Final exam – nursing 104

Science
A method of bringing together facts and giving them coherence and integrity

Hypothesis
Method
Data collection
Results
Evaluation
Scientific inquiry involves five aspects:
what are they?

D
When analyzing the data from her research study, a nurse researcher finds that nurses who work under indirect sunlight have 20% fewer headaches, which are less severe than reported by those who work under fluorescent lighting. Which step of scientific inquiry does this action by the nurse researcher represent?
A. Hypothesis
B. Method
C. Data collection
D. Evaluation

Theory
A group of related concepts that explain existing phenomena and predict future events

Inclusiveness
Consistency
Accuracy
Relevance
Fruitfulness
Simplicity
Criteria for theory acceptance involve six factors: what are they?

D
For a theory to be reliable and acceptable for guiding nursing practice, another nurse should be able to duplicate the theory. Which criterion for theory acceptance deals with replication?
A. Fruitfulness
B. Relevance
C. Accuracy
D. Simplicity

Nursing Science
Collection of data related to nursing that may be applied to the practice of nursing

Nursing Science
Guides the practice of nursing to better serve clients

Theory
An abstract generalization that presents a systematic explanation about how phenomena are interrelated

Theory
Must include at least two concepts that are related in a way that the theory explains

Conceptual model or framework
Concepts that are assembled because of their relevance to a common theme

conceptual model
Conceptual framework used interchangeably with

Conceptual model or framework
More loosely structured than theories

Conceptual model or framework
Four concepts basic to nursing that are included in models are nursing, person, health, and environment

nursing, person, health, and environment
What are the four concepts basic to nursing that are included in models

Nursing Theory
Guides research and practice

Nursing Theory
Basic ingredients are concepts

health, stress, adaptation
Examples of nursing concepts:

Concept
Construct
Conceptual model
Philosophy
Theory
Language of nursing theory

Schematic Models
Demonstrate concepts, usually through a picture or visual representation of ideas

Schematic Models
Clarify and show relationships between complex concepts

Schematic Models
Illustrate the layout and features specific to a theory—similar to the blueprint of a building

Levels of Theory
Range from a broad scope to a smaller, more specific scope

Grand Theory
broad in scope; describes and explains large segment of the human experience

Middle Range Theory
smaller in scope and may refer to a specific population

Florence Nightingale
Influences that directed her toward nursing theory
Classic education
Upper class life
Religion and spirituality
Era of reform throughout England

Classic education
Upper class life
Religion and spirituality
Era of reform throughout England
Influences that directed Florence Nightingale toward nursing theory

Canons of Nursing
foundation for health promotion and guidance for the practice of professional nursing

Ventilation and warming
Noise
Variety
Diet
Light
Chattering hopes and advice
Cleanliness
What are the parts of the “canons of nursing”?

Peplau
Interpersonal Relations as a Nursing Process: Man as an Organism That Exists in an Unstable Equilibrium

Peplau
Explored interpersonal relationship of the nurse and the client

Peplau
Identified the client’s feelings as a predictor of positive outcomes related to health and wellness

Rogers
Nurse promotes synchronicity between human beings and their universe/environment

Rogers
Science of unitary man: energy fields, openness, pattern, and organization

Rogers
Science of Unitary Human Beings: Humans as Energy Fields That Interact Constantly with the Environment

Orem
Nurse implements appropriate measures to assist the client in meeting needs by matching with an appropriate supportive intervention

Orem
Facilitates client self-care by measuring the client’s deficit relative to self-care needs

Orem
Self-Care Deficit Model: Self-Care, Self-care Deficits, and Nursing Systems

Roy
Adaptation occurs by assisting the biopsychosocial client in modifying external stimuli

Roy
Nurse will be the change agent in assisting the individual with adaptation when an insult renders him or her in need of environmental modification

Roy
Adaptation model: Assistance with the Adaptation to Stress to Facilitate the Integration Process of the Client

Watson
Holistic outlook addresses the effect and importance of altruism, sensitivity, trust, and interpersonal skills

Watson
Caring among nurse, environment, and client is essential to healing

Watson
Theory of Human Caring: Transpersonal Caring as the Fulcrum: Philosophy and Science as the Core Nursing

Newman
Every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness

Newman
Nurse’s role: recognize person’s unique pattern of life and work within that pattern to achieve person’s goals

Newman
Theory stimulated by concern for those whom health as the absence of disease or disability is not possible

Newman
Defines health as “expanding consciousness,” or increasing complexity

Newman
Health as Expanding Consciousness

Mishel
Four-step framework assists nurses in working with clients: stimuli frame, appraisal stage, initiation of coping mechanisms, and adaptation

Mishel
Uncertainty exists when client is unsure about a diagnosed illness

Mishel
Uncertainty in illness is stress-producing and capable of contributing to negative physical and/or psychological outcomes

Mishel
Uncertainty of Illness

Health care concerns in the 21st century
Major concerns: uninsured population, patient safety, nursing shortage, rising health care costs, technology, confidentiality issues, advanced practice nursing

Health care concerns in the 21st century
Primary focus of federal and state legislative agendas

Nursing theories in the 21st century
Will embrace complex issues such as genetics, computers, noninvasive surgery, robotics, decreasing energy sources, increasing pollutants under a thinning ozone layer, environmental hazards, new diseases, and antibiotic-resistant illness

Nursing theories in the 21st century
Established nursing theories will be reevaluated and modified to answer important health care questions

Nursing Research
systematic inquiry or study conducted to generate new knowledge or to refine existing knowledge

Nursing Research
Results provide foundation for practice decisions and behaviors

Nursing Research
Results create strong scientific base for nursing

Nursing Research
Results provide support for the quality and cost-effectiveness of interventions

Nursing Research
Application of results demonstrates professional accountability to insurers and health care consumers

Nursing Research
Generate knowledge in areas that indirectly affect nursing care process

Nursing education
Student characteristics
Student satisfaction
Research focus, 1900 to 1940

Teaching
Administration
Curriculum issues
Research focus, 1950s to 1970s

More qualified researchers
Widespread availability of computers for data collection and analysis
Qualitative studies
Research focus, 1980s

health care delivery issues such as cost, quality, and access
Research focus, 1990s:

evidence base for practice
Research focus of 21st century:

NINR Research Foci
Health promotion and disease prevention

NINR Research Foci
Quality of life

NINR Research Foci
Health disparities

NINR Research Foci
End of life

Potential Funding Areas
Determining disease risk and treatment through using genetic information

Potential Funding Areas
Determining effective health-promotion strategies for individuals, families, and communities

Potential Funding Areas
Discovering approaches that encourage people to effectively take responsibility for symptom management and health promotion

Potential Funding Areas
Improving symptom management for those at end of life

Potential Funding Areas
Understanding predisposition to disease, socioeconomic factors that influence health, and cultural health practices that protect from or expose to risk of health problems

Potential Funding Areas
Improving quality of caregiving in long-term care facilities, the home, and the community

Potential Funding Areas
Improving clinical settings in which care is provided

Potential Funding Areas
Assisting in identification and effective management of symptoms related to acute and chronic disease

Agency for Healthcare Research and Quality (AHRQ)
An agency of the U.S. Department of Health and Human Services that aims to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective services

Agency for Healthcare Research and Quality (AHRQ)
Promote patient safety and reduce medical errors through scientific inquiry, building of partnerships with health care providers, and establishment of Centers for Education and Research on Therapeutics (CERTS)

Agency for Healthcare Research and Quality (AHRQ)
Improve quality of health care through scientific inquiry, dissemination of findings, and facilitation of public access to information

Agency for Healthcare Research and Quality (AHRQ)
Advanced use of information technology for coordinating patient care and conducting quality and outcomes research

Agency for Healthcare Research and Quality (AHRQ)
Established an office for priority populations to ensure that the needs of low-income groups, minorities, women, children, older adults, and individuals with special health care needs are addressed by the agency’s research efforts

Robert Wood Johnson, W.K. Kellogg Foundation, Helene Fuld Trust
Private Foundations:

Sigma Theta Tau International (STTI)
Oncology Nurses Society (ONS)
American Nurses Foundation (ANF)
American Nurses Association (ANA)
Nursing Organizations That Fund Research:

Formulating the research question or problem
Defining the purpose of the study
Reviewing related literature
Formulating hypotheses and defining variables
Selecting the research design
Selecting the population, sample, and setting
Conducting a pilot study
Collecting the data
Analyzing the data
Communicating conclusions
Components of the Research Process: ( IN ORDER)

Study Designs
Plans that tell a researcher how data are to be collected, from whom data are to be collected, and how data will be analyzed to answer specific research questions

Needs assessment, Survey, Case study, Methodological, Meta-analysis, Experimental, Quasi-experimental, Secondary analysis, Triangulation, Pilot studies
What are the quantitative designs?

Case study
provides an in-depth analysis of a single subject, group, institution, or social unit

Survey
used to collect large amounts of information with little expenditure of time and money

Needs assessment
determines what is most beneficial to an aggregate group

Methodological
focuses on development and testing instruments to improve their reliability and validity

Meta-analysis
an advanced process by which research on a specific topic is reviewed and findings of multiple studies are statistically analyzed and expressed quantitatively

Experimental
studies that include the manipulation of one or more independent variables, random assignment to a control or a treatment group, and observation of the outcome or effect that is presumably the result of the independent variable

Quasi-experimental
lacks one of the components of experimental design (i.e., randomization, control group, or manipulation of one or more variables)

Secondary analysis
involves asking new questions on data collected previously. The data may have been generated from previous formal research or may have been gathered through any previous systematic collection of data.

Triangulation
use of various research methods or data collection techniques in the same study

Pilot studies
small-scale studies referred to as feasibility studies; purpose is to identify strengths and limitations of a larger planned study

Qualitative Designs
a method of research designed for discovery rather than for verification

Phenomenology
method used to study intangible experiences such as grief, hope, or risk taking. It is designed to provide an understanding of the patient’s “lived experience.”

Ethnography
a method used to study phenomena from a cultural perspective

Grounded theory
a method designed to explore a social process

B
A researcher is using data collected by the government on the use of prescription drugs by older adults. The new research question, “Why do older adults adhere to a prescription drug regimen?” was based on data from the previous study. The researcher is participating in which type of research?
A. Meta-analysis
B. Secondary data analysis
C. Quasi-experimental
D. Pilot study

C
The advantage of meta-analysis is that multiple studies are statistically analyzed, enhancing the power of the results. The disadvantage is that:
A Generalizability is limited
B. Confidence is small
C. The findings are only as reliable and valid as the original studies
D. The results are expressed qualitatively

Research use
there is extensive concern that nurses have failed to realize the potential for using research findings as a basis for making decisions and developing interventions

Locating published research
focus on the usefulness of computerized databases such as CINAHL and MEDLINE and the Annual Review of Nursing Research

Blind review
Abstract and findings
Critical appraisal of nursing research

Advancing Evidence-Based Practice
Assessment of barriers to EBP

Advancing Evidence-Based Practice
Corrections of misperceptions about EBP goals and processes

Advancing Evidence-Based Practice
Questioning current clinical practice

Clinical nurse specialist (CNS):
master’s degree-prepared nurse who is an expert clinician with additional responsibility for education and research; assesses agency’s readiness for research utilization; works with staff to identify clinical problems; helps staff find, implement, and evaluate findings relevant to current practice

Clinical nurse researcher (CNR)
doctoral prepared with clinical and research experience

Clinical nurse researcher (CNR)
Focuses on the conduct or facilitation of research

Clinical nurse researcher (CNR)
Works with staff to identify research questions

Clinical nurse researcher (CNR)
Designs studies

Clinical nurse researcher (CNR)
Disseminates findings to staff, administrators, and legislators

Clinical nurse researcher (CNR)
Emerging roles
DNP and CNL

types and levels of evidence
Journal article describing a single study
Systematic review methods (meta-analysis and meta-synthesis)
Intervention guidelines
Patient values and preferences
Expert opinion
Theory-based information
Compiled databases
WHAT ARE ALL OF THESE?

evidence- based practice
Heparinized saline for flushing peripheral intravenous catheters
Interventions such as exercise for cancer-related fatigue
Prevention and treatment of pressure ulcers

what are these examples of?

AHCPR (Agency for Health Care Policy and Research)
Clinical practice guidelines: developed by

evidence- based practice
Acute pain care management in infants, children, and adolescents
Prediction and prevention of pressure ulcers in adults
Identification and treatment of urinary incontinence in adults

are examples of?

Institutional review
IRB or human subjects committee required by institutions receiving federal funding
Historical examples

Nazi experiments
Tuskegee syphilis study
Jewish Chronic Disease Hospital in New York
Historical examples of unethical research

Policymakers
must be informed about findings, so results can be translated into health policy

Consumers
must be educated about the value of nursing research

Health care administrators
must foster research

Educators
must prepare students to appreciate and conduct research and evaluation at their level of preparation

Staffing
Activities required to ensure an adequate number and mix of health care team members to meet patient needs and provide safe, quality care

Staffing
Considerations are patient needs, staff satisfaction, and organizational needs

RNs
Research validates contribution of ____ to improved patient outcomes and prevention of premature mortality

Number of patients
Intensity of care required
Staff experience and preparation
Geography of the environment
Available technology
Primary considerations for staffing a nursing unit are:

Patient classification systems
Categorize patients according to care needs (acuity level)

Patient classification systems
Higher acuity levels mean that nursing care needs are more intense

Age and functional ability
Communication skills
Cultural and linguistic diversities
Severity and urgency of the admitting condition
Scheduled procedures
Ability to meet health care requisites
Availability of social supports
Other specific needs identified by patient and RN
ANA recommends that classification systems should consider patients

staff members
must have the educational preparation, skill, and experience necessary to meet patient care needs

executive level managers
Concerns about inadequate numbers of appropriately skilled and experienced staff should be addressed with

provide higher quality, more cost-effective care
Satisfied nurses generally provide

24 hours/day, 365 days/year
staffing needs make meeting the nurse’s personal needs difficult
Creative staffing

Creative staffing
options are available to meet varied needs of staff members

staff satisfaction
Methods to gain staff input about staffing and to enhance autonomy are the key to

Financial resources
Licensing regulations and accreditation standards
Customer satisfaction
Organizational needs affected by staffing include:

Efficient staff management
ensures the organization’s financial solvency

Numbers of staff working at any given time
Staff mix
Nurse manager accountable for budgetary guidelines for:

RNs
the most expensive staff; thus ratios for RNs to other types of care providers may be established

Licensing and accreditation agencies
do not impose mandatory staffing ratio but do look for evidence that patients are adequately cared for

Customer satisfaction
is critical to an organization’s success

is key to satisfaction
A customer’s personal interaction with employees

Nurse manager
Appropriate staffing within budget constraints with well-trained, competent, professional staff members who are committed to providing safe, high-quality care
who’s number one challenge is this?

Nursing Care Delivery Models
Detail how task assignments, responsibility, and authority are structured to accomplish patient care

Nursing Care Delivery Models
Describe which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions

Nursing Care Delivery Models
Basic premise is that the number and type of caregivers are closely matched to patient care needs in a cost-effective manner

Total patient care
Functional nursing
Team nursing
Primary nursing
Classic Nursing Care Delivery Models are?

Total Patient Care
Nurse is responsible for planning, organizing, and performing all patient care during the assigned shift

Total Patient Care
Oldest method of organizing patient care, sometimes referred to as case nursing

Total Patient Care
Nursing student typically performs

Total Patient Care
Advantages
RN maintains a high degree of practice autonomy
Lines of responsibility and accountability are clear
Patient receives holistic, unfragmented care
Communication at shift change is simple and direct

Total Patient Care
Disadvantage
Number of RNs required is very costly
Some tasks could be accomplished by a caregiver with less training and at a lower cost
Nursing shortage will affect RN availability

Total Patient Care
Common use areas: intensive care units, postanesthesia care units

Functional Nursing
Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients

RN nurse manager
assigns responsibility for completion of tasks to a group of health care workers
(Functional Nursing)

RN
is responsible for planning care and supervising workers
(functional nursing)

RN
retains accountability for the patient care provided
(Functional nursing)

Functional Nursing
Advantages of patient care
Provided economically and efficiently
Minimum number of RNs required for patient care
Tasks completed quickly; little confusion about responsibilities

Functional Nursing
Disadvantages of patient care
May be fragmented; possibility of overlooking priority patient needs
Patient may feel confused because of many different care providers
Caregivers may feel unchallenged when performing repetitive functions

Functional Nursing
Common use areas: operating room

Team Nursing
RN functions as a team leader and coordinates care for a small group of patients

Team Nursing
RN team leader is responsible for the following:
Planning care
Assigning duties
Directing, supervising, and assisting team members
Giving direct care
RN retains accountability for all patient care
RN team leader is responsible for encouraging a cooperative environment and maintaining clear communication

Planning care
Assigning duties
Directing, supervising, and assisting team members
Giving direct care
In Team Nursing what is the RN responsible for?

Team Nursing
Advantages
High-quality, comprehensive care can be provided with a relatively high proportion of ancillary staff
Each member participates in decision making, problem solving
Each member contributes his/her own special expertise or skills

Team Nursing
Continuity of care may suffer with daily team assignments
Team leader may not have the leadership skills required to effectively direct the team
Insufficient time for care planning and communication leads to unclear goals and fragmented care

Team Nursing
Common use areas: effective, efficient method of patient care delivery that has been used in most inpatient and outpatient health care settings

Modular Nursing
Modification of team nursing
Patient unit divided into modules; same team of caregivers assigned consistently to same geographic location
Each location or module has RN as team leader
Goal is to increase the involvement of the RN in planning and coordinating care
Designated modules should contain all the supplies needed by the staff to maximize efficiency

RN “primary” nurse
assumes 24-hour responsibility for planning, directing, and evaluating the patient’s care from admission through discharge
(primary nursing)

Primary Nursing
Provides total patient care while on duty

Primary Nursing
While off duty, care is provided by an associate nurse, who follows the care plan established by the primary nurse

Primary Nursing
RN “primary” nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient’s care from admission through discharge
Provides total patient care while on duty
While off duty, care is provided by an associate nurse, who follows the care plan established by the primary nurse

Primary Nursing
RN primary nurse has 24-hour responsibility and accountability for patient care
Associate nurses are responsible for following the plan of care
RN primary nurse is responsible for maintaining clear communication among all members of the health care team

Primary Nursing
Advantages
Direct patient care provided by a small number of nurses allows for high-quality, holistic patient care
Patient able to establish a rapport with the primary nurse, and patient satisfaction is enhanced
Job satisfaction high because nurses are able to practice with a high degree of autonomy and feel challenged and rewarded

Primary Nursing
Disadvantages
Implementation may be difficult because primary nurse is required to practice with a high degree of responsibility and autonomy
Inadequately prepared primary nurse may not be able to make the necessary clinical decisions or to communicate effectively with the health care team
RN may not be willing to accept 24-hour responsibility as required
Number of RNs required for this method of care may not be cost-effective and may be difficult to recruit and train

Primary Nursing
Common use areas: home health, hospice, long-term care

Partnership Model (or Co-primary Nursing)
RN is partnered with an LPN/LVN or a nursing assistant; pair work together consistently
Modification of primary nursing designed to ensure more efficient use of RN
Lines of responsibility and accountability
RN responsible for planning care, assigning duties, coordinating care, and supervising the partner
RN is accountable for patient care for all assigned patients

Partnership Model (or Co-primary Nursing)
Advantages
More cost-effective than the primary care system
RN can encourage training and growth of partner

Partnership Model (or Co-primary Nursing)
Disadvantages
RN may have difficulty delegating to the partner
Consistent partnerships are difficult to maintain on the basis of varied staff schedules

B
The nursing shortage escalates, and certain geographic areas must institute delivery models that require fewer numbers of registered nurses. Which type of nursing delivery models would be appropriate?
Total patient care and primary nursing
Team nursing and functional nursing
Total patient care and functional nursing
Primary care and team nursing

Patient-Centered Care
Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions”

Patient-Centered Care
Nurses, physicians, and other health professionals partner with patients and families to ensure that health care decisions respect patients’ wants, needs, and preferences

Patient-Centered Care
Philosophy of care
Not a typical nursing care delivery model but more a philosophy of care
Should be incorporated as an essential component of any nursing care delivery model

Patient-Centered Care
Methods to engage patients, families, and significant others as partners in care
Include them in developing care plans and discharge plans
Include them in change-of-shift or hand-off reports
Provide them with the information and education needed to make informed decisions
Establish “family advisory councils” to engage patients and families in decision making

C
A patient receives care for heart failure on a nursing unit in which the interprofessional team members— including nurses, physicians, and therapists—are committed to including the patient and spouse in change of shift reports and to seeking their input in all decisions affecting the patient’s care. What type of care model is represented in this unit?
Functional care
Primary care
Patient-centered care
Case management

Telehealth Nursing
Important method of providing nursing care to clients in ambulatory settings
Formally used to interact with patients, beginning in the early 1970s
Also called telephone triage, telephone nursing, or telehealth
Encompasses all telecommunication methods—e-mail, Internet, fax, and telephone

Triage
Interventions
Consultation
Surveillance and follow-up
Nurses’ Roles in Telehealth Nursing

Practice Standards (Published by the American Academy of Ambulatory Care Nursing)
Using protocols, algorithms, or guidelines to assess and address patient needs
Prioritizing the urgency of patient needs
Developing a collaborative plan of care
Evaluating outcomes of practice and care

Telehealth Nursing
Integral part of an outpatient clinic practice
Function of a centralized call center

telehealth
Ever-increasing opportunities for nurses in ____ to influence the quality of care

Case Management
Introduced in 1970s by insurance companies as a method to monitor and control expensive health insurance claims

Case Management
Today, most health insurance companies have a program for it

Case Management
By mid-1980s, hospitals recognized need for case management to manage patients’ treatment plan and length of stay because of the diagnosis-related group (DRG) payment method

Case Management
The RN case manager coordinates the patient’s care throughout the course of an illness, as an employee of the payer or as an employee of the health care facility

Case Management
Goal of _____________ is to focus attention on quality, outcomes, and cost of care, and to assist the patient to move through the continuum of care

Case Management
Studies have demonstrated the value of ______________ in improving patient outcomes and reducing costs

Case Management
Collaborative approach to providing and coordinating health care services, identifying and facilitating options and services for meeting health needs, decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes

Case Management
Nurse case manager “manages” a “case load” of patients from preadmission (onset of illness) to discharge (resolution of illness)

Case Management
Other disciplines, most notably social work, have been involved in developing ___________ programs

Case Management
When clinical knowledge is required, the RN is most effective in the ______________ role

Case Management
Variations in ___________ are found in almost all health care organizations

generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases
Supplemental form of nursing care that does not replace the nursing care delivery model already in place to provide direct patient care

case manager
assumes a planning and evaluative role and usually is not responsible for direct care duties

generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases
generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases

Clinical Pathways
Delineates a predetermined written plan of care for a particular health problem

Clinical Pathways
Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem

Clinical Pathways
Written to address common medical diagnoses such as heart failure and pneumonia, common nursing care needs such as immobility, and medical complications such as weaning from mechanical ventilation

Clinical pathways
define key processes and patient goals in the day-to-day management of care

Clinical practice guidelines
guide broader decision making and focus on decisions made in performing a procedure or service

Clinical Pathways
Developed to identify quality, cost-effective care plans to reduce the patient’s length of stay in the hospital

Clinical Pathways
Dictate the type and amount of care given and thus have financial implications for the health care facility

Patient outcomes
result of intervention by the health care team

Interdisciplinary intervention
collaborative effort by all disciplines, along with the patient and family, to reach desired health outcomes

Variance
any event that may alter the patient’s progress through the clinical pathway

Trigger
alerts caregiver that an unexpected event has occurred and identifies potential and actual variations in patient’s response to a planned intervention

Consults
Laboratory and diagnostic tests
Treatments and medications
Safety and self-care activities
Nutrition
Patient and family education needs
Discharge planning
May address triggers
Essential Components of Clinical Pathways

Clinical Pathways
A team supported by management, with representatives from various disciplines such as nursing, medicine, therapy, pharmacy, and dietary, develops clinical pathways

clinical practice guidelines
Medical specialty boards developed

Clinical Pathways
Based on accepted standards of practice

The Agency for Healthcare Research and Quality (AHRQ)
in conjunction with medical specialty associations, professional societies, and other health care organizations, has developed a series of clinical practice guidelines

Clinical Pathways
Developed for the health care organization’s most common or costly diagnoses

Clinical Pathways
A team supported by management, with representatives from various disciplines such as nursing, medicine, therapy, pharmacy, and dietary, develops clinical pathways

functional nursing
Emergency departments use __________ because emphasis is on efficient assessment and immediate treatment

Team nursing
medical-surgical units

Total patient care
is common in critical care units

primary nursing
Home health agencies may use

50%
A study found that more than ___- of staff from 26 hospitals reported using two or three nursing care delivery models, sometimes over the course of a single shift

Influences on the Type of Nursing Care Delivery Model Used
Health care setting
Acute care
Long-term care
Ambulatory care
Home care and hospice

Influences on the Type of Nursing Care Delivery Model Used
Organizational structure and resources
Management structure
Staffing resources
Supply resources
Physical layout of the facility
Patient needs
Acute
Long-term/chronic
Staff availability, skills, and competencies

Are patient outcomes achieved in a timely, cost-effective manner?
Are patients and families happy with care?
Are physicians and other health team members satisfied with care?
Does the system allow for implementation of the nursing process?
Does the system facilitate communication among all members of the health care team?
Evaluation of Nursing Care Delivery Models

Factors Influencing Changes in Nursing Care Delivery
Rapid technological advances
Fast-paced patient turnover in acute care settings
RN’s value in patient safety and quality care
Ongoing shortages of nurses and other health professionals
Strong focus on outcomes of care
Consumer demand for instant access to care and information
Need to focus on the underlying determinants of health that are affected by lifestyle and personal choice

traditional
models of nursing care focused on comprehensive knowledge of patient needs and care provided over an extended period

Present
nurses may be assigned an entirely new group of patients to care for every shift, or even more than once during a shift

Nurses of the future
must conduct focused assessments and set priorities to resolve before the patient is quickly transitioned to another level of care

Nurse leaders
will be challenged to identify new models that are cost-effective, will improve quality and safety of care, and facilitate relationship-based nursing

Relationship-based
care must be considered in high-tech fast-paced environments where care must be consistent with nursing values of compassion, caring, and healing

Care provider
Assessing clients, planning therapeutic interventions, coordinating and evaluating care

Care provider
Caring: central to nursing interventions

Educator and counselor
Teaching health promotion and health maintenance

Educator and counselor
Increasingly important in the changing health care environment

Advocate
Promoting what is best for the client

Advocate
Protecting the client’s rights

Change agent
Identifying client and health care delivery problems

Change agent
Assessing motivation and capacity for change

Change agent
Determining and exploring alternatives and assessing cost-effective resources

Change agent
Leading the change process

Leader and manager
Improving the health status and potential of individuals, families, and communities

Leader and manager
Enhancing effectiveness and level of satisfaction among colleagues

Leader and manager
Managing multiple resources in a health care facility

Leader and manager
Raising citizens’ and legislators’ attitudes toward and expectations of the nursing profession and the health care system

Researcher
Leading nursing research: nurses prepared at the doctoral and postdoctoral levels

Researcher
Participating in research: nurses prepared at the master’s, baccalaureate, and associate’s degree levels

Coordinator of the interprofessional team
Coordinating practice relationships among several health care disciplines to bond, interact, and unite toward common goals of patient care

Coordinator of the interprofessional team
Using successful health care team models with concepts related to interdisciplinary health care such as pain management, nutritional support, skin care, rehabilitation, mental health, hospice, discharge planning, and patient education

3 million
Approximately ________RNs in the United States

60 %
Approximately ______ of RNs employed full time

46.8
Average age for RN in 2008

1. 5.4 , 2. 6.2
Number of male RNs increased from ___1___% in 1996 to ___2___% in 2010

83.2
Approximately _____% of RNs are white/non-Hispanic

diploma
what type of nurse made up 20.4% ?

associates
what type of nurse made up 45.4?

bachelors or higher
what type of nurse made up 34.2?

Infection control
assess incidence of infection and conduct comprehensive review to ensure prompt and accurate treatment, so that it is not passed to other patients; determine source and onset of infection

Quality management
assess compliance of the institution with established standards; ensure that patient services are consistent with standards through chart review and ongoing interaction with staff

Coordinator positions
various coordinator positions, which require considerable experience in the specialty practice area

Specific client services
extensive list of client services that include intravenous team, ostomy care, support groups, and health education

C
. An RN enjoys caring for complex patients in acute care and is interested in returning to school for a graduate degree as a generalist to gain greater autonomy over care decisions at the bedside for those patients with multifaceted dynamic health status. This nurse should consider a career opportunity such as:
A. Flight nursing
B. Parish nursing
C. Clinical nurse leader
D. Case manager

C
A nurse establishes a “roadmap” for diagnostic tests, activities, and treatments that standardize care and increase safety while promoting excellence of care in the acute care setting. The nurse is operating in the role of:
Occupational health nurse
Informatics nurse specialist
Quality manager
Community health nurse

Home care
as patients shift from hospital to ambulatory care and home care, the role of the community health nurse has evolved beyond the traditional public health nurse concept

Home care
Dobutamine administration
Chemotherapy
Radiography or telemetry
Uterine monitoring

Nurse Educator
Minimum of master’s degree in the specialty area in which they teach

Nurse Educator
Must be competent in clinical practice at advanced generalist or specialist level

Nurse Educator
Expectations of the role include teaching, scholarship, and service to the community

Clinical Nurse Leader (CNL)
New role
Prepared as a master’s generalist
Oversees the care of a distinct group of patients in any setting
Actively provides direct patient care in complex situations
Evaluates patient outcomes
Puts evidence-based practice into action

“advance practice nurse” (APN)
consist of a licensed registered nurse prepared at the graduate degree level

Nurse practitioners (NPs)
Certified nurse-midwives (CNMs)
Certified registered nurse anesthetists (CRNAs)
Clinical nurse specialists (CNSs
What are advanced practice nurses?

APNs
Make independent and collaborative health care decisions

APNs
Engage in active practice as expert clinicians

APNs
Prepared through master’s level education/graduate level degree

APNs
Assume responsibility and accountability for health promotion, assessment, diagnosis and management of client problems, including prescription of medications

Nurse Practitioner (NP)
Can practice in a variety of specialty areas, such as family, adult, pediatric, geriatric, women’s health, school health, occupational health, mental health, emergency and acute care.

Nurse Practitioner (NP)
Assess, diagnose, manage medical and nursing problems.

Nurse Practitioner (NP)
Emphasis is on disease prevention, health promotion and maintenance

Nurse Practitioner (NP
Job responsibilities include:
Taking patient histories

Nurse Practitioner (NP
Conducting physical exams

Nurse Practitioner (NP
Ordering, performing, and interpreting diagnostic tests

Nurse Practitioner (NP
Prescribing medications, treatments, and therapies

Nurse Practitioner (NP):
Have advance education with emphasis on pathophysiology and pharmacology

Nurse Practitioner (NP):
Should be certified in their area of specialty

Nurse Practitioner (NP):
Achieve registration and licensure by state boards of nursing

Nurse Practitioner (NP):
State board of nursing regulate NP practice and prescriptive authority

Clinical nurse specialists (CNSs):
These are nurses who possess clinical expertise and advance knowledge in a specific area of nursing practice for a selected client population or clinical setting, such as oncology, pediatrics, psychiatric-mental health, adult health, acute-critical care, and community health.

Clinical nurse specialists (CNSs):
“The emphasis of this advanced nursing practice is to provide clinical support that improves client care and client outcomes.”

Clinical nurse specialists (CNSs):
Educated in graduated level programs

Clinical nurse specialists (CNSs):
Expertise is from graduate study and clinical experience

Clinical nurse specialists (CNSs):
Functions as an expert clinician, educator, consultant, researcher, and administrator

Clinical nurse specialists (CNSs):
Functions as a role model or preceptor for nurse generalists and students

Clinical nurse specialists (CNSs):
Monitors the care of clients and collaborate with the health care team

Clinical Nurse Leader (CNL)
New role

Clinical Nurse Leader (CNL)
Prepared as a master’s generalist

Clinical Nurse Leader (CNL)
Oversees the care of a distinct group of patients in any setting

Clinical Nurse Leader (CNL)
Actively provides direct patient care in complex situations

Clinical Nurse Leader (CNL)
Evaluates patient outcomes

Clinical Nurse Leader (CNL)
Puts evidence-based practice into action

Clinical Nurse Leader (CNLs)
are educated as generalists (overall, variety)

Clinical Nurse Leader (CNLs)
operate primarily on the clinical level involving small, frontline nursing units;

Clinical Nurse Leader (CNLs)
coordinate and implement evidence-based practice

Clinical Nurse Specialist (CNSs)
are prepared for specialty practice

Clinical Nurse Specialist (CNSs)
are engaged at the clinical frontline and organizational systems levels.

Clinical Nurse Specialist (CNSs)
have the added responsibility of generating new evidence

Certified Registered Nurse Anesthetist (CRNA):
Provides anesthesia and anesthesia-related care on request, assignment, or referral by a patient’s physician, most often to facilitate diagnostic, therapeutic, or surgical procedures

Certified Registered Nurse Anesthetist (CRNA):
Required to make independent judgment relative to all aspects of anesthesia care

Certified Registered Nurse Anesthetist (CRNA):
Required to complete a written exam for certification as a CRNA

Certified Registered Nurse Anesthetist (CRNA):
Educational preparation occurs at the graduate level

Certified Registered Nurse Anesthetist (CRNA):
Perform consultation for management of pain associated with obstetric labor and delivery, acute or chronic ventilator problems, or acute or chronic pain through diagnostic or therapeutic blocks

Certified Nurse Midwife (CNM):
Completed an accredited educational program in nurse-midwifery and passed the national certification examination administered by the ACNM Certification Council

Certified Nurse Midwife (CNM):
Focus on pregnancy, childbirth, postpartum period, care of newborn, family planning and gynecologic needs of women

Certified Nurse Midwife (CNM):
Primary care providers of women’s health care

Certified Nurse Midwife (CNM):
Midwifery occurs in a variety settings: homes, birthing centers, clinics, and hospitals.

Certified Nurse Midwife (CNM):
Midwifery practice is legal in all 50 states and the District of Columbia. They can prescribe medications in 48 states.

Nurse Administrator or Nurse Executive:
Focus on the administration of health care systems for the purpose of delivery services to groups of clients

Nurse Administrator or Nurse Executive:
Hold a master’s degree

Nurse Administrator or Nurse Executive:
Knowledge in business administration

Nurse Administrator or Nurse Executive:
Concerned with costs of nursing care and the relationships between nursing services and quality client care

Nurse Administrator or Nurse Executive:
View problems of nursing service delivery and delivery of health care services

Nurse Administrator or Nurse Executive:
Lead and direct large groups of nurses and ancillary personnel

Nurse Administrator or Nurse Executive:
Manage large budgets

Nurse Administrator or Nurse Executive:
Serve at all management levels in HCOs and the community

Doctor of Nursing Practice (DNP)
Expert in advanced nursing practice who has an earned clinically focused doctorate in nursing

Doctor of Nursing Practice (DNP)
In 2004, the American Association of Critical-Care Nurses (AACN) published a DNP position statement calling for transformational change in nursing education, recommending nurses practicing at the highest level should receive doctoral degrees

D
I can prescribe pharmacologic agents, conduct physical examinations, order test and interpret diagnostic tests. ___________
A. Nurse administrator
B. Registered nurse
C. Clinical nurse specialist
D. Nurse practitioner

Bb
I provide anesthesia and anesthesia-related care and facilitate diagnostic, therapeutic, or surgical procedures.__________________
A. Nurse practitioner
B. Certified registered nurse anesthetist
C. Clinical nurse specialist
D. Clinical nurse leader

C
I am certified by the ACNM Council. I manages women’s health care with a particularly focus on pregnancy, childbirth, postpartum care, and care of newborn.____________
a. Nurse Practitioner
B. Clinical nurse specialist
C. nurse-midwife
D. executive

D
I constitute 8.6% of the RN population. I am also prepared at the graduate degree level._______________
Baccalaureate nurse
Diploma nurse
Associate’s degree nurse
Advance practice nurse

Healthy People 2020
Health promotion and disease prevention

Healthy People 2020
National Initiative to improve the health of the nation

Healthy People 2020
Vision
Mission
Overarching goals
Topics

Healthy People 2020
initiative not only provides a plan for improving the health of communities in the United states, but it also monitors progress to determine if goals and objectives are being met.

Healthy People 2020
At the end of the 10-year period, outcomes are evaluated to help plan for the next 10 years.

Health promotion and maintenance
Illness prevention
Diagnosis and treatment
Rehabilitation and long-term care
Major Categories of Health Care Services

Diagnosis and Treatment
Traditionally the U.S. health care system has put major emphasis on diagnosis and treatment.

Diagnosis and Treatment
Historically health care focused on diagnosis and treatment (not health promotion, illness prevention, or early detection)

Governmental agencies, Voluntary agencies, Non-profit agencies, For profit agencies
what are the 4 health care delivery agencies?

Primary care services
could be MD office, student health services, emergency room, clinic, etc…

Secondary care services
goes beyond primary; involves prevention of complication of disease – traditionally took place in hospitals, but now can be in a variety of settings

Tertiary care services
provided to: acutely ill, those requiring long-term care or rehab services, to terminally ill – requires an interdisciplinary team

Primary Level
includes interventions that are used to maintain health and are used before illness occurs, example: health promotion – focus on health teaching including nutrition, exercise, vaccinations.

Secondary Level
a person is asymptomatic (without symptoms) but after the disease has begun, focuses on preventing further complications, Example would be screening, breast cancer screening or blood pressure screening for hypertension

Tertiary Level
the person has had an illness or injury and we want to maintain or improve functioning. Restoration and rehabilitation are examples. Prevention of complications.

Board of Directors
Expected to bring knowledge and expertise from the business world

Board of Directors
Carry significant responsibility for the mission of the organization, quality of service and financial stability

Board of Directors
Not involved in day-to-day activities

Board of Directors
Legally responsible for establishing policies and ensuring policies are executed

Board of Directors
May or may not be paid for service

Board of Directors
Delegate responsibility to the CEO – Chief Executive Officer

Chief Executive Officer (CEO)
Nurses with advanced degrees are good candidates as a result of their broad holistic education and clinical experience

Chief Executive Officer (CEO)
May be assisted by a chief operating officer (COO)

Chief Executive Officer (CEO)
Also has an external role in the community

Chief Executive Officer (CEO)
Responsible for making sure decisions of the board are implemented

Chief Executive Officer (CEO)
Usually has a minimum of a master’s degree in business or hospital administration

Chief Executive Officer (CEO)
Responsible for overall operation on a daily basis

the chief nurse executive (CNE) or chief nursing officer (CNO)
The senior administrative nurse in an organization is known as

CNO
is part of the board of directors

Systems Theory
offers a way to understand health care delivery systems.

System
is a set of interrelated parts that come together to form a whole that performs a function. Each part is a necessary component to make a complete whole.

Open system theory
organization affected not only by internal changes among its parts but also external changes in the environment that will have a direct influence on the organization.

Health care organizations
must be able to adapt to internal or external changes in order to survive.

Closed system theory
organization is totally independent on outside influences.

open system
receives feedback from the environment

closed system
receives no feedback from the environment – and theoretically won’t survive.

State and federal governments
play an increasingly important role in health care, especially as federal and state governments and multiple private players embark on health care reform

Nursing practice
is directly affected by health policy development which is, in turn, affected by the political action of citizens—nurses and many, many others

Patient safety and quality; access to affordable health coverage and services; and costs, value, and outcomes of services
what are the major debate among policymakers

political endeavor
Patient care and nursing practice is a ________

Private health policy
is made by health care organizations such as hospitals and managed care organizations

Public health policy
refers to local, state, and federal legislation; regulation; and court rulings that govern the behavior of individuals and organizations in the provision of health care services

Local health policy
Cities or counties offer a variety of health care services to meet the needs of their residents

Local health policy
Examples include free or reduced-rate immunizations, tobacco-free public buildings, safe drinking water, enforcement of seat belt and child restraint laws, and provision of an emergency medical system

State health policy
Governs nursing through nurse practice act

State health policy
Provides “invisible services” through regulatory activities

State health policy
Maintaining a safe meat supply through livestock inspections

State health policy
Ensuring safe food storage and preparation in restaurants

State health policy
Ensuring that health care facilities provide safe, quality care

State health policy
Pays for health care services through various programs:
Medicaid and State Children’s Health Insurance Program (SCHIP), which are partly funded by federal funds
Other indigent care programs, which vary from state to state

State Health Insurance Exchanges (SHIEs)
a set of state regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies

State Health Insurance Exchanges (SHIEs)
A key piece of the health care reform or ACA legislation is the opportunity for states to develop

Federal health policy
Funds health-related research

Federal health policy
Funds education for health professionals, including nurses and physicians

Federal health policy
Pays for health care through Medicare, Medicaid, SCHIP, and the Veterans Administration health care system

Federal health policy
Plays a monumental role in shaping nursing practice

Federal health policy
Passage of the Patient Protection and Affordable Care Act (PPACA) or ACA)(2010)

Nurse practice acts and registration of nurses, Sheppard-Towner Act, Hill-Burton Act, Medicare program, Renal disease program, Diagnosis-related groups (DRGs)
Federal policy that shaped nursing practice

Health Policy
Complex, dynamic process; occurs in various ways

Health Policy
Enactment of legislation and accompanying rules and regulations that carry the weight of law

Health Policy
Administrative decisions made by various governmental agencies

Health Policy
Judicial decisions that interpret the law

Health Policy
Involves numerous individuals and groups
1. Elected officials
2. Officials from governmental agencies
3. Experts in the related area
4. Stakeholders such as corporate representatives
5. Representatives from special interest groups
6. Other affected citizens

Health Policy
Involves all three branches of government
Executive
Legislative
Judicial

Legislative
process fundamental to movement from a public problem to a viable program

Societal problem
that may qualify for a policy solution are those brought to the attention of a policymaker who is willing to take definitive action through the policy process

issues for potential policy development
Public perception of the problem
Definition of the problem
Societal consequences and number of people affected
Degree of support and opposition from stakeholders

Steps in the Legislative Process
Include introduction, committee action, House and/or Senate action, and presidential action

Steps in the Legislative Process
Very complex and convoluted process, with only a fraction of legislation that is introduced actually making it through the final process to become law

executive
Once a bill becomes law, implementation falls under jurisdiction of one of the departments of the __________ branch

True
Implementation of new legislation often can be very different from what was intended when the bill was passed by Congress
true or false

Regulation
written set of rules issued by the government agency that has responsibility for administering the new law

Nurses
can play an influential role by providing input into the final regulations

true
Interval between interim rules and final rules critical for assessing effect of the policy; concerted nursing action is required
t or f

Regulations
_______carry the force of law

Politics
Process by which the decisions of others are influenced and control over situations and events is exerted

influence
________is the common denominator in any definition of politics

political influence
Forms of ___________ include money, knowledge, relationships, information, talent, and control over large groups of votes

Politics
is a necessary part of the policy process when multiple interest groups compete to achieve individual goals

Politics
also involves the varied agendas of the Democratic, Republican, and Independent parties

political strategies
Groups and individuals who have a stake in the fate of a piece of legislation or the election of a candidate use______________ to attain their desired outcomes

nurses
Through effective political action, ________ can positively influence legislative decisions and health policies

Nursing Process
is effective in identifying broader professional and health care issues

Assessment
Analysis and diagnosis
Planning
Implementation
Evaluation

Policy process and nursing process
are systematic approaches to address health care and nursing laws

Collection of information (assessment)
information and data must be gathered from as many sources as possible before the health care issues can be identified

Identification of issues (diagnosis)
information analyzed to identify real issue or problem that needs to be addressed

Development of a plan
includes options and a determination of professional consequences with each

Implementation of the plan
requires political action and a set of strategies

Grassroots
Registering to vote and voting in all elections

Grassroots
Joining a professional nursing organization

Grassroots
Working in candidates’ campaigns

Grassroots
Attending a “meet the candidates” town hall meeting

Grassroots
Visiting with policymakers or their staff

Grassroots
Communicating with policymakers by e-mail, fax, and phone

ANA
American Nurses Credentialing Center
American Nurses Foundation
American Academy of Nursing
Specialty organizations such as the American Association of Critical-Care Nurses

Who do these affiliate too?

ANA policy issues
Medicare and Medicaid reform
Patients’ rights
Whistle-blower protection
Access to health care
Comprehensive health care reform
Environmental and occupational health for nurses
What are these examples of?

Nurses Strategic Action Team (N-STAT)
Unifies nurses’ political voices across the country to enact measures to enhance health care for all

Nurses Strategic Action Team (N-STAT)
Empowers nurses by encouraging them to take action and make sure their opinions are heard and understood by Congress and the public

Nurses Strategic Action Team (N-STAT)
Provides structure and coordination for nurses across the country to be involved in grassroots lobbying

Health Care Reform
General term used to refer to policy initiatives to effect significant changes in how health care is delivered and paid for

health care reform
___________________legislation has become a reality with passage of The Patient Protection and Affordable Care Act of 2010

The Patient Protection and Affordable Care Act of 2010
Provides for affordable and accessible health care coverage for all Americans

Access to care
is the most significant problem to address through health care reform

Lack of insurance
greatest barrier to access to health care

50
___ % of the uninsured have no regular source of health care

uninsured
________ more likely to delay or ignore needed treatment

uninsured
_________ more likely to be hospitalized for avoidable conditions

IOM Future of Nursing Report
Report calling attention to the essentiality of nursing in reforming the health care system

IOM Future of Nursing Report
major recommendations:
Nurses should practice to the full extent of their education and training

IOM Future of Nursing Report
major recommendations:
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression

IOM Future of Nursing Report
major recommendations:
Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States

IOM Future of Nursing Report
major recommendations:
Effective workforce planning and policymaking require better data collection and information infrastructure

Regulation
“rules used to implement legislation and translate concepts into legal action so they can be put into practice”

regulation
“a written set of rules issued by the government agency that has the responsibility for administering the law”.

regulations
address public health problems

regulations
are enacted by the executive branch

regulations
carry the force of the law

regulations
shape health care policy

regulations
It is important that _______ reflect the intent of the law

implementation
Supporters must follow through and be involved in the discussion and process for _______________

legislative branch
possesses the sole federal power to enact legislation;

executive branch
is to recommend legislation and promote (but not originate) major policy initiatives;

judical branch
resolves disputes -> amends and interprets laws.

executive branch
also implements laws, manages programs after they have been passed by Congress

legislative branch
_______________originates and promotes major policy initiatives

Regulations being developed
stakeholders attend public hearing to comment.

Regulations published
open to public for comment for a period of time.

critical time before regulation is adopted
nurses can influence esp. if influences nursing care and nursing practice.

true
Supporters of the new law MUST be involved with its implementation esp. with regulations regarding the new law.
True or False?

Federal Register
Proposed rules and regulations at the federal level.

Federal Register
Regulations published daily

Federal Register
Best reference/resource for proposed new rules and changes in existing regulations in place for federal programs.

State Register
Similar publication

State Register
Proposed rules and regulations at the state level.

regulatory agencies that influence healthcare
Regulation of Physicians and other HC Professionals
Regulation of Hospitals and Other HC Institutions (Amb. Care Centers, HH agencies)
Regulation and Administration of HC finance
Regulation of Drugs and HC products
Regulation of Public Health Services
Regulation of HC Business Relationships
Regulation and Funding of HC Research

what are these?

Quality Assurance (QA)
_____________ which involved “monitors” to determine if process was “right or wrong”.

Hosptials
________ were first “health-related” organizations to explore and implement a “quality” mindset.

retrospective reviews
what’s right/what’s wrong; patient satisfaction; incident reports.

Focus
specific incident rather than global effect and needed improvements (cause)

quality improvement
Needed change of focus to preventing problems and improving care.

Accreditation
__________ is basically a “seal of approval” from an outside agency.

Accrediting Agencies
A method by which the quality of what takes place is assured.

Accrediting Agencies
Must show Quality Management strategies.

The Joint Commission (TJC)
Voluntary for hospitals serving various populations.

The Joint Commission (TJC)
One of the first regulatory agencies to embrace quality improvement principles in hospital-based settings.

The Joint Commission (TJC)
Examine standards of the organization and level of performance in three areas:
Patient rights
Patient treatments
Infection control

TJC
______ focus is on the organization’s ability to provide quality/safe care.

The Joint Commission (TJC)
It requires evidence that the agency actually does provide that care and how they demonstrate continued improvement.
“walk the talk”

Centers for Medicare and Medicaid Services (CMS)
Administers U.S. Medicare program

Centers for Medicare and Medicaid Services (CMS)
Non-voluntary accrediting agency

Centers for Medicare and Medicaid Services (CMS)
Mandatory for hospitals receiving Medicare & Medicaid reimbursements

Centers for Medicare and Medicaid Services (CMS)
Requires quality management (“conditions of participation”) in order to receive funds.

The National Committee for Quality Assurance (NCQA)
Voluntary accreditation body for managed care organizations (insurance companies), outpatient clinics and medical group practices.

The National Committee for Quality Assurance (NCQA)
Emphasis on performance measures of patient outcomes and results of practice patterns

Commission on Accreditation of Rehabilitation Facilities (CARF)
promotes quality management
requirements
standards.

TJC
________ required accredited hospitals to collect data on standardized “core performance measures”.

TJC and CMS
______ and _____ aligned their current and future measures common to both organizations.

Joint Commission
Hospitals had to collect and submit data on a minimum of core measures as described through _______________

ORYX Core Performance Measure Sets
Integration of outcomes and performance measured data for selected patient diagnoses.
(www.jointcommission.org)

ORYX Core Performance Measure Sets
Hospitals must collect and submit data on a minimum of four (4) core measure sets or a combination of core and non-core measures.

ORYX Core Performance Measure Sets
Standardized measures referred to a National Hospital Quality Measures reported publically on TJC website.

Core Measures of TJC
Core Measures address:
Acute Myocardial infarction
Heart Failure
Pneumonia
Pregnancy and related conditions
Surgical care improvement project (SCIP)
Children’s asthma care
Hospital outpatient department
Hospital-based inpatient psychiatric services

Acute Myocardial Infarction (MI)
Aspirin administered at arrival if not documented that it was given en route to the hospital

Acute Myocardial Infarction (MI)
Smoking history for the past year and documentation that smoking cessation information was given

Acute Myocardial Infarction (MI)
Complete home medication and discharge medication list

Pneumonia
Blood cultures must be drawn prior to starting the antibiotics

Pneumonia
Antibiotics must be administered within 6 hours of hospital arrival

Knowledgeable
Impacts nursing’s future; some new regulations may change nursing care and nursing practice.

Knowledgeable
Assess the effect of proposed regulation on nursing care and nursing practice (long term); patient advocate.

Knowledgeable
State Board of Nursing publication (Examiner).

Stakeholder
Attend public hearings, speak, write to legislators.

Stakeholder
Protect and influence nursing practice.

Regulations
are part of the process in the development of HC policy:
Identify health problem/issue
Legislation
Implementation (regulations)

1847
Massachusetts Health Insurance of Boston offers group policy

1861-1865
Insurance plans available during Civil War

1929
First group health coverage for a monthly charge for teachers in Dallas, Texas; beginning of Blue Cross/Blue Shield

1950s
Employee benefit packages initiated to attract workers

1965
Creation of Medicare and Medicaid programs, making comprehensive health care available to millions of Americans

1980-1990
Managed care plans emerge

1993
Hospitals come under DRGs

2003
Medicare Prescription Drug Improvement and Modernization Act of 2003; most significant expansion of Medicare since its enactment

2006
Pay-for-performance introduced

2008
Medicare no longer pays hospitals for treating preventable errors known as never events

2010
Congress passes sweeping health care reform legislation: Patient Protection and Affordable Care Act

Fee-for-service
payment method and economic incentives contributed to increased costs
The more tests or procedures performed, the greater the physician’s earnings because earnings tied to procedures
Economic incentives to provide as much care as possible
Patients insulated from costs because insurance was paying the bill

Fee-for-service
Lack of cost consciousness contributed to increased costs
Patients not aware of costs
Providers had little incentive to be concerned about costs
Providers received more income for using more services
Providers incurred no financial risk for using additional resources

Medicare
___________ expenditures increased rapidly
The program was implemented in 1965 with a fee-for-service payment mechanism
Rapid growth of expenditures became a major factor in the federal budget deficit

Medicare
__________ moved to a prospective payment system based on DRGs

Medicare
___________ limited total payment to the hospital to an amount preestablished for the patient’s specific DRG

Medicare
Shift critical for hospitals because ____________ was the largest single payer of hospital charges

Medicare
__________ extended financing revolution to physician reimbursement in the early 1990s and initiated the resource-based relative value scale (RBRVS)

RBRVS
___________ brought physician reimbursement more in line with skills required and actual time spent on procedures

Managed Care
Encompasses several different approaches
Health maintenance organizations (HMOs)
Preferred provider organizations (PPOs)
Point-of-service plan (POS)
The insurance company, a peer review organization, or another review mechanism evaluates patient’s medical options and brings cost consciousness to bear on medical decision making

Health maintenance organizations
(HMOs)

Preferred provider organizations
(PPOs)

Point-of-service plan
(POS)

Managed Care
Primary commonality is a method to oversee the use of health services
Coverage may be denied (in contrast to the previous “if it might help, do it” approach)
Goal is to minimize payment for inappropriate or excessive health services

Managed Care
Rapid expansion of managed care in response to numerous factors
Overuse of medical care and resources
Effects of employers’ health costs on business profits
International competitiveness

B
The 1983 “revolution” in health insurance reimbursement that formed the primary method of reimbursement in today’s health care system was due to:
A. The inferior care provided by managed care organizations
B. Rapidly rising health care costs
C. Technological advances that increased the cost of health care
D. The change from a prospective to a retrospective payment system

Lack of access to health care
Primarily reflects a lack of health insurance coverage
In 2010, 49.9 million people in the U.S. were uninsured (16.3% of the population)
Primary groups with no insurance
Working poor employed by small firms without insurance coverage
Part-time workers and unemployed people

Poor
________ more likely to lack usual source of care, less likely to use preventive services, and more likely to be hospitalized for avoidable conditions

Medicaid
Combined federal and state health insurance program

Medicaid
Intended to improve access to health care for the poor

Medicaid
Intended to improve access to health care for the poor

Medicaid
Recipients are not as likely to obtain needed health services

cost shifting
Underinsured and uninsured generate uncompensated care and “bad debt” for health care providers, who must then increase charges to paying customers (households and public and private insurers) in a process known as _________

Uncompensated care and cost shifting
primary reasons some groups advocate for national health insurance

Patient Protection and Affordable Care Act (PPACA)
Expands health insurance coverage to uninsured Americans while controlling costs and improving the quality of health care

Patient Protection and Affordable Care Act (PPACA)
Individual mandate for U.S citizens and legal residents to be covered by a health insurance plan

Patient Protection and Affordable Care Act (PPACA)
Addresses many issues including employer requirements, health insurance exchanges, and prevention and cost-reduction approaches

B
What is one rationale in support of health care reform?
A. The percentage of the gross domestic product (GDP) for health care in the United States is less than in countries with national health insurance.
B. Uninsured populations generate uncompensated care costs, leading to a process known as cost shifting.
C. Medicaid limits coverage to those who are at or below poverty level.
D. The government does a better job of managing expenditures when compared with private companies.

Labor
or inputs devoted to producing health care
Nurses, physicians, pharmacists, technicians, administrators
Education and training for “labor”

Capital
including all medical facilities and equipment available

Land
including the actual land area for hospitals and other facilities

entrepreneurship
encompasses skills and risk taking that businesspersons bring to health care organizations

Market System
Means by which a buyer and a seller come together so the buyer can purchase products or services from the seller

Market System
Implies private ownership of resources and private decision making by consumers about their purchases and by businesses about their products and sales

competitive market system
U.S. economy founded on the principles of a ________________

Competitive market
Numerous buyers and sellers in the market, so no single seller can manipulate the price
Consumers and sellers are well informed about market conditions and prices
New resources are free to enter and leave this market

Regulated market system
Implies some sort of government control over business owners/sellers

Regulated market system
U.S. health care system is a regulated market system because it is regulated to some extent by federal or state legislation

Regulated market system
Most European countries include a substantial amount of government planning in their health systems

U.S.
________ system violates principles of competitive market
Consumers may not know what health care to purchase without a provider’s diagnosis
Difficult to get information about prices of services
Providers may be in charge of decision making about what services the patient needs
Provider’s reimbursement incentives may encourage overuse or underuse of treatment options
Consumers often pay less than full price because the health insurance may pay part or all of the costs
With health insurance, the consumer may perceive health care as cheaper than it is and may be motivated to overconsume

Third-party payers
Entities other than the patient that assume responsibility for payment (e.g., health insurance company)
Interfere with common principles of a competitive market system

Private insurance
Accounts for the largest percentage of coverage for health care

Private insurance
Cost of health insurance to employees passed on by the employer to the consumer

Private insurance
Everyone pays part of the country’s health care cost in every purchase made

Private insurance
Individuals also pay a portion of their health care directly through payments for insurance premiums, deductibles, and copayments

Private insurance
With managed care products such as HMOs and PPOs, the premium the consumer pays for coverage has continued to rise

Government
is the biggest influence in the health insurance market, generating 50% of hospital revenues and 25% of physician incomes

Medicare
Largest health insurance program in the U.S.

Medicare
Entitlement program based on age or disability criteria rather than on need

Medicare
Part A covers inpatient hospital services, skilled nursing facilities (SNFs), and home health benefits

Medicare
Part B covers physician services

Medicare
Part D provides a prescription medication benefit

Medicaid
Joint federal-state program to provide health insurance coverage for impoverished families

Medicaid
Covers primarily disabled persons, low-income households with children, and those in nursing homes who qualify on the basis of low income

Medicaid
Primary payer of long-term care nationwide

Medicaid
represents the fastest growing component in the state budget

Pay-for-performance
method of reimbursing providers based on the quality of care provided with an emphasis on disease prevention and reduction of complications

Never events
Medicare no longer pays hospitals for the extra cost of treating preventable errors commonly referred to as never events

Never events
Purpose is to encourage hospitals to direct resources to preventing errors rather than being paid for them

Never events
hospital-acquired infections, injuries from falls, wrong site surgery, mismatched blood transfusions, and others

American Nurses Association’s Health System Reform Agenda
Supports quality health care as a basic human right and universal access to health care for all U.S. citizens

American Nurses Association’s Health System Reform Agenda
Confirms that the health care policies must be outcomes based and reflect the IOM’s six quality aims for health care: safe, effective, efficient, timely, patient-centered, and equitable

American Nurses Association’s Health System Reform Agenda
Targets primary care to lower dependence on costly secondary and tertiary care

American Nurses Association’s Health System Reform Agenda
Advocates team approach that includes consumers, providers, policymakers, and industry leaders to create an affordable health care system

Care coordination
decrease duplication of services and reduce wasted health care resources

Case Management
ensure that patients get effective treatment at the appropriate level of care

Disease Management
manage and improve the health status of a defined patient population over the course of a disease

Outcomes management
demonstrate efficiency of care via measurable, effective outcomes

Legislation
____________ is in place to protect individuals enrolled in managed care plans: access, quality, cost

1. 44,000 2.98,000
Between __1__ and __2__ Americans die from medical errors annually

2 billion
Medication-related errors for hospitalized patients cost ______ annually

49 million
__________ uninsured Americans exhibit consistently worse clinical outcomes than the insured and are at increased risk for dying prematurely

17
Lag between discovery of more effective forms of treatment and their incorporation into routine patient care is _____ years

25%
______ of patients are not receiving care that is recommended

National Healthcare Quality
The 2008 ________________ report notes that U.S. health care quality is suboptimal and continues to improve at a slow pace

Safe
avoiding injuries to patients caused by the care that is intended to help them

Timely
reducing waits and sometimes harmful delays for those who receive and give care

Effective
providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit

Efficient
avoiding waste of equipment, supplies, ideas, and energy

Equitable
providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, socioeconomic status

Patient-centered
providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Quality
customer defines quality

Scientific approach
organizational support for all employees to develop knowledge and skills in the science of QI

All one team
belief in the people who are working to serve the customer

Quality
Customers pay attention to both personal interactions and products or services

Quality
If the “bundle” of products or services provided is seen as a good value, then customer loyalty is enhanced

Scientific Approach
Improvement decisions based on sound, valid data

Scientific Approach
Variation in processes must be understood
Common cause variation: stable, predictable, and in statistical control
Special cause variation: unstable, unpredictable, and not in statistical control

Common cause variation
stable, predictable, and in statistical control

Special cause variation
unstable, unpredictable, and not in statistical control

All One Team
Believe in people and treat everyone in the workplace with dignity, trust, and respect

All One Team
Everyone in the organization works together to continually enhance customer satisfaction

W. Edwards Deming
Worked with the Japanese in post-World War II reconstruction efforts

W. Edwards Deming
Introduced U.S. to quality management principles

W. Edwards Deming
American pioneer in quality management movement

Hospitals
____the first health-related organizations to explore quality efforts beginning in the 1980s

Quality assurance
Inspection oriented
Reactive to problems
Corrected special problems and did not address overall process improvement
Responsibility belonged to only a few people

Quality improvement
Planning and prevention oriented
Problem solving by employees at all levels
Correction of common cause problems and improvement in work processes

Regulatory organizations
Centers for Medicare & Medicaid Services (CMS)
Administers the Medicare program
Requires quality management in “Conditions of Participation”
State licensing authorities require quality management activities and set quality standards

2002
TJC required accredited hospitals to collect data on standardized “core” performance measures

2004
TJC and CMS aligned their current and future measures common to both organizations

2009
reporting requirements allow hospitals to collect and submit data on a minimum of four core measure sets or a combination

C
A patient understands that the hospital where he is currently having a procedure done is “Joint Commission” accredited. The patient asks the nurse how accreditation ensures that patients receive the best care possible. The nurse informs the patient that there are several quality initiatives required by The Joint Commission in order for the hospital to be accredited. One of these quality initiatives is known as:
Pareto charts
Never events
Core measures
PDSA cycle

Flowchart
Maps out what actually occurs in a work process
Includes steps and substeps, and who does the work

Pareto chart
Bar chart
Reflects frequency at which events occur, or the effect events have on a process

Cause-and-effect diagram
Lists potential causes arranged by category to show their effect on a problem
Helps determine potential causes of a problem

Run chart
Graph of data points as they occur over time
Sometimes referred to as time plots
A control chart is a more sophisticated run chart that helps to distinguish between “common” cause and “special” cause

C
A quality improvement team was collecting data to determine how nurses use their time and to identify areas to improve nurses’ efficiency. The team found that 60% of nurses’ time was spent charting, 30% was spent in direct patient care activities, and 10% was spent on patient and family teaching. Which type of chart would best support the data collected by the quality improvement team?
Cause and effect
Flowchart
Pareto
Time plot

Purpose of Standardization
Referred to as best known methods or best practices
Care carried out in uniform, systematic method
Employees trained to perform procedures according to standards rather than learning by watching others
Avoids haphazard changes to procedures

Standardization
Clinical guidelines or pathways
Outline the optimal sequencing and timing of clinical interventions for a particular diagnosis or procedure

Standardization
Benefits
Reduction in variation of care provided
Facilitation and achievement of expected outcomes
Reduction in care delays and lengths of stay
Improvements in cost-effectiveness
Increase in patient and family satisfaction with care

Clinical algorithms or protocols
outline decision paths that a practitioner might take during a particular care episode or need (e.g., ACLS algorithms)

Institute for Healthcare Improvement (IHI)
Voluntary organization formed to assist health care leaders to improve quality
Led development of change concepts for specific areas
Reducing patient delays
Reducing cesarean deliveries
Reducing adverse drug events

Two-Part Model for Improving Health Care (IHI)
Plan-do-check-act (PDCA) cycle
Plan: develop action plan based on the three questions
Do: take action to test the action plan
Check: make refinements as needed
Act: implement resultant changes in real work settings

Plan
develop action plan based on the three questions

Do
take action to test the action plan

Check
make refinements as needed

Act
implement resultant changes in real work settings

Institute for Safe Medication Practices
Nonprofit organization known as an education resource for the prevention of medication errors
Provides independent, multidisciplinary, expert review of reported errors
Health care professionals across the nation voluntarily and confidentially report medication errors and hazardous conditions that could lead to errors
Offer Medication Safety Self Assessments to allow nurses and other health care professionals to assess the medication safety practices in their work setting

TJC sentinel event standard
Requires organizations to carry out designated steps to fully understand the factors and systems associated with adverse patient events

TJC sentinel event standard
Root cause analysis: conducted to understand the systems at fault within the organization so that improvements can be determined and implemented to prevent future occurrences

Root cause analysis
conducted to understand the systems at fault within the organization so that improvements can be determined and implemented to prevent future occurrences

TJC National Patient Safety Goals
Purpose: promote specific improvements in patient safety with the goals highlighting problematic areas and evidence-based solutions to the problems with system-wide solutions wherever possible

Purpose
promote specific improvements in patient safety with the goals highlighting problematic areas and evidence-based solutions to the problems with system-wide solutions wherever possible

TJC 2010 National Patient Safety Goals
Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
Improve the safety of using medications
Reduce the risk of health care-associated infection
Reduce the risk of patient harm resulting from falls
Prevent health care-associated pressure ulcers
The organization identifies safety risks inherent in its patient population
Universal Protocol—the organization fulfills the expectations set forth for eliminating wrong site, wrong procedure, wrong person surgery

Universal Protocol
the organization fulfills the expectations set forth for eliminating wrong site, wrong procedure, wrong person surgery

CMS “never events”
Serious, costly errors that should never happen
Examples: wrong site surgery, mismatched blood transfusions, patient falls, hospital-acquired infections
CMS will no longer pay the additional cost of hospitalization of such conditions as an incentive to hospitals to prevent the events

monitoring and initating
Two significant nursing functions closely influence patient safety and quality

National Database of Nursing Quality Indicators (NDNQI)
Indicators that strongly affect clinical outcomes
Two major purposes
Provide comparative data to health care organizations to support quality improvement activities
Acquire national data for better understanding of link between nurse staffing and patient outcomes

Interprofessional Teamwork
Work environment that supports effective communication of nurses with other health care professionals is critical to patient safety

Interprofessional Teamwork
Patient care dependent on effective communication to support coordination of activities to promote efficiency and safety

Quality improvement
______________ should not be considered a separate function within the nursing role but rather an ongoing part of the professional role

U.S. Health Care System
Most technologically advanced
Most expensive system in the world
Failures in the system occur with some regularity

IOM’s Quality Chasm Reports
Sustained the imperative to address inconsistent outcomes and prevent errors
Medical errors erode public confidence, increase health care costs, and increase morbidity and mortality

IOM’s 2003 Health Professions Education: A Bridge to Quality
Recommendations for health professions’ education
Identified competencies all health care professionals should achieve
Education needs to allow students to form a professional identity in preparation to deliver patient-centered care as members of an interprofessional team, emphasizing evidence-based practice, quality improvement, and informatics (Cronenwett et al., 2007; Greiner and Knebel, 2003)
Competencies are not discrete concepts but overlap

QSEN
Whos faculty determined that quality and safety should be separate because of the science supporting each?

QSEN
Funded by the Robert Wood Johnson Foundation and created to:
Facilitate the execution of changes in nursing education
Offer new opportunities for faculty development
Learn from a 15-school pilot collaborative

QSEN
six _______ competencies

Patient-centered care
Quality improvement
Teamwork and collaboration
Evidence-based practice
Safety
Informatics

Patient-Centered Care
recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs

Patient-Centered Care
Knowledge
Integrate understanding of multiple dimensions of patient-centered care
Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values

Patient-Centered Care
Skills
Elicit patient values, preferences, and expressed needs as part of clinical interview
Communicate patient values, preferences, and expressed needs to other members of the health care team

Patient-Centered Care
Attitudes
Value seeing health care situations “through patients’ eyes”
Respect and encourage individual expression of patient values, preferences, and expressed needs

Patient-Centered Care
What approach is this?
What is the most important thing I could do for my patient at this moment?
How can the patient and/or family participate in accurately assessing the patient’s pain and determining the best pain management plan that recognizes the patient’s attitudes and expectations about pain and suffering?
How can I assist family members with visiting hours and access to their family member to allay anxiety and include them as partners in care?

C
Nurses in a home health agency are implementing a policy to include input from the patient in the patient’s plan of care. This action by the nurses represents:
A. Evidence-based practice
B. Interprofessional teamwork
C. Patient-centered care
D. The communication technique of “call-out”

Teamwork and Collaboration
function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care

Teamwork and Collaboration
Knowledge
Describe one’s own strengths, limitations, and values in functioning as a team member
Describe examples of the effect of team functioning on safety and quality of care

Teamwork and Collaboration
Skills
Demonstrate awareness of one’s own strengths and limitations as a team member
Follow communication practices that minimize risks associated with hand-offs among providers and across transitions in care

Teamwork and Collaboration
Attitude
Acknowledge one’s own potential to contribute to effective team functioning
Appreciate the risks associated with hand-offs among providers and across transitions in care

66%
Up to ____ of health care errors are related to poor working relationships and communication

Standardized communication strategies
help team members share concerns, clarify decisions about care, and ensure accurate and complete information exchange

B
A patient who is 1 day postop following a right knee replacement is complaining of a pain level of 8 (on a 10-point scale) after having received his pain medication 2 hours ago. The pain medicine is ordered every 4 hours. The nurse calls the physician and provides the following information: “Dr. Michaels, this is Jane Stallings, RN at Fairview General. I am calling about Mr. Stuart Phillips. Mr. Phillips is 1-day postop right knee replacement and is reporting a pain level of 8 after receiving morphine 1 mg 2 hours ago. The medication is ordered to be given every 4 hours. His blood pressure is 148/86; pulse 104; respirations 24; temperature 98.6. The dressing on the right knee is clean and dry and 4+ pedal pulse. He may need a higher dose of morphine to control the pain. How would you like to change his orders?” What form of standardized communication is the nurse using?
A. Critical language
B. SBAR (situation background assessment recommendation)
C. Check-back
D. Hand-off

Evidence-Based Practice
integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

Evidence-Based Practice
Knowledge
Demonstrate knowledge of basic scientific methods and processes
Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preference

Evidence-Based Practice
Skills
Participate effectively in appropriate data collection and other research activities
Consult with clinical experts before deciding to deviate from evidence-based protocols

Evidence-Based Practice
Attitude
Appreciate strengths and weaknesses of scientific bases for practice
Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices

Quality Improvement
use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continually improve the quality and safety of health care systems

Quality Improvement
Knowledge
Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice
Describe approaches for changing processes of care

Quality Improvement
Skills
Seek information about outcomes of care for populations served in a care setting
Design a small test of change in daily work

Quality Improvement
Attitude
Appreciate that continual quality improvement is an essential part of the daily work of all health professionals
Appreciate the value of what individuals and teams can to do improve care

Safety
minimize risk of harm to patients and providers through system effectiveness and individual performance

Safety
Knowledge
Examine human factors and other basic safety design principles as well as commonly used unsafe practices
Discuss potential and actual effect of national patient resources, initiatives, and regulations

Safety
Skills
Demonstrate effective use of technology and standardization practices that support safety and quality
Use national patient safety resources for own professional development and to focus attention on safety in care settings

Safety
Attitude
Value the contributions of standardization/reliability to safety
Value relationship between national safety campaigns and implementation in local practices and practice settings

Safety
Health care organizations focused on safety use constant surveillance to manage the potential for humans (health professionals) to make unintentional mistakes

Informatics
use information and technology to communicate, manage knowledge, mitigate error, and support decision making

Informatics
Knowledge
Identify information that must be available in a common database to support patient care
Describe how technology and information management are related to the quality and safety of patient care

Informatics
Skills
Navigate the electronic health record
Respond appropriately to clinical

Informatics
Attitude
Value technologies that support clinical decision making, error prevention, and care coordination
Value nurses’ involvement in design, selection, implementation, and evaluation of information technologies to support patient care

informatics and IT
_________________are links to ensure patient safety through improved information access and data management

Statutory law
Laws written and enacted by legislative bodies
Violations are criminal offenses and are punishable by fines or imprisonment

The Federal False Claims Act
makes it an offense to submit a false claim to the government for payment of health care services

Whistle-blower
reports false or fraudulent claim

Emergency Medical Treatment and Active Labor Law (EMTALA)
Prohibits refusal of care for indigent and uninsured patients seeking medical assistance in emergency departments
Prohibits transfer of unstable patients, including women in active labor, from one facility to another
Applicable to nonemergency facilities (i.e., urgent care clinics)

Americans with Disabilities Act of 1990 (ADA)
prohibits discrimination against persons with disabilities by removing barriers that might prevent the same opportunities available to persons without disabilities

Patient Self-Determination Act of 1990
requires federally funded hospitals (Medicare, Medicaid) to inform adult patients in writing about their right to make treatment choices and to ask patients if they have a living will or durable power of attorney

Health Insurance Portability and Accountability Act of 1996; hippa
ensures confidentiality of a patient’s medical records; sets guidelines for maintaining the privacy of health data

The Patient Safety and Quality Improvement Act
allows certain disclosures of patient safety data

nurse practice act
Violations of the _____________t or rules and regulations
Licensing boards have the authority to hear and decide cases against nurses
Penalties that may be imposed:
Issuing a formal reprimand
Establishing a period of probation
Levying fines
Limiting, suspending, or revoking the nurse’s license

Child Abuse Prevention and Treatment Act and reporting statutes
Laws mandating reporting of specific health problems and suspected or confirmed abuse
Health professionals must report the following under penalty of fine or imprisonment for failing to do so:
Infant and child abuse
Dependent elder abuse
Specified communicable diseases
Most laws grant immunity from suit within the context of the mandatory reporting statute

licensing laws
All facilities that provide health care services must comply with_____________________
Generally contained within the law are:
Minimum standards for maintenance of the physical plant
Basic operational aspects for major departments—nursing, dietary, clinical labs, and pharmacy
Essential aspects of patient rights and informed consent process
Copies of licensing laws can be obtained from the state health department

A
A nurse is checking orders at the front desk when a visitor asks the room number of his father. The nurse leaves the chart open while looking up the room number on the computer, allowing the visitor to read the patient’s recent x-ray film report. Which law would protect this client from others having access to his or her medical information?
A. Health Insurance Portability and Accountability Act of 1996
B. Patient Self-Determination Act of 1990
C. Emergency Medical Treatment and Active Labor Law
D. Americans With Disabilities Act of 1990

American Nurses Association (ANA) Standards of Professional Performance
Should be used along with Standards of Quality Practice to guide nurses

Common Law
Created through cases heard and decided in federal and state appellate courts—also known as decisional or judge-made law

Common Law
Nursing case law
Body of written opinions about nursing practice
Importance cannot be overstated in establishing the current standard of practice
One important case established “affirmative duty”—the duty that nurses exercise independent judgment to prevent harm to patients
Nurses should review case law and journals dedicated to legal issues in nursing practice
Common law and case law provide courts with guidelines for deciding future cases

affirmative duty
the duty that nurses exercise independent judgment to prevent harm to patients

Civil Law
Negligence and malpractice

Negligence
failure to act in a reasonable and prudent manner

Malpractice
special type of negligence; that is, the failure of a professional, a person with specialized education and training, to act in a reasonable and prudent manner

Civil Law
Elements essential to prove negligence or malpractice
Nurse owed patient a special duty of care based on the establishment of a nurse-patient relationship
Nurse breached duty to the patient or client
The patient suffered actual harm or damage
Proximate cause or a causal connection has been established between the standard of care provided by the nurse and the patient’s injury

nursing negligence
Failure to ensure patient safety
Improper treatment or negligent performance of treatment
Failure to monitor patient and report significant findings
Medication errors
Failure to follow agency’s policies and procedures

res ipsa loquitor
Applies when the negligent act clearly lies within the range of a jury’s common knowledge and experience to determine the standard of care—”the thing that speaks for itself”
Expert nurse witness not required to help establish the standard of care
For example, studies confirm that approximately 1000 to 2500 foreign bodies annually(instruments, needles, sponges) are inadvertently left in the patient after surgery

Gross Negligence
Reckless act that reflects a conscious disregard for the patient’s welfare
Court may award special damages meant to punish the nurse for the outrageous conduct; these are referred to as punitive damages

student nurse
Dennis v Specialty Select Hospital—Flint, Mich., 2005

Criminal negligence
Constitutes a crime—the act is deemed so reckless that it results in serious injury or death to the patient
Consequences in addition to criminal charges
Loss of job and livelihood
Suspension or revocation of license
Out-of-pocket fines levied by the nursing board
Significant attorney’s fees
Malpractice insurance may not cover costs in all cases
Conservative estimates suggest that as many as 98,000 patients die each year as a result of negligence and malpractice of health care providers

B
While assisting in the labor room, a nurse is helping to stimulate a newborn infant who has a low Apgar score. The nurse stumbles, allowing the baby to fall to the floor, resulting in the infant’s death. This situation is referred to as:
A. Criminal negligence
B. Sentinel event
C. res ipsa loquitur
D. A negligent act

Emergency situations
nursing care rendered in a life-threatening emergency may breach the standard of care required under normal circumstances

Governmental immunity
individual health care workers employed in federal or state facilities are shielded from personal responsibility for damages in malpractice cases

Good Samaritan immunity
limits a nurse’s liability or shields the nurse from malpractice for rendering emergency assistance outside the employment setting

ANA Code of Ethics and American Medical Association’s Code of Medical Ethics
the central role of nurses is to prevent patient harm

tjc
In 2001 _____ established a safety standard requiring institutions to have a process in place to disclose unanticipated outcomes to patients

Malpractice Insurance
Some employers may fail to initiate an adequate defense for nurses
Insurance coverage limits that are lower than the actual judgment made against the nurse in a lawsuit
what type of insurance?

Liability
Asserts that every person is responsible for the wrong or injury done to another as the result of carelessness

Personal Liability
Requires nurse to assume responsibility for patient harm or injury that is a result of negligent acts
Nurse cannot be relieved of liability by another professional, such as a physician or nurse manager
Damages can be levied against current assets and future earnings

Personal liability with floating and cross-training
Nurses should be cognizant of state statutes and case law services outside their usual practice area
In no case is a nurse permitted to render services if the requisite knowledge to act competently is lacking
Nurses have a legal duty to refuse specific tasks that they cannot perform safely and competently but should consider negotiation and compromise with the supervisor

Personal liability for team leaders and managers
Held to the standard of care of a reasonably prudent supervisor
Team leaders and managers have been held negligent for issues surrounding:
Triage of staff and equipment
Supervision of subordinates
Delegation of patient care tasks
Reporting of team member performance deficits
Supporting or invoking the chain of command process when indicated

Nurse managers and administrators
_______ held liable for:
Inadequate training
Failure to periodically reevaluate staff competencies
Failure to discipline or terminate unsafe workers
Negligence in developing appropriate policies and procedures
Failure to uphold institutional licensing laws and state and federal statutes

RNs
___functioning in the role of team leader or in any supervisory capacity should review the following:
Detailed job description, including responsibilities when asked to supervise in an unfamiliar area or floor
Job descriptions for team members
Formal period of training and mentoring in the role
Validated proof of competencies
Guidelines for personal patient care assignments
Chain of command

Nurse managers and administrators
__________ should be aware of case law regarding incompetent charge nurses and team leaders

Personal Liability
________ in delegation and supervision of team members
Nurses must be absolutely clear about the lawfulness of patient care assignments
Determine whether it is reasonable and prudent to delegate a task on the basis of knowledge of the worker, patient status, and current work setting conditions
Employer liability: vicarious liability

vicarious liability
Defenses against claims of __________________________
Borrowed servant and “captain of the ship” doctrines
Employer also may be liable for negligent conduct of nurses within the scope of their employment
Based on the legal principle of respondeat superior (let the master answer)—adequate numbers of qualified nursing staff

Corporate liability
Health care corporation can be held to a specified standard of care
Health care facilities have been found corporately liable for failing to have adequate numbers of qualified nursing staff
TJC has developed standards related to orientation, training, and education of agency staff

Risk management systems
Track incidents and accidents in the facility
Assist in the development of policies and procedures to improve practice
Provide knowledge about federal and state laws, licensing laws, and health care case law

Intentional Torts in Nursing Practice
Direct violation of a person’s legal rights
Plaintiff does not have to prove that the nurse breached a special duty or was negligent
Consequences include fines and punitive damages, but may rise to the level of criminal acts

Assault
is causing a person to fear that he or she will be touched without consent

Battery
is the unauthorized touching or the actual harmful or offensive touching of a person and may rise to the level of a crime

Assault and battery
Nurse should ask patient’s permission before initiating any procedure and document permission granted

Libel
is defamation caused by written word; nurses subject to libel for subjective comments written in the medical record

Slander
is defamation caused by spoken word; nurses subject to slander when they repeat subjective comments about patients in public places

False imprisonment
Unlawful restraint or detention of another person against his or her wishes
Nurse has no authority to detain a patient even if there is likelihood of harm or injury

Invasion of privacy
Person’s private affairs (including health history and status) are made public without consent
Nurse has a legal and ethical duty to maintain patient confidentiality

Intentional infliction of emotional distress
Nurse’s behavior is so outrageous that it leads to the patient’s emotional shock

Crime
is an offense against society that is defined through written criminal statutes or codes
Punishable by fines, imprisonment, or the death penalty in some states
An increasing number of nurses are being charged with criminal acts

Misdemeanor offenses
Minor criminal offenses
Common offenses nurses are charged with
Illegal practice of medicine
Failing to report child abuse
Falsification of medical records
Assault and battery and physical abuse of patients

Felony acts
Major criminal offenses
Common offenses
Drug trafficking
Fraud in billing services for Medicare patients
Theft, rape, murder

The Law and Patient Rights
Advance directives
Statutes grant adults the right to refuse extraordinary medical treatment when no hope of recovery
Patient’s wishes are made known through execution of a formal document known as the living will
Medical and physician directives
Document that lists desire of patient in a particular scenario
If properly executed, provides physician with immunity from claims of negligence in the patient’s death

Durable power of attorney for health care
document that authorizes patient to name the person who will make the day-to-day and end-of-life decisions when he or she becomes decisionally incompetent

“Do not resuscitate” orders
Written by physician on the basis of directives by the patient
Nurses have absolute duty to respect patient’s DNR orders
A lawfully executed DRN order must be followed

informed consent
Physician or advanced practice nurse has duty to disclose information so patient can make intelligent choices
Mandated by federal statute and state law
Information that must be disclosed:
Nature of the therapy or procedure
Expected benefits and outcomes
Potential risks
Alternative therapies
Risks of not having the procedure

right to refuse treatment
An adult of sound mind has a right to refuse any treatment that has previously been agreed to
Nurse must notify provider if patient refuses treatment
Provider should give patient information about the consequences, risks, and benefits of refusing treatment and explore available alternatives

Against medical advice (AMA)
Nurse must act promptly to notify the provider
Nurse must clearly articulate the danger inherent in leaving
Value of AMA document will depend a great deal on the nurse’s charting, which should note that leaving the facility could result in the following:
Aggravated current condition and complicated future care
Permanent physical or mental impairment or disability
Complications leading to death
Nurses have been charged with offenses, including assault, battery, and false imprisonment, when they unlawfully detain patients

Nursing Ethics
system of principles that govern the actions of the nurse in relation to patients, families, other health care providers, policymakers, and society

Code of ethics
Implicit standards and values for the profession
American Nurses Association Code of Ethics
International Council of Nurses Code for Nurses

Bioethics
Interdisciplinary field within health care that has evolved with modern medicine to address questions that arise as science and technology produce new ways of knowing
Physicians, nurses, social workers, psychiatrists, clergy, philosophers, and theologians are joining to address ethical questions in health care

Bioethics
Dilemmas for health professionals
Life and death
Quality of life
Right to decide
Informed consent
Alternative treatment issues
Stem cell research
Therapeutic and reproductive cloning
In vitro fertilization; donor insemination
Surrogate motherhood
Organ transplantation

Bioethics
Dilemmas created by technology
Illnesses that once led to mortality are now manageable and are classified as chronic illnesses
Cost is a consequence of prolonging life with technology
Manipulation of DNA

Balancing science and morality
Nurses must examine life and its origins, as well as its worth, usefulness, and importance
Nurses must determine their own values and seek to understand the values of others

Health care decisions
Decisions are made with the patient, family, other nurses, and other health care providers
Nurses must develop a reasoned thought process and sound judgment in all situations that take place within the nurse-patient relationship

Value
personal belief about worth that acts as a guide to behavior

Value system
entire framework on which actions are based

Values clarification
a process by which people attempt to examine the values they hold and how those values function as a part of the whole

Moral development
forming a worldview and value system through an evolving, continuous, dynamic process that moves along a continuum of development

Examining value systems
Nurses must examine their own value systems; values clarification
Diane Ustal: first nurse leader to describe the role of values clarification
Ethics acculturation
Nurses must commit to a virtuous value system
Worldview
Provides a cohesive model for life
Encourages personal responsibility for living life
Prepares one for making ethical choices

Diane Ustal
first nurse leader to describe the role of values clarification

Infants
Begin with no concept of right or wrong
If the need for basic trust is met, infants will develop the foundation for secure moral thought

School-age children
Learn that good behavior is rewarded and bad behavior is punished
Begin to make choices that are based on an understanding of good and bad

Adolescent
Questions existing moral values and his or her relevance to society
Becomes more aware of contradictions in adults’ value systems

Adult
Strives to make sense of the contradictions and learns to develop own set of morals and values
Begins to make choices that are based on an internalized set of principles

Kohlberg’s theory
most widely accepted; a cognitive developmental process that is sequential in nature
Rules imposed by authority
Conformity to expected social and religious mores
Autonomous thinker who strives for a moral code beyond the issues of authority and reverence

B
Wong (Hockenberry et al, 2007) describes learning right from wrong as being based on developmental stages. At what developmental stage is a human first able to integrate values of significant others into his or her behavioral system?
A. Infant
B. Toddler
C. School-age child
D. Adolescent

Quality
_________ of complex health care decisions depends on the level of moral development of the professionals entrusted with decision making

Altruism
concern for the welfare of others

Autonomy
right to self-determination

Human dignity
respect for inherent worth and uniqueness of individuals and populations

Social justice
acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation

Ethics acculturation
Integrity, personal growth, practical wisdom, and effective problem solving

Ethical theory and ethical principles
can provide a basis for moving forward as a morally mature professional adult

D
A homeless person comes to the emergency department after being beaten. The nurse asks permission to remove the tattered clothing and carefully folds and places the clothing to prevent further soiling. The nurse informs the legal system that this person was assaulted and assists with securing legal representation. The nurse is at which moral development stage?
A. Unconventional
B. Preconventional
C. Conventional
D. Postconventional

Ethical Theory
a system of principles by which a person can determine what ought and ought not to be done

Utilitarianism
Rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences, or to the fewest possible bad consequences
Strongest approach for bioethical decision making—Which action will lead to the greatest ratio of benefit to harm for all persons involved?

Deontology
Rooted in the assumption that humans are rational and act out of principles that are consistent and objective, and compel them to do what is right
A decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty
All decisions are made in such a way that the decision could become universal law

Purpose of ethical principles
Establish common ground among nurse, patient, family, other health care professionals, and society for discussion of ethical questions and ethical decision making
Permit people to take a consistent position on specific or related issues
Provide an analytical framework by which moral problems can be evaluated

Autonomy
Principle of respect for the person: primary moral principle
Unconditional intrinsic value for all persons
People are free to form their own judgments and actions as long as they do not infringe on the autonomous actions of others
Concepts of freedom and informed consent are grounded in this principle

Beneficence
To promote goodness, kindness, and charity
To abstain from injuring others and to help others further their own well-being by removing harm; risks of harm must be weighed against possible benefits
Common bioethical conflict results from an imbalance between the demands of beneficence and those of the health care delivery system

Nonmaleficence
Implies a duty not to inflict harm
To abstain from injuring others
To help others further their own well-being by removing harm

Veracity
Principle of truth-telling
Belief that truth could at times could be harmful held for many years
Consumers expect accurate and precise information revealed in an honest and respectful manner
To develop trust between providers and patients, truthful interaction and meaningful communication must occur
Challenge is to mesh need for truthful communication with the need to protect

assessment
Identify the ethical issues and problems
What is the issue?
What are the hidden issues?
What are the complexities of the situation?
Is anything being overlooked?

alternatives for action
What are the reasonable possibilities for action?
How do the affected parties want to resolve the problem?
What ethical principles are required for each alternative?
What assumptions are required for each alternative and what are their implications for future action?
What additional ethical problems are raised by the alternatives?

select one alternative
Integration of multiple factors
A reasonable and purposeful decision results from the blending of ethical theory, principles, and values

Justify the selection
Decision maker must be prepared to communicate his or her thoughts through an explanation or the reasoning process used
Justification process
Specify the reasons for the action
Clearly present the ethical basis for these reasons
Understand the shortcomings of the justification
Anticipate objections to the justification

Bioethical Dilemmas: Life, Death, and Dilemmas in Between
Dilemmas that pose a choice between perplexing alternatives in the delivery of health care because of the lack of a clear sense of right or wrong
Nurses should consider the dilemmas that might arise in a given practice setting

Life
Bioethical abortion issue
When does life begin?
Nurses serving in women’s and children’s health settings must be prepared to face this morally laden issue
Reproduction issue: influenced by genetic screening, genetic engineering, and cloning

Death
Quality of life and definition of death issues: With advances in health care, what is usual and what is heroic care has become unclear
Euthanasia and assisted suicide present new ethical questions
Nurses in every setting must be prepared to consider end-of-life questions

Dilemmas in between
Right to health care
Health care system more selective in the amount and type of treatment offered as a result of managed care
Is each person entitled to the same health care package?
Does ability to pay affect specific level of entitlement?
How ethical is gatekeeping in the new managed care system?
Access to health care and respect for human dignity are at the core of nursing practice

Dilemmas in between
Allocation of scarce resources
Should the recipient of scarce resources be selected on the basis of quality of life? Ability to pay? Best prognosis? First-come, first-served?
Nurses should be prepared to consider questions regarding allocation of scarce resources

veracity
The challenge of _______-
Issues of alternative treatments and acknowledgment of uncertainty test truth-telling
Which treatment among two or more is best for the patient?
Which of the new drugs should be used?
Should every patient be subjected to every possible form of diagnostic treatment?
Should patient be made aware of questions and various options surrounding care?
Is disclosure of uncertainty beneficial or detrimental?

paternalism
The challenge of _____
Provider tries to act on behalf of the patient and believes that his or her actions are justified because of a commitment to act in the best interest of the patient
Interferes with a patient’s right to self-determination

autonomy
The challenge of ________
Makes way for the crucial legal step of informed consent
When are patients competent to make informed consent decisions? Can family members or surrogates make decisions by proxy?
Questions about informed consent are raised for minors, confused older adults, mentally compromised, imprisoned, inebriated, unconscious, and those in emergency situations
Nurses also must take responsibility for understanding and educating people about advance directives

accountability
The challenge of ____________
Nurses have an obligation to uphold the highest standards of practice, to assume full and professional responsibility for every action, and to commit to maintaining quality in the skills and knowledge base of the profession
Obligation to denounce a harmful action or potentially threatening situation may fall to a fellow member of the profession; to remain silent is to consent to the action of the threatening situation

health information technology (HIT)
Advancements in the widespread use of ___________________ first occurred in European countries
Germany initiated a universal HIT process in 1993
Norway in 1997
United Kingdom in 2002

HIT in the United States
For electronic health record (EHR) systems to have the greatest impact on cost and quality, they must be interoperable with the ability to exchange information across systems and settings in a standardized manner

Goal of both the Bush and Obama administrations has been to have universal EHR adoption in the United States by 2014

EHR; Electronic Health Records
is a system that captures, processes, communicates, secures, and presents data about a patient

EHR; Electronic Health Records
Integration of information from multiple sources
Serves as a primary source of information for patient care and quality

Data capture
collection and entry of data into an EHR system

Storage
the physical location of data

Information processing
provides for effective retrieval and processing of data into useful information

Information communication
interoperability of systems and linkages for exchange of data across disparate systems

Security
provide better protection of confidential health information because of incorporated controls

Institute of Medicine
______________recommends that EHR systems offer eight functionalities
Health information and data
Results management
Computerized provider order entry (CPOE) with or without decision support
Clinical decision support
Electronic communication and connectivity
Patient support for patient education and home monitoring, when applicable
Administrative processes
Reporting and population health management

Decision Support and CPOE
Two specific functionalities recommended as essential for improving the quality and safety of health care

Clinical decision support
i. Automatic reminders about preventive practices
ii. Drug alerts for dosing and interactions
iii. Electronic resources for data interpretation and clinical decision making

CPOE
Clinician with order writing authority sits at a computer to directly enter patient care orders
Eliminates lost orders and illegible handwriting
Prevents medical error
Improved communication and readily accessible knowledge
Requires key information (e.g., drug dose)
Calculation assistance
Checks performed in real time
Assistance with medication monitoring
Decision support
Rapid response and tracking of adverse events

Information Presentation
Information available through EHR systems must ensure that authorized caregivers (including nurses) have the information they need in their preferred presentation form
Examples:
Data organized by source, caregiver, encounter, problem, or date
Data can be presented in detail or summary form
Tables, graphs, narrative, and other forms of information presentation must be accommodated

EHR and “Meaningful Use”
Defined as a complex set of capabilities and standards to be met by EHR use in a series of stages over several years
Stage 1 (2011-2012)
Quality, safety, and efficiency
Engage patients and families in their health care
Improved care coordination
Improved population and public health
Privacy and security protections for PHI
Stage 2 (2014 – ): continuous quality improvement
Stage 3 (~ 2015 ): decision support tools and quality metrics

Opportunities and Barriers to EHR
Opportunities
Financial Incentives
Quality care, safety, efficiency
Continuity of care
Barriers
Meeting guidelines is strenuous and costly
Lack of interoperability
Corporate competition
EHR implementation cost

Health Insurance Portability and Accountability Act (HIPAA)
In the early 1990s, the U.S. President called together health care industry leaders to determine how the administrative costs of health care could be decreased
Leaders determined that the use of an electronic data interchange within the health care industry held the greatest promise for decreasing costs
Recommended that national standards for electronic data interchange and information privacy and security be established

regulations focus on the privacy and security of patient data

Health Insurance Portability and Accountability Act (HIPAA)
Any institution that collects/stores protected health information (PHI) is required to name a privacy officer, provide employee training, and implement HIPAA policies and procedures
Access to PHI must be to only employees with a need to know specific information
Individuals who violate HIPAA may be subject to criminal penalties and civil monetary penalties

B
The Health Insurance Portability and Accountability Act (HIPAA, 1996) provides:
A. Health insurance at a group rate in the event of unemployment
B. Regulations to ensure privacy and security of patient data
C. The ability for individuals within an organization to choose between different types of health insurance, such as health maintenance organizations or preferred provider organizations
D. A method to ensure that providers are ordering only necessary diagnostic testing to limit out-of-pocket spending

Point of Care Technologies
Paramount to deliver safe, efficient, quality patient care
Easy access to patient data (past and present), references, policies, procedures, evidence-based literature
Hand-held computers, laptops, tablets, smart phones, and PDAs
Moves from practice that relies on memory to continuous use of resources as they are needed

Telehealth
Telecommunications technology to assess, diagnose, and, in some cases, treat persons who are located some distance from the health care provider

Telehealth
Home care arena has seen significant changes as a result of telehealth

Telehealth
Telehome care devices: automated blood pressure monitors, glucometers, peak flowmeters, pulse oximeters, weight scales, video monitors

Telehealth
Real time data capturing improves management of chronic diseases

Web 2.0
Has made significant changes in the way people use the Web, most notably in enhancing people’s abilities to share, collaborate, and connect with each other and with ideas and information
Specific Web 2.0 technologies: blogs, social networking sites, wikis, podcasts, shared databases, and collaborative writing spaces
Has led to a more knowledgeable patient and requires clinicians to teach patients to be good consumers of health information

effective and efficient searchs
Search engine (“Google it”)
Advance searching (Google Scholar)
Brut Force (Specific web address)
Links

CINAHL
Scientific and research information usually requires literature resources that can only be found in scholarly databases such as _______

Authority
with regard to the topic, author, and author’s credentials

.edu
educational institutions

.org
nonprofit organization

.com
commercial enterprise

.net
internet service provider

.gov
governmental body

.mil
military

Objectivity
Is the purpose of the website clear?
Is the information factual or opinion?
Is the information primary or secondary in origin?
Who is sponsoring the site?

Accuracy
Look for documentation and referencing
Compare information on the website with other sources

Currency
Look for dates
Compare the last update with current literature

Usability
Is the site well designed, stable, and easy to use?
Content should be error-free and readable by the intended audience

C
A nurse is preparing a presentation and is reviewing websites to collect information on stem cell research. One site does not contain headings to direct the reader, and hyperlinks do not connect to the stated information. Which criterion to establish a reputable website is missing?
A. Authority
B. Objectivity
C. Usability
D. Currency

Trends
Current technologies that offer insight to possibilities
IBM partnering with Memorial Sloan to build a decision support tool
Examining using GPS to track individuals that may require in- home monitoring
No-touch health physicals
Voice recognition for dictation and note taking
Biometric technologies

Leaders
Attempt to influence the beliefs, opinions, or behaviors of a person or group
Guide people and groups to accomplish common goals
May not have formal authority but are still able to influence others

Managers
Coordinate people, time, and supplies to achieve desired outcomes in a defined area of responsibility
Have an appointed management position and a formal line of authority and accountability

Leadership
ability to guide or influence others

Management
coordination of resources (time, people, supplies) to achieve outcomes

Power
ability to motivate people to get things done with or without the formal right granted by the organization

Authority
legitimate right to direct others through an authorized position in an organization

Types of Power
Reward power
Coercive power
Legitimate power
Referent power
Expert power
Informational power
Connection power

Formal Leadership
Practiced by the nurse who is appointed to an approved position and is given authority by the organization to act

Informal Leadership
Exercised by the person who has no official authority to act but is able to influence others in the work group

Informal Leadership
Strategies for working with informal leaders
Understand their source of power
Involve them in decision making and change implementation processes
Clearly communicate goals and work expectations
Do not ignore attempts to undermine teamwork and change processes

Leadership Trait Theory
Based on the assumption that leaders are born with certain leadership characteristics
Traits associated with leadership include intelligence, alertness, dependability, energy, drive, enthusiasm, ambition, decisiveness, self-confidence, cooperativeness, and technical mastery

Interactional Leadership Theories
Integrate dynamics of interaction between leader, worker, and leadership situation
Effective leadership depends on:
Organizational culture
Values of the leader and followers
Influence of the leader/manager
Complexities of the situation
Work to be accomplished
Environment

Transformational Leadership
Suggests two types of leaders
Transactional
Transformational

Transactional leader
_____________is concerned with the day-to-day operations of the facility/unit

Transformational leaders
Committed to organizational goals and clearly communicate vision and direction
Empower the work group to accomplish goals
Impart meaning and challenge to work
Are admired and emulated
Provide mentoring to individual staff members on the basis of need

transformational
Nurse executives who demonstrate __________ leadership characteristics achieve higher levels of staff satisfaction and greater work group effectiveness

technical, human, and conceptual
Three major areas required for effective leadership :

Technical skills
clinical expertise and nursing knowledge

Human skills
ability and judgment to work with people in an effective leadership role

Conceptual skills
ability to understand the complexities of the overall organization and to recognize how one’s own area of management fits into the overall organization

technical skill and clinical expertise
At the staff nurse level of management, a considerable amount of ______ and ______ is needed

conceptual skills
As one advances from lower levels to higher levels in the organization, more advanced_______ are needed

Authoritarian
makes all decisions with no staff input and uses the position to accomplish goals

Democratic
encourages staff involvement in goal setting, problem solving, and decision making

Laissez-faire
provides little direction or guidance and will forgo decision making

Organizational Theory
Provides a framework for understanding complex organizations

Weber’s bureaucracy theory
Defined characteristics of bureaucracy, including authority and ability to apply general rules to specific cases
Emphasized rules instead of individuals and competency instead of favoritism
Failed to recognize the complexity of human behavior and constantly changing environments

Systems theory
Views organization as a set of interdependent parts that together form a whole
Anything that affects one aspect of the organization will affect the other parts
Open systems suggest that the organization is affected by not only internal changes but also external environmental forces

Chaos theory
Attempts to account for complexity and randomness in organizations
Views complicated behaviors, situations, and variations as predictable; reflects cultural diversity, constantly fluctuating patient census, and staffing shortages

B
The hospital’s nursing administration wants to implement a policy that all wound care be implemented and monitored by the hospital’s certified enterostomal nurse because of a high rate of hospital-acquired wound infections. The nursing administrator refuses to hire an outside consultant suggested by the nurse managers, stating, “We can do this ourselves; no one needs to know our problems.” The nursing administrator is adhering to which management theory?
A. Open systems
B. Closed systems
C. Chaos theory
D. Participative theory

management
Five ________ functions are interrelated:
1. Planning
2. Organizing
3. Staffing
4. Directing
5. Controlling
Different phases of the process occur simultaneously
Processes should be circular, with the manager always working toward improving the quality of health care, patient safety, and staff and customer satisfaction

Planning
Decide in advance what to do; how, when, and where it is to be done; and who is to do it

Planning
All management functions based on ___________

Strategic planning
long-range; extends 3 to 5 years into the future

Goals and objectives
state actions necessary to achieve the strategic plan

Operational planning
encompasses the day-to-day activities of the organization

Organizing
Establish formal structure to define the lines of authority, communication, and decision making
Define roles and responsibilities for each level of management and staff
Coordinate activities with other departments
Communicate to ensure a smooth workflow

Organizing
Organizational chart
Policies and procedures
Job descriptions

Staffing
Determine the number and type of staff needed
Recruit, interview, select, and assign personnel
Orient, train, socialize, and develop staff members
Implement ongoing staff development programs
Implement creative and flexible scheduling

RN
________ work satisfaction factors
Input into organizational decision making
Organizational leaders who actively promote cohesive work environments
High level of support and encouragement provided by the supervisor
High autonomy
Paid time off benefit
Distributive justice
Promotional opportunities
Strong group cohesion

Directing
Clearly communicate performance expectations
Create a motivating climate and team spirit
Positive reinforcement in the form of a sincere thank you is a powerful motivational resource
For positive reinforcement to be effective, it must:
Be specific, with praise given for a particular task
Occur as close as possible to the time of the achievement
Be spontaneous and unpredictable
Be given for a genuine accomplishment
Role model expected behaviors
Manage conflict and facilitate collaboration

Positive
______ reinforcement to be effective, it must:
Be specific, with praise given for a particular task
Occur as close as possible to the time of the achievement
Be spontaneous and unpredictable
Be given for a genuine accomplishment

Controlling
Ensure that employees accomplish goals while maintaining high-quality performance
Establish performance or outcome standards
Measure and evaluate performance against established standards
Determine an action plan to improve performance

Controlling
Resources for establishing performance standards
Written organizational policies and procedures
Standards for the practice of professional nursing developed by the ANA
Standards for professional nursing specialty practices

Evaluating employee performance
Occurs through formal annual evaluation process and frequent feedback and coaching
Consistent daily feedback and coaching clarify expectations, improve work quality, allow manager to correct problems before they become serious
Result of routine performance evaluations should be mutual goal setting designed to meet the employees’ training, educational, and work improvement needs

B
Which of the following would have the greatest influence on the success of a health care organization?
Effective protocols
Clear goals and objectives
A transactional nurse manager
Human skills

Competitive
_______ marketplace in which health care facilities compete for patients

Internal customers
Employed by the organization
Include patient care staff members, staff of other departments, administrators, social workers, dietitians, therapists, and so forth

External customers
Not employed by the organization
Include patients and families, as well as physicians, payers, and other users of the facility

Team
is a group of people organized to accomplish work

Teams
bring together a range of people with different knowledge, skills, and experiences to meet customer needs, accomplish tasks, and solve problems

Teams
_____ should create synergy through:
Defined goals and objectives
Commitment to work together
Good communication
Willingness to cooperate

Nurse Manager
______ as a role model for teams
Respect all members of the team; value their input
Clearly define team goals
Define the team’s decision-making authority
Encourage members to develop stewardship
Exhibit a personal commitment to team goals
Encourage team members to help each other
Provide resources necessary to accomplish goals
Teach members to exchange constructive feedback to achieve team goals
Provide relevant and timely feedback to the team

Resource Manager
Resources include personnel, time, and supplies needed to accomplish goals
Plan for the necessary resources (primarily staff and supplies) to manage the unit
Organize resources to meet identified goals
Staff appropriately, as determined by patient needs and the budget plan
Maintain resource allocations within budgetary guidelines
Control by analyzing financial reports and making adjustments where necessary

Decision making
Not always related to a problem situation
Required throughout all aspects of management

Problem solving
Focused on solving an immediate problem
Includes a decision-making step

Nursing process
__________ as a guide for decision making and problem solving

Assessment
gather all information about the issue

Analysis and diagnosis
use information/data from the assessment phase to identify the specific problem

Planning
identify and weigh options for risks, consequences, positive and negative outcomes

Implementation
implement the plan

Evaluation
ensure problem was resolved effectively

Change Agent
Responsible for guiding people through the change process

change
Rules to follow when _______ is necessary
Should be implemented only for good reason
Should always be planned and implemented gradually
Should never be unexpected or abrupt
Everyone who may be affected by the change should be involved in planning for the change

Lewin’s stages of change
Unfreezing stage, Moving stage, Refreezing stage

Unfreezing stage
change agent promotes problem identification and encourages awareness of the need for change

Moving stage
change agent clarifies the need to change, explores alternatives, defines goals and objectives, plans the change, and implements the change plan

Refreezing stage
change agent integrates the change into the organization

Nurse Manager
Important components of change
Involvement
Education and training

Clinical consultant
Resource for clinical advice
Role model for excellence in nursing care and evidence-based practice

Staff developer
Offers learning and training opportunities to enhance professional and personal growth for all employees
Accesses resources and plans staff development activities that meet the needs of individual staff members

Mentor
Accepts responsibility to act as a mentor to new nurses
Recognizes that mentoring is key to developing future nursing leaders and managers

Corporate supporter
Committed to the mission, goals, and objectives of the employing organization
Professional representative for the organization

Caring Actions
Offer sincere positive recognition
Praise and give thanks for a job well done
Spend time with staff members to reinforce positive work behaviors
Meet staff’s personal needs whenever possible
Provide guidance and support for professional and personal growth
Maintain a positive, confident attitude and a pleasant work environment

framework
Three national initiatives provide a __________ for making significant changes
A Proclamation for Change: Transforming the Hospital Patient Care Environment (Hendrich, Chow, and Goshert, 2009)
Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM and Page, 2003)
The Future of Nursing: Leading Change, Advancing Health (IOM, 2010)

Proclamation for Change
Provides evidence-based recommendations to address inefficiencies that threaten patient safety and to improve nurse retention
Basic tenets
Patient-centered design
System-wide, integrated technology
Seamless workplace environments
Vendor partnerships

IOM Report Keeping Patients Safe: Transforming the Work Environment of Nurses
Demonstrated a strong connection between the nurse’s work environment and medical errors
Scientific evidence that nurses are essential to patient safety continues to grow

IOM’s Keeping Patients Safe report
Promote transformational leadership and evidence-based management
Maximize workforce capability
Redesign work processes to prevent errors
Create and sustain a culture of safety

Future of Nursing
Purpose of the initiative:
Guide advancement of the nursing profession in recognition of the vital role that nurses play in safe, cost-effective, high-quality health care

Future of Nursing
Four key recommendations for nurses:
Practice to the full extent of their education and training
Achieve higher levels of education
Be full partners, with physicians and other health care professionals, in redesigning health care
Engage in effective workforce planning and policy making with better data collection and information infrastructure

Nursing pins
Symbolize the school’s philosophy, beliefs, and aspirations
Evidence of achievement, learning, and skills

Registry
Nightingale started the tradition of maintaining a registry of all graduates in 1860
Provided institutions and patients with the means to ascertain the skills and knowledge of graduates
Distinguished nurses from lay practitioners and local citizens who provided care to the ill and infirm

pins and registries
Recognition:

licensure
As nursing programs proliferated, the need to demonstrate a certain level of nursing skill and knowledge evolved
Primary purpose was, and still is, the protection of the public

1896
first attempts to license nurses in the United States
Failed because of lack of support by hospitals, physicians, and nurses

1901
International Council of Nurses passed a resolution that each state should examine and license nurses

States
______ established boards of nursing to develop rules for examination and licensure of nurses and govern the practice of nursing

1903
four states instituted permissive licensure, and nurses were not required to comply

1915
because of variability among states’ licensure requirements, ANA designed “model nurse practice acts”

Define nursing and scope of practice for RN, description of advanced practice nursing, requirements for prescriptive authority for advanced practice, nursing education, compact guidelines, and process for disciplinary actions

1923
all states had instituted examinations for permissive licensure

1947
New York first state to require mandatory licensure

1950
NLN administered first State Board Test Pool Examination, a standardized examination for licensure

1982
first NCLEX examination

1994
paper-and-pencil test replaced by computerized adaptive testing

Current licensing activities
Efforts to provide common definitions of nursing practice, standards of education, and testing for entry into practice for all states have been successful

mutual recognition model
Resolution adopted in 1997 by the delegate assembly of the National Council of State Boards of Nursing
Provides for individual state boards to adopt an interstate compact, allowing nurses licensed in one state to practice in all other states and territories

Nurse Practice Acts
Components
Statements that refer to protecting the health and safety of the populace
Statements to protect the title of registered nurse
Definition of professional nursing
Definition of advanced practice, which may be expressed in a single definition or may be separately defined
Description of requirements for licensure
Description of requirements and procedures necessary for entry into practice
Description of requirements for renewal of licensure
Designation of a regulatory board to administer the nurse practice act
Guidelines for delegation

board of nursing
Administering the state’s nurse practice act
Granting and renewing licenses and taking disciplinary action when provisions of the act are violated

governor’s office
Membership of the board of nursing usually appointed by the _______________

A
Components of Nurse Practice Acts include:
A. Definition of professional nursing
B. Certification requirements
C. Education requirements
D. Current NCLEX-RN plan

1976
California first state to institute mandatory continuing education for licensure or renewal

Continued Competency
Mandatory continuing education
Designated clinical practice hours
Portfolios
Continuing education requirements are found in nurse practice acts and in rules and regulations

Nurse Practice Acts
Special cases of licensure
As a U.S. government employee, nurses have to be licensed in only one state to practice across the country
Military and government nurses
Foreign nurse graduates: Nurses who receive education in another country must take a special examination administered by the Commission on Graduates of Foreign Nursing Schools before applying for a license to practice in this country
International practice

Nurse Practice Acts
Revision of nurse practice acts
Nurse practice acts are written and passed by legislators
Governmental agencies, administrators, and special interest groups seek to influence the legislation and accompanying rules and regulations
Nurses and nursing associations
Physicians, pharmacists, and other health-related specialties
Representatives of hospitals, long-term care groups, and managed care groups

Nurse Practice Acts
Because of varied interests, it is essential for nurses to understand the nurse practice act and additional legislation that will alter the act and influence nursing practice

Sunset legislation
Laws found in many states to ensure legislation are current and reflect the needs of the public
Through sunset activities, nurse practice acts are updated and revised

Nurse Practice Acts
Delegation of authority to others: regulations for delegating to unlicensed personnel and LPN/LVNs are found in the nurse practice act and may vary from state to state

Current licensure activities
Mutual recognition model
Continued competency

Certification
History
Began as a voluntary effort controlled by nursing organizations
Nurse anesthetists became the first nursing specialty to certify practitioners in 1946
American College of Nurse-Midwives began certifying practitioners in 1961
Need for standardization in certification programs recognized in 1975

American Nurses Credentialing Center (ANCC)
was formed as a central organization for certification of nurses

American Board of Nursing Specialties
was organized with eight members in 1991 with the mission to ensure high standards and quality in the education, evaluation, and practice of certified nurses

Certification
History
ANA
Occupational Health Nurses Certifying Board
Neuroscience Nurses Certifying Board
Rehabilitation Nurses Certifying Board
Nurse Anesthetists
Nutritional Support Nurses Certifying Board
Nephrology Nurses Certifying Board
Orthopedic Nurses Certifying Board
Some states now require certification for advanced practice

ANCC
Offers certification in 25 areas of specialty nursing
Certified more than 250,000 nurses as of 2009
80,000 Advanced Practice Registered Nurses

Certification
Purpose
Recognizes excellence in nursing practice
Nongovernmental agencies, usually professional nursing organizations, grant certification
Requirements and practice opportunities vary markedly

certification
Steps to __________________
Become informed about specific requirements in the chosen specialty
Contact the ANCC or specialty nursing organization offering certification to determine the educational experience and examination requirements
Contact the state board of nursing for information about legal requirements for practice in a specific specialty area

certification
Current issues in _____________-
Legal issues of scope of practice for advanced practice nurses
Reimbursement for nursing services
Federal regulations allow direct reimbursement for some nursing services, yet state and local practices vary

D
When one differentiates between licensure and certification, it should be known that:
A. Licensure recognizes advanced practice competence and knowledge.
B. Certification recognizes entry-level competence and knowledge.
C. Certification requires only successful completion of a standardized examination, whereas licensure requires completion of a set number of clinical hours to be completed during the nursing education process.
D. Licensure is administered via state boards of nursing, whereas certification is granted by nongovernmental agencies.

delegation
Nurse practice acts establish legal definitions of delegation
Guidelines for delegation developed by nursing organizations

Nurse licensure compact (NLC)
formed in 1997 by individual states to allow nurses to practice in more than one state without applying for multiple licenses

advanced practice nursing
Which organization will credential and regulate advanced practice nursing?
The NCSBN proposes that it is the best organization to credential, as well as license, advanced practice nursing
Nursing professional and specialty organizations are responding to this proposal

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