which is worrying. It will not be possible to gauge the size of the problem if nurses are reluctant to speak up. It is also unfair to colleagues to keep quiet. Today might have included verbal abuse from a relative, tomorrow (particularly if the situation is poorly handled) may lead to something much worse.
The report should be made as soon as is possible. Events should be clearly and comprehensively stated.


People who have been involved in aggressive or violent incidents need to be supported at work. Reporting the events can be traumatic and it is helpful to have assistance from a colleague when completing the necessary documentation (RCN 1998). It may be helpful to discuss what has happened with other members of staff. A debriefing should take place with the people concerned. The actual events should be explored, including any possible triggering factors and the feelings of those who took part. Ways of preventing recurrence should be considered.

Commonly, following verbal abuse or physical attack feelings of fear, guilt or anger may be experienced. These can manifest themselves in taking the ‘blame’ for provoking aggression, wondering if the experience will be repeated or anger towards the aggressor, the organisation or even oneself.
It may take time for a victim of abuse or violence to regain the confidence to visit alone again. Support may be offered by occupational health, professional organisations or counselling services. Support may also be needed for others involved, including the aggressor.

After careful consideration of the issues addressed within this chapter, turn back to the learning outcomes at the beginning and think about each one in turn. Look back at the notes made for the first exercise at the beginning of this chapter. Is there anything that you would like to add to them?
If this chapter has raised any concerns for practice, it is important that they are discussed with an experienced community nurse, either informally or through clinical supervision channels. Some useful addresses can be found at the end of this section.
Remember that the majority of staff working in community settings enjoy a close partnership with their patients and clients. The health centre or surgery is at the heart of the local community and relationships may build over a number of years. Visiting patients and clients in their homes is a privilege that greatly enhances the experience of community nursing. Taking practical precautions and taking time to think about safety can better prepare the community nurse for difficult situations that could arise.