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Professional Nursing Final Exam

Terms in this set (229)

WEEK 1
What are the characteristics of a profession?
• Education takes place in a college or university.
• Education is prolonged
• Work involves mental creativity
• Decision making is based largely on evidence-based practice.
• Values, beliefs and ethics are an integral part of preparation.
• Commitment and personal identification are strong.
• Workers are autonomous.
• People are unlikely to change professions.
• Commitment transcends material reward.
• Accountability rests with individual.
How are professions different than occupations?
The following are characteristics of an occupation that may be directly compared to the previous list.
• Training is usually on the job.
• Length of training varies.
• Work is largely manual.
• Decision making is largely guided by experience or trial by error.
• Values, belief and ethics are not prominent.
• Commitment and personal identification vary.
• Workers are supervised.
• People often change jobs.
• Material reward is main motivation.
• Accountability rests primarily with employer.
What is nursing's social contract?
Social contracts are the mechanisms by which society legitimizes professions and grants them authority and autonomy to carry out their functions. The nursing profession is urrently renegotiating its contract with society in a manner which clearly reflects a change from physician dominance, and emphasis on 'illness care' to increased independent and autonomous functioning within a newly developing framework of nursing science which emphasizes 'health care'.
- Nurses relationship with society and nurse's obligation to those who receive professional nursing care.
What is the role of the American Nurses Association in advancing the profession's objectives?
ANA is the official voice of nursing and therefore is the primary advocate for nursing interests in general. ANA encourages and supports high standards of practice.
What are the main recommendations of the IOM Report on the Future of Nursing in terms of the educational composition of the nurse workforce?
Remove scope of practice barriers - Advanced practice registered nurses should be able to practice to the full extent of their education and training.
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Expand opportunities for nurses to lead and diffuse collaborative improvement efforts - Expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems.
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Implement nurse residency programs - Completion of a transition-to-practice program (nurse residency) after completion of a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.
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Increase proportion of nurses with BSN from 50% to 80% by 2020 - Increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.
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Double number of nurses with doctorate by 2020 - This will add to the cadre of nurse faculty and researchers, with attention to increasing diversity.
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Ensure that nurses engage in lifelong learning - Ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.
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Prepare and enable nurses to lead change to advance health - Prepare the nursing workforce to assume leadership positions across all levels.
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Build an infrastructure for the collection and analysis of inter-professional health care workforce data - Effort to improve research and the collection and analysis of data on health care workforce requirements.
WEEK 2
What are the differences between for-profit, not-for-profit and government ownership of hospitals and other delivery organizations?
Not-for-profit agency is one that uses profits to pay personnel, improve services, advertise services, provide educational programs, or otherwise contribute to the mission of the agency. For-profit agencies distribute profits earned to partners or shareholders. Voluntary (private) agency gets its support generally through private donations. Non-governmental organization (NGO) is an association of citizens that operates independently of the government with the goal to deliver resources or serve a social or political purpose (example: MSF). Governmental (public) agencies contribute to the health and well-being of US citizens. Primarily supported by taxes, administered by elected or appointed officials, and tailored to the needs of the public.
What is the role of safety net hospitals in the United States?
A safety net hospital or health system provides a significant level of care to low- income, uninsured, and vulnerable populations. Safety net hospitals are not necessarily distinguished from other providers by ownership - some are publicly owned and operated by local or state governments and some are non-profit. Rather, they are distinguished by their commitment to provide access to care for people with limited or no access to health care due to their financial circumstances, insurance status, or health condition.
What are the differences in the complexity of care among primary, secondary, tertiary and sub-acute services? What types of services would you expect to encounter at each of these levels of care?
• Primary care is rendered at the point at which a patient first enters the health care system. Primary heath care provides: Entry into the system, emergency care, health maintenance, ,management of long-term and chronic conditions, treatment of temporary health problems that do not require hospitalization.
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• Secondary care involves the prevention of complications from disease. Allows patients to keep out of the hospital while managing their disease. (home health agencies, surgical centers, ambulatory care agencies).
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• Tertiary care is provided to acutely ill patients, to those requiring long-term care, to those needing rehabilitation services, and to terminally ill patients. Usually involves many health care professionals working as a team to provide care. (trauma centers, burn centers, skilled nursing long term care).
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• Subacute care (emerged in 1990s) is impatient care that lies between hospital care and long-term care. Provides lower cost care to acutely ill patients until stabilized. Creates a seamless transition through health care system.
How is healthcare financed (paid for) in the United States?
• Private Insurance - Premiums are paid to allow for health care benefits.
• Medicare - Nationwide federal health insurance program available to people over the age of 65, regardless of income.
• Medicaid - Jointly federal-state funded programs for low-income, elderly, blind and disabled individuals.
• Personal Payment - Out-of-Pocket Payment - "Straight up Benjamins, Yo."
What are the key provisions of the Affordable Care Act of 2010?
• Providing insurance options, covering preventive services, and lowering cost.
• Coverage available to children up to age 26.
• Yearly wellness visit and many free preventive services for some seniors with Medicare.
• Insurers must justify any premium increase of 10% or more before the rate takes effect.
• Putting information for consumers online.
• Prohibiting Denying Coverage of Children Based on Pre-Existing Conditions.
• Prohibiting Insurance Companies from Rescinding Coverage ( companies cannot use application errors to deny coverage).
• Eliminating Lifetime Limits on Insurance Coverage.
• Provides consumers a way to appeal Insurance Company Decisions.
• Establishing Consumer Assistance Programs in the States.
• Providing Small Business Health Insurance Tax Credits.
• Cracking Down on Health Care Fraud.
• Holding Insurance Companies Accountable for Unreasonable Rate Hikes.
• Increasing Payments for Rural Health Care Providers.
• Strengthening Community Health Centers.
What is the role of states/state governors in implementing the Affordable Care Act of 2010?
The governors need to decide whether or not expand the Medicaid program in their state. States that are expanding Medicaid will have larger gains in insurance coverage than those states that do not and will see very large reductions in the number of uninsured. Those states that have not expanded Medicaid will see less impact on the uninsured. These states have more uninsured to begin with, thus current disparities in coverage will increase, at least in the early years.
What is the role of the Joint Commission in the healthcare sector?
One of the two accrediting not-for-profit agencies approved by the CMS. JC serves as the nation's predominant stand-setting and accrediting body on health care. The goal of accreditation is to improve patient outcomes.
What is the difference between fee-for-service and managed care payment?
• Under the fee-for-service method, doctors and hospitals got paid for each service they performed. There were no limits on their treatment decisions; doctors or hospitals could order as many tests as they felt necessary. patients did not always benefit because their insurance companies would often only pay a percentage of the fees being charged.
• Managed care organizations supervise the financing of medical care delivered to members. They all are concerned with cost-effectiveness, or saving money. They make the primary care physician the core of health care delivery. Types of plans: HMOs, PPOs, POS.
What are the major recommendations of the IOM report on disparities in care in the US?
• Base decisions about resource allocation (e.g., which patients should receive particular treatments for specific health conditions) on published clinical guidelines;
• Take steps to improve access to care—including the provision of interpretation and translation services, where community need exists;
• To the extent possible, equalize access to the same health care products and services, to avoid fragmentation of health plans;
• Insure that physician financial incentives do not disproportionately burden or restrict minority patients' access to care;
• Support the use of community health workers and multidisciplinary treatment and preventive care teams;
• Collect and monitor data on patients' access and utilization of health care services by race, ethnicity, and primary language.
What are the major roles of the different professional groups on an interdisciplinary care team?
• Physicians - Responsible for medical diagnosis and interventions designated to restore patient health (4 years of education with 3-4 year residency).
• Physician Assistant - Perform many functions of the physician under direct supervision of the physician ( 2-3 years of education).
• Unlicensed Assistive Personnel - Work under nurse supervision to assist with basic patient care (on-the-job training).
• Licensed Practical Nurse - Provide basic bedside care under direction of physicians and RNs (1 year of education, state licensure).
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• Dietitians - Understand how what one consumes, whether oral or intravenous, can affect a patient's recovery and promote and maintain health (bachelor's or higher).
• Pharmacists - Prepare and dispense medications, instruct patients and other health workers about medications, monitor the use of controlled substances such as narcotics, and work to reduce medication errors (6 years of education, state board licensure).
• Technologists - Personnel who assist in the diagnosis of patient problems ( 1-4 years of education, state licensure).
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• Respiratory Therapist - Operate equipment such as ventilators, oxygen therapy devices, and intermittent positive-pressure breathing machines. (2-4 years of education, state licensure).
• Social Worker - Trained to assist patients and their families as they face the impact of illness and injury (bachelor's or higher).
• Therapist - Help patients with special challenges (physical, occupational) (Master's degree).
• Administrative Support Personnel - Clerical jobs such as admitting patients, answering phones, directing visitors, scheduling patient tests, filing insurance claims, filing forms, paying bills, facilitating payroll, and other support functions.
What structural and social factors account for disparities in access to and quality of healthcare in the United States?
• Cause of disparities may be due to: Race, ethnicity, gender, age, income, education, disability, sexual orientation, and place of residence.
• Provider bias had been mentioned as a contributing factor to health care disparities.
What are the major barriers to inter-professional team work in healthcare organizations?
Organizational Barriers:
• Lack of knowledge and appreciation of the roles of other health professionals.
• The need to make compelling arguments for team building to senior decision-makers
• Financial and regulatory constraints
• Legal issues of scope of practice and liability
• Reimbursement structures for different professions, including which services receive reimbursement
• Hierarchical administrative and educational structures that discourage inter-professional collaboration.
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Barriers at Team Level:
• Lack of a clearly stated, shared, and measurable purpose.
• Lack of training in inter-professional collaboration.
• Role and leadership ambiguity.
• Team too large or too small.
• Team not composed of appropriate professionals.
• Lack of appropriate mechanism for timely exchange of information.
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• Need for orientation for new members.
• Lack of framework for problem discovery and resolution.
• Difference in levels of authority, power, expertise, income.
• Difficulty in engaging the community.
• Traditions/professional cultures, particularly medicine's history of hierarchy.
• Lack of commitment of team members.
• Different goals of individual team members.
• Apathy of team members.
• Inadequate decision making.
• Conflict regarding individual relationships to the patient/client.
WEEK 4:
Pathways to Professionalism
Historical perspective on nursing in the U.S.
Education and entry to practice
Nurses' roles and responsibilities
Professional image and identity
What are the tenants of professional nursing practice as defined by the ANA?
Tenants of Nursing Practice (ANA)
1.Nursing practice is individualized
2.Nurses coordinate care by establishing relationships
3.Caring is central to the practice of registered nurses
4.Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumer
5.A strong link exists between the professional work environment and the RNs ability to provide quality care
2. What are the different educational programs to prepare nurses for entry into professional practice?
Education and Entry to Practice:
Diploma -hospital based schools of nursing. Early teaching by physicians. On the job training

Associates Degree -Community college education. Developed during WWII. Technically focused training

Bachelor's Degree -University based education. Preferred entry to practice degree; Theory, research and evidence base, emphasizes leadership and holistic approach.
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NURSES WITH THESE THREE EDUCATIONAL BACKGROUNDS ALL SIT FOR THE SAME NCLEX EXAM TO BE LISCENSED AS AN RN
RNs MOSTLY HAVE THE SAME JOB FUNCTIONS IN PRACTICE REGARDLESS OF THEIR EDUCATIONAL PREPARATION
MASTER'S DEGREES:
- developed in the 1960s and 1970s. Focus on specialization;. -Research foundation and practice development. Advanced Clinical Nursing Roles
-Multiple tracks in graduate education in nursing
-Nurse Practitioner, Anesthesia, Midwifery, Education, Administration, Clinical Nurse Specialist, Informatics (c. 1990s), Clinical Nurse Leader (c. 2004)
What is the difference between a PhD and a DNP degree?
.Doctoral Education in Nursing:
PhD in Nursing:
-Research focused degree; first doctoral programs in NURSING developed in the late 1950s. NYU created the first PhD program in nursing in the US.
-Theory development—to explain 'how' things work; Researchers advance the body of knowledge for the discipline.
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Doctor of Nursing Practice:
-Clinically-focused practice degree (widely implemented in the 2000s).
-Focus on clinical expertise and health systems leadership skills (leadership, policy, economics, evidence-based practice, quality improvement)
-States determine which nursing roles can attain the DNP degree ( for example, in NY only NPs are eligible for the DNP degree) .
What is the difference between certification and licensure in nursing?
LISENCE VS. CERTIFICATION:
LICENCE:
-Mandated by the state
-Legal credential needed to practice nursing
-Sets a minimum standard of knowledge and competence for practitioners
CERTIFICATION:
-Is voluntary
-Verifies that you possess a higher level of knowledge or proficiency in a particular -practice area
-Has professional status NOT legal status
-Certification is not standardized in Nursing
What strategies can nurses use to improve their credibility in the clinical setting?
-Use SBAR communication model; prepare what you're going to say before talking
-Focus on the facts and the key clinical data
-Develop personal rapport with physician colleagues
-Educate your physician colleagues on your education and experience and the nursing role
-Work to align the medical goals with the nursing goals when communicating with residents
-Present yourself in a competent manner (Don't say "I don't know" at the end of a statement or "I feel" to start off a request).
What are the major components of the nursing profession's identity?
Nurses' Professional Identity:
-Set of beliefs, attitudes and understanding about one's roles, within the context of work, is generally refer to as 'professional identity' (Adams et al., 2006; Lingard et al., 2002).
-The values and roles form a common view of "What we stand for".
-The professional identity of nursing has changed over time in response to social factors.
- Identity has an internal (how you see yourself) and external component (how others see you).
In what ways is the popular image of nursing at odds with the profession's image?
Professional Image and discrepancies:
-How nurses are portrayed in the media
-The status they are afforded to comment or share their expertise
-Primary values "What do nurses stand for?"
-Competence vs. sexual objects
-Primary or trivial role in healthcare delivery
-Dress, demeanor, comportment (look, act, behave)
Describe the social and historical factors that shaped professional nursing practice in each era of the 20th century (eg: 1900s; WWI; WWII; 1980s; 2000s).
1900s
Financing Mechanism: Private payment for physician, hospital, and nursing services. Philanthropic sponsored hospitals
Industry Structure: Specialty hospitals for specific disease. Proliferation of general hospitals; 1 bed per 304 people
Medical Terminology: Germ theory, aseptic techniques, and anesthesia developed Blood transfusions, Stethoscopes, thermometers, microscopes
Leading Causes of Mortality: Influenza, pneumonia, TB, gastritis, heart disease, stroke, personal injury, chronic nephritis, cancer, diseases of early infancy, diptheria
Nursing Profession: Nurse's training schools established, ANA founded First nurse registration laws
Organization of Nursing Services: Functional nursing in hospitals by student nurses. Private duty, public health visiting nurse careers for graduates.
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1930-1950
Financing Mechanism: Blue cross/Blue shield formed, Social Security Act, Hill-Burton and Lantham Acts, National Mental Health Act
Industry Structure: AMA-created hospital ownership designations, Joint Commision established
Medical Terminology: Sulfa drugs, penicillin, vaccines, EKGs and EEGs, ICU's established, University hospital system established
Leading Causes of Mortality: Heart disease, stroke, cancer, personal injury, respiratory disease, diabetes, suicide, chronic liver disease, homicide
Nursing Profession: Federal legislation to fund nursing education, State boards of nursing license exams, University-based nursing education advocated, Practical and associates depree programs established, NLN and ANF founded.
Organization of Nursing Services: Team nursing, Professional nursing (graduates move to hospitals)
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1960-1980
Financing Mechanism: Medicare legislation, Tax Equity and Financial Responsibility Act.
Industry Structure: rise of For-Profit hospitals and multihospital chains
Medical Terminology: Cardiac care units, chemotherapy, electronic monitoring, renal dialysis, open heart surgery, organ thansplants, computerized scanners
Leading Causes of Mortality: Heart disease, cancer, stroke, personal injury, pneumonia, liver disease, diabetes, suicide, homicide
Nursing Profession: ANA position paper on nursing education, commonwealth fund and nurses training act for advanced nursing education. First doctorate in nursing science program, prescriptive authority for NP's in some states, National center for Nursing research at NIH.
Organization of Nursing Services: Primary nursing, shared governance practice models.
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1990-2000
Financing Mechanism: Manage care financing/health reform, Balanced Budget Amendment, Medicare/Medicaid funding
Industry Structure: Mergers, alliances, partnerships, growth of for-profit and managed care delivery organizations
Medical Terminology: Second-generation scanners, telemedicine and information systems, clinical guidelines, service technologies, AIDS therapies
Leading Causes of Mortality: Heart disease, cancer, stroke, personal injury, COPD, pneumonia, flu, diabetes, suicide, liver disease, cirrhosis, HIV/AIDS
Nursing Profession: Pew report on the Health Professions, National Institute for Nursing Research, J&J Campaign for Nurses' future
Organization of Nursing Services: Introduction of unlicensed assistive personnel, trend towards multidisciplinary teams
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2000-2014
Financing Mechanism: Managed care and fee for service; Children's Health Act- insurance for low income children; HIPPA—Privacy protections; Affordable Care Act
Industry Structure: Mergers, trend towards ambulatory care, chronic disease management programs, patient-centered medical homes and accountable care organizations
Medical Terminology: IT and tele-health. Consumer-focused care, Cancer treatments, minimally invasive surgeried, biotechnology/genetics/personalized medicine
Leading Causes of Mortality: Heart disease, cancer, chronic respiratory disease, stroke, accidents, Alzheimers, flu, pneumonia, nephritis, suicide
Nursing Profession: IOM reports on quality and future of nursing, Carnegie report on educating nurses; CNL and DNP graduate programs established; funding for nursing education; NP regulations loosened in some states.
Organization of Nursing Services: Increased focus on care coordination quality improvement, patient-centered and multidisciplinary team approaches
WEEK 5
What is Martha Rogers's relationship to NYU?
-Developed the first PhD program in Nursing which was founded at NYU
Describe the nursing theories advanced by Nightingale, Henderson, Roy, Benner, Leininger, Peplau, Orem, and King.
Florence Nightingale (nursing theory):
•A social innovator and the founder of modern nursing
•Wrote Notes on Nursing, What it is and What it is Not and Notes on Hospitals
•Believed that healing occurs within the environment and nurses have a role in creating an environment to promote healing.
•Collected data and used statistics to document the effectiveness of the careful maintence of the environment on health outcomes during the Crimean War.
Nightingale's 8 aspects of Professional Nursing
1. Ventilation and Warming
2. Health of the Home
3. Noise
4. Variety
5. Bed and Bedding
6. Light
7. Cleanliness of rooms and walls
8. Observation of the sick
Virginia Henderson (Nursing theory)
Developed the classic definition of nursing in 1960s
" The unique function of the nurse is to assist the individual, sick or well, on performance of these activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength or knowledge."

•Viewed patients as individuals who required help towards achieving independence and wholeness of mind and body
•Developed 14 basic needs of the patient that nurses use to define their role, assist the patient/client over time
•The 14 needs include physical, psychological, emotional, social, spiritual, and developmental needs.
•In addition to her theory, Henderson created the first catalogue of nursing literature published between 1900-1954
Dorothea Orem (Nursing theory)
Self-Care Deficit Theory

Developed 3 interrelated theories
-Theory of Self-Care
-Theory of Self-Care deficits
-Theory of Nursing Systems
-Focuses on designing nursing actions so that people can meet their care needs
-The nurse prescribes and regulates the system based on the patient's self-care deficit
-Uses a process of assessment, relationship building, education and intervention to support self-care
Sr. Callista Roy (Nursing theory)
Adaptation Model
•Systems model focuses on how people adapt to situations, particularly illness
•Nurses/Nursing promotes the patient's adaptation and coping to achieve a health goal
•Effective coping promotes the integrity of the individual
Martha Rogers (Nursing theory)
Unitary Human Beings Model
-Developed from her work in physics and is based on uses systems theory
-Thought of humans as dynamic energy fields that interact with the environment
-Complex theory that focuses on the total experience of health and care; the continuum of care is more important than episodes of care
-A group of theorists and practitioners , known as Rogerians, continue to refine these ideas
-Credited with developing the first PhD program in NURSING founded at NYU
Hildegard Peplau (Nursing theory)
Interpersonal Relations Model
•Defines the relationship of the nurse and the patient
•Focus on understanding the patient so to promote healthy behavior
•Nurse and patient are viewed as a pair/dyad
•Interpersonal relationships promote 1) patient's survival and 2) patient's understanding of their health and behaviors to maintain health
•"Mother" of modern psychiatric nursing
Benner
Benner's Novice to Expert Model
-Landmark study of nursing practice by Patricia Benner published in 1984
-Examines the development of clinical nursing skills and expertise along a continuum from Novice to Expert
-Laid the foundation for research on clinical judgment, decision making, transition into practice and new work roles over the last 20 years

-Novice
-Advanced Beginner
-Competent (1-2 years in similar job)
-Proficient (3-5 years with similar patient population)
-Expert
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Stage 1: NOVICE
-NO EXPERIENCE
-Learns objective information
-Breaks tasks into steps
-Knowledge is context free and can be understood without experience
-Practice based on theory, rules, and procedures
-Rules determine action and are inflexible
-Dependent on others with greater experience
-Unable to use discretion in making judgments.
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Stage 2: ADVANCED BEGINNER
-Clinical situations present as a set of tasks that must be completed
-Work is shaped by concern to organize, prioritize, and complete tasks
-Assessment is more of a task than a way to structure care
-Respects and relies on judgment and opinion of more experiences nurses
-Fragmented grasp of patient care needs; tend to focus on physical needs.
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Stage 3: Competent
-Checklist approach sees as inadequate
-Struggles to learn how to read the situation
-Improved time management, efficiency, organization and technical skills
-Ability to anticipate care needs and demands
-Increased diagnostic reasoning with ability to make a clinical case to the physicians
-Ability to alter protocols or standards of care to meet a patient care need
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Stage 4: Proficient
-Increasingly accurate grasp of situations, able to tap into vague sense of unease/intuition
-Actively interprets change in clinical status
-Knows what can wait and what can't wait
-Engage with families and patients in ways that are helpful
-Able to recognize early warning signs of patient deterioration
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Stage 5: EXPERT
-Management of multiple tasks simultaneously with skill and the ability to "think in action"
-Grasp of big picture that goes beyond the immediate clinical situation
-Works to preserve the integrity of a close nurse-patient relationship
-Expert mastery of technology and caring with a prudent view of technology
-May have difficulty explaining why and how they know something
Leininger (Nursing theory)
Cultural congruence in care
-Planning nursing care that is based on knowledge that is culturally defined, classified and tested
-Using creativity to discover cultural aspects of human needs to make culturally congruent therapeutic decisions.
-Healthcare for a diverse society
King (Nursing theory)
-theory of goal attainment.View people is family and social contexts. . 3 interacting systems: personal, interpersonal, social
Leninger- theory of culture care delivery and universality- think of person's culture
What are core concepts that are the focus of nursing science?
THE SCIENCE OF NURSING
-Science is the systematic development of new knowledge based on systematic study (research)
-Nursing science is the study of problems experienced by humans across the health-illness continuum
-The ultimate goal of nursing research is to improve patient/client care and ultimately health outcomes
-Nursing is a 'synthetic' field in that it draws from the basic sciences and social sciences to develop knowledge to understand patient care/health systems problems
-Nursing science changes over time to determine "What is the nature of the knowledge that is needed to practice nursing?"
What are the characteristics of nursing science?
Person-Unique and adaptable; Open to the system; Influenced by genetics and environment; Motivated by needs; Seeks balance
Health -exists on a continuum; dynamic; holistic; affected by health beliefs and behaviors
Environment -Affects well-being; Physical (air, water, food, etc); Nonphysical (family, culture, social structure)
According to the ANA what is the role of the professional nurse in research?
•ANA Code of Ethics Provision 7: " The nurse participates in the advancement of the profession through contributions to practice, education, administration and knowledge development"
•All nurses are CONSUMERS of research. That is, your practice should be based on theory and empirical evidence.
Research Consumer Skills:
-Search the literature and select relevant articles
-Read, Interpret, and Judge the quality of a study/article
-Apply study findings to local practice to close the gap between the state of the science and clinical practice
-Intellectual curiosity and healthy questioning of practice routines
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Nursing Research:
-Systematic investigation of a phenomena related to patient care (pain, temperature regulation, wound healing, emotional distress)
-Stems from clinical observations or problems encountered in practice
-The goal of research is to generate new knowledge about how or why things work
-Research and evidence are the foundation of professional nursing practice
- How do nurses' roles in research vary according to educational level?
STUDENT- Learn about research; do an honors thesis; assist with professors on their work; apply for summer research experience
BSN - Identifies problems that can be studies; assists with data collection, interpretation, and dissemination activities
MSN-Replicates research, able to implement studies
PhD Design and implement studies; develop theory; establish career as an independent researcher
Post-Doctorate- Additional training to build skills to secure external funding (National Institute of Health); Independent researcher
What is evidence-based practice? What is the major goal of evidence-based practice in healthcare?
" An ongoing process by which evidence, nursing theory and the practitioners' clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care of the individual"
(Scott & McSherry, 2008; Integrative definition based on 83 articles)

EBP provides the basis for Nursing Diagnoses
-The formal language of nursing
-Used to identify problems for nursing intervention
-Classified into patient problems, interventions, outcomes
-Structured format enables nursing practice to be:
-Categorized in a consistent fashion
-Captured in documentation systems for PAYMENT and analysis
-Dynamic to identify new care problems for nurses' attention and intervention
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Standardized Nursing Languages:
Provides an Evidence-Based Clinical Decision Support Framework:
•Standardize clinical reasoning terms in your organization as a basis for determining effective care.
•Enable safe clinical judgment through the use of standardized definitions and evidence-based assessment criteria.
•Populate EHR assessments with evidence-based criteria that support effective clinical decision-making.
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Supports Evidence-Based Plans of Care:
•Prioritize key nursing diagnoses for the patient's problem list, and key elements for each patient's plan of care.
•Enable staff to identify patient needs and staff requirements to care for them.
•Monitor patient progress throughout an episode of care.
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Provides Quantitative Measures for Effective Nurse Staffing:
•Evaluate the cost-effectiveness of nursing care.
•Identify opportunities to reduce costs without compromising patient safety.
•Analyze nursing care requirements based on patient acuity.
•Compare nursing care requirements across facilities and departments.
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Provides Quantitative Measures for Staff Evaluation & Training
•Analyze staff clinical reasoning and judgment practices as documented in the Electronic Health Record.
•Identify staff strengths and developmental needs on both an individual and aggregate basis.
•Implement staff training, development and mentoring initiatives and track results.
A. What is the Nursing Intervention Classification System (NIC)? What is the Nursing Outcome Classification (NOC) System?
a. NANDA International (NANDA-I), the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) are comprehensive, research-based, standardized classifications of nursing diagnoses, nursing interventions and nursing-sensitive patient outcomes. These classifications provide a set of terms to describe nursing judgments, treatments and nursing-sensitive patient outcomes.
B. In what ways do the NIC and the NOC contribute to nursing practice?
b. Provides an Evidence-Based Clinical Decision Support Framework:
•Standardize clinical reasoning terms in your organization as a basis for determining effective care.
•Enable safe clinical judgment through the use of standardized definitions and evidence-based assessment criteria.
•Populate EHR assessments with evidence-based criteria that support effective clinical decision-making.
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Supports Evidence-Based Plans of Care:
•Prioritize key nursing diagnoses for the patient's problem list, and key elements for each patient's plan of care.•Enable staff to identify patient needs and staff requirements to care for them.
•Monitor patient progress throughout an episode of care.

Provides Quantitative Measures for Effective Nurse Staffing:
•Evaluate the cost-effectiveness of nursing care.
•Identify opportunities to reduce costs without compromising patient safety.
•Analyze nursing care requirements based on patient acuity.
•Compare nursing care requirements across facilities and departments.
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Provides Quantitative Measures for Staff Evaluation & Training:
•Analyze staff clinical reasoning and judgment practices as documented in the Electronic Health Record.
•Identify staff strengths and developmental needs on both an individual and aggregate basis.
•Implement staff training, development and mentoring initiatives and track results
What are the main components of the Health Belief Model?
a. The health beliefs model, created by Rosenstock (1966,1990) illustrates how people behave in relationship to health maintenance activities. It was created to help determine why some people change their health behaviors and others do not.
It includes 3 components:
i. Evaluation of one's vulnerability to a condition and the seriousness of that condition (e.g. family history)
ii. An evaluation of how effective the health maintenance behavior might be
iii. The presence of a trigger event (or cue to action) that precipitates the health maintenance behavior
WEEK 6
Why is nursing a regulated practice?
Nursing is a regulated profession to ensure that practitioners are competent as a means to protect public safety.
What is the role of the State Board of Nursing?
Typical powers and duties of a Board of Nursing are:
i) Enforcing the Nurse Practice Act and nurse licensure
ii) Accrediting or approving nurse education programs in schools and universities
iii) Developing practice standards
iv) Developing policies, administrative rules and regulations
v) Scope and responsibilities vary state-to-state. Therefore, nurses in the U.S. are responsible for knowing the regulatory requirements for nursing and the nurse practice act in every state that they practice.
How are members of the State Board of Nursing appointed?
In most states, RNs, LPNs, and members of the general public are appointed to the board by the governor.
What is the role of the National Council of State Boards of Nursing?
a) Independent, not for profit which boards of nursing act and counsel together on matters of common interested and concern, including the development of nursing licensure examinations. The council has developed suggested language for the content of state nurse practice acts. They also have created models to guide individual states' development and revisions of their nurse practice acts.
What are nurse practice acts?
a) Because nursing care poses a risk of harm to the public if practiced by professionals who are unprepared or incompetent, the state, through its police powers, is required to protect its citizens from harm. That protection is in the form of reasonable laws to regulate nursing.
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b) Although the specificity of NPAs varies among states, all NPAs include:
i) Authority, power and composition of a board of nursing
ii) Education program standards
iii) Standards and scope of nursing practice
iv) Types of titles and licenses
v) Requirements for licensure
vi) Grounds for disciplinary action, other violations and possible remedies
How are Administrative Rules and Regulations related to nurse practice acts? What areas of practice do the Administrative Rules and Regulations typically address?
Administrative Rules & Regulations are related to nurse practice acts at they:
i) Clarify and further specify the provisions of the Act.
ii) The Rules cannot set requirements that are more stringent than the Act.
iii) The Rules have the force and effect of law.
iv) The Rules and Regulations contain additional specifics for which you are accountable.
(1) Many states spell out the meaning of unprofessional conduct
(2) Expectations and limitations of delegation to others
v) Read the Rules and Regulations of your state's Nurse Practice Act.
vi) You are legally accountable for abiding by these rules.
What are the ANA's standards of professional practice?
STANDARDS OF PRACTICE:
i) Describes a competent level of nursing care demonstrated by the critical thinking model known as the nursing process
ii) The nursing process includes:
(1) Assessment
(2) Diagnosis
(3) Outcomes Identification
(4) Planning
(5) Implementation
(6) Evaluation
iii) The nursing process underpins the significant action taken by the registered nurse
What legal risks are associated with nursing practice?
In particular, delegation, informed consent, and confidentiality are fraught with legal risk. Nurses may also be charged with malpractice or assault and battery.
i) Malpractice- The greatest legal concern of all HCPs - negligence is central issue - not limited to what a nurse does, but limited to what a nurse failed to do.
ii) Delegation- giving someone authority to act for another- caries legal and safety implications- nurses can delegate independent nursing activities to nursing personnel but RNs retain legal accountability for acts delegated to another person. Legal and ethical concerns regarding patient's right to safe, effective nursing care.
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iii) Confidentiality- Both legal and ethical concern- exception to obligation of confidentiality: discussing with others involved in patient care, legally mandated to public health authorities, and information required by third-party payers (insurance companies). Nurses may be ordered by court to share information without patient consent, must report suspected child abuse or neglect, gunshot wounds, certain communicable diseases, and threats to third parties.
Under what conditions are nurses disciplined by the State Board of Nursing?
Disciplinary cases are often grouped into the following categories:
i) Practice-related: breakdowns or errors during aspects of the nursing process
ii) Drug-related: mishandling, misappropriation, or misuse of controlled substances
iii) Boundary violations: nontherapeutic relationships formed between a nurse and a client in which the nurse derives a benefit at the client's expense (NCSBN, 2009)
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iv) Sexual misconduct: inappropriate physical or sexual contact with a client
v) Abuse: maltreatment of clients that is physically, mentally, or emotionally harmful
vi) Fraud: misrepresentation of the truth for gain or profit (usually related to credentials, time, or payment)
vii) Positive criminal background checks: detection of reportable criminal conduct as defined by statute (NCSBN, 2011b, 2012e).
What is the nurse license compact?
Developed by the National Council of State Boards of Nursing, it allows an RN to have one license in the state of resident yet practice in other compact member states without an additional license in the state of employment. The nurse is subject to the state practice act in the state where her or she is practicing (not that where they have licensure). Individual states have to pass legislation enabling the board of nursing to enter into the interstate Nurse Licensure Compact.
What is the nurses role in obtaining informed consent? In protecting the confidentiality of patient information?
a) Informed consent is full, knowing authorization by the patient for care, treatment and procedures and must invlude information about the risks, benefits, side effects costs and alternatives. The role of nurses in informed consent, unless they are primary providers, is to collaborate with the primary provider (most often a physician). A nurse may witness a patient signature of informed consent documents but is NOT responsible for explaining the proposed treatment, but are responsible for determining that the elements for valid consent are in place, providing feedback if the patient wishes to change consent, and communication the patient's need for further information to the provider.
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b) Nurses have a duty to maintain confidentiality and only disclose information pertinent to a patient's treatment and welfare and only to those directly involved in the patient care. The nurse is required by law to report suspected child neglect or abuse (or elder abuse in some states), gunshot wounds, certain communicable diseases and threats towards third parties.
What are the major categories of negligence that result in malpractice lawsuits?
a) Failure to follow standards of care
b) Failure to use equipment in a responsible manner,
c) Failure to communicate (e.g. notifying a physician in a timely manner when conditions warrant it)
d) Failure to document, including failure to note pertinent information in the patient's medical record
e) Failure to assess and monitor
f) Failure to act as a patient advocate (e.g. providing a safe environment)
What are the main characteristics of the Patient Self-Determination Act?
The PSDA applies to acute care and long-term care facilities that received Medicaid and Medicare funding. It focuses on patients' legal and moral rights to informed consent with a focus on a person's right to choose.
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According to PSDA hospitals and long-term care facilities must:
i) Provide written information to all adult patients about their rights under state law
ii) Ensure institutional compliance with state laws on advanced directives
iii) Provide for education of staff and the community on advance directives
iv) Document in the medical record whether the patient has an advanced directive
What is professional liability insurance? Why is it a good idea to have liability insurance policies?
Professional liability insurance protects a nurse's assets and income in case they are required to pay monetary compensation to an injured patient. Policies vary, but generally they provide up to $2 million for a single incident and $4 million total. The amount of coverage depends on the specialty. It is important that nurses have insurance in the event that mistakes are made and a patient is injured.
WEEK 7
What are the major types of errors that occur in healthcare?
a. Medication - prescribing, dispensing, administering
b. Surgery - wrong site
c. Diagnostic inaccuracy - wrong treatment
d. Equipment failure - IV pump
e. Transfusion Error - blood type, wrong patient
f. Laboratory - incorrect labeling
g. System failure - no independent double check
h. Environment - child abduction
What is the difference between technical quality and service quality? How do these apply to healthcare?
a. Technical Quality
i. EBP
ii. Correct diagnosis & treatment plan
iii. Competent providers
iv. Data-based decision making
v. Standardization/care pathways, protocols (i.e. right person at the right time)
vi. Coordinated across providers and units
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b. Service Quality
i. Client centered care
ii. Goal is to surprise and delight customer
iii. Anticipating needs
iv. "Hotel Service"
How does the Institute of Medicine define healthcare quality?
a. Effectiveness
i. Providing care to achieving outcomes that are supported by scientific evidence
b. Efficiency
i. Maximizing the quality of care in proportion to resources
c. Equity
i. Providing quality care to those who differ in personal characteristics other than their clinical condition or care preferences
d. Patient Centered
i. Meets patient needs and preferences. Providing education and support
e. Safety
i. Actual or potential bodily harm
f. Timeliness
i. Obtaining care with minimal delays
What is the role of organizations in quality improvement?
a. Quality improvement is a MANGEMENT philosophy and a way of ORGANISATIONAL functioning
i. Hallmarks of Quality Management Model
1. Ethic of superior performance
2. Teams, teamwork, and emphasis on engaging ALL employees to contribute
3. Statistical analysis to guide continuous improvement efforts
4. Leadership at all levels of organization
5. Systems approach with focus on identifying and managing key processes
How do teams and teamwork relate to quality improvement?
Team: a small number of people with complementary skills that are committed to a common purpose, for which they hold themselves mutually accountable.
Describe the components of the G-R-P-I model of high performing teams (see team workshop slides).
G-R-P-I:
¥ GOALS
▫ Do we have clear purpose and clear performance goals?
▫ Are they shared and committed to by all team members?
¥ ROLES
▫ Are we clear on responsibilities?
▫ Is the work clearly organised and roles/tasks clarified?
▫ Is the leadership in this team shared?
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¥ PROCESSES
▫ Is this team able to problem solve? Do we apply sufficient creativity to our work?
▫ Is communication fluid and open to all?
▫ Are decisions made on the basis of competence and information?
▫ Do we address conflicts openly and constructively, and are we able to resolve them?
▫ Do we regularly review our team's processes and are we able to improve them?
¥ INTERPERSONAL
▫ Do we trust each other; do we take time to review each other's well being in the team?
▫ Are we sensitive to others?
Describe the characteristics of the quality improvement models commonly used in healthcare organizations (TQM/CQI; Six Sigma; Lean; Clinical Microsystems; Donabedian's Structure, Process, Outcome model)

TQM/CQI:
a. TQM/CQI (Total Quality Management/Continuous Quality Improvement):
i. Holistic approach
ii. Focuses on understanding and managing variation
iii. Emphasis on customer satisfaction
iv. Based on teams and teamwork
SIX SIGMA:
b. Six Sigma
i. Developed at Motorola in the 80's
ii. Six Sigma = Statistical notation used to measure variation from the mean
iii. Focuses on eliminating errors and reducing variations
iv. Goal in manufacturing is to have 3.4 defects per 1 million units
v. Practitioners achieve levels of mastery for statistic skills designated by belts (yellow, green, black)
LEAN:
c. Lean
i. Developed at Toyota
ii. Production is controlled by standardization and placing the right person and materials at each step of the process
iii. Uses the Plan-Do-Study-Act improvement cycle
iv. Performance measures vary from project to project. May inform new performance measures
v. Uses a master teacher
CLINICAL MICROSYSTEMS:
d. Clinical Microsystems
i. Based on Model of Service Excellence by Quinn
ii. Microsystem is the smallest replicable unit of service
1. Example: Orthopedic unit might have a total knee microsystem, a total hip microsystem, ect
iii. Members of the microsystem are interdependent and work together
iv. Improvement work uses Plan-So-Study-Act cycles and other QI display tools.
Donabedian's Structure, Process, & Outcomes:
e. Donabedian's Structure, Process, & Outcomes
i. Structure - Factors that affect the context in which care is delivered
1. Physical facility
2. Equipment
3. Human resources
4. Staff training
5. Payment methods
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ii. Process - sum of all actions that make up healthcare
1. Diagnosis
2. Treatment
3. Preventative care
4. Patient education
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iii. Outcomes - effects of healthcare on patients or populations
1. Changes to health status
2. Behavior
3. Knowledge
4. Patient satisfaction
5. Health related quality of life
What is the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Services) survey? How is it used to measure the quality of healthcare?
Survey given to patients to get their perspective on
i. Communication with doctors
ii. Communication with nurses
iii. responsiveness of hospital staff
iv. pain management
v. communication about medicines
vi. discharge information
vii. cleanliness of the hospital environment
viii. quietness of the hospital environment
ix. transition of care
What are the 2014 National Patient Safety goals for acute care settings?
a. Use at least two patient identifiers when providing care, treatment, and services.
b. Eliminate transfusion errors related to patient misidentification.
c. Report critical results of tests and diagnostic procedures on a timely basis
d. Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.
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e. Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
f. Maintain and communicate accurate patient medication information
g. Reduce the harm associated with clinical alarm systems
h. Reduce the risk of health care associated infections.
i. The hospital identifies safety risks inherent in its patient population.
1. Which agency is responsible for administering the National Patient Safety goals?
The Joint Commission
What is the difference between safety and quality in the delivery of healthcare services?
a. Safety
i. Design of the system
ii. Focuses on reducing errors, near misses and harm to the patient
iii. Takes human error into account and works to identify the root cause
iv. Cultural component - mindfulness in working and the ability of employees to speak up
v. Incident reporting
vi. Goal is to design the error out of the system
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b. Quality
i. Focuses on managing variation in the system and reducing it
ii. Plan-Do-Study-Act
iii. Quality improvement teams
Describe the nurse-sensitive quality indicators. Which agency is responsible for developing and administering the nurse-sensitive quality indicators?
a. Nurse-sensitive quality indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction
b. The National Database of Nursing Quality Indicators (NDNQI)
What is the role of nurses in improving quality and safety of healthcare?
a. As the demand for quality improvement increases so does the role of nurses
b. Nurses are the largest deliverer of Health care in the US
c. Nurses have been said to be
i. The heart and soul of the hospital
ii. The eyes and ears of the hospital
d. They spend the most time with the patients
e. They are in the best position to affect care patients receive while in the hospital
What is care coordination? Why are nurses well qualified to coordinate care across settings and episodes? In what ways does the nursing profession contribute to quality care through effective coordination and transition management?
a. Care coordination - function used to organize work and build relationships in teams
i. Patients are most vulnerable during transitions between services and levels of care
b. Nurses are well qualified to coordinate care because they have the most contact with the patient, they have traditionally been responsible for this, and they interact with all the disciplines
What are the nursing practice competencies in the Care Coordination and Transition Management Model?
a. Support for self-management
i. Enhance health literacy
b. Advocacy
i. Negotiate and secure patient services
ii. Coach patient in self-advocacy
c. Education and engagement of patient and family
i. Assess readiness to learn/learning styles
d. Cross setting communicating and transition
i. Coordination/collaboration between specialty and primary providers who develop and share the Patient Care Plan across settings
e. Coaching and counseling of patients and families
i. Answer questions patients/families have before and after provider visit
What barriers do nurses face in participating in quality improvement initiatives?
a. Lack of understanding of each group's knowledge, skills, abilities, culture, and values
b. Different goals of individuals and team members; weal team processes for communication, conflict resolution, decision making
c. Variations in autonomy, authority, scope of practice, power. Expertise, and incomes among professional groups.
d. Team not comprised of the appropriate members; too large or too small
e. Perceptions about the need for cooperation for patient -centered care
f. Financial and regulatory constraints; different reimbursement structures for different professions
1. What are the components of Tanner's Thinking Like a Nurse Model? Why is this an important model for nursing practice and education?
My summary points of the article:
• Clinical judgment is complex and based on many components (ie. experience)
• Model: notice, interpret, act/respond, reflect
• Reflection is an important step in going from novice to expert; it enables a bigger memory bank to draw upon to make clinical judgments
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• Clinical reasoning is very important in situations that are new, vague, etc.; You must consider the pathophysiological, diagnostic, patient and patient's family in the decision-making process
1. Through experience, nurses can respond instinctively
2. Personal biases are different than applicable professional experiences
3. Know your patient and their typical responses to best determine the best care plan
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• Variety of reasoning Patterns used alone or in combination
1. Analytic Processes
a. Break it down into elements
b. Often a mismatch between what is expected and what actually happens
2. Intuition
3. Narrative thinking
a. Paradigmatic thinking: considers a situation in relation to an instance of a general type—not very personalized
b. Narrative thinking promotes individualized care plans that incorporates many different individual patient components
c. Important in reflection process; learn better from experiences this way
How are Tanner's Thinking Like a Nurse Model and Benner's Novice to Expert Model related?
Both theories emphasize the importance and value in what nurses bring to the bedside based on past experiences. In both theories it is considered important to move beyond the existing clinical protocols/guidelines/templet-like examples and incorporate instinct and experience into work.
*For your reference, Pg 13 Benner's Novice to Expert Model*
What factors influence nurses' clinical judgment?
• Clinical Judgment: informed opinions and decisions based on:
1. Empirical knowledge
2. Experience
• Clinical judgment is developed gradually
1. Extensive direct patient contact is the best means of developing
• Factors that influence
1. Critical thinking
2. Clinical reasoning
3. Identifying patterns (ie. in patient behaviors)
4. Recalling facts
5. Knowing the limitations of your expertise
a.Seek consultation with professionals as needed
• Nine Key questions to consider when developing personal clinical judgment:
1. Define the expected outcomes
2. Define the issues at hand -- prioritize
3. Define the circumstances - ie. urgency
4. Know the problem-specific facts necessary in treating patients
5. Determine how much room there is for error
6. How much time do you have?
7. What resources do you have to help? (ie. human resources, nurse faculty, physical therapists, etc.)
What is the nursing process? What are the phases of the nursing process? How is the nursing process related to nurses' scope of practice?

• The Nursing Process:
1. Provides a framework for nursing practice
2. Used to identify patient needs, priorities of care
3. Patient centered
4. Goal oriented
5. Purpose: to resolve actual or potential problems the patient has.
6. Deals with human responses to illness and health
There are five phases to the nursing process:

Phase I: Assessment
1. Gather data from patient and family
2. Data includes: physiological, psychological, sociocultural, developmental, spiritual, environmental; financial limitations considered too
• Types of data to gather
a. Subjective
b. Objective
• Patient is the BEST source of info
3. Set the mood
4. 3 parts
• Interview
• Assessment
a. Physical exam
• Consultation
a. Utlizing other professionals to determine action
Phase II: Analysis and Identification of the problem
1. Data must be validated and compared to norms
2. Identify any patterns
3. ID medical diagnosis and determine nursing diagnosis
• Prioritize your nursing diagnoses
• ND should be written in collaboration with the patient
Phase three: Planning
1. Determine ways to reach the goal
2. Goals are used by the patient and nurse
• Patient goals should be written with the patient as the focus of action (ie. "Patient will be able to")
• Make the goals measurable!
a. Short term goals: within hours or days
b. Long term goals: usually represent major changes or rehabilitation
• Make sure goals are culturally congruent
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3. Nursing Orders: actions designed to assist the patient in achieving a stated goal
4. Nursing Interventions:
• Independent interventions: interventions for which the nurse needs no supervision or direction from others
• Dependent Interventions: require instructions, written orders or supervision of another health professional with prescriptive authority
• Interdependent Interventions: actions in which the nurse must collaborate or consult with another health professional before carrying out the action
• Protocols: define under what conditions and circumstances a nurse is allowed to treat the patient and what treatments are permissible
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5. Write the plan of care
• Critical paths: care tracks or care maps; multidisciplinary; facilitates communication and collaboration among all members of the health care team
Phase IV: Implementation of Planned Interventions
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Phase Five: Evaluation
May indicate need for change in care plan
How is the nursing process related to quality of care?
• The formal language of nursing
• Used to organize data and guide appropriate action
• Foundation for nursing care quality and clinical excellence
• Research demonstrates that the extent to which individual nurses use the nursing process and care systems promote the use of care planning, the less missed nursing care and the better the patient outcomes (Lucero, et al. 2009)
What are the similarities and differences between medical diagnoses, nursing diagnoses and collaborative diagnoses?
Medical diagnosis:
The identification of a disease condition based on specific evaluation of signs and symptoms
Nursing diagnosis:
A clinical judgment about the client in response to an actual or potential health problem
Collaborative problem:
An actual or potential complication that nurses monitor to detect a change in client status
What are Magnet hospitals?
• Magnet Hospitals were first founded in 1983 when there was a shortage of nurses
1. They actually interviewed CNEs (Chief Nurse Executives) and SNs (Staff Nurses) to identify the structures, characteristics, and attributes that their hospitals and nursing departments upheld (the chosen hospitals were based on being considered a "good places to work")
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• These hospitals are recognized by the ANCC (American Nurses Credentialing Center) "to recognize health care organizations that provide the very best in nursing care and uphold the tradition of professional nursing practice"
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• Achieving this status is a way to continue the growth of and respect for the nursing field
1. Recognizes caliber of nurses
• "Nurse Friendly"
1. Low turn-over rate
2. Provide opportunities for professional growth and development
How do hospitals become designated as a Magnet Hospital?
• The Magnet Recognition Program
1. Magnet Recognition program is run by the American Nurses Credentialing Center (ANCC), a branch of the ANA.
2. Number of magnet certified hospitals = 403
3. Total number of hospitals in U.S 5,723
4. Cost to become a Magnet Hospital
5. 100 or fewer beds= $13,750
6. 500-749 beds =$45,280
7. 950 + beds= $57,850
8. + Report review fee of $2,500/lead + $2,00/team member
9. + $1,850 per day/reviewer
What are the organizational characteristics that support clinical nursing excellence?
• Career ladders
• Education of workforce
• Shared governance councils/control over practice
• Structural empowerment -access to information and resources
• Staffing levels
• Use of nursing process, evidence based practice, quality improvement
What is a professional practice model? What is shared governance?
• This question is about the Erikson Article: "Professional Practice Model: Strategies for Translating Models into Practice"
• This article is about the creation of a model to clearly articulate the contributions nurses make
• In 1996 MGH (Massachusetts General Hospital) articulated and carried out a "professional practice model" that still had patient at the center of the care but also emphasized other components of care such as relationship preservation with the clinician.
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• Components:
1. Standards of care defined were: highest quality care, teaching tools and how to use stands to customize are
2. Collaborative Decision Making
a. Collaborative Governance
• "The decision-making process that places the authority, responsibility, and accountability for patient care with the practicing clinician and create an opportunity to look at the contributions of each discipline and integrate them into patient delivery system."
• "A celebration of each discipline's contributions"
• "...built on the premises of teamwork and team learning" - creating effective groups
b. Empower each individual
c. Teamwork/ team learning
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3. Professional Development
a. Encourage educational and leadership advancement
4. Patient delivery Model
a. Patient-centered
b. Cost-effective
c. Highest Quality Care
5. Public Trust
6. Research
a. Translates academic knowledge into practice
7. Theme-Based Practice
a. Important to know and understand themes behind practice

• In 2006 they added ONE new component
1. Narrative Culture
a. Determined that narrative thinking was useful/critical in analyzing care and learning from experience
14 FORCES OF MAGNETISM:
These are the qualities listed by the ANCC as the qualities that
1: Quality of Nursing Leadership
8: Consultation & Resources
2: Organizational Structure
9: Autonomy
3: Management Style
10: Community & Health Care Organization
4: Personnel Policies & Programs
11: Nurses as Teachers
5: Professional Models of Care
12: Image of Nursing
6: Quality of Care
13: Interdisciplinary Relationships
7: Quality Improvement
14: Professional Development
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The original Magnet® research study conducted in 1983 identified 14 characteristics that differentiated organizations best able to recruit and retain nurses during the nursing shortages of the 1970s and 1980s. These characteristics remain known as the ANCC Forces of Magnetism that provide the conceptual framework for the Magnet appraisal process.
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Described as the heart of the Magnet Recognition Program®, the Forces of Magnetism are attributes or outcomes that exemplify nursing excellence. The full expression of the Forces of Magnetism is required to achieve Magnet designation and embodies a professional environment guided by a strong and visionary nursing leader who advocates and supports excellence in nursing practice.
Force 1: Quality of Nursing Leadership
Knowledgeable, strong, risk-taking nurse leaders follow a well-articulated, strategic and visionary philosophy in the day-to-day operations of nursing services. Nursing leaders, at all organizational levels, convey a strong sense of advocacy and support for the staff and for the patient. The results of quality leadership are evident in nursing practice at the patient's side.
Force 2: Organizational Structure
Organizational structures are generally flat, rather than tall, and decentralized decision-making prevails. The organizational structure is dynamic and responsive to change. Strong nursing representation is evident in the organizational committee structure. Executive-level nursing leaders serve at the executive level of the organization. The Chief Nursing Officer typically reports directly to the Chief Executive Officer. The organization has a functioning and productive system of shared decision-making.
Force 3: Management Style
Health care organization and nursing leaders create an environment supporting participation. Feedback is encouraged, valued and incorporated from the staff at all levels. Nurses serving in leadership positions are visible, accessible and committed to effective communication.
Force 4: Personnel Policies and Programs
Salaries and benefits are competitive. Creative and flexible staffing models that support a safe and healthy work environment are used. Personnel policies are created with direct care nurse involvement. Significant opportunities for professional growth exist in administrative and clinical tracks. Personnel policies and programs support professional nursing practice, work/life balance, and the delivery of quality care.
Force 5: Professional Models of Care
There are models of care that give nurses responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practice as well as the coordination of care. The models of care (i.e., primary nursing, case management, family-centered, district, and holistic) provide for the continuity of care across the continuum. The models take into consideration patients' unique needs and provide skilled nurses and adequate resources to accomplish desired outcomes.
Force 6: Quality of Care
Quality is the systematic driving force for nursing and the organization. Nurses serving in leadership positions are responsible for providing an environment that positively influences patient outcomes. There is a pervasive perception among nurses that they provide high quality care to patients.
Force 7: Quality Improvement
The organization possesses structures and processes for the measurement of quality and programs for improving the quality of care and services within the organization.
Force 8: Consultation and Resources
The health care organization provides adequate resources, support and opportunities for the utilization of experts, particularly advanced practice nurses. The organization promotes involvement of nurses in professional organizations and among peers in the community.
Force 9: Autonomy
Autonomous nursing care is the ability of a nurse to assess and provide nursing actions as appropriate for patient care based on competence, professional expertise and knowledge. The nurse is expected to practice autonomously, consistent with professional standards. Independent judgment is expected within the context of interdisciplinary and multidisciplinary approaches to patient/resident/client care.
Force 10: Community and the Health Care Organization
Relationships are established within and among all types of health care organizations and other community organizations, to develop strong partnerships that support improved client outcomes and the health of the communities they serve.
Force 11: Nurses as Teachers
Professional nurses are involved in educational activities within the organization and community. Students from a variety of academic programs are welcomed and supported in the organization; contractual arrangements are mutually beneficial.
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There is a development and mentoring program for staff preceptors for all levels of students (including students, new graduates, experienced nurses, etc.). In all positions, staff serve as faculty and preceptors for students from a variety of academic programs. There is a patient education program that meets the diverse needs of patients in all of the care settings of the organization.
Force 12: Image of Nursing
The services provided by nurses are characterized as essential by other members of the health care team. Nurses are viewed as integral to the health care organization's ability to provide patient care. Nursing effectively influences system-wide processes.
Force 13: Interdisciplinary Relationships
Collaborative working relationships within and among the disciplines are valued. Mutual respect is based on the premise that all members of the health care team make essential and meaningful contributions in the achievement of clinical outcomes. Conflict management strategies are in place and are used effectively, when indicated.
Force 14: Professional Development
The health care organization values and supports the personal and professional growth and development of staff. In addition to quality orientation and in-service education addressed earlier in Force 11, Nurses as Teachers, emphasis is placed on career development services. Programs that promote formal education, professional certification, and career development are evident. Competency-based clinical and leadership/management development is promoted and adequate human and fiscal resources for all professional development programs are provided.
1. What characteristics do effective critical thinkers demonstrate?
¥ Inquisitive/curious/seeks out new information
¥ Self-informed/finds answers
¥ Analytic and confident in reasoning skills
¥ Open-minded
¥ Flexible
¥ Fair-minded
¥ Persistent
¥ Reasonable
¥ Honest about biases/self-aware
¥ Prudent/exercise sound judgment
¥ Willing to revise judgment in the face of new information
¥ Clear about issues
¥ Organized approach to problem solving
¥ Diligent in seeking information
WEEK 9
What are the core elements of patient-centered care?
• Incorporation of health promotion and self-care.
• Being realistic about what can be achieved. Why?
• Seeing the patient as a person.
• Sharing power and responsibility.
• Working to maintain the therapeutic relationship or alliance.
• Respecting patient choice.
• Effective communication.
• Respect for patients.
• Coordination of care.
• Integration of care.
• Information.
• Physical Comfort
• Emotional comfort/alleviation of fears and anxiety
• Involvement of family and friends
• Transition and continuity
• Finding common ground
• Communication
In what ways does culture influence patient-centered care?
• Reflective Practice
1. Understanding stereotypes
2. Non-judgmental acceptance
• Role expectations
1. Sometimes patients will have different views of medicine and different views of your role as a nurse; you have to be flexible in the role you play and the role you expect to perform for different patients depending on their beliefs and expectations of you... ?? Sorry, I tried.
2. Culture dictates care.
• Ethnocentrism
1. Judging another culture solely by the values and standards of one's own culture
• Influences and individual experience.
1. Gives meaning to illness.
2. Some patients consider illness as a punishment ... for example.
• Influences patterns of communication.
1. Personal space
2. Values
What are the attributes of a clinician who practices patient-centered care?
• Being polite
• Good etiquette
• Good manners
• A cohesive team of professionals
• Being respectful
• Sensitive
• Being welcoming
What are the systems barriers that impede the delivery of patient-centered care?
• Not having a translator available or nurses not utilizing translators can limit the understanding between patient and provider—providing a disservice to both parties (BOOK)
• Kitson Article
• Kitson Article
The System - Issues—from Kitson article:
1. Lack of time, staff, equipment
2. Deeper philosophical issues such as the tension between a person-centered approach and a more reductionist approach to healthcare delivery.

FYI, I thought this was an interesting quote from the article: "nursing articles tend to accentuate respecting patients' values and beliefs in promoting PCC while more medical attention has been devoted to understanding the nature of the informed decision-making process between the doctor and the patient."
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3. From class power-points:
• PCC and participation and patient involvement
1. What needs to take place?
2. Customized care
3. Patient needs are anticipated
4. Co-ordination and integration of care
5. Transition and continuity of care
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• PCC and the context of care
a. The System - Issues
1. Policy practice continuum/language used
2. Translating policy into practice
3. Patient rights and responsibility
4. Evidence based care
5. Patient safety issues
6. Access
7. Barriers to PCC
8. Supportive organizational system
9. Therapeutic environment
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b. DESPARATE FOCI
1. Nursing focuses on wider system, patients' values and beliefs.
2. Medicine focuses on the informed decision-making between physician and patient (see quote above).
3. Areas of less agreement across professional groups:
i. Personal attribute of the patient centered-professional.
ii. Creating a cohesive and cooperative team of professionals.
iii. Getting the language right around PCC for patients, professionals, and policy makes.
iv. Consistently addressing wider systems issues.
What are the phases of the nurse-patient relationship?
• Orientation Phase
I. Introductory phase
• Orientation Phase
• Getting to know someone
• Discovering commonalities
• There must be trust between two parties for the relationship to develop
• Nurses cannot expect parties to trust them automatically and to personal details. • personal details.
• Each party assesses the other.
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• Tasks of this phase
A. Patient and nurse develop trust to carry out work.
a. How to develop trust
1. Being non-defensive
2. Straightforward
3. Answering all questions as fully as possible
4. Willingness to find the answer
5. Following through
6. Active listening
7. Accept patient thoughts without passing judgment.
8. Avoiding platitudes and clichés
9. Avoid being dismissive.
10. Congruence between verbal and nonverbal communication.
B. Both see each other as individuals.
C. Agreement on working together.
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II. Working Phase:
• A degree of comfort in the relationship
• Periods of intense effort alternating with resistance
• Idealization to realism
• Meeting of expectations
• Resistance
• Stagnation or slowing
• Working Alliance:
1. Based on Rogers
2. Congruence
3. Empathy
4. Positive regard
5. Interpersonal approaches do affect a patient-clinician relationship
6. Any helping relationship requires collaboration
7. Tasks, Bonds, and Goals
8. Varies in degrees of willingness to collaborate, agreement, and task involvement.
9. Each has his/her own responsibility
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III. Termination Phase
• Ending the relationship
• Begins at orientation
• May continue indefinitely
• Involves positive and negative feelings
• Mixed emotions
• Maintaining professional and social boundaries
What are the differences between privacy and confidentiality in the delivery of patient care?
• Confidentiality:
1. Safeguarding patient information
2. Information that may only be disclosed to other members of the health care team for healthcare purposes.
3. Confidential information should be shared only with the patient's informed consent.
4. When legally required.
5. Or when failure to disclose the information could result in significant harm.
6. The nurse's obligation is universal.
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• Privacy:
1. Relates to the patient's right to be treated with respect and dignity
2. Build on trust
3. Disclosure of personal and sensitive information
4. "Need to know"
• Many times patients will let you in on personal information that has nothing to do with their direct care. There is an understanding and an expectation that these things will be kept between you and the patient and that the patient has put trust in you. To tell others about this would be a breach of this delicate relationship that is very hard to recover when lost.
5. How information will be used.
6. De-identification of information.
7. Enough information that leads someone to believe the information could be used to identify an individual.
8. Health Insurance Portability and Accountability Act (HIPAA).
What is the role of professional boundaries in the nurse-patient relationship?
• Where there is a power differential or a vulnerability there is a boundary
• Requires self-awareness
1. Personal weakness and strengths
2. Ego integrity
3. Reference of self
4. Personal boundaries
5. Personality type
6. Your own boundaries
How would you know if you breached a professional boundary when working with a client?
• The nurse is responsible for delineating and maintaining boundaries
• Nurse needs to examine any boundary crossing, it's implications, and avoid repeating
• The nature of the work affects the boundaries
• Avoid duel relationships
1. Does it meet the needs of the nurse or the patient?
What are the benefits for nurses in using social media?
• Professional connections
• Promotes timely communication
• Education
• Journaling/reflective practice
• Engage in helpful activities
What are the pitfalls for nurses in using social media?
• Inappropriate use can be reported to the Board of Nursing (BON)
• Lose license
In what ways can you be disciplined by the Board of Nursing for the inappropriate use of social media?
• Reprimand
• Sanction
• Censure - letter of concern
• Placing conditions on nurse's license
• Suspension of license
1. Violation of State and Federal Law
• Civil and criminal penalties
• Fines and possible jail time
• Personal liability
• Nurse may be individually sued for defamation, invasion of privacy, or harassment
What are the major principles associated with using social media as a professional nurse?
• Nurses have a legal obligation to maintain patient privacy
• Nurses are prohibited from transmitting any patient image
• Nurses are restricted from transmitting and information that may violate patient's rights to privacy
• Don't share or post anything about patients
• Don't refer to patients in disparaging ways
• Maintain boundaries
• Beware of who your personal contacts are
What are the principles of effective therapeutic communication?
• Eye contact
• Hand gestures
• Face to face
• Discover commonalities
• Understand that trust will not come automatically you must work for it
1. Developing trust
• Being non-defensive
• Straightforward
• Answering all questions as fully as possible
• Willingness to find the answer
• Follow through
• Active listening
• Accept patient's thoughts without judgment
• Avoiding being dismissive
• Congruence between verbal and non verbal communication
WEEK 10
What are the main characteristics of the ethical theories used to analyze healthcare issues in the United States?
o Deontology:
♣ Immanuel Kant (1724-1804) believed that an act was moral if its motives or intentions were good regardless of the outcome
♣ Ethical action consists of doing one's duty or honoring one's obligations to human beings
♣ Example:
• A nursing student is asked by her dying patient to call his estranged son, but the estranged son tells her that he's glad his father is dying
• The nursing student acted in an ethical manner because she fulfilled her duty by responding to her patient's request despite the outcome
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♣ Deontology can be divided into two subtypes:
• 1. Act deontology
o In order to determine the right thing to do all facts are gathered prior to making a decision
o Time and energy are required to evaluate each situation and once a decision is made, it must be universalized (if a moral judgment is made in one situation, it must be made in similar situations)
• 2. Rule deontology
o Principles guide actions (ex: "never tell a lie")
o The rule is to be followed in all situations
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o Utilitarianism:
♣ David Hume (1711-1776), Jeremy Bentham (1748-1832), John Stuart Mill (1806-1873)
♣ Based on the fundamental belief that the moral rightness of an action is determined solely by its consequence
♣ "What makes an action right or wrong is its utility, with useful actions bringing about the greatest good for the greatest number of people"
♣ Deals with balancing good and evil with the assumption that most people experience good rather than evil
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♣ Example:
• Triage
o The sick/injured are classified by the severity of their condition to determine priority of treatment
o Someone must make the decision as to who will and will not be treated
• How health care dollars are spent
o Orphan diseases
♣ Money is more likely to be spent on research for diseases that affect large numbers of people than for research on diseases that affect relatively few
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o Virtue Ethics:
♣ Plato, Aristotle, and early Christians
♣ Virtues are tendencies to act, feel, and judge and are developed through appropriate training but arise from natural tendencies - Aristotle
• An individual's actions are to some degree inborn innate moral virtues
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♣ Virtues are specific character traits such as:
• Truth telling, honesty, courage, respectfulness, kindness, fairness, compassion, integrity, etc.
♣ Virtues become noticeable through an individual's actions and are expressions of specific ethical principles (e.g., truthfulness embodies veracity)
♣ Virtuous people will instinctively choose to do the right thing when faced with a problem or dilemma because through life experiences they have developed character
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o Principalism:
♣ Uses key ethical principles of beneficence, nonmaleficence, autonomy, and justice in the resolution of ethical problems or dilemmas
♣ Fidelity and veracity are also important
• What are the main principles used to promote human dignity in the context of healthcare delivery?
• Human dignity and respect for persons are the foundation of the six ethical principles of autonomy, beneficence, non-maleficence, justice, fidelity, and veracity
1. Autonomy—autonomous decisions are based on individuals' values, adequate information, freedom from coercion, and reason and deliberation
2. Beneficence—"the doing of good"; nurses should always consider one's actions in the context of the patient's life and situation
3. Non-maleficence—the duty to do no harm; the foundation of the medical profession's Hippocratic Oath and is likewise critical to the nursing profession
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4. Justice—patients with the same diagnosis and health care needs should receive the same care, and those with greater or lesser needs should receive the care appropriate to their needs
♣ Models for distributing health care resources include:
• To each equally
• To each according to merit (this may include past or future contributions to society)
• To each according to what can be acquired in the marketplace
• To each according to need
5. Fidelity—faithfulness or honoring one's commitments or promises (for nurses specifically to patients); entails meeting reasonable expectations in the areas of nursing practice, nursing skills, keeping promises to patients, and abiding by employer's policies
6. Veracity—telling the truth or not lying; inherent nurse-patient relationships is the understanding that nurses will be honest with their patients
What is the ANA Code of Ethics?
o A code of ethics is a social contract through which the profession informs society of the principles and rules by which it functions
♣ A written, public document that reminds practitioners and the public they serve of the specific responsibilities and obligations accepted by the profession's practitioners
o Ethical codes shape professional self-regulation, serving as guidelines to the members of the profession
o 2001 - Code of Ethics for Nurses with Interpretive Statements
♣ The latest version of nursing's ethical code
♣ The nursing profession's expression of its ethical values and duties to the public
What are the provisions of the Code of Ethics?
♣ Provision 1.
• The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
♣ Provision 2.
• The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
♣ Provision 3.
• The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
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♣ Provision 4.
• The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.
♣ Provision 5.
• The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
♣ Provision 6.
• The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conductive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
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♣ Provision 7.
• The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
♣ Provision 8.
• The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
♣ Provision 9.
• The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
What are some common ethical dilemmas that nurses face?
o What information to share with patients
o How to manage and deal with colleagues professionally
o How to resolve problems when desires and needs of patients conflict with institutional policy
o End of life decisions
o Allocating care in emergency situations
o Advocating when nurse does not agree with the patient
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o Professional ethics vs. personal ethics
♣ Example: work situation where the two are not in conflict
o Dilemmas resulting from personal value systems
o Dilemmas involving peers' and other professionals' behavior
o Dilemmas regarding patients' rights
o Dilemmas caused by patient data access issues
o Dilemmas created by institutional and social issues
o Ethical issues related to immigration and migration
What is moral distress? Why are nurses prone to experiencing moral distress?
o Moral distress:
♣ Pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; however, as a result of real or perceived constraints, the person participates in perceived moral wrongdoing
♣ Occurs when personal values are in conflict with professional values
♣ When a person (nurse) is faced with a professional situation that has elements that do not align with their moral code or values
o Nurses are prone to experiencing moral distress because they may face ethical dilemmas but also encounter institutional constraints that limit their actions
Describe the stages of moral reasoning developed by Kohlberg. In what ways are they similar? In what ways are they different?
o Kohlberg's Stages of Moral Reasoning:
♣ Three levels of moral reasoning as a function of cognitive development
♣ 1. Preconventional
• Individual is inattentive to the norms of society when responding to moral problems
• Individual's perspective is self-centered
• What the individual wants or needs takes precedence over right or wrong
• Stage 1:
o Individual responds to punishment
• Stage 2:
o Individual responds to the prospect of reward
• Observed in children younger than age 9, some adolescents, and adult criminal offenders
• Example: a two year old who has yet to learn the meaning of "no"
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♣ 2. Conventional
• Characterized by moral decisions that conform to the expectations of one's family, group, or society
• Stage 3:
o Person makes moral choices based on what is pleasing to others
• Stage 4:
o Individual makes moral choices based on a larger notion of what is desired by society
• Individual follows family or cultural group norms when confronted with a moral choice
• Most adolescents and adults function at the conventional level
• Example: "because it's the law"
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♣ 3. Postconventional
• Consists of stages 5 and 6
• Involves more independent thinking
• A person has developed the ability to define their own moral values
• Individual may ignore self-interest and group norms when making moral decisions
• People create their own morality
• Only a minority of adults reach this level
Describe the stages of moral reasoning developed by Gilligan.In what ways are they similar? In what ways are they different?
o Gilligan's Stages of Moral Reasoning:
♣ The moral person is one who responds to need and shows a consideration of care and responsibility in relationships
♣ 1. Orientation to individual survival (preconventional)
♣ 2. A focus on goodness with recognition of self-sacrifice (conventional)
♣ 3. The morality of caring and being responsible for others as well as self (postconventional)
Kohlberg's and Gilligan's Stages= In what ways are they similar? In what ways are they different?
Kohlberg's Stages of Moral Reasoning
• Stages are sequential and build on one another
• Each stage is characterized by a higher capacity for moral reasoning
• Individuals at higher levels intellectually usually operate at a higher stage of moral reasoning
• Orientation toward justice
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Gilligan's Stages of Moral Reasoning
• Concerned that Kohlberg did not adequately recognize women's experiences in the development of moral reasoning
• Girl's and women's relational orientation to the world shaped their moral reasoning differently from that of boys and men
• Described a moral development perspective focused on care
• Each level (stage) represents a more complex understanding of the relationship between self and others
What is the current state of palliative and end of life care in the United States?
o Palliative care programs are growing and becoming more popular in U.S. hospitals (70% of large hospitals report the presence of a program)
o There is a greater understanding of hospice and palliative care in society
o More patients are opting for palliative care earlier in their illness
o Although hospice and palliative care services are gaining momentum, there is still disparity in access geographically
o There is also a disparity in what types of care patients receive in hospitals
o Medicare is highly influential in end-of-life care
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o Hospice patients are no longer just cancer patients, but also now include chronic conditions
♣ Hospices are increasingly used by people with noncancerous diagnoses
o There still remains uneasiness or unwillingness to discuss end-of-life issues/care
o The unique needs of the terminally ill remain poorly addressed in the U.S. health care system
o Often the care provided is not the care the patient and family choose, desire, or understand
o Results of the SUPPORT study indicate that many critically ill patients do not want aggressive life-prolonging care
Describe regional disparities in palliative and end of life care in the United States.
o Type of care patients receive at the end of their life depends and varies according to where they live and what facility they are a patient in
o In some western and northwestern states, Medicare beneficiaries had a less than 20% change of dying in a hospital
o Medicare beneficiaries in southern and eastern states have a 50% chance or greater of dying in a hospital
What is the difference between palliative and end of life care? What clients are candidates for these services?
o Palliative care:
♣ Comprehensive treatment of the discomfort, symptoms, and stress of serious illness regardless of diagnosis
♣ A resource for anyone with a long-term chronic disease that may, in time, cause death
♣ Provided in any setting, including hospitals, nursing homes, outpatient palliative care clinics, other specialized clinics, or at home
♣ World health Organization (WHO): an approach that improves quality of life for patients and their families facing the problems associated with life-threatening illness, through the prevention and relieve of suffering by means of early identification and impeccable assessment and treatment of problems, including physical, psychosocial, and spiritual.
♣ Ideally palliative care would segue into hospice care (end of life care)
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o Hospice care:
♣ Like palliative care, hospice provides comprehensive comfort care to the dying person as well as support to his or her family
♣ Attempts to cure the person's illness are stopped
♣ The goal of hospice is to relieve symptoms
What are the obstacles for effective end of life care?
o Lack of comfort levels from nurses when it comes to discussing end-of-life care or treatment options with patients
o Fear of confrontation and bad news
o Not all practitioners are competent
o Access to end-of-life care services
♣ Awareness of palliative and hospice services
♣ Payment and financial coverage
o The predominant culture is biomedical where death is seen as a failure
o Expired or unavailable documents
o Discomfort with the discussion
o Lack of skill set for talking about palliative care
o Payment and financial coverage for palliative and hospice benefits
o Poor compliance with Patient-Self-Determination Act of 1991
In what ways can nurses lead on improving palliative and end of life care in the United States?
o Educate and improve nurses' communication skills regarding end-of-life conversations
o Increase knowledge about hospice and palliative care
o Greater symptom control for patients with end-stage diseases
o Improve advance care planning
o Better quality of life
o Less money spent on achieving better outcomes
What is the difference between politics and policy? How are they related? How are they different?
o POLICY
♣ Involves principles that govern actions directed toward given ends, such as allocation of resources
♣ May result in laws, regulations, or guidelines that govern behavior in public or private arenas, such as health policy.
♣ Policy decisions reflect the values and beliefs of those making the decisions
• As values and beliefs change, so do policy decisions
♣ Ex. ANA focuses on policy issues of health promotion, illness prevention, and nursing practice
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o POLITICS
♣ Politics is a process that influences the allocation of scarce resources.
♣ Examples: money, people, time, supplies, equipment
♣ Stakeholders are individuals or groups who are affected by the decisions. They also have a vested interest in influencing the politicians, or others in power, who make the policy decisions.
♣ Stakeholders can include health care professionals, affected patients and families, administrators of nursing organizations, hospitals, etc.
♣ The greater an impact stakeholders make in influencing politicians, the greater will be the likelihood their preferred policies will be implemented.
o Policies are the decision; politics is the process
o Policy is shaped to a great degree by those who are successful in the political arena
What is the role of professional associations in policy and politics?
¥ Represent workers (individuals and the group).
¥ Reflect mission statements, which are generated by the membership, and define the organization's purpose
¥ Represent nurses on both professional issues and working conditions (the ANA, labor unions, and specialty organizations are involved in political action with legislators and regulators in the government arena)
¥ Individuals within these organizations develop the positions that nursing organizations believe are in nursing's best interests
In what ways does political activism advance the profession's agenda for safe and effective patient care?
Political activism of nurses using their experience and expertise as front-line policymakers enhances the quality of health care and enhances the nursing profession. Politically active nurses fight for laws that ensure appropriate RN staffing and control educational requirements for unlicensed assistive personnel
How do nurses gain personal and professional power?
Personal Power:
¥ Sociability (all encounters are opportunities for expanding and diversifying your network: explore)
¥ Thinking long-term (Build ties before you "need" them & recognize the rule of reciprocity)
¥ Understanding the natural tendency (to stick to our own kind) and break out of it.
¥ Realize that belonging to more networks not always better (too many relational demands consumes time and slow things down)
¥ Understanding what you want to achieve
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Professional Power:
¥ Developing leadership skills
¥ Certification
¥ Continuing education
¥ Political activism
¥ Opportunities to define practice standards, take positions on practice issues, and develop ethical guidelines
¥ Opportunities to engage in research projects
What strategies can you use to build your social capital (who you know)?
♣ Accessing resources through your network of contacts
♣ Coordinating other peoples knowledge and expertise
♣ Considering the breadth (diversity, seniority, places of work), depth (effective use of time, frequency of interaction, strength of relationships), and leverage (influence, number of contacts, centralization) of personal networks.
What is the role of unions/collective bargaining in promoting nurses' power?
¥ Unions are organizations that represent workers -individuals and the group—to the managers of organizations
¥ Collective Bargaining is the process that unions use to represent workers to negotiate terms and conditions of work
¥ **Works on the principal of mutual aid and protection
In what ways can nurses act as advocates for nurses and nursing? In what ways do nurses occupying different work roles advocate for nurses and nursing in different ways?
Nurse Citizen:
¥ Register to vote.
¥ Keep informed about health care issues.
¥ Speak out when services or working conditions are inadequate.
¥ Participate in public forums.
¥ Join politically active nursing organizations.
¥ Participate in community organizations that need health experts.
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Nurse Activist:
¥ Joining politically active nursing organizations
¥ Registering people to vote
¥ Contributing money to a political campaign
¥ Working in a campaign
¥ Forming or joining coalitions that support an issue of concern
¥ Writing letters to the editor of local newspapers
¥ Inviting legislators to visit the workplace
Nurse Politician:
¥ Run for an elected office
¥ Seek appointment to a regulatory agency
¥ Be appointed to a governing board in the public or private sector
¥ Use nursing expertise as a front-line policy maker who can enhance health care and the profession
What are the major types of professional nursing organizations? Why do professional nurses become active members of professional organizations?
1. Broad-purpose professional associations (ex. American Nurses Association)
2. Specialty practice associations (for area of clinical interest, 66 specialty organizations are represented in the Nursing Organizations Alliance)
3. Special interest associations (ex. the Honor Society of Nursing (must be invited to join), and the American Association for the History of Nursing)
What is the National Student Nurses Association?
♣ US nonprofit organization founded in 1952 to mentor nursing students preparing for an initial licensure as an RN and to promote professional development (~58,000 members) **Facilitates entrance into the profession by providing educational resources, leadership opportunities, and career guidance.
In what ways can nurse activists make changes in specific issues?
¥ Know the issue. What is wrong? What should happen? Why is it not happening? What is needed: leadership, a plan, pressure, or data?
¥ Know the players. Who is on your side, and who is not? Who will make the decision? Who knows whom? Will a coalition be effective? Are you a member of the professional nursing organization?
¥ Know the process. Is this a vote? Is this an appropriation? Is this a legislative procedure? Is this a committee or subcommittee report?
¥ Know what to do. Should you write, call, arrange a lunch meeting, organize a petition, show up at the hearing, give testimony, demonstrate, or file a suit?
What are the roles and responsibilities of the executive, legislative and judicial branches of government in shaping health policy?
♣ Executive: Can be both objective and accountable. The chief executive may be free to divert from party political positions or to change those positions. The executive branch usually has many agencies concerned with health and social policy.
♣ Legislative: Collects full information from a wide range of objective sources; part of its mandate is to protect and promote the health of the public. It has the power to engage in a lengthy and deliberative process in enacting legislation.
♣ Judicial: Reach verdicts regarding certain issues and cases within healthcare, but may lack experience with scientific or ethical thinking. They rarely receive education or training in health issues.
THIS SET IS OFTEN IN FOLDERS WITH...