Final exam - nursing 104
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
Quality
Customers pay attention to both personal interactions and products or services
1861-1865
Insurance plans available during Civil War
Telehealth Nursing
Integral part of an outpatient clinic practice Function of a centralized call center
ORYX Core Performance Measure Sets
Integration of outcomes and performance measured data for selected patient diagnoses. (www.jointcommission.org)
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
Peplau
Interpersonal Relations as a Nursing Process: Man as an Organism That Exists in an Unstable Equilibrium
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?
Usability
Is the site well designed, stable, and easy to use? Content should be error-free and readable by the intended audience
regulations
It is important that _______ reflect the intent of the law
The Joint Commission (TJC)
It requires evidence that the agency actually does provide that care and how they demonstrate continued improvement. "walk the talk"
Nurse Practitioner (NP
Job responsibilities include: Taking patient histories
Grassroots
Joining a professional nursing organization
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?
Health Policy
Judicial decisions that interpret the law
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
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
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
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
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
Nurse Administrator or Nurse Executive:
Knowledge in business administration
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
Largest health insurance program in the U.S.
Nurse Administrator or Nurse Executive:
Lead and direct large groups of nurses and ancillary personnel
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
Board of Directors
Legally responsible for establishing policies and ensuring policies are executed
Cause-and-effect diagram
Lists potential causes arranged by category to show their effect on a problem Helps determine potential causes of a problem
Currency
Look for dates Compare the last update with current literature
Health promotion and maintenance Illness prevention Diagnosis and treatment Rehabilitation and long-term care
Major Categories of Health Care Services
Felony acts
Major criminal offenses Common offenses Drug trafficking Fraud in billing services for Medicare patients Theft, rape, murder
APNs
Make independent and collaborative health care decisions
Leader and manager
Managing multiple resources in a health care facility
Continued Competency
Mandatory continuing education Designated clinical practice hours Portfolios Continuing education requirements are found in nurse practice acts and in rules and regulations
Centers for Medicare and Medicaid Services (CMS)
Mandatory for hospitals receiving Medicare & Medicaid reimbursements
Flowchart
Maps out what actually occurs in a work process Includes steps and substeps, and who does the work
1847
Massachusetts Health Insurance of Boston offers group policy
Chief Executive Officer (CEO)
May be assisted by a chief operating officer (COO)
Board of Directors
May or may not be paid for service
Market System
Means by which a buyer and a seller come together so the buyer can purchase products or services from the seller
clinical practice guidelines
Medical specialty boards developed
2003
Medicare Prescription Drug Improvement and Modernization Act of 2003; most significant expansion of Medicare since its enactment
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?
Never events
Medicare no longer pays hospitals for the extra cost of treating preventable errors commonly referred to as never events
2008
Medicare no longer pays hospitals for treating preventable errors known as never events
2 billion
Medication-related errors for hospitalized patients cost ______ annually
governor's office
Membership of the board of nursing usually appointed by the _______________
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
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 Educator
Minimum of master's degree in the specialty area in which they teach
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
Clinical nurse specialists (CNSs):
Monitors the care of clients and collaborate with the health care team
Conceptual model or framework
More loosely structured than theories
U.S. Health Care System
Most technologically advanced Most expensive system in the world Failures in the system occur with some regularity
Nurse Educator
Must be competent in clinical practice at advanced generalist or specialist level
Theory
Must include at least two concepts that are related in a way that the theory explains
Accrediting Agencies
Must show Quality Management strategies.
Current licensure activities
Mutual recognition model Continued competency
1950
NLN administered first State Board Test Pool Examination, a standardized examination for licensure
Planning
Decide in advance what to do; how, when, and where it is to be done; and who is to do it
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
quality improvement
Needed change of focus to preventing problems and improving care.
Civil Law
Negligence and malpractice
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
Clinical nurse researcher (CNR)
Designs studies
Nursing Care Delivery Models
Detail how task assignments, responsibility, and authority are structured to accomplish patient care
1947
New York first state to require mandatory licensure
Clinical Nurse Leader (CNL)
New role
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
Change agent
Determining and exploring alternatives and assessing cost-effective resources
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
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
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
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
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
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
Potential Funding Areas
Discovering approaches that encourage people to effectively take responsibility for symptom management and health promotion
Clinical nurse researcher (CNR)
Disseminates findings to staff, administrators, and legislators
Home care
Dobutamine administration Chemotherapy Radiography or telemetry Uterine monitoring
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
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
Decision making
Not always related to a problem situation Required throughout all aspects of management
External customers
Not employed by the organization Include patients and families, as well as physicians, payers, and other users of the facility
Board of Directors
Not involved in day-to-day activities
1. 5.4 , 2. 6.2
Number of male RNs increased from ___1___% in 1996 to ___2___% in 2010
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
Case Management
Nurse case manager "manages" a "case load" of patients from preadmission (onset of illness) to discharge (resolution of illness)
transformational
Nurse executives who demonstrate __________ leadership characteristics achieve higher levels of staff satisfaction and greater work group effectiveness
Orem
Nurse implements appropriate measures to assist the client in meeting needs by matching with an appropriate supportive intervention
Total Patient Care
Nurse is responsible for planning, organizing, and performing all patient care during the assigned shift
Numbers of staff working at any given time Staff mix
Nurse manager accountable for budgetary guidelines for:
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
Rogers
Nurse promotes synchronicity between human beings and their universe/environment
Assault and battery
Nurse should ask patient's permission before initiating any procedure and document permission granted
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
Intentional infliction of emotional distress
Nurse's behavior is so outrageous that it leads to the patient's emotional shock
Newman
Nurse's role: recognize person's unique pattern of life and work within that pattern to achieve person's goals
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"
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
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
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
Chief Executive Officer (CEO)
Nurses with advanced degrees are good candidates as a result of their broad holistic education and clinical experience
Triage Interventions Consultation Surveillance and follow-up
Nurses' Roles in Telehealth Nursing
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
Total Patient Care
Nursing student typically performs
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
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
ANCC
Offers certification in 25 areas of specialty nursing Certified more than 250,000 nurses as of 2009 80,000 Advanced Practice Registered Nurses
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
Total Patient Care
Oldest method of organizing patient care, sometimes referred to as case nursing
executive
Once a bill becomes law, implementation falls under jurisdiction of one of the departments of the __________ branch
The Joint Commission (TJC)
One of the first regulatory agencies to embrace quality improvement principles in hospital-based settings.
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
Nurse Practitioner (NP
Ordering, performing, and interpreting diagnostic tests
Organizing
Organizational chart Policies and procedures Job descriptions
Financial resources Licensing regulations and accreditation standards Customer satisfaction
Organizational needs affected by staffing include:
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
Case Management
Other disciplines, most notably social work, have been involved in developing ___________ programs
Clinical Nurse Leader (CNL)
Oversees the care of a distinct group of patients in any setting
Medicare
Part A covers inpatient hospital services, skilled nursing facilities (SNFs), and home health benefits
political endeavor
Patient care and nursing practice is a ________
Interprofessional Teamwork
Patient care dependent on effective communication to support coordination of activities to promote efficiency and safety
2006
Pay-for-performance introduced
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
Federal health policy
Pays for health care through Medicare, Medicaid, SCHIP, and the Veterans Administration health care system
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
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
Quality improvement
Planning and prevention oriented Problem solving by employees at all levels Correction of common cause problems and improvement in work processes
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
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
Certified Nurse Midwife (CNM):
Primary care providers of women's health care
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
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:
Health care concerns in the 21st century
Primary focus of federal and state legislative agendas
Medicaid
Primary payer of long-term care nationwide
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
Robert Wood Johnson, W.K. Kellogg Foundation, Helene Fuld Trust
Private Foundations:
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
Advocate
Promoting what is best for the client
Stakeholder
Protect and influence nursing practice.
Advocate
Protecting the client's rights
State health policy
Provides "invisible services" through regulatory activities
Organizational Theory
Provides a framework for understanding complex organizations
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
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"
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
Never events
Purpose is to encourage hospitals to direct resources to preventing errors rather than being paid for them
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
Clinical Nurse Leader (CNL)
Puts evidence-based practice into action
Advancing Evidence-Based Practice
Questioning current clinical practice
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
Team Nursing
RN functions as a team leader and coordinates care for a small group of patients
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
Telehealth
Real time data capturing improves management of chronic diseases
Medicaid
Recipients are not as likely to obtain needed health services
pins and registries
Recognition:
Grassroots
Registering to vote and voting in all elections
Federal Register
Regulations published daily
Certified Registered Nurse Anesthetist (CRNA):
Required to complete a written exam for certification as a CRNA
Certified Registered Nurse Anesthetist (CRNA):
Required to make independent judgment relative to all aspects of anesthesia care
evidence base for practice
Research focus of 21st century:
Nursing education Student characteristics Student satisfaction
Research focus, 1900 to 1940
Teaching Administration Curriculum issues
Research focus, 1950s to 1970s
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
Clinical consultant
Resource for clinical advice Role model for excellence in nursing care and evidence-based practice
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
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
Change Agent
Responsible for guiding people through the change process
Chief Executive Officer (CEO)
Responsible for overall operation on a daily basis
Nursing Research
Results create strong scientific base for nursing
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
Types of Power
Reward power Coercive power Legitimate power Referent power Expert power Informational power Connection power
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
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
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
provide higher quality, more cost-effective care
Satisfied nurses generally provide
Rogers
Science of Unitary Human Beings: Humans as Energy Fields That Interact Constantly with the Environment
Rogers
Science of unitary man: energy fields, openness, pattern, and organization
CINAHL
Scientific and research information usually requires literature resources that can only be found in scholarly databases such as _______
Hypothesis Method Data collection Results Evaluation
Scientific inquiry involves five aspects: what are they?
effective and efficient searchs
Search engine ("Google it") Advance searching (Google Scholar) Brut Force (Specific web address) Links
Clinical nurse specialists (CNSs):
"The emphasis of this advanced nursing practice is to provide clinical support that improves client care and client outcomes."
Health maintenance organizations
(HMOs)
Orem
Self-Care Deficit Model: Self-Care, Self-care Deficits, and Nursing Systems
Acute Myocardial Infarction (MI)
Smoking history for the past year and documentation that smoking cessation information was given
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?
Clinical Pathways
Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem
ORYX Core Performance Measure Sets
Standardized measures referred to a National Hospital Quality Measures reported publically on TJC website.
Knowledgeable
State Board of Nursing publication (Examiner).
Nurse Practitioner (NP):
State board of nursing regulate NP practice and prescriptive authority
true
Supporters of the new law MUST be involved with its implementation esp. with regulations regarding the new law. True or False?
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
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
Telehealth
Telecommunications technology to assess, diagnose, and, in some cases, treat persons who are located some distance from the health care provider
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
is key to satisfaction
A customer's personal interaction with employees
Theory
A group of related concepts that explain existing phenomena and predict future events
State Health Insurance Exchanges (SHIEs)
A key piece of the health care reform or ACA legislation is the opportunity for states to develop
Accrediting Agencies
A method by which the quality of what takes place is assured.
Science
A method of bringing together facts and giving them coherence and integrity
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
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
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
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
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
Clinical Pathways
A team supported by management, with representatives from various disciplines such as nursing, medicine, therapy, pharmacy, and dietary, develops clinical pathways
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.
technical, human, and conceptual
Three major areas required for effective leadership :
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)
nurses
Through effective political action, ________ can positively influence legislative decisions and health policies
Diagnosis and Treatment
Traditionally the U.S. health care system has put major emphasis on diagnosis and treatment.
competitive market system
U.S. economy founded on the principles of a ________________
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
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
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 _________
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
66%
Up to ____ of health care errors are related to poor working relationships and communication
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
Mentor
Accepts responsibility to act as a mentor to new nurses Recognizes that mentoring is key to developing future nursing leaders and managers
Private insurance
Accounts for the largest percentage of coverage for health care
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
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
Nurse Practitioner (NP):
Achieve registration and licensure by state boards of nursing
Clinical Nurse Leader (CNL)
Actively provides direct patient care in complex situations
Staffing
Activities required to ensure an adequate number and mix of health care team members to meet patient needs and provide safe, quality care
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
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
Partnership Model (or Co-primary Nursing)
Advantages More cost-effective than the primary care system RN can encourage training and growth of partner
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
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
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
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
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
Planning
All management functions based on ___________
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
Chief Executive Officer (CEO)
Also has an external role in the community
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?
W. Edwards Deming
American pioneer in quality management movement
Theory
An abstract generalization that presents a systematic explanation about how phenomena are interrelated
Pneumonia
Antibiotics must be administered within 6 hours of hospital arrival
Nursing Research
Application of results demonstrates professional accountability to insurers and health care consumers
60 %
Approximately ______ of RNs employed full time
3 million
Approximately ________RNs in the United States
Advancing Evidence-Based Practice
Assessment of barriers to EBP
Safety
Attitude Value the contributions of standardization/reliability to safety Value relationship between national safety campaigns and implementation in local practices and practice settings
Patient-Centered Care
Attitudes Value seeing health care situations "through patients' eyes" Respect and encourage individual expression of patient values, preferences, and expressed needs
46.8
Average age for RN in 2008
Nurse Administrator or Nurse Executive:
View problems of nursing service delivery and delivery of health care services
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
Nurse practitioners (NPs) Certified nurse-midwives (CNMs) Certified registered nurse anesthetists (CRNAs) Clinical nurse specialists (CNSs
What are advanced practice nurses?
Needs assessment, Survey, Case study, Methodological, Meta-analysis, Experimental, Quasi-experimental, Secondary analysis, Triangulation, Pilot studies
What are the quantitative designs?
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
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
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
Primary Nursing
While off duty, care is provided by an associate nurse, who follows the care plan established by the primary nurse
QSEN
Whos faculty determined that quality and safety should be separate because of the science supporting each?
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
Private insurance
With managed care products such as HMOs and PPOs, the premium the consumer pays for coverage has continued to rise
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
Interprofessional Teamwork
Work environment that supports effective communication of nurses with other health care professionals is critical to patient safety
W. Edwards Deming
Worked with the Japanese in post-World War II reconstruction efforts
Grassroots
Working in candidates' campaigns
Clinical nurse researcher (CNR)
Works with staff to identify research questions
"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
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
States
______ established boards of nursing to develop rules for examination and licensure of nurses and govern the practice of nursing
TJC
______ focus is on the organization's ability to provide quality/safe care.
25%
______ of patients are not receiving care that is recommended
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
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
Competitive
_______ marketplace in which health care facilities compete for patients
Poor
________ more likely to lack usual source of care, less likely to use preventive services, and more likely to be hospitalized for avoidable conditions
TJC
________ required accredited hospitals to collect data on standardized "core performance measures".
Hosptials
________ were first "health-related" organizations to explore and implement a "quality" mindset.
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
uninsured
_________ more likely to be hospitalized for avoidable conditions
Medicare
__________ extended financing revolution to physician reimbursement in the early 1990s and initiated the resource-based relative value scale (RBRVS)
Accreditation
__________ is basically a "seal of approval" from an outside agency.
Medicare
__________ moved to a prospective payment system based on DRGs
RBRVS
___________ brought physician reimbursement more in line with skills required and actual time spent on procedures
Legislation
____________ is in place to protect individuals enrolled in managed care plans: access, quality, cost
Quality Assurance (QA)
_____________ which involved "monitors" to determine if process was "right or wrong".
Quality improvement
______________ should not be considered a separate function within the nursing role but rather an ongoing part of the professional role
health care reform
___________________legislation has become a reality with passage of The Patient Protection and Affordable Care Act of 2010
informatics and IT
_________________are links to ensure patient safety through improved information access and data management
legislative branch
_______________originates and promotes major policy initiatives
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
Transactional leader
_____________is concerned with the day-to-day operations of the facility/unit
influence
________is the common denominator in any definition of politics
Regulations
_______carry the force of law
Grounded theory
a method designed to explore a social process
Qualitative Designs
a method of research designed for discovery rather than for verification
Ethnography
a method used to study phenomena from a cultural perspective
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
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
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
Ethical Theory
a system of principles by which a person can determine what ought and ought not to be done
Human skills
ability and judgment to work with people in an effective leadership role
Leadership
ability to guide or influence others
Power
ability to motivate people to get things done with or without the formal right granted by the organization
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
Social justice
acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation
regulations
address public health problems
The Patient Safety and Quality Improvement Act
allows certain disclosures of patient safety data
executive branch
also implements laws, manages programs after they have been passed by Congress
Politics
also involves the varied agendas of the Democratic, Republican, and Independent parties
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
Variance
any event that may alter the patient's progress through the clinical pathway
Clinical Nurse Leader (CNLs)
are educated as generalists (overall, variety)
regulations
are enacted by the executive branch
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
RN nurse manager
assigns responsibility for completion of tasks to a group of health care workers (Functional Nursing)
case manager
assumes a planning and evaluative role and usually is not responsible for direct care duties
Safe
avoiding injuries to patients caused by the care that is intended to help them
Efficient
avoiding waste of equipment, supplies, ideas, and energy
All one team
belief in the people who are working to serve the customer
Teams
bring together a range of people with different knowledge, skills, and experiences to meet customer needs, accomplish tasks, and solve problems
Grand Theory
broad in scope; describes and explains large segment of the human experience
Nurses
can play an influential role by providing input into the final regulations
Ethical theory and ethical principles
can provide a basis for moving forward as a morally mature professional adult
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
regulations
carry the force of the law
Refreezing stage
change agent integrates the change into the organization
Clinical Nurse Leader (CNLs)
coordinate and implement evidence-based practice
Care coordination
decrease duplication of services and reduce wasted health care resources
Needs assessment
determines what is most beneficial to an aggregate group
Plan
develop action plan based on the three questions
.edu
educational institutions
entrepreneurship
encompasses skills and risk taking that businesspersons bring to health care organizations
Operational planning
encompasses the day-to-day activities of the organization
Democratic
encourages staff involvement in goal setting, problem solving, and decision making
Evaluation
ensure problem was resolved effectively
Case Management
ensure that patients get effective treatment at the appropriate level of care
1896
first attempts to license nurses in the United States Failed because of lack of support by hospitals, physicians, and nurses
.gov
governmental body
Lack of insurance
greatest barrier to access to health care
Capital
including all medical facilities and equipment available
Land
including the actual land area for hospitals and other facilities
Governmental immunity
individual health care workers employed in federal or state facilities are shielded from personal responsibility for damages in malpractice cases
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.
.net
internet service provider
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.
EHR; Electronic Health Records
is a system that captures, processes, communicates, secures, and presents data about a patient
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
Assault
is causing a person to fear that he or she will be touched without consent
Customer satisfaction
is critical to an organization's success
Slander
is defamation caused by spoken word; nurses subject to slander when they repeat subjective comments about patients in public places
Private health policy
is made by health care organizations such as hospitals and managed care organizations
CNO
is part of the board of directors
RN
is responsible for planning care and supervising workers (functional nursing)
Battery
is the unauthorized touching or the actual harmful or offensive touching of a person and may rise to the level of a crime
Quasi-experimental
lacks one of the components of experimental design (i.e., randomization, control group, or manipulation of one or more variables)
Good Samaritan immunity
limits a nurse's liability or shields the nurse from malpractice for rendering emergency assistance outside the employment setting
Strategic planning
long-range; extends 3 to 5 years into the future
IOM Future of Nursing Report
major recommendations: Effective workforce planning and policymaking require better data collection and information infrastructure
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
Team nursing
medical-surgical units
Pay-for-performance
method of reimbursing providers based on the quality of care provided with an emphasis on disease prevention and reduction of complications
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."
.mil
military
Safety
minimize risk of harm to patients and providers through system effectiveness and individual performance
traditional
models of nursing care focused on comprehensive knowledge of patient needs and care provided over an extended period
Health care organizations
must be able to adapt to internal or external changes in order to survive.
Consumers
must be educated about the value of nursing research
Policymakers
must be informed about findings, so results can be translated into health policy
Nurses of the future
must conduct focused assessments and set priorities to resolve before the patient is quickly transitioned to another level of care
Health care administrators
must foster research
staff members
must have the educational preparation, skill, and experience necessary to meet patient care needs
Educators
must prepare students to appreciate and conduct research and evaluation at their level of preparation
.org
nonprofit organization
Labor
or inputs devoted to producing health care Nurses, physicians, pharmacists, technicians, administrators Education and training for "labor"
Closed system theory
organization is totally independent on outside influences.
Scientific approach
organizational support for all employees to develop knowledge and skills in the science of QI
Value
personal belief about worth that acts as a guide to behavior
Laissez-faire
provides little direction or guidance and will forgo decision making
Middle Range Theory
smaller in scope and may refer to a specific population
Do
take action to test the action plan
American Nurses Credentialing Center (ANCC)
was formed as a central organization for certification of nurses
Clinical nurse specialists (CNSs):
Educated in graduated level programs
Certified Registered Nurse Anesthetist (CRNA):
Educational preparation occurs at the graduate level
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
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
functional nursing
Emergency departments use __________ because emphasis is on efficient assessment and immediate treatment
Clinical nurse researcher (CNR)
Emerging roles DNP and CNL
Nurse Practitioner (NP)
Emphasis is on disease prevention, health promotion and maintenance
Internal customers
Employed by the organization Include patient care staff members, staff of other departments, administrators, social workers, dietitians, therapists, and so forth
1950s
Employee benefit packages initiated to attract workers
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
Health Policy
Enactment of legislation and accompanying rules and regulations that carry the weight of law
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
NINR Research Foci
End of life
APNs
Engage in active practice as expert clinicians
Leader and manager
Enhancing effectiveness and level of satisfaction among colleagues
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
State health policy
Ensuring safe food storage and preparation in restaurants
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
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
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
Nursing theories in the 21st century
Established nursing theories will be reevaluated and modified to answer important health care questions
Clinical Nurse Leader (CNL)
Evaluates patient outcomes
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
telehealth
Ever-increasing opportunities for nurses in ____ to influence the quality of care
Newman
Every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness
All One Team
Everyone in the organization works together to continually enhance customer satisfaction
Private insurance
Everyone pays part of the country's health care cost in every purchase made
The Joint Commission (TJC)
Examine standards of the organization and level of performance in three areas: Patient rights Patient treatments Infection control
Informal Leadership
Exercised by the person who has no official authority to act but is able to influence others in the work group
Doctor of Nursing Practice (DNP)
Expert in advanced nursing practice who has an earned clinically focused doctorate in nursing
Clinical nurse specialists (CNSs):
Expertise is from graduate study and clinical experience
Peplau
Explored interpersonal relationship of the nurse and the client
Orem
Facilitates client self-care by measuring the client's deficit relative to self-care needs
1929
First group health coverage for a monthly charge for teachers in Dallas, Texas; beginning of Blue Cross/Blue Shield
Certified Nurse Midwife (CNM):
Focus on pregnancy, childbirth, postpartum period, care of newborn, family planning and gynecologic needs of women
Nurse Administrator or Nurse Executive:
Focus on the administration of health care systems for the purpose of delivery services to groups of clients
Problem solving
Focused on solving an immediate problem Includes a decision-making step
Clinical nurse researcher (CNR)
Focuses on the conduct or facilitation of research
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
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
political influence
Forms of ___________ include money, knowledge, relationships, information, talent, and control over large groups of votes
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
Mishel
Four-step framework assists nurses in working with clients: stimuli frame, appraisal stage, initiation of coping mechanisms, and adaptation
Clinical nurse specialists (CNSs):
Functions as a role model or preceptor for nurse generalists and students
Clinical nurse specialists (CNSs):
Functions as an expert clinician, educator, consultant, researcher, and administrator
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
Federal health policy
Funds education for health professionals, including nurses and physicians
Federal health policy
Funds health-related research
Health Care Reform
General term used to refer to policy initiatives to effect significant changes in how health care is delivered and paid for
Nursing Research
Generate knowledge in areas that indirectly affect nursing care process
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
State health policy
Governs nursing through nurse practice act
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
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
Nursing Theory
Guides research and practice
Nursing Science
Guides the practice of nursing to better serve clients
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
Nurse Practitioner (NP):
Have advance education with emphasis on pathophysiology and pharmacology
Newman
Health as Expanding Consciousness
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
Safety
Health care organizations focused on safety use constant surveillance to manage the potential for humans (health professionals) to make unintentional mistakes
Influences on the Type of Nursing Care Delivery Model Used
Health care setting Acute care Long-term care Ambulatory care Home care and hospice
NINR Research Foci
Health disparities
Healthy People 2020
Health promotion and disease prevention
NINR Research Foci
Health promotion and disease prevention
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
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?
Patient classification systems
Higher acuity levels mean that nursing care needs are more intense
Nazi experiments Tuskegee syphilis study Jewish Chronic Disease Hospital in New York
Historical examples of unethical research
Diagnosis and Treatment
Historically health care focused on diagnosis and treatment (not health promotion, illness prevention, or early detection)
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
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
Nurse Administrator or Nurse Executive:
Hold a master's degree
Watson
Holistic outlook addresses the effect and importance of altruism, sensitivity, trust, and interpersonal skills
Telehealth
Home care arena has seen significant changes as a result of telehealth
primary nursing
Home health agencies may use
1993
Hospitals come under DRGs
Joint Commission
Hospitals had to collect and submit data on a minimum of core measures as described through _______________
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.
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 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
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
Institutional review
IRB or human subjects committee required by institutions receiving federal funding Historical examples
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?
Schematic Models
Illustrate the layout and features specific to a theory—similar to the blueprint of a building
True
Implementation of new legislation often can be very different from what was intended when the bill was passed by Congress true or false
Code of ethics
Implicit standards and values for the profession American Nurses Association Code of Ethics International Council of Nurses Code for Nurses
Nonmaleficence
Implies a duty not to inflict harm To abstain from injuring others To help others further their own well-being by removing harm
Market System
Implies private ownership of resources and private decision making by consumers about their purchases and by businesses about their products and sales
Regulated market system
Implies some sort of government control over business owners/sellers
Nurse Manager
Important components of change Involvement Education and training
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
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
Scientific Approach
Improvement decisions based on sound, valid data
Potential Funding Areas
Improving clinical settings in which care is provided
Potential Funding Areas
Improving quality of caregiving in long-term care facilities, the home, and the community
Potential Funding Areas
Improving symptom management for those at end of life
Leader and manager
Improving the health status and potential of individuals, families, and communities
tjc
In 2001 _____ established a safety standard requiring institutions to have a process in place to disclose unanticipated outcomes to patients
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
Planning care Assigning duties Directing, supervising, and assisting team members Giving direct care
In Team Nursing what is the RN responsible for?
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
Pareto chart
Bar chart Reflects frequency at which events occur, or the effect events have on a process
Clinical Pathways
Based on accepted standards of practice
Nursing Theory
Basic ingredients are concepts
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
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
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
Pneumonia
Blood cultures must be drawn prior to starting the antibiotics
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
Steps in the Legislative Process
Include introduction, committee action, House and/or Senate action, and presidential action
Educator and counselor
Increasingly important in the changing health care environment
Florence Nightingale
Influences that directed her toward nursing theory Classic education Upper class life Religion and spirituality Era of reform throughout England
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.
Watson
Caring among nurse, environment, and client is essential to healing
Care provider
Caring: central to nursing interventions
Board of Directors
Carry significant responsibility for the mission of the organization, quality of service and financial stability
Patient classification systems
Categorize patients according to care needs (acuity level)
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
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
Quality assurance
Inspection oriented Reactive to problems Corrected special problems and did not address overall process improvement Responsibility belonged to only a few people
Local health policy
Cities or counties offer a variety of health care services to meet the needs of their residents
Schematic Models
Clarify and show relationships between complex concepts
Total patient care Functional nursing Team nursing Primary nursing
Classic Nursing Care Delivery Models are?
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
Standardization
Clinical guidelines or pathways Outline the optimal sequencing and timing of clinical interventions for a particular diagnosis or procedure
AHCPR (Agency for Health Care Policy and Research)
Clinical practice guidelines: developed by
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
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
Corporate supporter
Committed to the mission, goals, and objectives of the employing organization Professional representative for the organization
Health Policy
Complex, dynamic process; occurs in various ways
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)
Conceptual model or framework
Concepts that are assembled because of their relevance to a common theme
executive level managers
Concerns about inadequate numbers of appropriately skilled and experienced staff should be addressed with
Nurse Practitioner (NP
Conducting physical exams
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
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
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
Coordinator of the interprofessional team
Coordinating practice relationships among several health care disciplines to bond, interact, and unite toward common goals of patient care
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
Advancing Evidence-Based Practice
Corrections of misperceptions about EBP goals and processes
Private insurance
Cost of health insurance to employees passed on by the employer to the consumer
Medicaid
Covers primarily disabled persons, low-income households with children, and those in nursing homes who qualify on the basis of low income
regulation
"a written set of rules issued by the government agency that has the responsibility for administering the law".
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
Centers for Medicare and Medicaid Services (CMS)
Administers U.S. Medicare program
Agency for Healthcare Research and Quality (AHRQ)
Advanced use of information technology for coordinating patient care and conducting quality and outcomes research
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
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
83.2
Approximately _____% of RNs are white/non-Hispanic
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
Acute Myocardial Infarction (MI)
Aspirin administered at arrival if not documented that it was given en route to the hospital
Liability
Asserts that every person is responsible for the wrong or injury done to another as the result of carelessness
Knowledgeable
Assess the effect of proposed regulation on nursing care and nursing practice (long term); patient advocate.
Nurse Practitioner (NP)
Assess, diagnose, manage medical and nursing problems.
Care provider
Assessing clients, planning therapeutic interventions, coordinating and evaluating care
Change agent
Assessing motivation and capacity for change
Potential Funding Areas
Assisting in identification and effective management of symptoms related to acute and chronic disease
APNs
Assume responsibility and accountability for health promotion, assessment, diagnosis and management of client problems, including prescription of medications
Healthy People 2020
At the end of the 10-year period, outcomes are evaluated to help plan for the next 10 years.
technical skill and clinical expertise
At the staff nurse level of management, a considerable amount of ______ and ______ is needed
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
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
Stakeholder
Attend public hearings, speak, write to legislators.
Grassroots
Attending a "meet the candidates" town hall meeting
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
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
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
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
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
All One Team
Believe in people and treat everyone in the workplace with dignity, trust, and respect
Nursing Science
Collection of data related to nursing that may be applied to the practice of nursing
Medicaid
Combined federal and state health insurance program
A
Components of Nurse Practice Acts include: A. Definition of professional nursing B. Certification requirements C. Education requirements D. Current NCLEX-RN plan
Common Law
Created through cases heard and decided in federal and state appellate courts—also known as decisional or judge-made law
1965
Creation of Medicare and Medicaid programs, making comprehensive health care available to millions of Americans
Inclusiveness Consistency Accuracy Relevance Fruitfulness Simplicity
Criteria for theory acceptance involve six factors: what are they?
Clinical Pathways
Developed for the health care organization's most common or costly diagnoses
Clinical Pathways
Developed to identify quality, cost-effective care plans to reduce the patient's length of stay in the hospital
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
The National Committee for Quality Assurance (NCQA)
Emphasis on performance measures of patient outcomes and results of practice patterns
State health policy
Ensuring that health care facilities provide safe, quality care
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
Medicare
Entitlement program based on age or disability criteria rather than on need
Patient Protection and Affordable Care Act (PPACA)
Expands health insurance coverage to uninsured Americans while controlling costs and improving the quality of health care
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
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
Patient Protection and Affordable Care Act (PPACA)
Individual mandate for U.S citizens and legal residents to be covered by a health insurance plan
Private insurance
Individuals also pay a portion of their health care directly through payments for insurance premiums, deductibles, and copayments
Classic education Upper class life Religion and spirituality Era of reform throughout England
Influences that directed Florence Nightingale toward nursing theory
EHR; Electronic Health Records
Integration of information from multiple sources Serves as a primary source of information for patient care and quality
select one alternative
Integration of multiple factors A reasonable and purposeful decision results from the blending of ethical theory, principles, and values
Ethics acculturation
Integrity, personal growth, practical wisdom, and effective problem solving
Medicaid
Intended to improve access to health care for the poor
1901
International Council of Nurses passed a resolution that each state should examine and license nurses
true
Interval between interim rules and final rules critical for assessing effect of the policy; concerted nursing action is required t or f
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
17
Lag between discovery of more effective forms of treatment and their incorporation into routine patient care is _____ years
Concept Construct Conceptual model Philosophy Theory
Language of nursing theory
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
Statutory law
Laws written and enacted by legislative bodies Violations are criminal offenses and are punishable by fines or imprisonment
Accuracy
Look for documentation and referencing Compare information on the website with other sources
State health policy
Maintaining a safe meat supply through livestock inspections
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
Centers for Medicare and Medicaid Services (CMS)
Non-voluntary accrediting agency
delegation
Nurse practice acts establish legal definitions of delegation Guidelines for delegation developed by nursing organizations
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
Medicare
Part B covers physician services
Medicare
Part D provides a prescription medication benefit
State Register
Proposed rules and regulations at the state level.
Certification
Purpose Recognizes excellence in nursing practice Nongovernmental agencies, usually professional nursing organizations, grant certification Requirements and practice opportunities vary markedly
NINR Research Foci
Quality of life
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
Leader and manager
Raising citizens' and legislators' attitudes toward and expectations of the nursing profession and the health care system
Levels of Theory
Range from a broad scope to a smaller, more specific scope
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
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
Medicare
Shift critical for hospitals because ____________ was the largest single payer of hospital charges
Nurse Practitioner (NP):
Should be certified in their area of specialty
American Nurses Association (ANA) Standards of Professional Performance
Should be used along with Standards of Quality Practice to guide nurses
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
Functional Nursing
Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients
Transformational Leadership
Suggests two types of leaders Transactional Transformational
implementation
Supporters must follow through and be involved in the discussion and process for _______________
2004
TJC and CMS aligned their current and future measures common to both organizations
2002
TJC required accredited hospitals to collect data on standardized "core" performance measures
American Nurses Association's Health System Reform Agenda
Targets primary care to lower dependence on costly secondary and tertiary care
Educator and counselor
Teaching health promotion and health maintenance
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
Case Management
Today, most health insurance companies have a program for it
Lewin's stages of change
Unfreezing stage, Moving stage, Refreezing stage
Nurses Strategic Action Team (N-STAT)
Unifies nurses' political voices across the country to enact measures to enhance health care for all
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
The National Committee for Quality Assurance (NCQA)
Voluntary accreditation body for managed care organizations (insurance companies), outpatient clinics and medical group practices.
50
___ % of the uninsured have no regular source of health care
Trigger
alerts caregiver that an unexpected event has occurred and identifies potential and actual variations in patient's response to a planned intervention
1923
all states had instituted examinations for permissive licensure
Clinical Nurse Specialist (CNSs)
are engaged at the clinical frontline and organizational systems levels.
Regulations
are part of the process in the development of HC policy: Identify health problem/issue Legislation Implementation (regulations)
Clinical Nurse Specialist (CNSs)
are prepared for specialty practice
Policy process and nursing process
are systematic approaches to address health care and nursing laws
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
Moving stage
change agent clarifies the need to change, explores alternatives, defines goals and objectives, plans the change, and implements the change plan
Unfreezing stage
change agent promotes problem identification and encourages awareness of the need for change
Technical skills
clinical expertise and nursing knowledge
Interdisciplinary intervention
collaborative effort by all disciplines, along with the patient and family, to reach desired health outcomes
Data capture
collection and entry of data into an EHR system
.com
commercial enterprise
Altruism
concern for the welfare of others
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
"advance practice nurse" (APN)
consist of a licensed registered nurse prepared at the graduate degree level
Management
coordination of resources (time, people, supplies) to achieve outcomes
Primary care services
could be MD office, student health services, emergency room, clinic, etc...
Quality
customer defines quality
Clinical pathways
define key processes and patient goals in the day-to-day management of care
Outcomes management
demonstrate efficiency of care via measurable, effective outcomes
Licensing and accreditation agencies
do not impose mandatory staffing ratio but do look for evidence that patients are adequately cared for
Clinical nurse researcher (CNR)
doctoral prepared with clinical and research experience
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
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
Efficient staff management
ensures the organization's financial solvency
Value system
entire framework on which actions are based
Specific client services
extensive list of client services that include intravenous team, ostomy care, support groups, and health education
Negligence
failure to act in a reasonable and prudent manner
1982
first NCLEX examination
Diane Ustal
first nurse leader to describe the role of values clarification
Locating published research
focus on the usefulness of computerized databases such as CINAHL and MEDLINE and the Annual Review of Nursing Research
Methodological
focuses on development and testing instruments to improve their reliability and validity
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
Moral development
forming a worldview and value system through an evolving, continuous, dynamic process that moves along a continuum of development
Canons of Nursing
foundation for health promotion and guidance for the practice of professional nursing
1903
four states instituted permissive licensure, and nurses were not required to comply
Teamwork and Collaboration
function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care
Assessment
gather all information about the issue
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
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
Clinical practice guidelines
guide broader decision making and focus on decisions made in performing a procedure or service
Clinical Nurse Specialist (CNSs)
have the added responsibility of generating new evidence
Standardized communication strategies
help team members share concerns, clarify decisions about care, and ensure accurate and complete information exchange
Never events
hospital-acquired infections, injuries from falls, wrong site surgery, mismatched blood transfusions, and others
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
Planning
identify and weigh options for risks, consequences, positive and negative outcomes
Act
implement resultant changes in real work settings
Implementation
implement the plan
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
Identification of issues (diagnosis)
information analyzed to identify real issue or problem that needs to be addressed
Collection of information (assessment)
information and data must be gathered from as many sources as possible before the health care issues can be identified
Evidence-Based Practice
integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care
Information communication
interoperability of systems and linkages for exchange of data across disparate systems
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.
Team
is a group of people organized to accomplish work
Politics
is a necessary part of the policy process when multiple interest groups compete to achieve individual goals
Total patient care
is common in critical care units
Libel
is defamation caused by written word; nurses subject to libel for subjective comments written in the medical record
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
Nursing Process
is effective in identifying broader professional and health care issues Assessment Analysis and diagnosis Planning Implementation Evaluation
Government
is the biggest influence in the health insurance market, generating 50% of hospital revenues and 25% of physician incomes
Access to care
is the most significant problem to address through health care reform
executive branch
is to recommend legislation and promote (but not originate) major policy initiatives;
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 practice to the full extent of their education and training
Check
make refinements as needed
Authoritarian
makes all decisions with no staff input and uses the position to accomplish goals
The Federal False Claims Act
makes it an offense to submit a false claim to the government for payment of health care services
Disease Management
manage and improve the health status of a defined patient population over the course of a disease
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
critical time before regulation is adopted
nurses can influence esp. if influences nursing care and nursing practice.
Present
nurses may be assigned an entirely new group of patients to care for every shift, or even more than once during a shift
Emergency situations
nursing care rendered in a life-threatening emergency may breach the standard of care required under normal circumstances
Systems Theory
offers a way to understand health care delivery systems.
Regulations published
open to public for comment for a period of time.
Clinical Nurse Leader (CNLs)
operate primarily on the clinical level involving small, frontline nursing units;
Creative staffing
options are available to meet varied needs of staff members
1994
paper-and-pencil test replaced by computerized adaptive testing
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
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
Legislative
process fundamental to movement from a public problem to a viable program
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
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
Commission on Accreditation of Rehabilitation Facilities (CARF)
promotes quality management requirements standards.
open system
receives feedback from the environment
closed system
receives no feedback from the environment - and theoretically won't survive.
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
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
2009
reporting requirements allow hospitals to collect and submit data on a minimum of four core measure sets or a combination
Whistle-blower
reports false or fraudulent claim
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
Implementation of the plan
requires political action and a set of strategies
judical branch
resolves disputes -> amends and interprets laws.
Human dignity
respect for inherent worth and uniqueness of individuals and populations
Patient outcomes
result of intervention by the health care team
RN
retains accountability for the patient care provided (Functional nursing)
Autonomy
right to self-determination
QSEN
six _______ competencies Patient-centered care Quality improvement Teamwork and collaboration Evidence-based practice Safety Informatics
Pilot studies
small-scale studies referred to as feasibility studies; purpose is to identify strengths and limitations of a larger planned study
Goals and objectives
state actions necessary to achieve the strategic plan
Nursing Ethics
system of principles that govern the actions of the nurse in relation to patients, families, other health care providers, policymakers, and society
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
ANA Code of Ethics and American Medical Association's Code of Medical Ethics
the central role of nurses is to prevent patient harm
affirmative duty
the duty that nurses exercise independent judgment to prevent harm to patients
RNs
the most expensive staff; thus ratios for RNs to other types of care providers may be established
Universal Protocol
the organization fulfills the expectations set forth for eliminating wrong site, wrong procedure, wrong person surgery
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.
Storage
the physical location of data
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
Special cause variation
unstable, unpredictable, and not in statistical control
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
Coordinator positions
various coordinator positions, which require considerable experience in the specialty practice area
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
Governmental agencies, Voluntary agencies, Non-profit agencies, For profit agencies
what are the 4 health care delivery agencies?
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
diploma
what type of nurse made up 20.4% ?
bachelors or higher
what type of nurse made up 34.2?
associates
what type of nurse made up 45.4?
retrospective reviews
what's right/what's wrong; patient satisfaction; incident reports.
Regulation
"rules used to implement legislation and translate concepts into legal action so they can be put into practice"
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?
Team Nursing
Common use areas: effective, efficient method of patient care delivery that has been used in most inpatient and outpatient health care settings
Acute Myocardial Infarction (MI)
Complete home medication and discharge medication list
2010
Congress passes sweeping health care reform legislation: Patient Protection and Affordable Care Act
Staffing
Considerations are patient needs, staff satisfaction, and organizational needs
Blind review Abstract and findings
Critical appraisal of nursing research
Schematic Models
Demonstrate concepts, usually through a picture or visual representation of ideas
student nurse
Dennis v Specialty Select Hospital—Flint, Mich., 2005
health, stress, adaptation
Examples of nursing concepts:
Nurse Educator
Expectations of the role include teaching, scholarship, and service to the community
Board of Directors
Expected to bring knowledge and expertise from the business world
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
Conceptual model or framework
Four concepts basic to nursing that are included in models are nursing, person, health, and environment
Change agent
Identifying client and health care delivery problems
Quality
If the "bundle" of products or services provided is seen as a good value, then customer loyalty is enhanced
Knowledgeable
Impacts nursing's future; some new regulations may change nursing care and nursing practice.
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
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
Health Policy
Involves all three branches of government Executive Legislative Judicial
Researcher
Leading nursing research: nurses prepared at the doctoral and postdoctoral levels
Nurse Administrator or Nurse Executive:
Manage large budgets
1980-1990
Managed care plans emerge
staff satisfaction
Methods to gain staff input about staffing and to enhance autonomy are the key to
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
Regulated market system
Most European countries include a substantial amount of government planning in their health systems
Healthy People 2020
National Initiative to improve the health of the nation
Sigma Theta Tau International (STTI) Oncology Nurses Society (ONS) American Nurses Foundation (ANF) American Nurses Association (ANA)
Nursing Organizations That Fund Research:
Researcher
Participating in research: nurses prepared at the master's, baccalaureate, and associate's degree levels
Federal health policy
Passage of the Patient Protection and Affordable Care Act (PPACA) or ACA)(2010)
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
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
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
Clinical Nurse Leader (CNL)
Prepared as a master's generalist
APNs
Prepared through master's level education/graduate level degree
Nurse Practitioner (NP
Prescribing medications, treatments, and therapies
Politics
Process by which the decisions of others are influenced and control over situations and events is exerted
The Patient Protection and Affordable Care Act of 2010
Provides for affordable and accessible health care coverage for all Americans
Nurses Strategic Action Team (N-STAT)
Provides structure and coordination for nurses across the country to be involved in grassroots lobbying
Primary Nursing
Provides total patient care while on duty
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
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
TJC sentinel event standard
Requires organizations to carry out designated steps to fully understand the factors and systems associated with adverse patient events
Chief Executive Officer (CEO)
Responsible for making sure decisions of the board are implemented
Nursing Research
Results provide foundation for practice decisions and behaviors
State Register
Similar publication
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
Case Management
Studies have demonstrated the value of ______________ in improving patient outcomes and reducing costs
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
Telehealth
Telehome care devices: automated blood pressure monitors, glucometers, peak flowmeters, pulse oximeters, weight scales, video monitors
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
National Healthcare Quality
The 2008 ________________ report notes that U.S. health care quality is suboptimal and continues to improve at a slow pace
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
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
monitoring and initating
Two significant nursing functions closely influence patient safety and quality
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
Healthy People 2020
Vision Mission Overarching goals Topics
Grassroots
Visiting with policymakers or their staff
TJC and CMS
______ and _____ aligned their current and future measures common to both organizations.
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
Development of a plan
includes options and a determination of professional consequences with each
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
Authority
with regard to the topic, author, and author's credentials
Regulation
written set of rules issued by the government agency that has responsibility for administering the new law
Point-of-service plan
(POS)
Preferred provider organizations
(PPOs)
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?
Roy
Adaptation model: Assistance with the Adaptation to Stress to Facilitate the Integration Process of the Client
Roy
Adaptation occurs by assisting the biopsychosocial client in modifying external stimuli
conceptual skills
As one advances from lower levels to higher levels in the organization, more advanced_______ are needed
1. 44,000 2.98,000
Between __1__ and __2__ Americans die from medical errors annually
1976
California first state to institute mandatory continuing education for licensure or renewal
Grassroots
Communicating with policymakers by e-mail, fax, and phone
conceptual model
Conceptual framework used interchangeably with
Newman
Defines health as "expanding consciousness," or increasing complexity
Board of Directors
Delegate responsibility to the CEO - Chief Executive Officer
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
Clinical Pathways
Dictate the type and amount of care given and thus have financial implications for the health care facility
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
Peplau
Identified the client's feelings as a predictor of positive outcomes related to health and wellness
W. Edwards Deming
Introduced U.S. to quality management principles
Medicaid
Joint federal-state program to provide health insurance coverage for impoverished families
Change agent
Leading the change process
Federal health policy
Plays a monumental role in shaping nursing practice
Formal Leadership
Practiced by the nurse who is appointed to an approved position and is given authority by the organization to act
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
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)
IOM Future of Nursing Report
Report calling attention to the essentiality of nursing in reforming the health care system
Centers for Medicare and Medicaid Services (CMS)
Requires quality management ("conditions of participation") in order to receive funds.
More qualified researchers Widespread availability of computers for data collection and analysis Qualitative studies
Research focus, 1980s
Informatics
Skills Navigate the electronic health record Respond appropriately to clinical
Nursing pins
Symbolize the school's philosophy, beliefs, and aspirations Evidence of achievement, learning, and skills
Chief Executive Officer (CEO)
Usually has a minimum of a master's degree in business or hospital administration
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
Quality
_________ of complex health care decisions depends on the level of moral development of the professionals entrusted with decision making
Nursing process
__________ as a guide for decision making and problem solving
Authority
legitimate right to direct others through an authorized position in an organization
Informatics
use information and technology to communicate, manage knowledge, mitigate error, and support decision making
Analysis and diagnosis
use information/data from the assessment phase to identify the specific problem
Triangulation
use of various research methods or data collection techniques in the same study
Survey
used to collect large amounts of information with little expenditure of time and money
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
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
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
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
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
Patient Protection and Affordable Care Act (PPACA)
Addresses many issues including employer requirements, health insurance exchanges, and prevention and cost-reduction approaches
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
Health Policy
Administrative decisions made by various governmental agencies
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
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
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
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
Federal Register
Best reference/resource for proposed new rules and changes in existing regulations in place for federal programs.
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
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
Primary Nursing
Common use areas: home health, hospice, long-term care
Total Patient Care
Common use areas: intensive care units, postanesthesia care units
Functional Nursing
Common use areas: operating room
Certified Nurse Midwife (CNM):
Completed an accredited educational program in nurse-midwifery and passed the national certification examination administered by the ACNM Certification Council
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
Nurse Administrator or Nurse Executive:
Concerned with costs of nursing care and the relationships between nursing services and quality client care
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
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
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
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
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
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
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
Clinical Pathways
Delineates a predetermined written plan of care for a particular health problem
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
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
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
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
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
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
Case Management
Introduced in 1970s by insurance companies as a method to monitor and control expensive health insurance claims
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
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
Certified Nurse Midwife (CNM):
Midwifery occurs in a variety settings: homes, birthing centers, clinics, and hospitals.
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
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)
Federal Register
Proposed rules and regulations at the federal level.
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
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
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
Adolescent
Questions existing moral values and his or her relevance to society Becomes more aware of contradictions in adults' value systems
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
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
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
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?
health care delivery issues such as cost, quality, and access
Research focus, 1990s:
RNs
Research validates contribution of ____ to improved patient outcomes and prevention of premature mortality
Nursing Research
Results provide support for the quality and cost-effectiveness of interventions
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
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
Nurse Administrator or Nurse Executive:
Serve at all management levels in HCOs and the community
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
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
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
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
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
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
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
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
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
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?
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
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
the chief nurse executive (CNE) or chief nursing officer (CNO)
The senior administrative nurse in an organization is known as
Watson
Theory of Human Caring: Transpersonal Caring as the Fulcrum: Philosophy and Science as the Core Nursing
Newman
Theory stimulated by concern for those whom health as the absence of disease or disability is not possible
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
Decision Support and CPOE
Two specific functionalities recommended as essential for improving the quality and safety of health care
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
Case Management
Variations in ___________ are found in almost all health care organizations
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
The Joint Commission (TJC)
Voluntary for hospitals serving various populations.
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
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?
nursing, person, health, and environment
What are the four concepts basic to nursing that are included in models
Ventilation and warming Noise Variety Diet Light Chattering hopes and advice Cleanliness
What are the parts of the "canons of nursing"?
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?
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.
Case Management
When clinical knowledge is required, the RN is most effective in the ______________ role
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.
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
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
uninsured
________ more likely to delay or ignore needed treatment
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
Nurse managers and administrators
__________ should be aware of case law regarding incompetent charge nurses and team leaders
49 million
__________ uninsured Americans exhibit consistently worse clinical outcomes than the insured and are at increased risk for dying prematurely
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
___________ limited total payment to the hospital to an amount preestablished for the patient's specific DRG
Hospitals
____the first health-related organizations to explore quality efforts beginning in the 1980s
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
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
RN "primary" nurse
assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge (primary nursing)
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.
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
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.
Clinical algorithms or protocols
outline decision paths that a practitioner might take during a particular care episode or need (e.g., ACLS algorithms)
legislative branch
possesses the sole federal power to enact legislation;
Uncompensated care and cost shifting
primary reasons some groups advocate for national health insurance
Security
provide better protection of confidential health information because of incorporated controls
Tertiary care services
provided to: acutely ill, those requiring long-term care or rehab services, to terminally ill - requires an interdisciplinary team
Case study
provides an in-depth analysis of a single subject, group, institution, or social unit
Information processing
provides for effective retrieval and processing of data into useful information
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
Effective
providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit
Timely
reducing waits and sometimes harmful delays for those who receive and give care
Medicaid
represents the fastest growing component in the state budget
regulations
shape health care policy
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
Focus
specific incident rather than global effect and needed improvements (cause)
Common cause variation
stable, predictable, and in statistical control
24 hours/day, 365 days/year
staffing needs make meeting the nurse's personal needs difficult Creative staffing
Regulations being developed
stakeholders attend public hearing to comment.
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
Nursing Research
systematic inquiry or study conducted to generate new knowledge or to refine existing knowledge