faMily NurSing study Guide

Petunjuk Penyusunan Pengkajian Keluarga Model Friedman

A. Identifikasi Data
1. Nama keluarga: diisi dengan nama keluarga (kepala keluarga)
2. Alamat dan nomer telepon lengkap
3. Komposisi keluarga
a) Data anggota keluarga

No Nama Jenis kelamin Hubungan TTL Pekerjaan Pendidikan





b) Genogram
Genogram merupakan diagram yang menggambarkan silsilah keluarga dan berisi catatan informasi tentang anggota keluarga serta hubungannya minimal dalam 3 generasi.
Genogram mencakup informasi sistem keluarga mencakup generasi, usia, jenis kelamin, dan riwayat kesehatan anggota keluarga mencakup morbiditas dan mortalitas.
Genogram juga digunakan untuk menggambarkan struktur anggota keluarga, pola interaksi keluarga dan informasi penting yang lain, misalnya kejadian khusus seperti masalah pada hubungan keluarga.
4. Tipe keluarga
Menjelaskan tipe keluarga, misalnya: keluarga inti, extended family, single parent dsb.
5. Latar belakang budaya
a) Menjelaskan latar belakang budaya keluarga.
b) Bahasa yang digunakan keluarga
c) Asal Negara atau daerah
d) Hubungan sosial keluarga dari dari etnis yang sama atau tidak
e) Aktivitas agama, sosial, budaya, rekreasi, dan pendidikan keluarga
f) Kebiasaan diet dan berpakaian tradisional atau modern
g) Dekorasi rumah menandakan dipengaruhi budaya daerah tertentu
h) Struktur kekuatan keluarga banyak dipengaruhi oleh budaya tradisional atau modern
i) Pemanfaatan pelayanan dan praktek kesehatan, menggunakan pelayanan kesehatan tradisional atau meyakini budaya kesehatan tradisional penduduk asli.
6. Identifikasi agama
a) Agama keluarga
b) Perbedaan antar anggota keluarga dalam berkeyakinan
c) Keaktifan keluarga dalam menjalankan ibadahnya
d) Pengaruh agama sebagai dasar keyakinan atau nilai yang mempengaruhi kehidupan keluarga.

7. Status kelas sosial
Merupakan ilustrasi pekerjaan , pendidikan, dan pendapatan. Memuat informasi tentang pencari nafkah di dalam keluarga, siapa yang member bantuan untuk memenuhi kebutuhan keluarga, tentang keadequatan pendapatan dalam mensupport keluarga, serta bagaimana keluarga mengatur pendapatan-pengeluaran mereka.
8. Rekreasi keluarga
Identifikasi tipe dan aktivitas keluarga serta seberapa sering hal tersebut dilakukan. Dapatkan juga informasi tentang perasaan anggota keluarga terhadap waktu luang mereka.

B. Riwayat dan Tahap Perkembangan Keluarga
a) Tahap perkembangan keluarga saat ini
Menjelaskan tahapan perkembangan keluarga saat ini, apakah keluarga berada pada tahap keluarga dengan anak usia sekolah, keluarga dengan lansia dan sebagainya.
b) Tahap perkembangan keluarga yang belum terpenuhi
Merupakan kesenjangan dari tahap perkembangan keluarga yang seharusnya telah dilalui baik pada keluarga atau masing-masing anggota keluarga.
c) Riwayat keluarga inti
Meliputi deskripsi perkembangan mental, status kesehatan yang unik,dan pengalaman seperti kematian, kehilangan, dan perceraian.
d) Riwayat keluarga sebelumnya
Merupakan riwayat dari kedua orang tua, termasuk riwayat kesehatannya.

C. Data Lingkungan
a) Karakteristik rumah
Berisi denah rumah, status kepemilikan serta deskripsi kondisi rumah, meliputi ventilasi, penetrasi cahaya, kelembaban, dsb. Kaji juga sistem sanitasi keluarga seperti pembuangan limbah, pembuangan sampah, keadaan air, fasilitas toilet, sabun, handuk dan penggunaannya. Observasi secara umum kebersihan dan sanitasi rumah. Identifikasi sumber-sumber ada tidaknya zat berbahaya.
b) Karakteristik tetangga dan komunitas
Karakteristik fisik tetangga dan komunitas, tipe penduduk seperti rural, urban, suburban, atau perkotan. Tipe hunian seperti daerah industry, perumahan, pertanian dsb. Fasilitas apa saja yang ada di komunitas tersebut seperti kesehatan, pasar, pelayanan agensi social, rumah ibadah, sekolah, transportasi, keamanan dan kasus kejahatan yang terjadi di komunitas.
c) Mobilitas geografis keluarga
Mobilitas geografis mencakup berapa lama keluarga tinggal di daerah tersebut, adakah sejarah pindah dan dari mana pindahnya.
d) Perkumpulan keluarga dan interaksi dengan komunitas
Poin ini mencakup bagaimana anggota keluarga mengetahui penggunaan pelayanan komunitas, frekuensi dan fasilitas apa yang didapat, apakah keluarga memiliki perhatian terhadap pelayanan yang sesuai dengan kebutuhan mereka, bagaimana perasaan keluarga terhadap kelompok atau organisasi yang memberi bantuan dan bagaiman keluarga memandang komunitas.

e) Sistem pendukung keluarga
Sistem pendukung meliputi pihak yang member bantuan, konseling terhadap aktivitas keluarga. System pendukung ini dapat bersifat informal (teman, tetangga, kelompok sosial, pegawai) dan formal (pelayanan kesehatan, agensi, lembaga pemerintahan).

D. Struktur Keluarga
a) Pola komunikasi
Observasi dari seluruh anggota keluarga dalam berhubungan, bagaiman akekuatan dari fungsi dan disfungsi komunikasi, berikan contohnya. Seberapa baik anggota keluarga menjadi pendengar, kejelasan dalam menyampaikan informasi dan perasaan, frekuensi terjadinya perdebatan karena penyampaian pesan yang tidak adequat, apakah tipe emosinya konstruktif atau destruktif. Identifikasi juga mengenai faktor-faktor yang mempengaruhi pola komunikasi keluarga (situasi, tahap siklus kehidupan keluarga, latar belakang budaya, kondisi keluarga, status sosial ekonomi).
b) Struktur kekuatan keluarga
Kekuatan di sini merefleksikan pihak yang berwenang mengambil keputusan, seberapa penting keputusan atau issue di keluarga seperti anggaran keluarga. Bagaimanakah proses pengambilan keputusan, dengan consensus, tawar-menawar, kompromi dsb.
c) Struktur peran
Menjelaskan bagaimana pelaksanaan peran, apakah ada konflik di dalam peran, bagaimana perasaan individu terhadap perannya, apakah peran berlaku fleksibel. Jika ada masalah di dalam peran, siapa yang mempengaruhi anggota keluarga dalam penyelesaiannya.
Analisa tentang model peran, siapa yang menjadi model peran dan berpengaruh terhadap pelaksanaan peran tersebut, siapa yang memberikan pengaruh terhadap perkembangan anggota keluarga. Kaji juga mengenai variabel yang mempengaruhi peran, pengaruh sosial ekonomi, budaya, dan perkembangan terhadap angota keluarga dalam menjalankan perannya,
d) Nilai-nilai keluarga
Dalam hal ini dikaji nilai-nilai kebudayaan yang dianut oleh keluarga, nilai inti keluarga seperti siapa yang berperan dalam mencari nafkah, orientasi masa depan, kesesuaian antara nilai-nilai keluarga dan nilai-nilai sub sistem keluarga, serta bagaimana nilai-nilai tersebut mempengaruhi kesehatan keluarga.

E. Fungsi Keluarga
a) Fungsi afektif
Apakah anggota keluarga merasakan kebutuhan individu lain dalam keluarga, bagaimana sensitivitas anggota keluarga dengan melihat tanda-tanda yang berhubungan dengan perasaan, apakah anggota keluarga memiliki orang yang mereka percayai.
Fungsi afektif juga menggambarkan bagaimana anggota keluarga saling memperhatikan, saling mendukung satu sama lain, apakah terdapat hubungan yang akrab dalam keluarga.
b) Fungsi sosialisasi
1) Cara keluarga dalam membesarkan anak
Kaji bagaimana keluarga membesarkan anak (meliputi kontrol perilaku seperti disiplin, reward and punishment, otonomi dan ketergantungan, memberi dan menerima cinta, serta latihan perilaku yang sesuai dengan usia. Pada aspek fungsi sosialisasi, juga dikaji mengenai siapa yang menerima tanggungjawab dan peran membesarkan anak, apakah fungsi ini dilaksanakan bersama-sama, bagaimana juga hal ini diatur.
2) Penghargaan terhadap anak dalam keluarga
Bagaimana anak-anak dihargai dalam keluarga, keyakinan kebudayaan yang dianut dalam membesarkan anak, serta bagaimana faktor sosial mempengaruhi pola pengasuhan anak.
3) Resiko dalam sosialisasi
Apakah keluarga mempunyai resiko tinggi dalam membesarkan anak, faktor resiko apa saja yang menempatkan keluarga masuk resiko tinggi, apakah lingkungan memberikan dukungan dalam perkembangan anak seperti memfasilitasi tempat bermain dan istirahat.
c) Fungsi perawatan kesehatan
1) Nilai yang dianut keluarga.
Fungsi ini mencakup nilai yang diberikan keluarga untuk kesehatan, apakah ada konsistensi anggota keluarga terhadap nilai-nilai kesehatan yang dianut, apakah anggota keluarga selalu terliabat dalam kegiatan peningkatan kesehatan di keluarga.
2) Definisi keluarga tentang sehat-sakit.
Bagaimana keluarga mendefinisikan sehat-sakit, tanda-tanda sakit, siapa yang mengambil keputusan di keluarga tentang sehat-sakit, apakah keluarga dapat melaporkan tanda dan perubahan penting tentang kesehatannya, dan apa saja sumber informasi kesehatan bagi keluarga.
3) Status kesehatan keluarga dan kerentanan terhadap sakit
Bagaimana keluarga mengkaji tingkat kesehatan, masalah kesehatan apa yang diidentifikasi keluarga saat ini, dan apa persepsi keluarga terhadap kontrol yang mereka lakukan untuk menjaga kesehatan.
4) Diet keluarga
Apakah keluarga mengetahui sumber-sumber makanan bergizi, apakah diet keluarga memadai, siapa yang bertanggungjawab terhadap perencanaan belanja dan pengolahan makanan, bagaimana makanan disajikan (seperti seringnya digoreng, direbus, dipanggang, bersantan), berapa jumlah makanan yang dikonsumsi dalam sehari, apakah ada batas anggaran rumah tangga, bagaimana sikap keluarga terhadap makanan dan jam makan.
5) Kebiasaan istirahat-tidur
Apakah jumlah jam istirahat tidur anggota keluarga sesuai dengan tingkat perkembangan, apakah ada jam tidur tertentu yang harus diikuti oleh anggota keluarga, siapa yang memutuskan anak untuk tidur siang, serta bagaimana kualitas tempat istirahat tidur keluarga (apakah cukup kondusif untuk beristirahat)
6) Latihan dan rekreasi
Apakah keluarga menyadari pentingnya rekreasi bagi kesehatan, jenis rekreasi yang dilakukan keluarga secara teratur, apakah keluarga mempunyai kesempatan untuk melakukan aktivitas latihan/ barolahraga.
7) Kebiasaan penggunaa obat-obatan oleh keluarga
Apakah ada penggunaan alkohol, tembakau dan kopi, berapa lama penggunaan obat tertentu dan alkohol dalam keluarga, apakah penggunaan tersebut merupakan suatu masalah dalam keluarga, apakah keluarga sering menggunakan obat-obatan tanpa resep, bagaimana penyimpanan obat-obatan, apakah cukup aman dari jangkauan anak-anak.
8) Peran keluarga dalam praktek perawatan dirilingkungan
Apa yang dilakuikan keluarga untuk memperbaiki status kesehatannya, apa upaya keluarga untuk mencegah terjadinya suatu penyakit, siapa yang mengambil keputusan dalam kesehatan, apa yang dilakukan keluarga untuk menyelesaikan masalah kesehatan yang ada, apakah ada keyakinan, sikap serta nilai-nilai dalam hubungannya dengan perawatan di rumah.
9) Tindakan preventif
Bagaimana perasaan keluarga tentang keadaan fisik ketika berada dalam keadaan sehat, kapan terakhir kali anggota keluarga melakukan pemeriksaan kesehatan.
10) Kesehatan gigi
Apakah keluarga menggunakan air yang mengandung florida, apakah anak-anak dianjurkan untuk menggosok gigi secara teratur, kapan waktu yang tepat untuk menggosok gigi bagi keluarga, apakah keluarga mempunyai frekuensi yang cukup sering dalam mengkonsumsi gula dan kanji, apakah keluarga telah menerima perawatan gigi yang memadai untuk mencegah terjadinya kerusakan pada gigi.
11) Riwayat kesehatan keluarga
Bagaimana kesehatan anggota keluarga dan keluarga yang lain dalam satu keturunan, apakah ada penyakit keturunan dalam keluarga.
12) Pelayanan kesehatan yang diterima
Perawatan kesehatan diperoleh dari mana, apakah tenaga kesehatan yang datang bertemu dengan seluruh anggota keluarga.
13) Persepsi tentang pelayanan kesehatan
Apa yang diketahui keluarga tentang pelayanan kesehatan yang ada di komunitas, bagaimana perasaan dan persepsi keluarga terhadap pelayanan kesehatan di komunitas, bagaimana pengalaman keluarga dalam menerima perawatan kesehatan yang terdahulu-apakah keluarga merasa puas, percaya dan nyaman dengan perawatan yang diberikan oleh tenaga kesehatan, apabila tidak ada pelayanan darurat-tahukah keluarga kemana harus meminta pertolongan, apakah keluarga mengetahui cara memanggil ambulan dan perawatan medis, apakah keluarga memiliki suatu perencanaan kesehatan darurat.
14) Sumber pembiayaan
Bagaimana keluarga membayar pelayanan yang diterima, apakah keluarga menjadi anggota Asuransi kesehatan, apakah keluarga juga mendapatkan perawatan gratis.
15) Logistik untuka mendapatkan perawatan
Seberapa jauh fasilitas perawatan dari keluarga, alat transportasi apa yang digunakan untuk mencapai pelayanan kesehatan, masalah apa saja yang ditemukan jika kleuarga menggunakn fasilitas umum.

F. Koping Keluarga
Koping keluaraga terkait dengan kemampuan keluarga dalam mengatasi stressor, merupakan respon yang positif, sesuai dengan masalah-afektif-persepsi, serta respon perilaku yang digunakan keluarga. Apakah keluarga mampu bertindak berdasarkan penilaian yang objektif dan realistis terhadap stressor. Perlu dikaji juga mengenai reaksi keluarga terhadap stressor, strategi koping yang diambil, apakah anggota keluarga mempunyai koping yang berbeda-beda, bagaimana strategi koping internal dan external yang diajarkan. Koping internal meliputi kelompok kepercayaan keluarga, penggunaan humor, self evaluation, penggunaan ungkapan, pengontrolan keluarga terhadap masalah, pemecahan masalah secara bersama, dan fleksibilitas peran. Strategi koping external meliputi pencarian informasi, pemeliharaan hubungan dengan komunitas, serta pencarian dukungan sosial.




































EMPHATHY

As a nurse who cares for Mrs. A, how should you create communication to show your empathy and respect?

Empathy is the capacity to feel others’ feelings, that we understand how they are feeling, and about what causes their reactions without becoming emotionally involved in their situation.

Some aspects of empathy are:
1. Mental aspect:
The ability to view another person’s world using their paradigm. It also means to understand others emotionally and intellectually.
2. Verbal:
The ability to give a verbal understanding of the reasons for a client’s feelings, emotions and reactions. To show empathy verbally, the following aspects are required:
a. Accuracy.
Accuracy is essential for verbalizing a clients’ feelings and problems.
b. Clarity.
Empathy should be clearly demonstrated on certain topics that are suitable for our clients.
c. Naturally.
Nurses should use their normal language to communicate with a client.
d. Checking.
The function of checking is to know whether our empathic response is suitably effective or not.

3. Non verbal:
Non verbal aspects concern the ability to show empathy with warmth and genuineness.
A. Warmth.
Nonverbally warm are:
a) Grimace-
Forehead : relaxed, no wrinkles.
Eyes : comfortable eye contact, natural eye movements.
Mouth : relaxed, no wrinkles, no biting of lips, smiling as needed, relaxed jaw.
Expression : relaxed, no fear, no worries, showing attention and interest.
b) Posture/position-
Body : facing each other, shoulders parallel with the partner.
Head : sitting or standing up at the same height, bending down if needed.
Shoulder : easy movements, no tightness or stiffness.
Arm : easy movements, not holding on to a chair or a wall.
Hand : not touching each other, not playing with objects such as ballpoint pens.
Chest : regular breathing, not unnatural swallowing.
Leg : no trembling.

Things that could be destroy warmth are:
a. Looking around while communicating with others;
b. Tapping of the fingers;
c. To leave suddenly;
d. Not smiling.

Barriers to showing warmth are:
a. Rushing;
b. Excessive emotion;
c. Shocking;
d. Others visions that drive us to distract to our problem.


B. Genuineness.
Genuineness is a similar response to verbal and non verbal by showing an interest in talking to a partner.


Respect Technique
Respect is an attitude that shows attention, a liking for, and an appreciation of the client. “To nurse is to appreciate a client as someone valuable, and accepting them without no question” (Stuart and Sundeen, 1995).

Respect could be shown as:
1. Looking at the client.
2. Giving attention.
3. Keeping eye contact.
4. Smiling in the right time.
5. Moving closer to a client.
6. Giving a right greeting and response
7. Holding a client’s hand.












CONFRONTATION TECHNIQUE


Confrontation is an interpersonal process used by a nurse to facilitate, modify, and explore another person’s self image. Its aims to encourage others to realize their feelings, attitudes, and improve their confidence.

Confrontation is used if someone has:
1. a non-cooperative attitude;
2. a broken spirit;
3. take others’ rights away.

According Stuart and Laraia (2001) the main factors should be paid attention to before ‘confrontation’ are:
1. Confidential relationships;
2. Time;
3. Client stress’ level;
4. Client’s strength to cope;
5. Client’s vision of the importance of their relations with others;
6. Client’s anger and tolerance level in response to the perception of others.

Confrontation categories according to Stuart and Sundeen (1995) are:
a. An improper understanding of self concept and self ideal;
b. An improper use of verbal expression and display of attitude;
c. A difference between client’s expression of their experiences and the nurse’s experience
with the client.
Two parts of confrontation:
a. Make others to recognize their unproductive attitude;
b. Make decisions about how to behave more productively and constructively.


There are 3 phases of confrontation:
a. Introduction phase;
b. Implementation phase;
c. Termination phase.

How to conduct a confrontation?
a. Clarify: making something clearer to understand;
b. Articulate: expressing personal opinions with carefully considered words;
c. Request: asking for something;
d. Encourage: giving support, hope, and trust.

Example of a confrontation:
Nurse: “Hadi said that he wanted to get well soon and go home, but now he refuses to take the medication.” How can he recover quickly if he reacts like that?








THERAPEUTIC COMMUNICATION FOR CHILDREN AND TEENAGE CLIENTS


Children are unique individuals, not miniature adults. The ability to communicate with a child is influenced by the child’s neurological and intellectual development.
Communication techniques used to communicate with a child client include:
a. The 3rd person technique;
This is usually used with infants and toddlers by involving a person closely related to them.
b. Story telling;
c. “What if” questions;
d. Facilitative responding;
e. Three wishes;
f. Writing;
Writing about feeling or the many things that children love to do.
g. Drawing;
h. Playing;
i. Dreaming;
j. Pros and Cons.;
Asking children to write down the positive and negative things they experience.
k. Bibliotherapy.

Nurses have to pay attention to effective therapeutic communications with a child. These involve:
a. Giving attention;
b. Actively listen;
c. Choosing interesting topics to discuss;
d. Avoiding to give criticism and making judgments, especially for teenagers;
e. Not over reacting;
f. Keeping an open mind.

Of importance when communicating with children is taking care in considering the characteristics of their developmental level:
1. Infancy:
a. Using non-verbal communication
b. Infants would be smiling when they feel comfortable, but crying when feel the opposite.
2. Early childhood:
Egocentric;
Using toys;
Involve parents in communication;
Other people’s experiences are not interesting to early-childhood children;
Using consistent language, simple, and short.
3. School-age years:
Children pay attention to their integrity;
Children need information about what to do and how to perform actions;
Nurses need to give explanations if they want school-age children to do something.
4. Adolescence:
a. Children want to interact with nurses;
b. Children need an opportunity to express their feelings;
c. Nurses must create a trust by:
 Spending time together;
 Giving the opportunity and support to children to express their feelings and ideas;
 Respecting children’s views;
 Being able to tolerate diversities;
 Respecting their privacy;
 Giving positive reinforcement.



THERAPEUTIC COMMUNICATION FOR OLDER PEOPLE.

Classifications of the elderly are:
a. Middle aged : 45-59 years old;
b. Elderly : 60-70 years old;
c. Old : 75-90 years old;
d. Very old : > 90 years old.

Older people experience changes both physically and mentally; for example:
a. Cell degeneration;
b. Neuro-sensory system;
c. Cardio-vascular system;
d. Respiratory system;
e. Gastro-intestinal system;
f. Genito-urinaria system;
g. Endocrine system;
h. Integumen system;
i. Musculo-skeletal system;
j. Chronic illnesses;
k. Loss.

Verbal communication used with older people includes:
a. Speaking with the client respectively and using their full name;
b. Avoiding the use of high tension in the voice;
c. Using the common language used by the client;
d. Using simply structured language;
e. Discussing only one topic at one time;
f. Validating that the client understands;
g. Writing the order of the important things to remember.

There are many older people experiencing problems both physically or mentally.
There are many ways to implement therapeutic communication with them:
1. Older people with defective hearing:
a. Standing close and facing the client;
b. Touching the client;
c. Speaking louder and more slowly;
d. Giving frequent breaks when speaking;
e. Avoiding excessive lips movement.
f. Using body language and facial expressions;
g. Using short sentences;
h. Reviewing misunderstanding by using different words;
i. Avoiding turning away while speaking;
j. Making sure that hearing aids well.
2. Older people with defective vision:
a. Introducing ourselves;
b. Approaching from the front;
c. Explaining/demonstrating the room’s facilities;
d. Creating a well-lit environment;
e. Checking that glasses function well.
3. Older people with anger:
1. Clarifying the cause of the anger;
2. Helping and supporting the client to express anger constructively;
3. Using open questions;
4. Spending time with them every day;
5. Reinforcing and supporting the client’s every effort.
4. Older people with anxiety:
1. Listening to the client;
2. Giving short and clear explanations;
3. Identifying with the client what issues lead to nervousness;
4. Involving staff and family members.
5. Older people who are uncooperative:
1. Accepting the situation calmly;
2. Avoiding confrontation on the client’s uncooperativeness;
3. Helping client to express their discomfort/sadness;
4. Involving the family.
6. Older people with depression.
1. Contacting them as often as impossible;
2. Giving continuous attention;
3. Involving the client in helping themselves;
4. Using open questions;
5. Involving staff and family members in giving attention.

Therapeutic Communication for Chronic Illness Clients.

Clients with chronic illness or with a terminal condition will have a crisis experience. They are usually feel:
1. Decrease of physical functions: basic needs;
2. Anxiety;
3. Loss of function;
4. Depression;
5. Hopelessness;
6. Guilt;
7. Sleep disturbance.

Steps in client’s crisis:
a. Denial;
b. Anger;
c. Bargaining;
d. Depression;
e. Acceptance.

Therapeutic communications techniques a nurse should implement to interact with a client in the crisis phase:
a. Creating a trust relationship between each other;
b. Giving warmth;
c. Showing an emphatic understanding;
d. Touching;
e. Giving information.

Every client’s crisis phase has different characteristics. Thus, a nurse should be able to respond differently for each situation. The communication techniques implemented by the nurse in every crisis phase include:
1. Denial phase:
a. Giving a chance to be constructive in coping facing death;
b. Always being available to the client;
c. Keeping eye contact.
2. Anger phase;
a. Giving clients a chance to express their feelings;
b. Being prepared to listen again and again;
c. Using respectful techniques.
3. Bargaining phase:
a. Giving the client a chance to bargain;
b. Asking the client about what they want.
4. Depression phase:
a. Avoid trying to make client happy;
b. Allow the client and their family to cry to express their sadness.
5. Acceptance phase;
Spend time with the client, and with the family to discuss feelings about client’s impending death.




Refusing an Unreasonable Request.


Unreasonable requests
Nurses often accept a request for information, emotional support, or other assistance. Such requests are a common. Even objectively nurses consider that such requests are a common phenomenon. But when receiving requests, nurses need to consider how these will impact on them personally. It depends upon whether the request is considered acceptable or not.
A request is considered acceptable if it conforms to a right or an obligation according to nursing ethics, values, and beliefs. Unacceptable requests can lead to negative feelings, or even the destruction of positive thinking about certain aspect of nursing. Often nurses are asked to do something which does not respect their position, or shows no consideration for their personal safety or their physical ability. It is unacceptable for nurses to be expected to accept and fulfill requests which can hurt them both physically and emotionally. They may even lead to a nurse taking on a work overload.

As nurses, we have our own right to work comfortably so that we can provide our best services to clients and ensure good relationships within the working team. A nurse is someone who accepts considerable responsibility; however, they also have rights. These are:
1. Right to respected;
2. Right to work with a rational load;
3. Right to receive a proper salary;
4. Right to decide their own priorities;
5. Right to ask for what they need;
6. Right to refuse without feeling guilty;
7. Right to make mistakes and take the responsibility for it;
8. Right to give and ask for information as needed professionally;
9. Right to do the best for their clients;
10. Right to be a human being and to treated as human.

Requesting information or ideas, giving attention, performing tasks within a nurse’s physical capability, need time to fulfill. We need to check our source before we make an agreement to any request. When we receive a request which is beyond our capability, we will lose our self control. Before saying “Yes” to a request, it would be better for us to check first whether we are able to manage it or not. If it appears unreasonable, we have to refuse it. It would be better for us to refuse than to be confronted with a serious problem.
If you are aware that you can not handle something bad, and if you are not ready to make a total commitment, its mean you are not ready to say yes to whatever it is that is required of you.

Saying “No”.
The ability to say no is to refuse in an assertive way. Becoming assertive means protecting ourselves by refusing tasks that we can not handle, but we show respect on the other party by refusing in a polite way. Our willingness to help our clients and colleagues, and our desire to be of service, often drive us to not say no clearly and simply.



Asking for Help from Client, Colleagues, or Another Health Team.


Case:
Nurse Ana works in an afternoon shift in which there are just 2 nurses on duty. There are lots of patients needing care, making it impossible for just 2 nurses. Nurse Ana is the one who takes the responsibility for asking for additional nurses during the afternoon shift.

Often as a nurse we need to ask for help from our colleagues. Literature research indicates that there is a strong relationship between social support and health. There is a lot of evidence which shows that some illnesses could be prevented, or recovery from an illness can be easier and faster if there were strong social support. It also related to positive mental health. Support within the working environment is also important for the workers.

Determining support that is needed within a workplace or a school:

Support means all those things that help you to work effectively. If you think that support can be cognitive, affective, and physical, the definitions will give you more clues in regard to nursing.
Cognitive support helps you to think accurately about work, to define how to overcome a problem, to determining how to perform your duties, and to provide many performance criteria.
Affective support is a positive feeling about openness and direct communication with colleagues. Colleagues who share views and who are comfortable in expressing their ideas show that there is a positive feeling in your workplace.
Physical support is the concrete help given by people, computers, and equipment to enhance your performance as a nurse.
One of method in giving positive support is by giving guidance. In relation to guidance, the nurse leader should give career guidance, academic stimulation, and become a professional role-model. A hospital should implement a strategic plan to attract and retain its nursing by involving clinical specialists, nursing research support, and by conducting staff development and staff orientation.

In terms of affective support, nurses need acknowledgement of their performance. They need continuous support and confirmation of their important role. Occasional giving of thanks and showing an appreciation of nursing staff is a joyful experience that promotes good will among nursing staff. Callahan (1990) believes that lots of anxiety occurs as nurses realize that there are no chances to build on their talents, and that they are not acknowledged for the services they perform.

Making a support request in a workplace:
The first thing is to identify the nurses’ needs for support. The next step is determine whether the nurses need it or not. If yes, it is necessary to determine a strategic planning to gain the required support.
Nurses should answer these questions:
1. Who is the appropriate person to ask for support?
2. What is the best way to ask for help or support?
3. How can I express my problem so that I can find a support easily?

You are a 3rd semester student who has to complete assignments, but journals in the library are limited. Therefore you need the school to improve the situation.
In the cognitive area you need improved access to information. You decide to complain it to Library Officer, but there is no action, and then you try to forward it the School Director.
After making an appointment with the Director, you have to prepare your strategy. In the 20 minutes given to you, you have to make the Director realize that there is only a very limited journal collection in the library, convince the director of the seriousness of the problem, and ask him to do something about it.
This case needs supporting data, so you might need to do a survey of book titles or journal titles that needed.
When you have the interview with the Director, you have to prepare yourself, be relaxed and patient. Argue your needs clearly and in an assertive way. Pay attention to your Director’s responses, what he asks or the notes that he makes. Make sure that the Director personally facilitates the remediation of the problem, and that students will be provided information.



Conveying Bad News.

One of the most difficult duties for a nurse is to convey bad news.
An example: “ Mr. Rudi, I have bad news from your cancer biopsy result. The result was positive.”
Your duty is to convey the news to the family. Many nurses will refuse this task to convey this kind of bad news. There is a lack of training for nurses to improve their ability to convey bad news.

What are the steps when conveying bad news?

Preparation
1. Understand yourself as a nurse and prepare yourself with all the necessary information and notes available to you, including the client’s medical record.
2. The best way to convey bad news is by meeting with the person directly. Sometimes we don’t have any choice, so we need to convey the bad news through a telephone conversation. It is better to avoid conveying bad news with a request that will cause worry, such as: “ Mrs. Kardi, please come soon, I have something to convey to you!”
If there is laboratory exam which has a strong possibility to result in bad news , a planning meeting must be held immediately. It is better to plan beforehand if there is a possibility for bad news.
3. Select a comfortable place where there will be minimal distraction, and allow as much time to convey the news as required. Seat yourself comfortably, indicating that you are paying full attention and not in a rush. Avoid to speak while you are on the move or in an improper place - for example: in a crowded place. Make a note for your colleagues to not disturb on interrupt you. Manage your tone of voice so it sounds normal, without a sign of anxiety or nervousness.

Create a relationship
Commence with some pre conversation techniques, even though you may assume that the person you are speaking to already have a feeling of what you are about to say.
Some important considerations in creating a relationship are:
1. Pre conversation:
Introduce yourself and any other people who are with you. If there are people unknown to you, find out who they are.
2. Assess the recipient’s status:
Ask about their needs and the recipient’s understanding of the situation. This assists nurses to make the transition to conveying the bad news, and enables them to asses the client’s perception of the situation. Nurses may ask question such as: “ What do you understand about the situation at this time?” or by asking why a test was (or should be) performed.

Sharing news
There is a metaphor that illustrates bad news as a bomb, the explosion of which could have many repercussions. Here are some techniques to share news:
1. Speak softly. Use clear sentences and avoid ambiguity.
2. Give prior notice. You might say “I’m afraid that I have bad news for you”. Stop speaking for a moment and observe the client’s response.
3. Convey the news you wish to convey. The sentences should be short and simple. For example: “ The biopsy result seems not as you wished. It is cancer”.

The consequence of bad news
1. Wait in a relaxed manner for a reaction. Prepare yourself for unpredictable consequences. The recipient may accept the news in an unpredictable way. Possible reactions may be: crying, unconsciousness, screaming, keeping silent, laughing, or suddenly asking many question in a row. Sometimes they act as if they did not hear what was said. Whatever the recipient’s response, let it happen. Show that you are there, and that you understand the situation. Do not try to compensate for your own discomfort by speaking about it further.
2. The reaction could be questions or signs so that the nurses may show their empathy. Response should be a simple acknowledgement of the shock recipient experienced. Prevent giving too much data to the client. To assess the client’s response, the nurse might say; “ I understand this is so difficult for you. What are you thinking now?”
3. Pay attention and follow up on the client. Some recipients can accept the new information better than others. Try to place things into perspective for them. Bad news is part of everyday life. Accidentally losing control is a part of pre-shock. You can help recipients to control it by asking :” Would you like further information, or shall we discuss it later?”. It is necessary to prompt the client into taking control of the situation.

Follow up transition
1. Make a schedule to follow up. Plan concrete steps to follow up as soon as possible. This follow up meeting is the proper time to give further detailed information, and to allow the asking of questions.
2. Explain your position in the process. If you are a nurse is who going to care for the client, explain that you will be there and will take care of the client. If you have to refer the client to another ward, explain who will take over the responsibility for them there..
3. You as a nurse began the process, so you will also close it. Finish your meeting with empathy and show that you are prepared to maintain contact with the client.

Give attention and respect to the client’s feeling, and also the nurse’s personal needs
The nurse often feels it difficult and stressful when conveying bad news. They may seek personal support by expressing their experience and feelings to other colleagues who can be a support system for them.
Give yourself time relax by meditation or praying.

Health Counseling.


One of the problem faced by clients and their families is dependence upon nurses or other health services, even to decide about the health service from where to obtain assistance. This dependence is not beneficial to client and their families.
Its is necessary for clients and their families to become independent in making the best decisions for themselves. It is necessary to improve the clients’ and families’ understanding about themselves and their health problems. This is known as Health Counseling Services.

Limitation and Characteristics
Counseling is a process during which someone helps another to make decisions or to find solutions for their problems through understanding about the facts and feelings involved.
The definition covers:
1. Role.
One side as a counseling giver to help others to an action, and the other side as a counseling recipient. Making decisions is not a counseling task.
2. Facts.
Information conveyed by clients (family background, illness history, and health, the hopes of clients and their families).
Information conveyed by counselor (illness information, therapy, prognosis, and preventive care).
3. Client’s feeling.
This involves the health problems, fears, worry, attitude, and values about health and therapy.



The influenced factors.
The factors influencing the purpose of a counseling service are:
1. Means of Counseling-
Counseling service must be conduct in a quiet and comfortable room (not too hot, not too cool, quiet, not crowded) and also private and confidential.
2. Counseling condition-
The counseling atmosphere should be conducive to helping clients to trust and be open towards the nurse. The nurse needs to be friendly, familiar, open, respectful, etc.
3. Counselor.
The counselor must be able to create trust and openness in explaining health problems, but by no means act like a teacher.

Client’ rights.
There are 10 client’s rights:
1. Right to information
Right to know all the health information as needed by the client.
2. Right to access
Right to get services without discrimination because of gender, religion, ethnic belief, marital status, and location.
3. Right to choose
Right to decide freely in choosing how to solve their problem.
4. Right to safety
Right to get services safely and effectively.
5. Right to confidentiality and secrecy
Right to get a guarantee that the personal information given is kept confidential.
6. Right to privacy
Right to get privacy in counseling.
7. Right to dignity
Right to get services and be fully appreciated as a human being.


8. Right to comfort
Right to feel comfortable in obtaining services.
9. Right to continuity
Aright to a guaranteed continuity and readiness of services and equipment as needed.
10. Right to give the opinion.
Right to be able to state an opinion freely and openly.

Counseling competencies level
1. Observation competency step in placing relationships on a firm basis.
In the counseling process, doctors need to have an observation competency towards their clients.
In the assessment, a doctor will be able to see the client’s condition, whether the client is fearful, or restless… . Counseling through an interview can be beneficial. The use of a good relationship is the basis of a successful helping process through which the client is able to obtained proper information. This step needs friendliness from the health provider.
2. Listening and asking competency step.
In this step, nurses discover full information by using a variety of techniques. It is aimed that in this step nurses are able to ask, and the client is able to answer, so that the data needed to make a decision is efficiently collected.
The making of decisions in counseling is held by the client. Influencing means giving information as needed, or suggesting problem-solving alternatives such as interpreting, informing, and giving feed back.
3. Confrontation competency step.
This means that the client actions are inappropriate, or there is disagreement between the nurse and the client. Usually, it useful to encourage the client to recognize that the conflict is within themselves. For example: in a situation where a client who is not willing to have children, but also not willing to accept the family planning program, the nurse can point out the contradiction and let the client decide what action to take.