Exam 2 - Comp. 4, 5, & 8

Q: Certain disparities effect a person's ability to access health care. Which of the following is the number one predictor of limited access, and thus poor health, in the United States?

Age Gender Race *Socioeconomic status*

Cross-Sectional vs Longitudinal Research

CS: simple in design, a snapshot or cross-section of the population at any given time L: long-term, follows subjects over a specific amount of time to see changes. Multiple observations/collections of data over time

DRG's

Diagnosis Related Groups - Established in 1982 - *Prospective Payment System:* flat-rate method of payment based on diagnosis/procedure, pay prior to treatment - Designed to give hospitals incentives to operate more efficiently and to contain costs

Benchmarking

Continuous, collaborative process of measuring/comparing results of key work processes with those considered to be the best in their field

Q: The RN is reading the section of a research article that provides an overview of current research findings as well as existing gaps in research on the subject matter being studied. Which component of the research article is this RN reading?

Data analysis *The literature review* Description of the research design The purpose of the study

Audits

Data collection tools - Process (how do things work) and structure (how the system works) audits - Outcome audits look at what happens at the end, how the patient was affected

Q: Private sources of financing health care include which one of the following?

Department of Veteran's Affairs Medicare *Health maintenance* *Organizations* *(HMO's)* Medicaid - Marquis and Huston page 248-251

Medical errors

Depending on source: 8th leading cause of death - Adverse drug rxns, medication errors.. *due to flawed system!* Combat with: leapfrog initiatives (large jumps in safety, affordability of health care), bar coding, smart IV pumps, med reconciliation,

NDNQI

National Database of Nursing Quality Indicators - Examine relationship between nursing and patient outcomes - Purpose: to measure nursing quality, improve nurse and patient satisfaction, assess staffing levels - *Largest provider of unit-level performance data to hospitals*

Quality Improvement

Ongoing and continually improving quality - "doing it the right way before problems occur" - Includes TQM (Total Quality Management): always room for improvement, looking at customer response, everyone in organization is involved, *quality is more important than profit* - Goal: continuously improve quality by preventing errors - Tasks: review nursing activities, data driven changes, staff development, system changes

Nurse-Sensitive Indicators

Outcomes directly related to the quality of nursing care Ex: falls, nosocomial infections, pressure ulcers

PICO

P: patient population I: intervention/interest area C: comparison or control O: outcome

Q: Which of the following organizations or agencies administers financial reimbursement for health services by Medicare and Medicaid?

The Agency for Healthcare Research and Quality (AHRQ) The Food and Drug Administration (FDA) The Institute of Medicine (IOM) *Centers for Medicare and Medicaid Services (CMS)*

Nursing Responsibility in Consumer Relationships

Service: consumer focused, nursing care quality, caring atmosphere, relationship Advocacy: promotes rights of others, meet needs of others, promotes self-determination of others, promote autonomy, ensure respect, equality... Teaching: essential nursing activity! Leadership: recognize staff members unique contributions, promote staff worth, be open and flexible, make caring visible

Q: The RN is a member of a Quality Improvement Committee which is studying whether skin-to-skin contact between mother and newborn improves day 2 feeding patterns in breastfeeding mother-baby dyads. In their PICO question to guide their study, which of the following is the C (comparison or control) factor?

Skin-to-skin contact between mothers and newborns Breastfeeding mother-baby dyads Day 2 feeding breastfeeding patterns *Mother-newborn dyads not using skin-to-skin*

Q: Magnet hospitals foster the philosophy that nurse leaders are needed at all levels of the organization. As a staff nurse and clinical leader on your unit, which of the following activities would be viewed as non-supportive of the hospital's philosophy in a magnet facility?

Staff nurse serving as the chairperson of the nursing practice council. *Medical physician serving in the role of chairperson of the nursing practice council.* Staff nurses conducting cancer screening education in the community. Medical practitioners collaborating with nursing personnel on an interdisciplinary task force.

Q: The U.S. government has developed a number of initiatives aimed at reforming healthcare financing. Which of the following actions served as an initial catalyst for health care financing reform?

The Affordable Care Act The Insitiute of Medicine (IOM) report "To Err is Human" *Prospective payment based on Diagnosis-Related Groups (DRG)s* The ANCC Magnet Recognition Program

Standards of Quality Care - *External*

"A predetermined level of excellence that serves as a guide for patients" - ANA, Nurse Practice Acts, Joint Commission, National Patient Safety Goals, IOM

Q: During an interview, the graduating nurse is asked, "Why do you want to work here?" Which of the following is the best response from the graduating nurse?

"Because you advertised with many nursing position openings." "I understand you offer the highest shift differential in the area, and the best benefits package" *"I enjoyed my clinical rotation here and admired the way the staff worked as a cohesive team."* "I want to continue my education and I understand you offer tuition reimbursement for higher education."

Q: The novice nurse needs to perform a central line dressing change for the first time. Which of the following is the best response by the novice nurse in preparing for this skill?

"No problem, I practiced it so can figure it out by myself." *"I haven't performed this skill before, who can talk me through it?"* "I have never done that, I'd prefer to watch someone else do it." "Does this have to be done now, or can it be delegated to the next shift?"

Q: A new graduate nurse is interviewing for a staff nurse position. Which of the following statements by the nurse recruiter demonstrates a commitment to assisting novice nurses transition into professional nursing roles?

"We have many openings on alternate shifts for new hires. How do you feel about working night shift?" "You had clinical here, so your orientation will not need to be very long since you are already prepared." "We allow new hires to spend a week or two of clinical shifts with an experienced nurse on the unit." *"Our mentor and residency programs are for all new graduate nurses during the first six months."*

Patient Safety Event

"an event, incident, or condition that could have resulted or did result in harm to a patient." *All agencies are encouraged to report sentinel events.*

Q: What process of continuous quality improvement is the nurse manager employing when the nurse manger compares the hospital's patient fall rate of 5% against the nation's leading hospital, who has a patient fall rate of less than 1% ?

*Benchmarking* Evaluating standards of care Developing clinical practice guidelines Creating a storyboard

Q: The Registered Nurse utilizes evidence from research to guide clinical practice. In which of the following situations is the RN incorporating research into practice?

*Conferences with the physician to try a wound dressing that has been found to decrease cost and accelerate healing time.* Administers a cleansing enema to a client in early labor because it has always been routinely done. Injects air into a client's g-tube while auscultating the abdomen as this is the most reliable method to determine g-tube placement. Lubricates two inches of the outer aspect of a foley catheter prior to inserting the catheter into a male client.

Descriptive vs Experimental Research

*Descriptive*: assessments/descriptions of subjects *Experimental*: a variable is manipulated and results of the experimental group are compared to the control group

Q: The Chief Nursing Officer at a hospital decides to establish a patient advocate position on an oncology unit. Advocacy is best described as... ?

*Empowering others by promoting self- determination* Providing education about treatment options to a non-English speaking patient without using a translator Asking social services to answer the patient's medical questions Sharing patient information with providers not involved in the patient's care

Q: When composing a resume, which of the following approaches is the most effective for the graduating nurse?

*Focus on their own strengths an skills and the prospective employers needs* Specify in writing the areas and shifts the graduating nurse will consider working Request an interview appointment with a range of acceptable dates to meet Attach a copy of personal references and a temporary license permit

Q: The Patient Protection and Affordable Care Act was passed in March 2010. Which of the following key provisions are still included in the law? Select All That Apply

*Health Insurance Marketplaces* Individual Mandate *Expanded Medicaid coverage* Cost Sharing Reduction Plans *A provision for receiving preventive services at no cost.*

Q: Two landmark reports on health care safety and quality entitled To Err is Human and Crossing the Quality Chasm have been released in recent years. Which of the following organizations released these two reports?

*Institute of Medicine* The Leapfrog Group Joint Commission American Nurses Association

Q: Which of the following examples are ways of making caring visible? SELECT ALL THAT APPLY

*Listening actively* Asking patients to repeat their medical information to multiple providers. *Expressing appreciation* *Explaining your purpose to the patient and what you will be doing before starting a procedure.*

Retrospective vs Prospective Reserch

*Retro*: collects data from past records *Pro*: attempts to predict what the outcome might be. Science experiments, RCTs are generally prospective

Q: Nursing Research is measured by nurse-sensitive indicators (NSI's). Which of the following describes the reason for the use of NSI's?

*They measure nursing care activity that falls within the nurse's scope of practice.* They measure an individual nurse's perception of patient satisfaction rates. To prevent development of unnecessary complications and injury They are the only valid measurements utilized in nursing professional research.

Factors that affect one's ability to access health care:

- *INCOME* - Gender - Race/Ethnicity - Geographic proximity - System characteristics

Competent Nurse

- 2-3 years in the same area of nursing - Competent stage is the most pivotal in clinical learning because the learner must begin to recognize patterns and determine which elements of the situation warrant attention and which can be ignored - Devises new rules and reasoning procedures for a plan while applying learned rules for action on the basis of the relevant facts of the situation

Benefits of Specialty Certification

- A sense of accomplishment and achievement - Validation of specialty knowledge and competence to peers and patients - Increased credibility, self-confidence - Greater autonomy of practice - Increased career opportunities, salary incentives

Proficient Nurse

- After 3-5 years the nurse moves into the proficient stage of nursing - Large qualitative leap beyond competent nurse - Nurses at this level demonstrate a new ability to see changing relevance in a situation including the recognition and the implementation of skilled responses to the situation as it evolves.

Factors contributing to rising health care costs:

- Aging population - Increased utilization of pharmaceuticals - Technological advances - Rising hospital costs - Physician behavior - WASTE YET... infant mortality is among highest in advanced world, life expectancy is lower than most advanced nations, reduced access to care, quality has not improved

Meta-Analysis

- Analysis of a greater collection of data from multiple studies - Evidence is considered "very strong"

Organizations Promoting Quality Improvement

- CMS (Medicare/Medicaid): began hospital quality initiative in 2001 making data available to all consumers to promote accountability - *Pay-for-Performance model:* align payment with quality of care. Penalties for high readmission rates, nosocomial infections, EHR incentives - HCAHPS: patient surveys on their perception of their hospitalization and care - NCQA: measures performance, used by >90% od US health plans

TQM (Total Quality Management)

- Comprehensive systematic approach - decisions are based on data - Proactive: prevents errors before they occur - Optimizes patient outcomes, prevents care problems, mitigates adverse events - Foster a culture base don sustained improvement

3 Major Sources of Health Care Financing:

- Government (largest source of healthcare financing): medicare (hospice), medicaid, military/veterans services, native americans, federal prisoners - Private Insurance: provided by employers, premiums and co-pays - Out of pocket costs

Advanced Beginner Nurse

- Has marginally acceptable performance having coped with enough real situations to note meaningful components of situations - Guided by rules and oriented by task completion - Still requires mentor or experienced nurse to assist with defining situations, to set priorities, and to integrate practical knowledge

Contemporary Perspectives on Health Care

- Health care is run as a business - Managed care: based solely on productivity (quantity vs quality)

Magnet Recognition

- Hospitals that are able to attract and retain professional nurses and are consistently able to provide a high quality of care Forces of Magnetism: quality of nurse leadership, organizational structure, management style, models of care, quality of care, QI, consultation and resources, autonomy, community, nurses as teachers, high job satisfaction... *Magnet hospitals typically... have lower mortality rates, reduced readmission within 30 days, earlier recognition of potential complications/adverse events, higher patient satisfaction*

Organizational Benefits to EBP

- Improved recruitment of nurses - Improved retention of nurses - Improved employee satisfaction - Higher percentage of nurses pursuing advanced degrees in nursing

Joint Commission

- Independent, non-profit org - Accreditation is required by medicare and medicaid for reimbursement - Developed standards to guide critical activities to be performed by health care organizations - Mandatory for all hospitals to have a QA program ('81) *Maintains national database of Sentinel Events* - patient safety events: an event, incident, or condition that could have resulted or did result in harm to a patient - *Publishes national patient safety goals annually,* these promote improvements in care related to patient safety

Expert Nurse

- Intuitive, flexible, and fluid - Comprehensive and authoritative knowledge and skill in a particular area

Interview - Preparation

- Know the organization: mission, values, know stats and facts - Have a copy of your resume - Plan appearance - Mentally prepare for questions - Be prepared to ask questions

Medical Liability Reform

- Medical liability and litigious society are *barriers* to learning from mistakes - *Reporting of patient safety hazards by employees and patients must be done without fear of personal risk* - Replace blame with a focus on education and improving care - Improvement in mortality and complication rates since '05

Benner's Stages of Clinical Competence

- Novice - Advanced Novice - Competent Nurse - Proficient Nurse - Expert Nurse

Quantitative

- Objective - Use of hard facts, figures, numbers to measure a theory - *RCTs (randomized control trials) are the gold standard* - Evidence is considered "strong"

Standards of Quality Care - *Internal*

- Patient satisfaction surveys, employee opinion surveys, patient rounds, institutional guidelines

Novice Nurse

- Person has no background experience of the situation in which he or she is involved - There is difficulty discerning between relevant and irrelevant aspects of the situation - Beginner to profession or nurse changing area of practice - Generally this level applies to nursing students

Medicaid

- Provides insurance for individuals below certain income - Cost is shared by federal and state governments - Controlled by CMS (Centers for for Medicare & Medicaid Services)

Medicare

- Provides public insurance to ages 65 and older - Also provides coverage for some disabled populations - Controlled by CMS (Centers for for Medicare & Medicaid Services)

Patient Benefits to EBP

- Reduced length of stay - Reduced admissions - Reduced mortality and morbidity - Improved satisfaction

Qualitative

- Subjective - Involves narratives, interviews, lived experiences - Often provides foundation for more research

Issues w/ Transitioning from SN to RN:

- lack of confidence to perform skills, critical thinking, gaining knowledge - developing relationships with peers and preceptors - struggling with wanting to be independent right out of the gate - frustrations with work environment - organizations of priority setting - communication with physicians *nurse residencies, internships, and externships, orientation, mentors and preceptors, be active during orientation process can help with these issues...*

Quality Control

3 basic steps: 1) standard or criterion is determined 2) information is collected to see if standard is being met 3) educational or corrective action is taken if standard not met - then outcome is evaluated - Priority of quality measurement is benefiting patients - All are expected to participate - Decisions to change/Improvements are based on data, research, EBP

ACA as of 2018

3 pillars repealed: - Individual mandate - Eliminated cost sharing reductions - Increased promotion and use of state medicaid waivers

Q: A registered nurse who has only worked for over 2 years in a pediatric clinic was recently hired to work in the hospital pediatric department. On the first day the RN states," I feel like things are so different here, it's not what I am used to." According to Benner, which of the following stages is this this RN experiencing in this new environment?

A Novice *An Advanced Beginner* A Proficient Nurse An Expert Nurse

Q: A client had a R hip replacement 3 days ago but still requires frequent physical therapy prior to being able to safely return home. The RN is coordinating the client discharge plans. Based on the client status, which of the following settings is the most appropriate placement for the client at this time?

A continued acute care stay in the hospital A long term unskilled care facility An outpatient clinic setting *A rehab facility with skilled care and physical therapy*

Q: A new graduate nurse is interviewing for a hospital staff RN position. The interviewing team asks "Tell us about an area of weakness for you." Which of the following is the best response by the graduate nurse?

Answers: "I have received very strong clinical evaluations and have very few areas of weakness in my clinical practice." *"I know I really need to work on organization and delegation, and I hope to be able to make progress in these areas during my orientation."* "I have never successfully started an IV, and I have not had opportunities to put in a foley catheter or an NG tube." "I really like working by myself and do very well, so I will be challenged to work together with the whole team."

Q: A graduating nurse is beginning to seek a first RN position. Which of the following is the best strategy for this nurse to employ in the search?

Apply only where the graduating nurse has had clinical rotations, as the graduating nurse is familiar with the culture at those organizations. *Research potential employers by networking at school, employer websites, and student and professional organizations.* Talk to nurses who have formerly worked at prospective employment organizations about what it was like. Accept the first job offer even if it doesn't necessarily fit with the graduating nurse's long term goals or general interests

Q: The novice nurse is anxious about placing a foley catheter for the first time since graduating from nursing school. Which of the following skill sets does the novice nurse need to further refine?

Assertiveness skills *Clinical skills* Interpersonal skills Organizational skills

Q: What source of knowledge is the RN utilizing when the RN adheres to the AHRQ Guidelines for Pressure Ulcer Management by turning a bed-bound client every two hours?

Authority Tradition *Evidence based research* Trial and error

EBP

Goal: 90% of all clinical decisions to be supported by accurate, timely, up-to-date information based on the best available evidence by 2020 Barriers: time, organizational structure, lack of EBP knowledge and skills

Q: Health care costs and financing have changed significantly over the past decades. Which of the following statements about health care is consistent with contemporary perspectives regarding the costs of health care in the U.S.?

Health care professionals control all the knowledge, skills and decision-making authority. Everyone is provided the right to free health care, regardless of the cost of needed interventions. Health care funding for all citizens is fully supported and paid for by taxation. *Health care is treated as a business where clients have access to care at a cost.*

Q: The quality improvement process consists of a structured series of steps. Which of the following is a part of this process?

Identify desires most important to the organization Review the organization's practices without looking at what other organizations are doing *Collect data to measure the current status of the topic involved* Pick an implementation plan based on a consensus model

Q: Quantitative research design has been used extensively in health care research. Which of the following is expected in quantitative research design?

Interpretation of non-numeric narratives to discover patterns of relationships *Statistical presentation of numerical data with systemic analysis of their meaning* Researcher collects data without introducing an intervention into the study The smaller the size of study population, the stronger the evidence

Q: Benner described the nurse at the Competent level of development. Which of the following best describes an RN at the Competent level?

Knowledge is developing, and the nurse has marginally acceptable performance because of prior experience in actual situations. The nurse has an intuitive grasp of each situations and operates from a deep understanding of the total situation. *Through conscious deliberate planning the nurse demonstrates efficiency, coordination, and confidence in actions and skills.* The nurse understands each situation as a whole within the long-term goals and has improved decision-making based on holistic understanding.

Quality Assurance

OLD WAY Look at what happened after the fact... *retrospective reviews* - Goal: improve quality by discovering and correcting errors - Tasks: inspect nursing activities, chart audits, utilization review

Q: A novice nurse is aware of the need to improve organizational skills. In which of the following situations is the novice nurse actively working on organizational skills?

Observes experienced nurses perform skills on the unit at every opportunity Attends and participates in unit meetings and volunteers for committee work Is pleasant and open to suggestions by preceptor and other staff members *Utilizes report sheets and time management logs to identify when tasks must be completed*

Affordable Care Act

law passed in 2010 to expand access to insurance Included: - *Individual Mandate:* no longer part of law... stated everyone needed to be covered - *Employer requirements:* >50 employees = have to provide insurance - *Changes to private insurance:* have to provide insurance regardless of pre-existing conditions, can't increase cost based on gender, health hx... - *Expanded Medicaid coverage:* providing access to more low-income adults and families - *Health benefit exchange:* place to purchase healthcare, education available -Required chain-restaurants to show nutritional values on menus