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Aug.29.2019
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Communication: Communicating with an Anxious Person (AUS and NZ)

ALERT

Elsevier Clinical Skills covers the principles of this procedure. Follow local guidelines and procedures concerning available equipment, resources and documentation.

LEARNING OBJECTIVES

After completing all elements of the skill, the learner should be able to:

  1. Understand the triggers of anxiety and the associated physiological response.
  2. Identify signs and behavioural manifestations of anxiety.
  3. Communicate effectively with an anxious person to assist them to cope with their emotions.

National Safety and Quality Health Service Standards (AUS), 2nd ed.

Standard and Criterion

Standard 1: 1.1

National Safety and Quality Health Service Standards (AUS), 2nd ed.

Standard and Criterion

Standard 1: 1.3, 1.4, 1.8, 1.18, 1.19
Standard 2: 2.2, 2.5
Standard 3: 3.1, 3.2, 3.5, 3.11, 3.12, 3.15
Standard 5: 5.1, 5.3, 5.5
Standard 6: 6.1, 6.2, 6.3, 6.4, 6.11

RN Standards of Practice (AUS)

Standard and Indicator

Standard 1: 1.1, 1.2, 1.3, 1.4
Standard 2: 2.1, 2.2, 2.5
Standard 4: 4.1, 4.2
Standard 5: 5.1, 5.2, 5.3
Standard 6: 6.1, 6.2, 6.5
Standard 7: 7.1, 7.2, 7.3

EN Standards of Practice (AUS)

Domain, Standard and Indicator

Professional and Collaborative Practice:
Standard 3: 3.1

Competencies for Registered Nurses (NZ)

Domain and Competency

Domain 1 Professional Responsibility: 1.1, 1.3, 1.4, 1.5
Domain 2 Management of Nursing Care: 2.1, 2.2, 2.3, 2.6
Domain 3 Interpersonal Relationships: 3.1, 3.3
Domain 4 Interprofessional Health Care and Quality Improvement: 4.1, 4.2

Competencies for Enrolled Nurses (NZ)

Domain and Competency

Domain 1 Professional Responsibility: 1.1, 1.2, 1.3, 1.4, 1.5, 1.6
Domain 2 Management of Nursing Care: 2.1, 2.2, 2.3, 2.4, 2.5, 2.6
Domain 3 Interpersonal Relationships: 3.1, 3.2
Domain 4 Interprofessional Health Care and Quality Improvement: 4.1, 4.2, 4.3

INTRODUCTION

The skill Communicating with an Anxious Person (AUS and NZ) refers to the use of effective communication strategies to assist a person to cope with or adapt to a situation that precipitates anxiety. This skill is performed in the healthcare context by registered nurses (RNs), registered midwives (RMs) or enrolled nurses (ENs). The healthcare setting is a particularly stressful environment for many people. As such, it is important for healthcare professionals to be able to recognise signs of anxiety and respond appropriately. In order to provide optimal care, the healthcare professional performing this skill must have a sound understanding of the principles of effective communication and excellent interpersonal skills. They must also possess theoretical knowledge of triggers and physiological responses to anxiety, the observation skills to identify an anxious person and knowledge of appropriate techniques to assist the affected person.

THEORY AND EVIDENCE BASE

Defining the characteristics of anxiety

Anxiety is an emotional response to a situation where a person perceives their safety or wellbeing to be at risk. It is characterised by persistent worry and can interfere with a person’s ability to function effectively in situations which would otherwise not cause problems (undefined#ref10">Cooper, 2014). Peplau (1963) identified the following four levels of anxiety.

  1. Mild anxiety. The person is alert with an increased perceptual field. This type of anxiety motivates learning and produces growth and creativity.
  2. Moderate anxiety. The person selectively focuses on immediate problems with a decreased perceptual field and a reduced capacity to listen and understand. If directed, however, the person can pay more attention.
  3. Severe anxiety. The person has a significantly decreased perceptual field and tends to focus on fragmented details. All behaviour is focused on relieving the anxiety and strong direction is required to focus on another area.
  4. Panic. The person is overwhelmed, unable to notice their surroundings and cannot cope with any other demands. The distressed person cannot communicate or function effectively and cannot relate to others. Increased motor activity and irrational thought patterns are displayed.
  5. ( Peplau, 1963)

Triggers for anxiety

Anxiety can be caused or triggered by single or multiple factors. While the cause and degree of anxiety will vary between individuals (Lovallo, 2015), some common groupings of triggers include:

  • personal issues such as physical ill health, financial stress, work stress, and family/relationship difficulties. Death or loss of a loved one, depression, genetic predisposition and substance abuse are also potential anxiety triggers (Goldberger et al., 2011).
  • trauma such as verbal, sexual, physical, emotional and financial abuse.
  • environmental factors such as limited access to health services and infrastructure and social isolation (Kushnir et al., 2012).

Pathophysiology of anxiety

Anxiety manifests itself through behavioural, cognitive, affective and physiological responses; however, the specific symptoms experienced vary according to the degree of anxiety. An anxious person’s physiological and behavioural signs and symptoms as well as their cognitive and affective responses should be assessed to establish the level of anxiety that they are experiencing (Perry et al., 2013) (see Table 1).Table 1).

The physiological responses associated with anxiety (see Table 1) are modulated by the brain through the autonomic nervous system (ANS). The ANS regulates the body’s involuntary processes such as breathing, digestion and heart rate to maintain internal homeostasis (Table 1) are modulated by the brain through the autonomic nervous system (ANS). The ANS regulates the body’s involuntary processes such as breathing, digestion and heart rate to maintain internal homeostasis (Price, 2017). It is made up of parasympathetic nerves which conserve body responses and sympathetic nerves which activate body responses (Buijs et al., 2013).

During an episode of anxiety, the sympathetic fight-or-flight reaction prepares the body for a perceived emergency situation ( Stuart, 2013). The cortex of the brain activates the sympathetic fight-or-flight response as a reaction to the apparent threat. The adrenal glands are activated and cortisol (a stress hormone) is produced. Adrenaline is also released from the adrenal cortex causing increases in heart rate, respiration and arterial blood pressure, as well as increased energy through faster cell metabolism (Bankenahally & Krovvidi, 2016).

After the stressful event has passed, the fight-or-flight reaction subsides back to the pre-anxiety/stress phase. The parasympathetic nervous system is activated to restore the body to normal function by decreasing the amount of cortisol produced. Some people may remain in a stressed or anxious state for prolonged periods with symptoms such as dizziness, sweating, palpitations, chest pain or breathlessness due to the released stress chemicals still circulating within their body. This can delay deactivation and restoration of normal function (Jarrett et al., 2003).

Responses to anxiety

An anxious person may experience an array of responses including physical signs and symptoms, behavioural responses, and cognitive or affective responses. Each of these is discussed briefly below.

Physical responses

Physical responses to anxiety are often overt and may include tachycardia, rapid breathing, shaking or trembling, dizziness, a dry mouth, sweaty palms, a low or high tone of voice and sweating (Stuart, 2013). Refer to Table 1 for more examples of physical responses.

Behavioural responses

A behavioural response to anxiety is a reflection of both the personal and interpersonal characteristics of a person, and can reflect a person’s coping mechanism(s) (Stuart, 2013). The person’s behaviour may change in ways such as withdrawal and decreased interpersonal involvement. An anxious person may also adopt ritualistic behaviours and become intent on performing activities in a certain way (Meiner, 2011). Refer to Table 1 for more examples of behavioural responses.

Cognitive responses

A cognitive response occurs when the person’s mental or thought processes are affected by anxiety. The person may display symptoms such as confusion, difficulty concentrating, inattention or loss of focus (Stuart, 2013). Refer to Table 1 for more examples of cognitive responses.

Affective responses

An affective response refers to a person’s emotional reaction and their subjective description of their experience or feelings in coping with anxiety. A person may describe themselves as ‘jumpy’, ‘apprehensive’, ‘overwhelmed’ or ‘worried’, or make statements like ‘I’m afraid but I don’t know why’ or ‘I’m scared’ (Perry, 2013). Refer to Table 1 for additional examples of affective responses.

Framework for communication with an anxious person

Effective communication is fundamental to developing successful therapeutic relationships in the healthcare setting. Healthcare professionals can support people to decrease their anxiety through developing effective communication that assists them to regain control of their emotions (Bramhall, 2014).

Opening the encounter

The process of establishing effective therapeutic communication with an anxious person should begin with the aim of developing an open, trusting relationship. The healthcare professional should introduce themselves and provide a brief purpose for the interaction to follow, to ensure the person’s understanding and consent (Boschart, 2009). Commencing the relationship in an open and friendly way assists in establishing a trusting relationship, supporting the person and reducing their anxiety levels. The healthcare professional should also ask questions to identify the causes of the person’s anxiety. Possible communication barriers, such as the environment, values or language, should be assessed. Family members can be involved in the discussion after it has been determined that they are not contributing to the person’s anxiety. Involving family members with the person’s permission may assist in gathering useful information about the person from the perspective of those closest to them (Keltner, 2011).

Assessing for signs of anxiety

The healthcare professional should use effective communication strategies to assess the nature and intensity of the symptomatic responses displayed by the anxious person (Meiner, 2011). The person’s response to the perceived threat should be assessed in order to provide optimal support, treatment and care (Perry et al., 2013). Anxiety should be managed according to the person’s presenting behaviour with consideration of any cognitive or physical impairment related to the anxiety. It is important for the healthcare professional to encourage the anxious person to discuss their feelings of anxiety while conveying, through verbal and nonverbal communication, awareness and acceptance (Kushnir et al., 2012).

Communication strategies with anxious people

The use of effective communication strategies by the healthcare professional can assist an anxious person to clarify the causes of their anxiety. Once a therapeutic relationship has been established, the healthcare professional may be able to assist the anxious person to identify strategies to cope with their anxiety and regain control of their emotions (Roohangiz et al., 2016). Effective communication improves overall satisfaction with care and health outcomes (Aust et al., 2016).

Nonverbal cues

It is important that the healthcare provider pays attention to nonverbal cues during their communication with an anxious person. Nonverbal communication can powerfully demonstrate that the healthcare professional is present and assists in creating a therapeutic relationship. The healthcare professional should ensure that their posture, body position, gestures, eye contact, facial expression and movements are calm and congruent with the communication taking place (Bensing et al., 2008). Using active listening skills is an effective way to demonstrate to the anxious person that the healthcare professional is focused on their current state and wishes to understand their situation fully. The healthcare professional should also allow ample personal space between themselves and the anxious person in order to avoid increasing the person’s anxiety through crowding (Stuart, 2013).

Verbal behavioural cues

Appropriate verbal communication that is clear and concise is important in preventing a person’s anxiety levels from increasing. Brief statements that acknowledge the person’s current feelings and provide direction, such as ‘It appears to me that you’re irritable or anxious’ or ‘I notice that you seem anxious’, can provide reassurance to the person (Fortinash & Holoday-Worret, 2008; Perry et al., 2013). The healthcare professional should also observe that the tone, pitch, rate and volume of their voice is calm and measured when verbally communicating with an anxious person. Effective communication strategies should be used to avoid tense or combative interactions which escalate anxiety (Gwynn et al., 2008; Stuart, 2013). For example, the healthcare professional should avoid asking ‘why’ questions in relation to a person’s behaviour (Rohrer et al., 2008). For further information about effective communication strategies, see the related skills Therapeutic Nurse-Patient Interactions (AUS and NZ) and Communication: Defusing Anger (AUS and NZ).

The healthcare professional’s anxiety

It is important for the healthcare professional to recognise their own anxiety when communicating with an anxious person as this has the potential to affect the therapeutic care (Perry et al., 2013). The healthcare professional’s awareness of their own feelings can prevent the transference of their own fears and frustrations onto the anxious person, thereby avoiding provocation of discomfort or defensiveness which may, in turn, exacerbate the person’s anxiety.

Teaching anxiety management strategies

Healthcare professionals can provide the anxious person with management strategies through effective use of communication and coaching techniques. Teaching the person to identify possible sources of anxiety and use coping strategies can help them to understand and manage their anxiety better (Aust et al., 2016). For example, a deep breathing technique (where the person takes a deep breath and counts for 5 seconds before slowly exhaling) can enhance relaxation and reduce the perception of anxiety (Mellor, 2007). It is important to note that when people are under stress, they may require repeated explanations of techniques before they can comprehend and implement them (Perry et al., 2013).

Other coping strategies that can alleviate a person’s anxiety include the use of non-pharmacological comfort measures, such as modifying the environment and reducing anxiety triggers such as noise or visitors (Fortinash & Holoday-Worret, 2008). Supportive physical measures such as massage, art or visual therapy, warm baths or ambient music may also appeal to the affected person (Stuart, 2013). It is important to assess the anxious person’s interests as activities such as walking, swimming and other hobbies may provide a distraction from anxiety symptoms while increasing participation and enjoyment of other aspects of life (Stuart, 2013).

Documentation and follow-up

The healthcare professional should record all details of the interaction in the progress notes or according to the specific facility’s documentation requirements. The notes should include the level and cause of the person’s anxiety, any signs and symptoms and the communication/management strategies used to relieve the anxiety (Perry et al., 2013).

People with severe anxiety may require referral for a medical review and pharmacological interventions. Antidepressants or benzodiazepines can be prescribed to assist the anxious person to cope effectively with their emotions (Cooper, 2014).

  • Alcohol-based hand rub (ABHR)
  • Appropriate personal protective equipment (PPE)
  • Progress notes
  • Medication chart

PROCEDURE

  1. Identify the indication for therapeutic communication with the person experiencing anxiety.
  2. Rationale: To determine the need for intervention and the goals of care.
  3. Perform hand hygiene and apply PPE in accordance with standard or transmission-based precautions.
  4. Rationale: To reduce the risk of cross-contamination and cross-infection and to comply with infection control principles ( NHMRC, 2010; ACSQHC, 2017). Hand hygiene is the single most effective action to reduce healthcare-associated infections ( ACSQHC, 2017; HHA, 2016). Use PPE in accordance with standard precautions or, if required, transmission-based precautions, as indicated ( NHMRC, 2010).
  5. Engage in therapeutic communication.
    1. Introduce self (name and function/designation).
    2. Confirm the person’s identity (minimum of three identifiers: e.g. full name, date of birth, medical record number).
    3. State intent, outline the procedure and answer any questions.
    4. Rationale: (a) To establish rapport, (b) to ensure the person’s safety and (c) to promote person-centred care, which requires the person to have a clear understanding of what task is planned and why the task is required in order to give consent ( ACSQHC, 2017).
  6. Assess the environment to ensure it is conducive to therapeutic communication. Decrease environmental stimulation if required.
  7. Rationale: To identify and reduce anxiety precipitating stressors ( Fortinash & Holoday-Worret, 2008).
  8. Allow ample personal space between self and the anxious person.
  9. Rationale: To avoid increasing the person’s anxiety due to crowding ( Stuart, 2013).
  10. Establish an open, trusting relationship by actively listening to the person and encouraging them to discuss their feelings of anxiety.
  11. Rationale: To reduce the person’s level of anxiety by engaging with their concerns and building rapport ( Stuart, 2013).
  12. Recognise own anxiety and consciously try to remain calm. Be aware of nonverbal cues that indicate own anxiety.
  13. Rationale: To avoid increasing the person’s anxiety and to prevent the transfer of fears and frustrations from the healthcare professional to the person seeking care. ( Perry et al., 2013).
  14. Evaluate the person’s ability to discuss the factors which cause them anxiety and to establish the contributing triggers.
  15. Rationale: To understand the source of anxiety and facilitate appropriate support. To measure the person’s ability to attend and focus ( Perry et al., 2013).
  16. Look for physical, behavioural and verbal cues that indicate that the person is anxious.
  17. Rationale: To determine the person’s level of anxiety. Raised anxiety levels interfere with usual communication and may affect the success of the intervention.
  18. Encourage family members to give their perspective on the possible causes of the person’s anxiety (if appropriate).
  19. Rationale: To gather new information or understanding of the situation about the person from a different perspective ( Keltner, 2011).
  20. Encourage the person to discuss their coping strategies and provide education on anxiety reduction strategies.
  21. Rationale: To allow the person to manage their own anxiety in challenging circumstances ( Perry et al., 2013).To measure the person’s ability to adopt health-promoting behaviour ( Keltner, 2011).
  22. Observe for signs, symptoms or behaviours that suggest the person remains anxious at the conclusion of the encounter.
  23. Rationale: To determine to what extent the planned interaction has relieved the person’s anxiety ( Stuart, 2013).
  24. Ensure the person is safe, positioned comfortably and has access to the call bell and personal items.
  25. Rationale: To avoid adverse outcomes and to ensure that the person is content ( ACSQHC, 2017).
  26. Perform hand hygiene in accordance with standard or transmission-based precautions after contact with the person.
  27. Rationale: To reduce the risk of cross-contamination and cross-infection and to comply with infection control principles ( NHMRC, 2010; ACSQHC, 2017). Hand hygiene is the single most effective action to reduce healthcare-associated infections ( ACSQHC, 2017; HHA, 2016).
  28. Document the cause of the person’s anxiety and any exhibited signs and symptoms. Document coping methods used to relieve anxiety.
  29. Rationale: To record the delivered care and to determine the effect of the intervention ( ACSQHC, 2017).
  30. Report any deterioration or abnormal findings to the healthcare professional in charge. Refer to the medical team for assessment if indicated.
  31. Rationale: To ensure escalation of care in the event of deterioration ( ACSQHC, 2017). To provide appropriate management of severe anxiety. In such cases, pharmacological intervention may be required to reduce core symptoms and improve functionality ( Fenton et al., 2010).

ADDITIONAL INFORMATION

PAEDIATRIC CONSIDERATIONS

  • Children largely demonstrate their anxiety through physical and behavioural signs. Children younger than 5 years are unable to express anxiety verbally (Hockenberry & Wilson, 2011). School-age children may express anxiety through restless behaviour, failure to concentrate at school, poor sleeping, physical complaints such as stomach aches, or behavioural regression such as clinging to a parent (Albano & Kendall, 2002).
  • Anxiety can be triggered in children when a lot of challenges occur together such as bullying at school, moving house or starting a new school (Royal Children’s Hospital Melbourne, 2003).
  • When working with children and their families, it is important to modify professional behaviour and communication techniques to suit the age and development stage of the child (Hockenberry et al., 2017). The parent or caregiver should be included if their presence helps to calm the child.

GERONTOLOGICAL CONSIDERATIONS

  • Anxiety is one of the most common symptoms in older adults (Perry, et al., 2013).
  • Older adults who are socially isolated may have multiple medical problems and are more likely to have anxious or depressive symptoms (Perry, et al., 2013).
  • To promote autonomy and self-determination and subsequently reduce anxiety, healthcare professionals should ensure that lifestyle aids such as hearing aids, glasses and walking frame are always available.

INDIGENOUS CONSIDERATIONS

  • Healthcare professionals should use culturally appropriate communication strategies with people who are anxious. For example, it is important to be aware of Indigenous spiritual beliefs such as seeing spirits or hearing voices of the deceased and to treat discussion of these issues with respect (Freeman, et al., 2014).
  • Healthcare professionals should be aware of topics and behaviours which can cause shame within the person’s community. For example, in some communities talking about mental health conditions can cause individuals to feel shame and stigma and in turn exacerbate anxiety (Freeman, et al., 2014). One way to manage this issue is to concentrate on discussing behaviours and feelings, rather than talking about labels and medical conditions (Aboriginal Mental Health First Aid Training and Research Program, 2008).

REFERENCES

  1. Aboriginal Mental Health First Aid Training and Research Program. (2008). Cultural considerations & communication techniques: guidelines for providing mental health first aid to an Aboriginal or Torres Strait Islander Person. Melbourne: Mental Health First Aid Australia and beyondblue. Retrieved from:
  2. Albano, A. M. & Kendall, P. C. (2002). Cognitive behavioural therapy for children and adolescents with anxiety disorders: clinical research advances. International Review of Psychiatry, 14(2), 129–134. doi: 10.1080/09540260220132644
  3. Aust, H., Rüsch, D., Schuster, M., Sturm, T., Brehm, F. & Nestoriuc, Y. (2016). Coping strategies in anxious surgical patients. BMC Health Services Research, 16(1).
  4. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2017). National Safety and Quality Health Service Standards (2nd ed.). Retrieved from: www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/nsqhs-standards-second-edition/
  5. Bankenahally, R. & Krovvidi, H. (2016). Autonomic nervous system: anatomy, physiology, and relevance in anaesthesia and critical care medicine. BJA Education, 16(11), 381–387.
  6. Bensing, J., Verheul, W. & Van Dulmen, A. (2008). Patient anxiety in the medical encounter. Health Education, 108(5), 373–383.
  7. Boschart, V. A. (2009). Communication intervention for nursing staff in chronic care. Journal of Advanced Nursing, 65(9),1823.
  8. Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard, 29(14), 53–59.
  9. Buijs, R. & Swaab, D. (2013). Autonomic nervous system. Edinburgh: Elsevier.
  10. Cooper, H.C. (2014). Thriving with social anxiety. Daily strategies for overcoming anxiety and building self-confidence. Berkeley, CA: Althea Press.
  11. Fenton, M. C., Keyes, K. M., Martins, S. S. & Hasin, D. S. (2010). The role of a prescription in anxiety medication use, abuse and dependence. The American Journal of Psychiatry, 167(10), 1247–1253.
  12. Fortinash, K. & Holoday-Worret, P. (2008). Psychiatric mental health nursing. (4th ed). St Louis: Mosby.
  13. Freeman, T., Edwards, T., Baum, F., Lawless, A., Jolley, G., Javanparast, S. & Francis, T. (2014). Cultural respect strategies in Australian Aboriginal primary health care services: beyond education and training of practitioners. Australian and New Zealand Journal of Public Health, 38(4), 355–361.
  14. Goldberger, J. J., Kruse, J., Kadish, A. H., Passman, R. & Bergner, D. W. (2011). Effect of informed consent format on patient anxiety, knowledge, and satisfaction. American Heart Journal, 162(4), 780–785. doi: 10.1016/j.ahj.2011.07.006
  15. Gwynn, R. C., McQuistion, H. L., McVeigh, K. H., Garg, R. K., Frieden, T. R. & Thorpe, L. E. (2008). Prevalence, diagnosis, and treatment of depression and generalized anxiety disorder in a diverse urban community. Psychiatric Services, 59, 641.
  16. Hand Hygiene Australia (HHA). (2016). The 5 moments for hand hygiene. Retrieved from: www.hha.org.au/hand-hygiene/5-moments-for-hand-hygiene
  17. Hockenberry, M. J. & Wilson, D. (2011). Wong’s nursing care of infants and children (9th ed.) St Louis: Mosby.
  18. Hockenberry, M. J., Wilson, D. & Rodgers, C. C. (2017). Wong’s essentials of pediatric nursing (10th ed.). St Louis, Missouri: Elsevier.
  19. Jarrett, M., Burr, R., Cain, K., Hertig, V., Weisman, P. & Heitkemper, M. (2003). Anxiety and depression are related to autonomic nervous system function in women with irritable bowel syndrome. Digestive Diseases and Sciences, 48(2), 386–394.
  20. Keltner, N. L. (2011). Psychiatric nursing (6th ed.). St Louis: Mosby.
  21. Kushnir, J., Friedman, A., Ehrenfeld, M. & Kushnir, T. (2012). Coping with preoperative anxiety in caesarean section: physiological, cognitive and emotional effects of listening to favourite music. Birth, 39(2), 121–127.
  22. Lovallo, W. R. (2015). Stress and health: biological and psychological interactions (3rd ed.). Sage: Thousand Oaks.
  23. Meiner, S. (2011). Gerontologic nursing (4th ed.). St Louis: Mosby.
  24. Mellor, A. (2007). Management of the anxious patient: what treatments are available? Dental Update, 34(2), 108–110, 113–114.
  25. National Health and Medical Research Council (NHMRC). (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. Retrieved from: www.nhmrc.gov.au/guidelines-publications/cd33
  26. Peplau, H. (1963). A working definition of anxiety. In: Burd, S. & Marshall, M. Some clinical approaches to psychiatric nursing. New York: Macmillan.
  27. Perry, A., Potter, P. A. & Ostendorf, W. (2013). Clinical nursing skills and techniques. St Louis: Elsevier.
  28. Price, B. (2017). Managing patients’ anxiety about planned medical interventions. Nursing standard, 31(47), 53–63.
  29. Rohrer, J. E., Wilshusen, L., Adamson, S. C. & Merry, S. (2008). Patient centeredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients? Journal of Evaluation in Clinical Practice, 14(4), 548.
  30. Roohangiz, N., Maryam, A., Maryam, S, Mehrdad K. & Elham, S. (2016). Communication barriers perceived by nurses and patients. Global Journal of Health Science, 8(6), 65–74.
  31. Royal Children’s Hospital Melbourne. (2003). Community paediatric review. Retrieved from: www.rch.org.au/uploadedFiles/Main/Content/ccch/CPRVol12No2.pdf
  32. Stuart, G. (2013). Principles and practice of psychiatric nursing (10th ed.). Maryland Heights: Elsevier Saunders.

ADDITIONAL RESOURCES

Crisp, J., Douglas, C., Rebeiro, G. & Waters, D. Potter and Perry's fundamentals of nursing – Australian version (5th ed.). Sydney: Elsevier.

Nicol, M., Bavin, C., Cronin, P., Rawlings-Anderson, K., Cole, E. & Hunter, J. (2012). Essential nursing skills (4th ed.). Edinburgh: Mosby Elsevier.

Nursing and Midwifery Board of Australia (NMBA). (2018). Code of Professional Conduct for Nurses. Retrieved from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Patton, K. & Thibodeau, G. (2016). Anatomy & physiology (9th ed.). St Louis: Elsevier.

Rebeiro, G., Wilson, D., Scully, N. & Jack, L. (2017). Fundamentals of nursing: clinical skills workbook (3rd ed.). Sydney: Elsevier.

Acknowledgements

Elsevier Australia would like to thank the following people who contributed to this skill: Vanessa Caple and Ruby Walter (Authors); Tina Campbell and Louise Ward (Section Editors); and Elizabeth Matters (Clinical Consultant).

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