N138 Midterm 1

HIPAA Protections for Clients

1. Copies of medical records for clients within 30 days of requests; can request corrections; provider can charge them for mailing/make copies 2. Patients' rights providers must give patients written notice describing patient's rights 3. Limitations are placed on length of time that medical records can be retrieved, shared, etc.

Confidentiality

A legal and ethical concern in nursing practice; the protection of private information gathered about a client during the provision of health care services. The Code of Ethics for Nurses emphasizes the importance of this, and HIPAA (federally, legally) enforces protections for clients.

2 Requirements of Malpractice Action

1. Nurse (defendant) practices with specialized knowledge and skills 2. Through this practice of specialized knowledge and skills, the nurse caused patient's (plaintiff's) injury

*4 domains of Interprofessionality (Education Collaborative Expert Panel Report, 2011)*

1. Values/ethics for interprofessional practice 2. Roles/responsibilities 3. Interprofessional communication 4. Teams and teamwork

Reflective Thinking

ACTIVE process valuable in learning and changing behaviors, perspectives, or practices

Clinical Judgement

An interpretation or conclusion about a client's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response + empirical knowledge and experience *Knowing the limitations of your expertise is an important aspect of clinical judgement* - Fine line between nursing expertise and requiring health care/medical consultations - NPA, health agency policies, school of nursing policies, profession's standard of practice can help guide nurses regarding knowledge and procedures

Practice Settings + Roles of Professional Nurses

Direct patient care Research Advanced education APRN

NCSBN

Established in 1978 to develop the NCLEX-RN. Each state participates in licensing process through the NCSBN. Each state is responsible for licensing through the state board of nursing.

4. Practitioners are *educated* in institutions of higher learning

First university based nursing education was established at the University of Minnesota in 1909 1965: The ANA said that nursing schools need to take place at higher level of education

Malpractice lawsuits are part of ______ law.

civil

Critical thinking leads to good ___________ ____________

clinical judgement

*3 Components of Collegiality*

*1. Essence -* promotion of supportive, healthy work environment *2. Support -* for nurses and students *3. Collegial behaviors -* share knowledge with colleagues and students, take part in professional organizations, publish in professional literature, etc.

Clinical Judgement: 9 Key Questions

*1. What major outcomes (observable beneficial results) do we expect to see in this particular patient, family, or group when the plan of care is terminated?* If using standardized/pre-determined plan, that it is appropriate for the client; or else have to create a personalized one for them that is realistic. *2. What problems or issues must be addressed to achieve the major outcomes?* Answering this question helps you prioritize *3. What are the circumstances?* Who is involved? Child, parent, group? How urgent are the problems? Client's beliefs, values, cultural influences? *4. What knowledge is required?* Regarding diagnoses, disease physiology, symptoms, complications that may occur, etc. *5. How much room is there for error?* Depends on the condition of the overall health of the client; this is where clinical judgement comes in bc the orders for postop ambulation may be the same for two clients who have different comorbidities and overall health *6. How much time do I have?* Time frame depends on urgency of the problem, planned length of contact, etc. *7. What resources can help me?* Human resources like CNS *8. Whose perspectives must be considered?* Important to consider client's perspective; also family members, SOs, caregivers, relevant third parties (insurers) *9. What is influencing my thinking?* Identifying personal biases and other factors influencing your critical thinking, and ergo, your clinical judgement

Meleis - Transition Theory

*4 types of transitions:* - Developmental - Situational - Health/illness - Organizational (family or community level) *Transition Conditions* - Meanings - Expectations - Level of knowledge/skill - Environment - Level of planning - Emotional and physical well-being *Universal transition properties* Change in identity, roles, relationships, abilities, structure, function, dynamics *Nursing Therapeutics* - Assessment of readiness (requires understanding of client) - Preparation for transition (education) - Interventions (role supplementation)

Civil vs. Criminal Law

*Criminal laws* regulate crimes, or wrongs committed against the government, or construed as an offense against public safety/society e.g. murder, assault, theft, drunk driving *Civil laws* regulate disputes between private parties e.g. breach of contract, child custody case, defamation, negligence resulting in injury or death *(malpractice)*, property damage

Authority and Powers of the State Board of Nursing

*Executive* - authority for BON to administer the NPA *Legislative* - authority to adopt rules to clarify provisions in the NPA *Judicial* - authority to deny, suspend, revoke, license or application for licensure

Nursing Process Phase II: Diagnosis

*I. Data must first be validated and then compared with the norms to sort of info that may indicate a problem; involves validating and clustering the information* Nurses must use nursing, biological sciences, social sciences to observe and interpret information from various pieces of client data *Nursing diagnosis* = identifies the problems the client is experiencing as a result of the disease process; human response to illness, injury, or threat *Medical diagnosis* = focuses on disease process; nursing diagnoses were never meant to replace this Critics believe that the language of nursing diagnosis obscures rather than clarifies client problems -> still widely used, but the idea is that we will move away from this in the future **Accuracy is very important; depend on accurate diagnoses to have effective interventions.** Paans and colleagues (2011) found 4 reasons that affect nurses' accurate documentation of diagnoses: 1. Nurses themselves as effective diagnosticians 2. How nurses are educated about nursing diagnoses 3. Complexity of a client's situation 4. Degree to which a hospital's policy and environment supports use of nursing diagnoses *II. Create the nursing diagnosis:* (a) Diagnostic label from NANDA-I (b) Etiology (causal factors, but cannot be medical related "related/to") (c) Symptoms/defining characteristics ("as evidenced by") *III. Prioritizing Nursing Diagnoses:* 1. Relative danger to the client (life-threatening vs overall general health; Maslow's Hierarchy of Needs) 2. Potential to cause harm or injury 3. Related to overall health of client (ineffective airway clearance > sleeping problems > knowledge deficit)

Nursing Process Phase III: Planning

*I. Identification of client goals and determination of ways to reach those goals* - *Bloom's Taxonomy* to help classify nursing goals - Psychomotor domain (involves physical movement) - Cognitive domain (involves knowledge and intellectual skills) - Affective domain (emotions, feelings, values, attitudes) Goals should be agreed on by both nurse and client - Goals or objectives are statements of what is to be accomplished and are derived from the diagnoses - Goals begin with "the patient will" and set general direction - Outcome criteria are steps that make goal achievable - Short and long term goals - Culturally congruent; involve the client and ask about cultural aspects to achieve goals Every goal has specific intervention - *Independent interventions:* requires no supervision bc they are within the nurse's scope of practice (e.g. teaching client how to breastfeed) - *Dependent interventions:* requires instructions, orders, supervision from other health care providers (e.g. administering medications, inserting a Foley catheter) - it is the responsibility of the nurse to know how to administer ordered medications safely and to monitor their effectiveness; nurse must also question prescription orders if they a re not congruent with safe care - *Interdependent (Collaborative) interventions:* protocols define under what conditions and circumstances a nurse is allowed to treat the client as well as what treatments are permissible (e.g. insulin administration is blood glucose is too high, participating in a code) *Writing plans of care/using standardized ones:* - Electronic Health Records automatically generate with checkboxes; however, although this saves documenting time, nurses still need to develop personalized care plans for clients - *Critical Pathways:* multidisciplinary plans of care involving medical/other HCP and nursing care plans; there is increased pressure to decrease hospital stay days for clients, so goals must be time limited and specific to get clients better, faster; this facilitates comms among all members of health care team

3 Branches of Government

*Legislative-* makes statutory law, delegates authority to governmental agencies to create rules and regulations that meet the intent of statutes (administrative law) *Executive-* implements laws through governmental agencies *Judicial-* makes court decisions that amends and expands common law; interprets statutory law

Legal Issues Affecting Nursing

*NPA needs to be updated regularly* to explicitly support the expanding role of the nurse, or else it puts nurse at risk for legal troubles *Professional organizations;* nurses should participate in these to advocate for their own roles as autonomous professionals (lobby against AMA and hospital admin lobbies who think it's in their best interest to regulate nursing practice) Legal nurse consultants specialize in the evaluation of standard of care, causation, damages, medically related issues in legal cases. LNCs are extensively educated in both nursing practice + legal field *Prescriptive authority;* generalist nurses need to know who they can accept prescription orders from, and nurse practitioners have to stay within their legal scope of practice when writing prescriptions; constantly evolving

Nursing Practice Act

*Objectives of NPA:* - defines practice of professional nursing - describes the authority, power, and composition of the BON - defines educational program standards - sets the minimum educational qualifications and other requirements for licensure - determines and protects the legal titles and abbreviations nurses may use - provides disciplinary action of licensees for certain causes In many states, NPA is a statutory law affecting nursing practice within bounds of the state

Process of Professionalization

*Occupation -> Profession Continuum* (as seen through the earliest recognized "learned" professions like law, medicine, divinity--they all followed this sequential development) 1. practitioners practice full time in discipline 2. determined work standards, identified a body of knowledge, established educational institutions 3. promoted organization 4. established a code of ethics

*Professional Preparation & Commitment*

*Professional preparation and commitment include:* 1. *instruction* within the specialized body of knowledge and techniques of the profession 2. *orientation* to the beliefs, values, and attitudes expected of the members of the profession 3. *commitment* transcends the expectation of money (material reward) 4. *personal identity in a profession* - less common to change careers than occupations

3 (Main) Types of Laws in the US

1. *Common law:* laws that are generated through court decisions; every time a judge makes a decision, the body of common laws expand 2. *Statutory law:* laws established through formal legislative processes 3. *Administrative law:* result when the legislative branch of government delegates authority to governmental agencies to create laws that meet the intent of the statute --> MOST COMMON IN NURSING/MEDICAL FIELD e.g. when a nurse practices without a valid license

4 Elements of Negligence - Failing to Meet Standard of Care

1. *Duty* - the professional nurse assumed duty of care for the client 2. *Breach* - the professional nurse failed to meet standard of care, and thus, basic prudent nursing care 3. *Causation* - the failure of professional nurse to meet standard of care was the proximate case of the injury 4. *Damages* - the injury is proved All 4 elements must be proved

*Nursing Standards est. by Profession Itself*

1. *Nursing's Social Policy Statement* -> describes *obligation to the patients*; includes the ANA's contemporary definition of nursing 2. *Nursing: Scope and Standards of Practice* -> expectations of the professional role and lists of standard competencies (latest one is from 2015) 3. *Code of Ethics for Nurses with Interpretive Statements*; dates back to Florence Nightingale; ultimately, strengthens and guides decision-making (a) statement of the ethical values, obligations, duties, an professional ideals of nurses individually and collectively (b) nursing's non-negotiable ethical standard (c) expresses nursing's own understanding of its commitment to society

*Barriers to Professionalism in Nursing*

1. *Varying levels of education for entry into practice:* no other profession allows entry into practice at less than a bachelor's level; yet nursing has 3 entry levels: BSN, ADN, diploma in nursing; to the contrary, many professions like law, medicine, dentistry, and PT require grad school; professional status and power increase with education, so a legitimate question nursing must ask itself is how professional peers level with nurses when most nurses don't hold a bachelor's degree? 2. *Gender Issues:* Continues to play a role in the perceived value of professions dominated by women such as teaching, social work, and nursing; the persistent devaluing of women's work in our society has created an ongoing struggle for professions such as nursing and teaching to increase their status, increase their compensation, and improve working conditions; recognize that gender politics does affect nursing's professional development 3. *Historical Influences:* Nursing's historical connections with religious orders and the military continue to have influence; e.g. unquestioning obedience, which runs counter to the professional values of autonomy and self-determination in nursing; also altruism, which prevents nurses from demanding fair economic valuation of their work without looking greedy or selfish 4. *External Conflicts:* Tensions between medicine and nursing have risen; lobbying efforts in state legislatures to ensure the legal scope of nursing practice is protected and reflects current training and expertise of professional nurses; however, nurses must strive for collaboration, NOT COMPETITION, with physicians and other health care providers 5. *Internal Conflicts:* Power and influence within nursing are fragmented by subgroups and dissension; tensions among nurses with various levels of education reduce the vitality of the profession. The fact that most nurses are not members of any professional organization hampers nursing's ability to govern itself, set standards, and use its collective power to lobby effectively.

Nursing Education (3 Ways to Qualify for NCLEX)

1. 4 year education at a college or university (BSN) 2. 2 year education at a community college or technical school 3. Diploma in nursing (hospital-based program that typically takes 3 years to complete + prerequisites)

Strategies to Limit Possibility of Legal Action

1. Practice in safe setting *a. Qualities of safe agencies:* institution hires a variety of nurses who are experienced/inexperienced, institution provides orientation for ALL new employees, personnel promote quality and safety of procedures, equipment is in good working order, all levels of employees are supervised *b. Risk management: * identifying concerns about medication errors, failing to respond to patient monitors, patient falls, etc. *c. The Joint Commission and 2005 Patient Safety Goals:* regulatory body ensures hospital is following guidelines 2. Communicate: with client + families, healthcare team, document well (conversations, ADPIE, phone calls with family members, etc.) 3. Meet standard of care (minimum); HealthStream modules, latest research/tech 4. Carry and understand professional liability insurance; make sure it has portable coverage, covers court judgements, out-of-court settlements, legal fees, court costs; and a policy that covers incidents occurring anytime 5. Promote positive interpersonal relationships

Role of Nurse in Informed Consent

1. collaborate with primary provider 2. witness patient's signing 3. nurse is NOT responsible for evaluating the physician 4. nurse is responsible for determining that the elements of valid consent are in place, providing feedback, and communicating the patient's need and further information to the primary provider 5. advocate for the patient if you sense they want to change their minds, need more information, etc. and relay that to the primary care team

Although scholars have not always agreed on the number of criteria and types of behaviors and characteristics of all professions, three criteria consistently appear:

1. service/altruism 2. specialized knowledge 3. autonomy/ethics

Patient Self-Determination Act (PSDA) 2010

A federal law that mandates that every individual has the right to make decisions regarding medical care, including the right to refuse treatment and the right-to-die Acute and long term care facilities funded by Medicare and Medicaid must: 1. provide written information to all adult patients about their rights under state law 2. ensure institutional compliance with state laws on advance directives 3. provide for education of staff and community on advance directives 4. document in the medical record whether the patient has one Legal issues with this act: not always carried out in practice due to family members, directive not specific enough for specific situations, etc.

Nurse Entrepreneur

A nurse, usually with an advanced degree, who may manage a clinic or health-related business, conduct research, provide education, or serve as an adviser or consultant to institutions, political agencies, or businesses. Examples: opening nurse-managed centers to provide direct care to clients; present educational workshops and seminars; establish own apparel businesses; manufacturing clothing for premature babies or for person with physical challenges; own and operate health equipment companies, health insurance agencies, etc. Nurse entrepreneurs have great autonomy derived from owning and operating their own health related businesses. Disadvantages include financial instability during early years of business

The Nursing Process

A universal intellectual standard for nurses Method of critical thinking focused on solving client problems in a professional practice Conceptual framework with 5 dynamic steps Combines the "art of nursing" with systemic theory + scientific method to produce high level care for clients that is both interpersonal and interactive

Assault & Battery

Assault includes a threat or attempt to injure Battery includes the unlawful touching of another person without consent e.g. Nurse threatens client that she will give him a shot if he doesn't take his vitamins; the threat is assault, and the battery is if the nurse gave the client a shot for not taking his vitamins (patients can refuse treatment)

1. The *services provided are vital* to humanity and the welfare of society.

Caring is the core of nursing

Bridges' Transition Model

Change is something that happens to people even if they don't agree with it Transition is internal: it's what happens in people's minds as they go through change Change happens quickly, while transition usually occurs more slowly 3 Stages of Transition: 1. Ending, Losing, Letting Go 2. The Neutral Zone 3. The New Beginning *Stage 1: Ending, Losing, Letting Go* - resistance and upheaval since people are forced to let go of something - fear, denial, anger, sadness, frustration, uncertainty, grief - accept and understand these emotions; allow them to accept the change and let go; listen empathically, communicate openly; provide resources if they need help; communicate a positive future *Stage 2: The Neutral Zone* - confused, uncertain, impatient - people are still attached to the old while trying to adapt to the new - might experience resentment toward change initiative, low morale/productivity, anxiety about their identity, skeptic about the change initiative - this stage can be one of innovation and renewal; encourage people to try new ways of thinking or working - remind people of their goals, provide them with direction, give feedback, set short term goals *Stage 3: The New Beginning* - acceptance and energy; embracing the change initiative - people are likely to experience high energy, openness to learning, commitment to the role - long term goals

Nursing Diagnosis

Clinical judgement that an independent nursing intervention can prevent or resolve. Actual or actual nursing diagnoses. Actual problem is present. Possible problem may be present, but more data are needed to confirm or disconfirm the problem. Potential problem may occur; defining characteristics are present as risk factors. Controversy regarding nurses diagnosing medical conditions in the 1970s-80s bc physicians did not think nurses who were unqualified should be able to -> nursing diagnosis came about. Nurses are accountable for nursing diagnoses bc it is within their scope of practice.

New Nurse Opportunities

Clinics, community-based facilities, medical offices, hospitals, homes, schools, retail clinics, homeless shelters, etc. Nurses need to consider many things: special talents, likes, dislikes, etc. *Health care reform and push to transform health care system means nurses are constantly moving into new territory;* numerous new opportunities and roles are being developed that use the nurses' skills in innovative and exciting ways

*Kelly's Criteria: 8 Characteristics of a Profession (1981)*

Contemporary nursing embodies the characteristics of these criteria: 1. The *services provided are vital* to humanity and the welfare of society. 2. There is a special body of knowledge that is continually enlarged through *research*. 3. The services involve *intellectual activities*; individual responsibility *(accountability)* is a strong feature. 4. Practitioners are *educated* in institutions of higher learning (first university based nursing education was established at the University of Minnesota in 1909). 5. Practitioners are relatively independent and control their own policies and activities *(autonomy)* -> . 6. Practitioners are *motivated by service (altruism)* and consider their work an important component of their lives. 7. There is a *code of ethics* to guide the decisions and conduct of practitioners. 8. There is an organization *(association)* that encourages and supports high standards of practice.

Nurse Licensure Compact (NLC) 2000

Created by the NCSBN in 2000 A form of interstate compact specific to nurse licensure that provides an agreement between two or more states for the purpose of recognizing nurse licensure between and among a group of participating states. States must enter into one legally in order to achieve mutual recognition. Negates the need for NLC state nurses to apply for licensure by endorsement. As of now, NLC has been adopted by 34 states Nurses who are moving to different states that are under this compact do not need to apply for license by endorsement; if nurse changes permanent residence, they may practice under the license from former state of residence for up to *90 days* while they get their new license

Exceptions to Obligation of Confidentiality

Discussing the care of patients to others who are directly involved in care Quality assurance activities Legally mandated disclosure to public health authorities Info required by third party payers (insurance companies?) Disclosing info without the patient's consent when the safety of innocent parties is in question

North American Nursing Diagnosis Association International (NANDA-I)

Facilitates the development, refinement, dissemination and use of *standardized nursing diagnostic terminology* with the goal to improve health care for all people 235 diagnoses approved for clinical testing Diagnoses are retired if usefulness is limited or outdated

Malpractice

Failure by a health professional to meet accepted standards of care Malpractice by: 1. *Commission*: doing something that should not have been done 2. *Omission*: failing to do things that should have been done

Flexner (Sociologist, 1910)

Flexner's Report inspected and critiqued medical schools around the country and found that they are unequal; called on medical schools to implement high standards for admission and graduation *Flexner Report (1915)* published a list of criteria that he believed were characteristic of all true professions: 1. Is basically intellectual (as opposed to physical) and is accompanied by a high degree of individual responsibility 2. Is based on a body of knowledge that can be learned and is developed and refined through research 3. Is practical, in addition to being theoretical 4. Can be taught through a process of highly specialized professional education 5. Has a strong internal organization of members and a well-developed group consciousness 6. Has practitioners who are motivated by altruism (the desire to help others) and who are responsive to public interests

Five Rights of Delegation

From licensed RN to a UAP/another licensed RN: 1) Right task 2) Right circumstance - is it appropriate to delegate this task? think about client acuity 3) Right person 4) Right direction/communication 5) Right supervision/evaluate the performance of the task

Cohen: The Image of Nursing

Gallup poll identified that nurses are the #1 most trusted profession in the US for 5 years straight Nurses' image used to be very poor; from seen as the "angel of mercy" to sexual stereotypes; even Florence Nightingale depicted the nurse as inferior to physicians. ER and House depict nurses in a negative way. 2001: Center for Nursing Advocacy was founded to clean up images of nurses in the media, advertisements, etc. (e.g. convinced Coors brewery to stop using the "naughty nurse" imagery in their ads) Nurses need to clean up their image, like in the way they dress: "you're the only thing bt the patient and death, and you're covered in clothes with cartoons; no wonder you have no authority." *Redefining nursing image:* 1. Value nursing and project that image daily 2. Take pride in nursing work 3. Recognize the value of nursing 4. Believe in nurses and colleagues 5. Be professional 24/7; don't disparage nursing as a profession or dissuade children from going into nursing bc you believe it's an environment where they are not respected, underpaid, and have to deal with peoples' unrealistic expectations 6. Identify yourself properly "I am ___, your registered nurse today" 7. Speaking to civic and community groups about what nursing is 8. Teaching communication skills and how to deal with negative colleagues in a manner that confronts and ends the bad behavior 9. Work together to cultivate a professional image so the public can see the nursing profession clearly

Nursing Process Phase I: Assessment

Gathering information or data about individual, family, or community *Subjective* = what the client or family claims is the source of their symptoms and overall problems (e.g. pain, nausea, feeling hot, shaky, etc.) *Objective* aka "signs" = measurable, observable client behaviors (e.g. patient holding arm over area that hurts, blood pressure, pulse rate, diaphoretic, pale, tachypneic, etc.) Objective and subjective data are usual congruent and are in agreement with one another Data can be physiological, psychological, sociocultural, developmental, spiritual, and environmental information; client's available financial or material resources should also be assessed and recorded in a standard format. *Methods of gathering assessment data:* (1) *Interviewing* the client via observation, listening (primary way of gathering most useful subjective and objective data) (2) *Physical/objective examination*, use the methods of inspection, auscultation, percussion, and palpation (3) *Consultation* with client family members and other health care members Organizing patient data: how data fits into nursing theory stuff in chapter 9 HIPAA & Confidentiality of Client Data: can only share client data with people who absolutely need it; ethical and legal issues

ANA Model Practice Act (1996, 2012)

Guide state nurses' associations seeking revisions in their NPAs; urges the following content be included to protect nurses: 1. Clear differentiation bt advanced and generalist nursing practice 2. Authority for boards of nursing to regulate advanced practice nursing 3. Authority for boards to oversee delegation and supervision of UAPs 4. Clarification of nurses' responsibility for delegation to and the supervision of other personnel 5. Support mandatory licensure for nurses while retaining sufficient flexibility to accommodate the changing nature of nursing practice The 2012 version was developed to guide individual states' development and revisions of their NPAs; the goal of this is to: (1) development of more consistent standards nationally (2) increased protection for the public

Practice Settings for RNs

Hospitals 63.2% Ambulatory care 10.5% (clinics, medical offices, SNFs) Public and community health 7.8% Home health 6.4% Extended care facilities 5.3% Others 6.8%

*Miller's Wheel of Professionalism in Nursing (1985)*

Identified "behaviors deemed necessary in maintaining or increasing nurses' professionalism. They are: 1. Competence and continuing education 2. Adherence to the code of ethics 3. Participation in the primary and professional organizations (i.e., ANA and state constituent member association) 4. Publication and communication 5. Orientation toward community services 6. Theory and research development and utilization 7. Self-regulation and autonomy

Task Force on Professionalism (2000)

Identified 10 common characteristics of the members of a profession (pharmacy task force that studied to encourage pharmacy student professionalism): 1. Prolonged specialized training in a body of abstract knowledge 2. A service orientation 3. An ideology based on the original faith professed by members 4. An ethic that is binding on the practitioners 5. A body of knowledge unique to the members 6. A set of skills that forms the technique of the profession 7. A guild of those entitled to practice the profession 8. Authority granted by society in the form of licensure or certification 9. A recognized setting in which the profession is practiced 10. A theory of societal benefits derived from the ideology

"Captain of the Ship" Doctrine

Implies that the physician is ultimately in charge of all patient care and thus should be responsible financially (not the case anymore, outdated)

Interprofessionality

Important to develop core competencies within a profession as well as enhanced teamwork across disciplines and team-based care; WHO noted in 2010 that in the current healthcare climate, it is no longer enough for health care workers to be professional, they also need to be interprofessional

Professional Liability Insurance (NSO)

Individual professional liability insurance policy protects you from paying thousands of dollars in attorney fees simply from being named in a malpractice lawsuit - employer's professional liability insurance policy may primarily focus on defending the employer's interests - if you are named in a malpractice lawsuit and the legal costs exceed the employer's coverage limits, you may be required to make up the difference - discounts for newly graduated students, credit given for premium if you attend risk management course - covers medical expenses for assaults that occur at the workplace

Licensure by Endorsement

Individual states' SBNs participate in a cooperative effort to assist in the interstate mobility of nurses NCLEX = national exam, so theoretically, any nurse that is educated in the US and passes at the NCLEX can practice in any other state Nurses can practice in other states without retaking exam but must apply for endorsement Requires proof of licensure in another state + licensure fee Cannot work as an RN during this time as you apply to get a license in a different state

ANA and NCSBN

Influence what is written in each state's Nursing Practice Act (NPA)

5. Practitioners are relatively independent and control their own policies and activities (autonomy).

Licensure by the state boards of nursing means that nurses are autonomous practitioners who are responsible for their own practice 3 groups that have historically tried to control nursing practice are organized nursing, organized medicine, and health service administration; "organized" = collective professional bodies that are the voice speaking for the interests of their respective professions (ANA, AMA, National Nurses United etc.); medicine and health administration are well organized and well funded powerful lobbies at the state and national levels, which poses a major challenge to full autonomy for nurses; unfortunately, organized nursing does not yet have available economic resources to compete effectively against influential lobbying forces seeking to neutralize nursing autonomy *Magnet Recognition Program* is an initiative of the American Nurses Credentialing Center (ANCC) that demonstrates organizational recognition of nursing excellence. By early 2012, 391 hospitals had achieved Magnet designation, most in the US and some internationally. Recognizes hospitals that attract and retain nurses, acknowledging that this achieves better patient outcomes.

Example of NPA being challenged through the legal system

NPs want to practice independently without having a physician oversee or sign off on their orders

NCLEX-RN

National Council Licensure Examination for Registered Nurses that is developed by the NCSBN Computer adaptive testing (algorithm determines the level of question's complexity based on how the test taker answered the previous question); minimum 75 questions, maximum 265 questions Duration: 6 hrs max This is a NATIONAL exam; pass rates for each state approved nursing school are posted on the BON website

Employment Outlook in Nursing

Nurses can expect employment opportunities to grow "much faster than average": around 15% employment growth from 2016 - 2026 Home health care positions are expected to increase fastest -> heavy emphasis placed on primary care bc the research shows that more funding to get people primary care = cheaper and easier to manage health later down the line Several factors contribute: technological advances, increase in primary care demand, aging of nation's population, and increased percentage of medical procedures performed in outpatient settings

2. There is a special body of knowledge that is continually enlarged through *research*.

Nursing has its own PhD Nursing no longer based on simple problem solving it increasingly relies on theory and research for theory of practice evidence-based practice

3. The services involve *intellectual activities*; individual responsibility *(accountability)* is a strong feature.

Nursing process, individual accountability for RNs (according to Code of Ethics for Nurses, accountability = being answerable to someone for something one has done) Accountability is rooted in loyalty, veracity, *beneficence*, respect for dignity

Nursing Process Phase IV: Implementation

Occurs when nursing orders are actually carried out; as the nurse carries out planned interventions, they are continuously assessing the client, noting responses to interventions, and modifying the care plan; nurses who skip the prior 3 steps and go straight to implementation are not providing care in a responsible or professional manner Examples of nursing interventions: managing pain, preventing post-op complications, educating clients, monitoring client's physiological status *Document implementation*; did not happen if not documented

Affordable Care Act

Passed in 2010 by the 111th Congress; basically has 2 laws: *1. The Patient Protection & Affordable Care Act 2. Health Care and Education Affordability Reconciliation Act* The combination of these laws provide incremental but progressive change to the way that Americans *access* and *pay for* their health care Give resources for RNs to redesign healthcare

Profession vs Occupation

Profession = a calling, vocation, or form of employment that provides a needed service to society and possesses characteristics of expertise, autonomy, long academic preparation, commitment, responsibility *a profession is someone's personal identity* Occupation = a person's regular work or job A profession differs from an occupation in 2 major ways: *preparation and commitment*

Delegation and Malpractice

Professional nurses may delegate independent nursing activities (as well as medical functions that have been delegated to them) to other registered nursing personnel State NPAs do NOT give LPN/LVNs the authority to delegate since they are not state licensed Professional RNs retain accountability for acts delegated to another person; however, if the task is delegated to another licensed RN, they may also be legally liable if something goes wrong It is the legal responsible of the RN to know the limitations of the UAP; UAP absolutely cannot assess or interpret info that is the responsibility of the RN's (e.g. vital signs can be obtained or delegated by UAP, but it is the nurse's responsibility to analyze)

7. There is a code of ethics to guide the decisions and conduct of practitioners.

Provides professional standards and a framework for moral decision making -> the Nightingale Pledge functioned as nursing's first code of ethics. The trust placed in the nursing profession requires the nurses to act with integrity.

Hall (Sociologist, 1968)

Published his work on professionalism; similar to Flexner's criteria, described a professional model with 5 attributes of professions: 1. Use of a professional organization as a primary point of reference 2. Belief in the value of public service 3. Belief in self-regulation 4. Commitment to a profession that goes beyond economic incentives 5. A sense of autonomy in practice Hall recommended that each profession needed to develop its own methods of measuring professionalism that recognize the uniqueness of the discipline

Nursing in the U.S.

RNs are the largest group of health care providers >4 million licensed RNs in 2016 91% of nurses younger than 50 y/o are employed; older nurses are more likely to stay in the workforce bc this field is reasonably protected from layoffs and downsizing compared to other professions 8% of RNs are men 19% of RNs are "ethnic minorities"; the greatest disparity is with Hispanics/Latinos, then African Americans, and Asian Americans actually exceed its representational percentage *Nursing migration*; push and pull factors involved - Nurses are flexible and can easily move between jobs and states - COL/salary, political instability (Covid-19), etc.

Critical Thinking Attributes

Raises questions and problems and formulates them clearly and precisely Gathers and assesses relevant information Arrives at conclusions and solutions that are well reasoned and tests them against relevant standards Open-minded, recognizes alternative ways of seeing problems, implications, consequences Communicates effectively with others as solutions to complex problems are formulated

Push & Pull Factors

Recruitment of foreign-educated nurses to the US has been a strategy to expand the nursing workforce in response to the increased demand of nurses; controversial; issues may include language/communication barriers, racist peers who do not see them as knowledgeable equals, cultural differences, recruitment of these international nurses may cause shortages in their home countries. *Push factors:* poor compensation, political instability, poor working conditions, lack of opportunities for career advancement *Pull factors:* better quality of life, personal safety, professional incentives like increased pay, better working conditions

The State Board of Nursing has the authority to set and enforce minimum criteria for nursing education

Requirements: an applicant for licensure must graduate from a *state-approved* nursing education program There is currently no national accreditation standard in the US (more stringent)

HIPAA (Health Insurance Portability and Accountability Act) 1996

Requires all health care providers to ensure privacy and confidentiality of patients Violating HIPAA = violating federal law

Utley-Smith Article (Accelerated Second Degree Nursing Education)

Returning to School Syndrome Model: *1. Honeymoon:* positive glow of experience of returning to school, aware of similarities between new school + old environment, reinforces original role identity (spans a few hours or months; during first sem of nursing school) *2. Conflict:* turbulent, negative emotions surface; student not able to trust previous knowledge for help bc nursing is just so different and new; student depression, bursts of anger, helplessness, academic difficulties/insecurities, sadness, etc. can be physically and emotionally exhausting *3. Reintegration:* multiphasic; in the beginning stage, *strong rejection of new culture*, students blame institution, faculty, etc. for their unsatisfactory achievement; the common behavior is hostility; during reintegration phase, students are able to integrate their original work culture in with new nursing culture *(biculturalism)* *perception of nursing is forever altered"* *Maladaptation* (as opposed to positive resolution): *false acceptance* in which students pretend to believe in the validity of the ABSN curriculum and usually ends up with maladaptive alternatives like *chronic hostility* Why this model is useful: instructors can use it to educate ABSN students so they can proactively get support and resources when they understand what is happening to them

8. There is an organization (association) that encourages and supports high standards of practice.

The ANA is the official voice of nursing and therefore is the primary advocate for nursing interests in general. Membership in the state nurses association automatically conveys membership the ANA. Goal of the ANA is to improve health standards and availability of health care services for all people, foster high standards of nursing practice, stimulate and promote the professional development of nurses and advance their economic + general welfare. Only 10% of all RNs join the ANA.

6. Practitioners are motivated by service (altruism) and consider their work an important component of their lives.

The desire to "help people" is foundational to nurses' identities and recognition that their work is important. No one questions the rights of other professionals to charge reasonable fees for the services they render, but nurses' altruism is sometimes called into question when they demand higher compensation and better working conditions. Tension bt organized nursing vs. nurses who see collective bargaining as antithetical to the ideal of nursing as altruistic. Commitment to nursing is important. Those who simply view it as a job may be responsible for the delay in the development of professional attitudes and behaviors for the profession as a whole.

Respondeat Superior Doctrine

The employer is responsible for the actions of the employee

Houle's Characteristics of a Profession

The evolution from occupation to profession was analyzed by Houle (1980), who identified a number of characteristics that indicate that an occupational group is toward professional status Step 1: define the group's mission and foundations of practice Step 2: mastery of theoretical knowledge Step 3: development of *collective identity* as an occupation evolves into a profession -> includes formal training, credentialing, creation of a subculture, legal right to practice, discipline of unethical/incompetent practitioners, formalization of the role in relation to other professions

State Board of Nursing Sanctions

The judicial powers of the BON: 1. *probation* (cannot have complaints made against them within this period of time) 2. *suspension* (after x amount of time, the person can go back to practicing as an RN) 3. *revocation* (take away license for doing something especially egregious) Most common reason for disciplining nurses: practicing while under the influence of alcohol or drugs (drugs that are taken from the workplace) -> nurses have the same likelihood of abusing drugs and alcohol as the general public, but have easier access to drugs

Nursing Process Phase V: Evaluation

The nurse examines the client's progress *in relation to the goals and outcome criteria* to determine whether a problem is resolved, in the process of being resolved, or unresolved Evaluation may reveal new data, diagnoses, goals, and nursing interventions Evaluation may indicate a need for change in care plan according to the client's response and condition to the interventions

Collegiality

The promotion of a supportive and healthy work environment, cooperation, and recognition of interdependence among members of the nursing profession e.g. professional nurses demonstrate collegiality by sharing with, supporting, assisting, and counseling other nurses and student nurses; take part in professional orgs, serve as role models for students, welcome learners and their instructors in a practice setting, publish in professional literature, and support peer assistance programs for impaired nurses Can find more info about the value of collegiality in *Nursing: Scope and Standards of Practice* 3 types of collegiality: (1) Essence- creating a healthy work environment and supporting the interdependence of other nurses (2) Support for peers, student nurses (3) Collegial behaviors (participating in research, assisting, counseling other nurses)

State Board of Nursing (SBN)

The regulatory body in each state that regulates and enforces the *scope of practice* and *discipline* of the members of the nursing profession; delegated by the governor (executive branch) to administer aka carry out the NPA Legislature writes the law for each state --> delegates authority to enforce the law to executive agency (Board of Nursing), where the law is then enforced 3 functions that mirror those of the federal and state governments: (1) Executive - authority to administer the NPA (2) Legislative - authority to adopt rules necessary to implement the NPA (3) Judicial - authority to deny, suspend, or revoke a license/deny application for licensure *State Board of Nursing's authority is limited;* they can adopt rules that clarify general provisions of the NPA, but cannot enlarge the law.

Informed Consent

Three major conditions: 1. consent must be given voluntarily 2. consent must be given by an individual with the capacity and competence to understand (in the case of language barriers, need to ensure they understand what is happening via professional translator--having family members translate is unacceptable) 3. the patient must be given enough information

Telehealth

Use of technology to deliver health-related services and information, including telemedicine *Available technologies* include remote access to laboratory reports, digitalized imaging, counseling patients on meds, diet, activity, or therapy on mobile phones or internet calls, interdisciplinary team consultation about a complex patient issue online etc. Underserved populations; however, issues surrounding this include possible lack of access to adequate technology, internet, lighting, etc. for video calls with healthcare provider Legal and Regulatory Issues* (nursing licensure) surround telehealth care; however, in 2015, 8 telehealth related bills were introduced in the US Congress; one of them *(H.R. 2516)* allows health professionals working for the US Department of Veterans Affairs to treat veterans nationwide under ONE state license; previously, if a VA healthcare provider was seeing someone outside of the state in which they were licensed, they would either have to lie or cancel the appointment with the client Coronavirus Preparedness & Response Supplemental Operations Act (2020): any individual seeking Telehealth can see any provider in any state due to increased need for health care demand; payers have to reimburse telehealth visits as a clinic visit (big deal)

Legal Risks in Professional Nursing Practice: Determining

Was the prevailing standard of care met? Nursing standard of care is what a reasonable, prudent nurse, under similar circumstances, would have done Standard of care - "do no harm" Nonmaleficence "Prevailing" is ascertained through expert witness testimony, documents, patient record, other pertinent evidence (direct testimony of those involved) - what may be negligent now may not have been negligent back then

Wage Compression

When new employees require higher starting pay than the historical norm, causing narrowing of the pay gap between experienced and new employees Leads to nurses who end up seeking higher education or leaving nursing completely

At both the federal and state governmental levels, the ________ branch administers and implements the law

executive From there, the state governor delegates the responsibility for administering the NPA to the State Board of Nursing State Board of Nursing's authority is limited; they can adopt rules that clarify general provisions of the NPA, but cannot enlarge the law.