NURS 507 Final Exam

USDHHS Surgeon General Report: Mental Health: Culture, Race, Ethnicity (2002)

**First ever Surgeon General Report on mental health** - how do mental health disparities affect racial and ethnic minorities? Findings: 1. Mental illness is a disabling condition affecting all populations regardless of race or ethnicity 2. Racial and ethnic minorities are more likely to have less access and receive poorer quality services, and be underrepresented in research 3. These disparities result in minorities being overrepresented among the most vulnerable pops. 4. Culture and society play pivotal roles in how mental health services are perceived and received

Sullivan Commission on Diversity in the Health Care Workforce: Missing Persons: Minorities in Health Professions (2004)

**Implications of not having diverse healthcare workforce** Key Recommendations: 1. Diversity if a key to excellence in health care 2. Leadership commitment and accountability essential for success 3. 3 overarching principles were developed to drive increased diversification in US healthcare workforce *Schools increase diversity of leadership *New and non-traditional paths to health professions *Commitment at highest levels of universities and colleges is essential

What is the significance of the ANCC Magnet Recognition Program?

*Designed to focus on infrastructure and practices that maximize nurse input *Goal to attract and retain nurses *Magnet hospitals have better patient outcomes *Call for BSN prepared nurses BUT *Resource intensive -must be renewed every 5 years -cannot attract enough BSN nurses Other programs: -Pathway to excellence program -new program for nursing home

Factors that influence ethical decision-making?

*Not made in a vacuum* Examples: *Ethical Code for Nurses *Patients' rights *Social and cultural attitudes *Science and technology *Legislation *Judicial decisions *Personal, religious, philosophic viewpoints

What is the policy development theory of Kingdon's model?

*One of the most widely used frameworks Views policy development process as occurring in 3 streams: 1. Problem stream 2. Policy stream 3. Political stream "Window of opportunity" = coupling of any two streams *Window and acting on it are considered crucial in policy development

Workplace factors that influence ethical decision making?

*Status as an employee *Collective bargaining contracts *Collegial relationships *Ethical committees in health care *Consumer involvement in health care

What is a generalization?

*Think of as a green light to go and get more information about a person to make sure you are treating them as they want to be treated *Rules and/or patterns that groups adopt about other groups

What is a stereotype?

*Think of as a stop sign, a conclusion; a conscious decision not to get more information, but to act on what one thinks or feels *Over simplified conception, opinion, or belief about some aspect of an individual or group of people

Things to remember about patient safety?

- It is NOT about being clinically competent, intent and will. It assumes good intent and will do the right thing - It is about systems that support humans to do what they know how to do well

What are the key components of evidence-based practice (EBP)?

- Use of current evidence - Patient preferences and values - Judgment based on clinical expertise

What is a just work culture?

-A work culture valuing accountability and leaders who recognize the role of the system and system failures in staff performance (i.e. not blaming those responsible for iatrogenic errors - but holding them accountable) -Culture focused on preventing harm to patients and valuing staff input and participation in developing systems that will prevent harm

What are basic ethical concepts/principles?

-Autonomy of the PATIENT (freedom from external control or influence; independence) -Beneficence (action that is done for the benefit of others) and Nonmaleficence (to do no harm - the pertinent ethical issue is whether the benefits outweigh the burdens) -Justice (just behavior or treatment) -Fidelity (faithfulness to a person, cause, or belief, demonstrated by continuing loyalty and support) -Veracity (truth)

What are/is ethics?

-Branch of philosophy -Derived from Greek term, ethos, which means customs, habitual usage, conduct, and character -Reflects the "should" of human behavior

1991 Patient Self Determination Act

-Federal -Requires all facilities who are reimbursed by Medicare to --inform all patients of importance of ADs -Does not require patients to actually complete an AD -Facilitates patient autonomy -Maryland: EMS cannot honor an AD or health care proxy....MUST have a completed EMS DNR form or MOLST form (signed by MD, NP, or PA) - both of these forms are voluntary -The MOLST form does not expire, but requires signatures and dates when updated

What are the specific benefits of advance directives?

-Increased understanding of ethical and legal aspects of ADs -Increased # of patients approached about ADs -Improved ability to discuss/educate patient and family/health care proxy on ADs -Increased # of patients with completed ADs in chart

What is the CLAS Standards Structure? (Culturally and Linguistically Appropriate Standards for Health Care Delivery)

-Principal Standard (#1): Provide equitable, understandable, and respectful quality care and services response to diverse cultural health beliefs and practices, preferred languages, health literacy and other comm. needs -Governance, Leadership, and Workforce (#2-4) -Communication and Language Assistance (#5-8) -Engagement, Continuous Improvement, and Accountability (#9-15)

What is The Leapfrog Group for Patient Safety?

-Private sector org which works with its employer members to improve standards related to safety, quality, and efficiency of care -Leapfrog Hospital Survey compares hospital performance on national safety, quality, and efficiency standards

What is a code of ethics?

1. A blueprint or guideline for professional self-regulation 2. A contract by which a group (profession) informs society of the rules and principles of how it will function 3. Informs new members of the ethical positions accepted by other members and guides behavior

What is a treatment directive? (2 types)

1. A living will that provides specific instructions to health care providers about particular kinds of health care treatment an individual would or would not want to prolong life. Often used to declare a wish to refuse, limit, or withhold life-sustaining treatment. 2. Verbal directives allowed in some states if there is clear and convincing evidence of the patient's wishes

What is the public policy process?

1. Agenda setting 2. Legislation and regulation 3. Implementation 4. Evaluation

What is subjectivism?

1. Any of various theories maintaining that moral judgments are statements concerning the emotional or mental reactions of the individual or the community. 2. Any of several theories holding that certain states of thought or feeling are the highest good.

Blueprint for 21st Century Nursing Ethics: Report of the National Nursing Summit (2014)

1. Clinical practice: Create/evaluate tools and guidelines to promote ethical environments and disseminate results 2. Education: Create recs. for preparing faculty to teach ethics effectively 3. Nursing Research: Create metrics for ethics research to identify common outcomes (care quality, clinical outcomes, costs, impact on staff and work environment) 4. Policy: Create criteria to measure and evaluate workplace culture and moral distress

What are the 3 categories that the 15 CLAS standards are divided into? (2000)

1. Culturally competent care 2. Language access services 3. Organizational supports

What are ethical theories of particular interest in health care?

1. Deontology (Take the right course of action, irrespective of the consequences) - Immanuel Kant 2. Utilitarianism (Greatest good for the greatest number) - Bentham and Mill 3. Social Equity and Justice (How do we best allocate scarce resources?) - John Rawls

IOM: Unequeal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003)

1. Determine the presence and extent of racial/ethnic disparities that could not be attributed to access 2. Evaluate potential sources of disparities including the role of bias, discrimination, and stereotyping at the individual, institutional, and health systems level 3. Provide recommendations regarding interventions to eliminate racial/ethnic disparities

What are the five stages of group process/development? (Jensen/Tuckman)

1. Forming 2. Storming 3. Norming 4. Performing 5. Adjourning

What is the EBP process?

1. Identify the clinical problem (question or issue) 2. Search for evidence 3. Critique what you find 4. Synthesize findings and patient view 5. Implement evidence-based change 6. Evaluate impact

Framework for Ethical Decision Making

1. Identify, clarify ethical problem 2. Gather data 3. Establish problem context 4. Identify options 5. Make a decision 6. Act and assess impact

What does generalization look like as a tool?

1. Impression management begins with self-awareness 2. Probe to find out if individual you are engaging with fits cultural pattern 3. Adopting a generalization should be the springboard from which you determine the extent to which an individual adheres to certain cultural characteristics

Release of the ANA's revised Code of Ethics for Nurses (2015)

1. Provisions 1-3: Fundamental values and commitments of the nurse 2. Provisions 4-6: Boundaries of duty and loyalty 3. Provisions 7-9: Duties of the nurse that extend beyond individual encounters

What are the 14 forces of magnetism of the ANCC Magnet Recognition Program?

1. Quality of Nursing Leadership 2. Organizational Structure 3. Management Style 4. Personnel Policies and Programs 5. Professional Models of Care 6. Quality of Care 7. Quality Improvement 8. Consultation and Resources 9. Autonomy 10. Community and the Healthcare Organization 11. Nurses as Teachers 12. Image of Nursing 13. Interdisciplinary Relationships 14. Professional Development

What are the 5 models of the ANCC Magnet Recognition Program?

1. Transformational Leadership 2. Structural Empowerment 3. Exemplary Professional Practice 4. New Knowledge, Innovations, and Improvements 5. Empirical Quality Outcomes

What are the factors contributing to the need for lateral integration?

1. Trends in Health Care 2. Trends in Nursing 3. System Network Issues 4. Internal System Issues

What are the two types of errors?

1. Unintended action --> slips (attention failure) or lapses (memory failure) 2. Intended action --> mistake (good-intentioned) or violation (mal-intentioned)

What are some case examples of ADs?

1998-2005 - Terry Sciavo 1983-90 - Nancy Cruzan 1975-85 - Karen Ann Quinian

ANCC Magnet Recognition Program

5 Model Components 14 Forces of Magnetism

What is an appointment directive?

A durable power of attorney for health care allows an individual to appoint someone (health care proxy/agent/surrogate) to make health care decisions for him or her should they lose the ability to make decisions or communicate wishes

What is a moral agent?

Acting on behalf of someone (Nurses are moral agents)

TJC: Roadmap for Hospitals (2010 - Updated 2014)

Advancing Effective Communication, Cultural Competence, and Patient and Family-Centered Care

TJC: Field Guide (2011 - Updated 2014)

Advancing Effective Communication, Cultural Competence, and Patient and Family-Centered Care for the LGBT Community (A Field Guide)

What is the AHRQ?

Agency for Healthcare Research and Quality -Lead federal gov. agency for patient safety research and oversight of Patient Safety Organizations (PSOs) and a network of patient safety databases set in motion by the Patient Safety and Quality Improvement Act of 2005

What are some dysfunctional behaviors in groups? (self-serving)

Aggressor Blocking Self-Confessing Joker Avoider Dominating Special Interest Pleading Recognition Seeker

What is/are bioethics?

Application of ethical theory and practice to health care

Silence kills: 7 most crucial concerns?

Broken rules Mistakes Lack of support Incompetence Poor teamwork Disrespect Micromanagement

How does the legislative branch formulate policy?

By... Enacting laws Creating and funding health programs Balancing health policy with other policy domains

How does the executive branch implement policy?

By... Implementing laws Proposing legislation Approving or vetoing legislation Promulgating rules and regulations

How does the judicial branch interpret policy?

By... Interpreting constitutional and statutory law Developing a body of case law Preserving rights Resolving disputes

What does lateral integration look like currently in practice?

Case Management Disease Management Patient Navigation Transitional Care

What is competency?

Cluster of knowledge, skills and abilities (KSA)

What are strategies to promote safe patient care?

Daily Practice - clinically competent employees, safety checks in place, medications stocked, supplies stocked, pateint identifiers, universal protocol Standardized Practice - protocols, policies, procedures (ex. AACN procedure manual, textbooks, hospital education courses) Documentation Communication - 4 p's of communication and SBAR

What is the goal of lateral integration?

Develop strong communication between health professional through patient-centered care and to create synergy, collaboration, and value for the contributions each discipline brings to care Key issue: who implements it? How does it get implemented?

What are the Patient's Bill of Rights?

Developed by American Hospital Association (AHA) Developed to promote effective patient care Patient has a right to.... 1. High quality hospital care 2. Clean and safe environment 3. Involvement in their care 4. Protection of privacy 5. Help with bills and filing insurance claims 6. Help when leaving the hospital

Why were the CLAS standards developed? Are they mandatory?

Developed by federal government, designed to replace the patchwork of definitions and requirements used in health care around issues of culture; NOT mandatory (not a legal requirement)

What are examples of ethical rights?

Examples: 1. Self-determination (Patient Self-Determination Act) 2. Cultural relativism 3. Unborn 4. Privacy and confidentiality (HIPAA Act)

What are the characteristics of the adjourning stage?

Final stage Ideally occurs when desired outcomes are met Leaders encourage feedback about group and group interaction Suggestions for future growth and/or improvement Norm of confidentiality does not end with completion of group

TJC: Hospitals, Language & Culture: A Snapshot of the Nation (2007)

Findings: 1. Challenging to accomplish goal of culturally and linguistically competent care 2. Difficult to find staff with the desired cultural and linguistic competence 3. Managing and satisfying a culturally diverse staff is challenging 4. Financially stressful to provide culturally competent care and maintain an engaged and dedicated culturally competent workforce

What is the policy development theory of the advocacy coalition framework? (Sabatier and Jenkins-Smith)

Focuses on impact of coalition structure and behavior, shared beliefs and coordination patterns, and scientific evidence and technological information on policy change

What is the definition of a group?

Gathering of two or more individuals that share a common purpose and achieve an identifiable goal

What are maintenance behaviors?

Harmonizing Gate-Keeping Encouraging Compromising Standard-Setting Sensing, Expressing Feelings Group feelings

What are the overall benefits of advance directives?

Health care professionals, especially nurses, can improve end-of-life decision making by talking about and encouraging completion of ADs before the individual loses decisional capacity

What are some common group problems?

Inadequate decision making Monopolizing member Conflict Apathy

What are the characteristics of the forming stage?

Initial phase Members self-select or are chosen Polite phase - shyness, uncertainty Extroverts may assume leadership positions Members want acceptance and safety Orientation Abstract discussions about concepts and issues *Serious issues and feelings are avoided*

What are task behaviors?

Initiating Seeking information Clarifying, elaborating Summarizing Consensus taking Testing

Definition of lateral integration?

Integration of care provided by multiple, interdependent, and independent disciplines across a continuum of a patient admission or experience

What is the Transforming Care at the Bedside (TCAB) initiative? - RWJF Foundation

Joint effort of RWJF and Institute for Healthcare Improvement Goals: 1. Enhance quality of patient care and service on medical surgical units 2. Create more effective health care teams on med surg units 3. Improve patient and staff satisfaction on med surg units Results: 1. Evidence-based road map to boost safety, reliability, and patient-centered care 2. Doable, affordable best practice benchmarks Participating hospitals reported: -Better clinical outcomes -Increased direct care time for nurses -Reduced nurse turnover -Lower costs

Who called for lateral integration as a core CNL skill?

Jolene Tornabeni (Chair, CNL Task Force, AACN; EVP and COO, Inova Health System)

What is policy competency?

Knowledge, skills, and abilities to accurately analyze impact of the policy making process in your interest area AND expertly influence the process **Key: decision making process that requires insight into the policy making process

What are morals?

Latin word: Mores (customs or habits) -Basic standards for what we consider to be right or wrong -Often based on religious beliefs, social influences, and group norms -Reflects the "is"of human behavior

What are the roles of the 3 branches of government in policy-making?

Legislative - Formulates Policy Executive - Implements Policy Judicial - Interprets Policy

What are the characteristics of the norming stage?

Members share more responsibility for leadership of group Sense of group belonging, relief due to resolution of personal issues Feedback more spontaneous Group starts working well together May regress to storming stage when issues arise Development of team spirit and goals Able to give and accept constructive criticism Natural leaders may be those who were not obvious in stages 1 and 2

What are the characteristics of the performing stage?

Most goals and tasks get accomplished - productive Group cohesiveness Group identity is complete, morale high, loyalty intense Group is self-directed Task function becomes genuine problem solving, leading towards optimal solutions and optimum group development Affirmation may develop

What is the NCQA?

National Committee for Quality Assurance -Private sector org. which awards accreditation to health care orgs. and health plans, certification to programs, and recognition status to an array of health care orgs.

What are the ANA Safety and Nursing Quality Initiatives?

National Database of Nursing Quality Indicators (NDNQI) initiated by ANA to enable hospital quality performance comparisons against national, regional, and state norms to the hospital unit level. *Now controlled by Press Ganey

HRC: Working for Lesbian, Gay, Bisexual, and Transgender Equal Rights (2016) (Healthcare Equality Index)

National LGBT benchmarking tool evaluating facility policies and practices related to equity and inclusion for LGBT patients, visitors, and employees. (2060 healthcare facilities nationwide)

What is the NQF?

National Quality Forum -Private sector org. that convenes private and public stakeholder groups to foster continuous quality improvement across the nation. Endorses consensus standards for performance measurement and reporting

What does amoral mean?

Not involving questions of right or wrong; without moral quality; neither moral nor immoral

PICOT method for crafting the clinical question?

P = Patient population or disease I = Intervention of interest C = Comparison of intervention O = Outcome T = Time it takes for the intervention

What are the 4 P's of communication?

Patient (ID and PMH) Problems (abnormal findings, lab results, recent condition changes) Plan for Patient (brief plan, what to watch for, treatments, procedures, meds, orders, etc.) Precautions (communicate pertinent info, code status, isolation, fall risks, other safety concerns)

What is your role in patient safety?

Patient advocacy Simple to Complex Items (following isolation policies, correct blood draws) Do not be complacent - act on issues Know and adhere to TJC Sentinel Events Policies and Procedures

What is the policy development theory of incrementalism?

Policy makers limit themselves to small changes at the margins of existing policies rather than systematically tackling entire existing policies *The focus on small changes can be limiting

What are the universal protocols?

Prevent wrong site, wrong person, wrong procedure surgery

What is policy?

Principles, values, or guidelines driving actions towards given ends Sets a plan, direction, or goal for action

What is the CLAS principal standard (#1)?

Provide equitable, understandable, and respectful quality care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs

What is assisted suicide?

Providers provides the means for patient death, but does not directly perform the procedure (ex. lethal injection as in euthanasia) Legal in six states (Oregon, Washington, Montana, Vermont, California) Pending in Washington DC

What is SBAR?

Situation - what is happening at the present time? Background - what are the circumstances leading to this situation? Assessment - what do I think the problem is? Recommendation - what should we do to correct the problem? What to watch for?

How to use EBP to improve patient outcomes?

Specific EBP projects Journal clubs Nursing grand rounds Developing or updating policies, procedures Crafting clinical pathways or protocols

What are descriptive ethics?

Study of peoples' beliefs about morality - what do people think is right?

What is altruism?

The principle or practice of unselfish concern for or devotion to the welfare of others

What is the policy development theory of rational approach?

The problem is defined, goals are identified, policy alternatives are examined, and a policy is selected that is the best fit with this goal *Assumes ideal world in which rationality dominates without consideration of influence of emotion and special interests *Similar to Nursing Process

What are the characteristics of the storming stage?

Transitional phase, uncomfortable Cope with power and control issues Competition, conflict in personal relationships Individuals use testing behaviors to elicit boundaries, comm. styles, and personal reactions from others Unrealistic goals and expectations *Leads to development and group norms* Leader holds important role - coach, models effective group behavior

What are politics?

Ways people try to influence decision making and divvy up resources

Advance Directives

~Not Mandatory, but HIGHLY ADVISED~ 1. Allow individuals to provide directions about the kind of medical care they do/do not want should they become unable to make decisions or communicate their wishes 2. Provides guidance for health care professionals and families about decision making that reflects the person's wishes 3. Provides immunity for health care professionals and families from civil and criminal liability when health care professionals follow the advance directive in good faith