Med surge chapter 1 Nursing

4 components of wellness

1) the capacity to perform to the best of one's ability, (2) the ability to adjust and adapt to varying situations, (3) a reported feeling of well-being, and (4) a feeling that "everything is together" and harmonious (Hood, 2013).

Cultural diversity population demographics

An appreciation for the diverse characteristics and needs of people from varied ethnic and cultural backgrounds is important in health care and nursing. Some projections indicate that by 2030, racial and ethnic minority populations in the United States will triple. The 2010 census classified five distinct races (White, Black, Asian, Native American, and Native Hawaiian/Pacific Islander). The Asian race had the largest growth rate among these five racial groups. The Hispanic population, classified primarily under the White race, was noted to account for more than half of the increased population growth. With increased immigration, this figure could approach 50% by the year 2030 (Humes, Jones, & Ramerez, 2011). By the middle of the 21st century, it is projected that the majority-minority crossover will occur, meaning that the non-Hispanic Caucasian population will proportionally decrease so that it will no longer comprise the majority population, and other ethnic and racial minority populations will collectively comprise the majority of all Americans (Ortman & Guarneri, 2011). As the cultural composition of the population changes, it is increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups not only bring various health care beliefs, values, and practices to the health care setting but also have unique risk factors for some disease conditions and unique reactions to treatment. These factors significantly affect a person's responses to health care problems or illnesses, to caregivers, and to the care itself. Unless these factors are assessed, understood, and respected by nurses, the care delivered may be ineffective, and health care outcomes may be negatively affected (see Chapter 7). (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

pay for performance

As a result of the landmark IOM reports (IOM, 2000; IOM, 2001) previously cited, and because of provisions within the ACA (HHS, 2016a), the landscape of health care is rapidly changing to ensure that quality benchmarks are established. Whether or not providers and health care systems meet these benchmarks may then be publicly reported to health care consumers. Many health insurance companies are adopting pay for performance measures, also known as value-based purchasing. Pay for performance is a health insurance model that reimburses health care provider groups, hospitals, and health care agencies for either meeting or exceeding metrics that demonstrate that the care and treatments rendered are both cost-efficient and of best quality. By the same token, these same insurance companies may disallow reimbursement for care or treatment that either does not meet a predetermined quality metric or for care that is necessary because of provider error (i.e., iatrogenic). (Hinkle 8) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Quality safety and evidence based practice

At the turn of the millennium, the Institute of Medicine (IOM) (2000) reported an alarming breakdown in quality control in the American health care system. The IOM report To Err Is Human: Building a Safer Health System (2000) noted that nearly 100,000 Americans died annually from preventable errors in hospitals, and many more suffered nonfatal injuries from errors. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), described an inefficient, fragmented, health care system fraught with inequities and inaccessibility. It envisioned a reformed health care system that is evidence-based and systems-oriented. Its proposed six aims for improvement included ensuring that patient care is safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001). The following sections describe a series of recent laws, provisions, and practices that are aimed at improving quality and safety and ensuring use of evidence-based practices (EBPs) within the US health care system. (Hinkle 7-8) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Gerontologic Considerations population demographics

Both the number and proportion of Americans 65 years of age and older have grown substantially in the past century. In 2013, an estimated 44.7 million older adults resided in the United States; this number is expected to grow to 79.7 million by 2040. The rate of growth among all older adults will continue to climb, with the greatest growth in the Hispanic population (Administration on Aging [AoA], 2014). The health care needs of older adults are complex and demand significant investments, both professional and financial. Many older adults suffer from multiple chronic conditions that are exacerbated by acute episodes. In particular, older women are frequently underdiagnosed and undertreated. Although older women continue to outnumber older men, the overall number of older men has also increased over the past decade (Howden & Meyer, 2011) (see Chapter 11). (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Patients basic needs maslows hierarchy

Certain needs are basic to all people. Some of these needs are more important than others. Once an essential need is met, people often experience a need on a higher level of priority. Addressing needs by priority reflects Maslow hierarchy of needs (see Fig. 1-1). Maslow ranked human needs to include physiologic needs, safety and security, sense of belonging and affection, esteem and self-respect, and self-actualization. Self-actualization includes self-fulfillment, desire to know and understand, and aesthetic needs. Lower-level needs always remain; however, a person's ability to pursue higher-level needs indicates movement toward psychological health and well-being (Maslow, 1954). Such a hierarchy of needs is a useful framework that can be applied to many nursing models for assessment of a patient's strengths, limitations, and need for nursing interventions. (Hinkle 5) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

population demographics

Changes in the population in general are affecting the need for and the delivery of health care. The US Bureau of the Census estimated that nearly 309 million people reside in the country (Mackun & Wilson, 2011). Not only is the population increasing, but its composition is also changing. The decline in birth rate and the increase in lifespan have resulted in proportionately fewer school-age children and more senior citizens, many of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of members of ethnic minorities to urban settings. Poverty is a greater concern; it is estimated that on any given night, more than 400,000 Americans are homeless, with more than 1.5 million experiencing homelessness annually. Of these, 37.2% of homeless persons come from homeless families, which are mostly headed by women with two children, and tend to be of ethnic minority status (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Changing pattern of disease and wellness

During the past several decades, the health problems of the American people have changed significantly. Chronic diseases, including cardiovascular disease, cancers, diabetes, and chronic lung diseases, account for 7 out of 10 leading causes of death (Centers for Disease Control and Prevention [CDC], 2015). Nearly half of all adults live with one diagnosed chronic condition; 60 million live with two or more (Mereya, Raval, & Sambamoorthi, 2015). Tobacco use, substance abuse (e.g., alcohol, illicit drugs), poor physical activity and nutrition habits, and obesity have become major health concerns, and are associated with multiple chronic conditions such as hypertension, coronary artery disease, diabetes, and cancer (CDC, 2015). As the prevalence of chronic conditions increases, health care broadens from a focus on cure and eradication of disease to include health promotion and the prevention or rapid treatment of exacerbations of chronic conditions. Nursing, which has always encouraged patients to take control of health and wellness, has a prominent role in the current focus on management of chronic illness and disability (see Chapter 9). (Hinkle 7) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Health

How health is perceived depends on how health is defined. The World Health Organization (WHO, 2006) defines health in the preamble to its constitution as a "state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity" (p. 1). This definition implies that health and illness are not polar opposites. Theoretically, therefore, it is possible for a patient to have a physical illness and yet strive for and perhaps attain health in another domain (e.g., mental, social). Although commonly cited worldwide, this definition has been criticized for being too utopian—after all, it is not possible for anyone to achieve complete physical, mental, and social well-being (Pender, Murdaugh, & Parsons, 2015) (Hinkle 5) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

ANA definition of nursing

In the American Nurses Association (ANA) Scope and Standards of Practice (ANA, 2015b, p. 1), nursing is defined as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations." (Hinkle 5) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Interpressuonal collaborative practice

It is worth noting that the IOM has not only made recommendations about the future of the profession of nursing (IOM, 2010), but also about health professions education. Another IOM report, Health Professions Education: A Bridge to Quality (IOM, 2003), challenged health professions education programs to integrate interdisciplinary core competencies into respective curricula to include patient-centered care, interdisciplinary teamwork and collaboration, EBP, quality improvement, safety, and informatics. In response to this report, the Interprofessional Education Collaborative Expert Panel (IPEC) published Core Competencies for Interprofessional Collaborative Practice (IPEC, 2011) with the goal to "prepare all health professions students for deliberately working together with the common goal of building a safer and better patient-centered and community/population oriented US health care system" (p. 3). Interprofessional collaborative practice involves employing multiple health professionals to work together with patients, families, and communities to deliver best practices, thus assuring best patient outcomes. Interprofessional teamwork is viewed as central to this model, which incorporates the interdisciplinary core competencies identified in the 2003 IOM report as displayed in Figure 1-3. The IPEC devised four collaborative practice competency domains, which include values/ethics for interprofessional practice, roles and responsibilities for collaborative practice, interprofessional communication practices, and interprofessional teamwork and team-based practice. The interplay between these competency domains, practice settings, and professional learning trajectories is displayed in Figure 1-4. Implementation of the IPEC model should not only result in improved collaborative practice between nurses, physicians, and other health professions, but it should also promote safe, quality care, and best practices. (Hinkle 15-16) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Medical surgical nursing

Medical-surgical nursing is a specialty area of practice that provides nursing services to patients from adolescence through the end-of-life in a variety of inpatient and outpatient clinical settings. These settings may include traditional hospital medical-surgical units, clinics, ambulatory care units, urgent care centers, home health care agencies, and long-term care facilities (Academy of Medical-Surgical Nurses [AMSN], 2012, 2016). The Scope and Standards of Medical-Surgical Nursing Practice (AMSN, 2012) mirror the scope of practice and standards for practice set by the ANA (2015b) for professional nursing practice; the AMSN (2012) further delineates specific role expectations for the medical-surgical nurse. Medical-surgical nurses can demonstrate proficiency in their role by completing certification requirements. They may also enhance practice by completing graduate degree programs in nursing (AMSN, 2012). (Hinkle 12) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

The future of nursing

Nearly one-third of the $2 trillion spent on health care in the United States is spent on hospitalizations. Of these, approximately 20% are rehospitalizations within 30 days of discharge; and, of these, an estimated 76% are avoidable (Rutherford, Nielsen, Taylor, et al., 2013). These rehospitalizations are not only costly; patients rehospitalized are sicker and tend to become skeptical that the health care system can meet their needs. Health insurance plans are increasingly holding hospitals accountable for readmissions within 30 days of hospital discharge; many times, the plans will not reimburse hospitals for costs associated with these readmissions (Laderman, Loehrer, & McCarthy, 2013). Rehospitalizations can result from problems in discharge planning processes, patients' inability to manage their own care, and poor communication between the hospital and the next level of care (e.g., home health agency, primary care office) regarding patient needs and resources. All of these problems are collectively referenced as breakdowns in care transitions (Rutherford et al., 2013). Patient care must be coordinated seamlessly from the inpatient hospital environment through transitions into the community setting. Various nursing roles have evolved to provide improved care coordination and care transitions, including the nurse navigator, case manager, and the clinical nurse leader (CNL). Nurse navigators are registered nurses employed by hospitals and health networks who work with a given population of patients with a common diagnosis or disease (e.g., cancer). Their role involves helping the patient and the patient's family transition through different levels of care (e.g., from hospital to a skilled nursing facility, from home care to assisted care). One example of an essential role function for the nurse navigator is patient medication reconciliation, which ensures that the patient adheres to the prescribed medication regimen, including taking medications that are newly prescribed, as well as ceasing to take those that must be discontinued. Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. Case managers may be nurses or may have backgrounds in other health professions, such as social work. The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other health care personnel who provide care, and insurance companies. In some settings, particularly the community setting, the case manager focuses on managing the treatment plan of the patient with complex conditions. The case manager may follow the patient throughout hospitalization and at home after discharge in an effort to coordinate health care services that will avert or delay rehospitalization. The caseload is usually limited in scope to patients with similar diagnoses, needs, and therapies (Case Management Society of America, 2016). A CNL is a certified nurse generalist with a master's degree in nursing educated to help patients navigate the complex health care system (AACN, 2016). The CNL coordinates care for a distinct group of patients, may provide direct care as the situation warrants, and assumes a leadership role among members of the health care team. The CNL integrates evidence-based practices with advocacy, care coordination, outcomes measurement, risk assessment, quality improvement, and interprofessional communication skills (AACN, 2016). Currently, CNLs are being utilized in hospital-based environments as well as in community settings. (Hinkle 12-13) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

The nurse as a coordinator of care transitions

Nearly one-third of the $2 trillion spent on health care in the United States is spent on hospitalizations. Of these, approximately 20% are rehospitalizations within 30 days of discharge; and, of these, an estimated 76% are avoidable (Rutherford, Nielsen, Taylor, et al., 2013). These rehospitalizations are not only costly; patients rehospitalized are sicker and tend to become skeptical that the health care system can meet their needs. Health insurance plans are increasingly holding hospitals accountable for readmissions within 30 days of hospital discharge; many times, the plans will not reimburse hospitals for costs associated with these readmissions (Laderman, Loehrer, & McCarthy, 2013). Rehospitalizations can result from problems in discharge planning processes, patients' inability to manage their own care, and poor communication between the hospital and the next level of care (e.g., home health agency, primary care office) regarding patient needs and resources. All of these problems are collectively referenced as breakdowns in care transitions (Rutherford et al., 2013). Patient care must be coordinated seamlessly from the inpatient hospital environment through transitions into the community setting. Various nursing roles have evolved to provide improved care coordination and care transitions, including the nurse navigator, case manager, and the clinical nurse leader (CNL). Nurse navigators are registered nurses employed by hospitals and health networks who work with a given population of patients with a common diagnosis or disease (e.g., cancer). Their role involves helping the patient and the patient's family transition through different levels of care (e.g., from hospital to a skilled nursing facility, from home care to assisted care). One example of an essential role function for the nurse navigator is patient medication reconciliation, which ensures that the patient adheres to the prescribed medication regimen, including taking medications that are newly prescribed, as well as ceasing to take those that must be discontinued. Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. Case managers may be nurses or may have backgrounds in other health professions, such as social work. The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other health care personnel who provide care, and insurance companies. In some settings, particularly the community setting, the case manager focuses on managing the treatment plan of the patient with complex conditions. The case manager may follow the patient throughout hospitalization and at home after discharge in an effort to coordinate health care services that will avert or delay rehospitalization. The caseload is usually limited in scope to patients with similar diagnoses, needs, and therapies (Case Management Society of America, 2016). A CNL is a certified nurse generalist with a master's degree in nursing educated to help patients navigate the complex health care system (AACN, 2016). The CNL coordinates care for a distinct group of patients, may provide direct care as the situation warrants, and assumes a leadership role among members of the health care team. The CNL integrates evidence-based practices with advocacy, care coordination, outcomes measurement, risk assessment, quality improvement, and interprofessional communication skills (AACN, 2016). Currently, CNLs are being utilized in hospital-based environments as well as in community settings. (Hinkle 12-13) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

The practice of nursing in today's healthcare delivery system

Novice, entry-level registered nurses, as well as those with advanced degrees who work in highly specialized settings, all engage in the practice of nursing. The ANA (2015b) notes that the profession of nursing's scope of practice encompasses the full range of nursing practice, pertinent to general and specialty practice. "The depth and breadth in which individual registered nurses and advanced practice registered nurses engage in the total scope of nursing practice is dependent on education, experience, role, and the population served" (p. 2). The ANA (2015b, pp. 7-9) also identifies the following tenets characteristic of all nursing practice: Caring and health are central to the practice of the registered nurse. Nursing practice is individualized. Registered nurses use the nursing process to plan and provide individualized care for health care consumers (see Chapter 2). Nurses coordinate care by establishing partnerships. A strong link exists between the professional work environment and the registered nurse's ability to provide quality health care and achieve optimal outcomes. The profession of nursing has a distinct disciplinary body of knowledge, education, and specialty standards of practice (ANA, 2015b); social contract (ANA, 2010; Fowler, 2015); and code of ethics (ANA, 2015a). Nursing's Standards of Practice describe basic competencies in delivering nursing care using the nursing process (see Chapter 2), whereas the Standards of Professional Performance describe expectations for behavioral competencies (ANA, 2015b, pp. 5-6), which include that the registered nurse: Practices ethically Practices in a manner that is congruent with cultural diversity and inclusion principles Communicates effectively in all areas of practice Collaborates with the health care consumer and other key stakeholders in the conduct of nursing practice Leads within the professional practice setting and the profession Seeks knowledge and competence that reflect current nursing practice and promote futuristic thinking Integrates evidence and research findings into practice Contributes to quality nursing practice Evaluates one's own and others' nursing practice Utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible Practices in an environmentally safe and healthy manner (Hinkle 11) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing Responsibilities

Nurses have a responsibility to carry out their role as described in Nursing's Social Policy Statement (ANA, 2010; Fowler, 2015), to comply with the nurse practice act of the state in which they practice, and to comply with the Code of Ethics for Nurses as spelled out by the ANA (2015a) and the International Council of Nurses (ICN, 2012). (Hinkle 5) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Advanced Nursing Roles

Nurses may enroll in specialized graduate nursing education programs and pursue role preparation in a myriad of specialties, including as nurse researchers, nurse administrators, nurse informatics specialists, and nurse educators, to name a few. They may also enroll in either master's programs in nursing or doctor of nursing practice (DNP) programs (American Association of Colleges of Nursing [AACN], 2015) and pursue role preparation as certified nurse practitioners (CNPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs), all of whom are collectively identified as advanced practice registered nurses (APRNs) (APRN Consensus Work Group & the National Council of State Boards of Nursing [NCSBN] APRN Advisory Committee, 2008). Each of these programs prepares APRNs to demonstrate competence with a focused population that is the recipient of care. The population foci include family, adult-gerontology, neonatal, pediatrics, women's health, and psychiatric-mental health (APRN Consensus Work Group & the NCSBN APRN Advisory Committee, 2008). The APRN roles that are most relevant to medical-surgical nursing are the CNP and CNS roles, and the most relevant population focus is adult-gerontology. CNPs who are educationally prepared with a population focus in adult-gerontology or pediatrics receive additional focused training in primary care or acute care. CNPs may practice autonomously, diagnosing and treating individual patients with undifferentiated clinical manifestations as well as those with confirmed diagnoses. The scope of CNP practice includes health promotion and education, disease prevention, and the diagnosis and management of acute and chronic diseases for individual recipients of care (APRN Consensus Work Group & the NCSBN APRN Advisory Committee, 2008). The primary role of CNSs, on the other hand, is to integrate care across the health care continuum through three spheres of influence—the patient, the nurse, and the health care system. In each of these spheres of influence, the goal of CNS practice is to monitor and improve aggregate patient outcomes and nursing care. CNSs identify their role to include core competency in direct care; consultation; systems leadership; collaboration; coaching; research; evaluation of clinical practice; and ethical decision making, moral agency, and advocacy (National CNS Competency Task Force, 2010). (Hinkle 12) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Patient satisfaction a quality metric

Patients' satisfaction with the care they receive when hospitalized is an important quality metric. CMS partnered with the Agency for Healthcare Research and Quality (AHRQ) to launch the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS is a survey that is given to a random sample of recently hospitalized patients within 6 weeks of discharge. Most items on the HCAHPS survey measure patients' satisfaction with the quality of the nursing care they receive, including their satisfaction with communication with the nurses, the responsiveness of the hospital staff, the quietness of the environment, pain management, communication about medications, and discharge information. Discharged patients are also asked to provide an overall rating of the hospital and whether or not they would recommend the hospital. Hospitals' HCAHPS scores are calculated and publicly reported on the HCAHPS Web site (CAHPS Hospital Survey, 2015). (Hinkle 9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Impacts on healthcare delivery system and nursing

Shifting population demographics; changing patterns of disease and wellness; advances in technology and genetics; and greater emphasis on health care quality, costs, and reform efforts have impacted health care delivery and nursing. (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nightingale definition of nursing

Since the time of Florence Nightingale, who wrote in 1858 that the goal of nursing was "to put the patient in the best condition for nature to act upon him," nursing scholars and leaders have described nursing as both an art and a science. (Hinkle 5)

Summary for progress on recommendations

Summary of the Committee for Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health In the Committee's view, the work of the Campaign and others would best be advanced if it were driven by the following three themes: The need to build a broader coalition to increase awareness of nurses' ability to play a full role in health professions practice, education, collaboration, and leadership; The need to continue to make promoting diversity in the nursing workforce a priority; and The need for better data with which to assess and drive progress. The Committee hopes that, taken together, the 10 recommendations presented in this report provide a blueprint for advancing implementation of the recommendations of The Future of Nursing. Recommendation 1: Build common ground around the scope of practice and other issues in policy and practice The Campaign should broaden its coalition to include more diverse stakeholders. The Campaign should build on its successes and work with other health professions groups, policy makers, and the community to build common ground around removing scope-of-practice restrictions, increasing interprofessional collaboration, and addressing other issues to improve health care practice in the interest of patients. Recommendation 2: Continue pathways toward increasing the percentage of nurses with a baccalaureate degree. The Campaign, the nursing education community, and state systems of higher education should continue efforts aimed at strengthening academic pathways for nurses toward the baccalaureate degree—both entry-level baccalaureate and baccalaureate completion programs. Recommendation 3: Create and fund transition-to-practice residency programs. The Campaign, in coordination with health care providers, health care delivery organizations, and payers, should lead efforts to explore ways of creating and funding transition-to-practice residency programs at both the registered nurse and advanced practice registered nurse levels. Such programs are needed in all practice settings, including community-based practices and long-term care. These efforts should include determining the most appropriate program models; setting standards for programs; exploring funding and business case models; and creating an overarching structure with which to track and evaluate the quality, effectiveness, and impact of transition-to-practice programs. Recommendation 4: Promote nurses' pursuit of doctoral degrees. The Campaign should make efforts, through incentives and expansion of programs, to promote nurses' pursuit of both the doctor of nursing practice (DNP) and PhD degrees so as to have an adequate supply of nurses for clinical care, research, faculty, and leadership positions. More emphasis should be placed on increasing the number of PhD nurses in particular. To maximize the potential value of additional education, nurses should be encouraged to pursue these degrees early in their careers. DNP and PhD programs should offer coursework that prepares students to serve as faculty, including preparing to teach in an evolving health care system that is less focused on acute care than has previously been the case. Recommendation 5: Promote nurses' interprofessional and lifelong learning. The Campaign should encourage nursing organizations, education programs, and professional societies, as well as individual nurses, to make lifelong learning a priority so that nurses are prepared to work in evolving health care environments. Lifelong learning should include continuing education that will enable nurses to gain, preserve, and measure the skills needed in the variety of environments and settings in which health care will be provided going forward, particularly community-based, outpatient, long-term care, primary care, and ambulatory settings. Nurses should work with other health care professionals to create opportunities for interprofessional collaboration and education. The Campaign could serve as a convener to bring together stakeholders from multiple areas of health care to discuss opportunities and strategies for interdisciplinary collaboration in this area. Recommendation 6: Make diversity in the nursing workforce a priority. The Campaign should continue to emphasize recruitment and retention of a diverse nursing workforce as a major priority for both its national efforts and the state Action Coalitions. In broadening its coalition to include more diverse stakeholders (see Recommendation 1), the Campaign should work with others to assess progress and exchange information about strategies that are effective in increasing the diversity of the health workforce. Recommendation 7: Expand efforts and opportunities for interprofessional collaboration and leadership development for nurses. As the Campaign broadens its coalition (see Recommendation 1), it should expand its focus on supporting and promoting (1) interprofessional collaboration and opportunities for nurses to design, implement, and diffuse collaborative programs in care and delivery; and (2) interdisciplinary development programs that focus on leadership. Health care professionals from all disciplines should work together in the planning and implementation of strategies for improving health care, particularly in an interprofessional and collaborative environment. Recommendation 8: Promote the involvement of nurses in the redesign of care delivery and payment systems. The Campaign should work with payers, health care organizations, providers, employers, and regulators to involve nurses in the redesign of care delivery and payment systems. To this end, the Campaign should encourage nurses to serve in executive and leadership positions in government, for-profit and nonprofit organizations, health care delivery systems (e.g., as hospital chief executive officers or chief operations officers), and advisory committees. The Campaign should expand its metrics to measure the progress of nurses in these areas. Recommendation 9: Communicate with a wider and more diverse audience to gain broad support for Campaign objectives. The Campaign should expand the scope of its communication strategies to connect with a broader, more diverse, consumer-oriented audience and galvanize support at the grassroots level. The Campaign, including its state Action Coalitions, should bolster communication efforts geared toward the general public and consumers using messages that go beyond nursing and focus on improving health and health care for consumers and their families. The Campaign should recruit more allies in the health care community (such as physicians, pharmacists, and other professionals, as well as those outside of health care, such as business leaders, employers, and policy makers) as health care stakeholders to further demonstrate a collaborative approach in advancing the recommendations of The Future of Nursing. Recommendation 10: Improve workforce data collection. The Campaign should promote collaboration among organizations that collect workforce-related data. Given the absence of the National Health Care Workforce Commission, the Campaign can use its strong brand and partnerships to help improve the collection of data on the nursing workforce. (Hinkle 14-15) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based curriculum that trains health care professionals to achieve improved teamwork skills and communication, based upon the assumption that if teamwork improves, quality and safety will also improve (AHRQ, 2015). The premise that undergirds the development of TeamSTEPPS is that teams that train together make fewer mistakes. Hence, TeamSTEPPS developed teamwork competencies based upon four teachable-learnable team skills, including communication, leadership, situation monitoring, and mutual support. Teams that achieve competency demonstrate the knowledge of a shared mental model, the attitudes of mutual trust and team orientation; and demonstrate adaptable, accurate, productive, efficient, and safe performance (AHRQ, 2013). The TeamSTEPPS curriculum features tools that may be used by team members to enhance a given competency; a commonly used example of such a tool is the SBAR format for communicating critical information. SBAR is an acronym, which includes the following components: S—Situation—What is going on with the patient? B—Background—What is the clinical background or context? A—Assessment—What do I think the problem is? R—Recommendation or Request—What would I do to correct it? The TeamSTEPPS 2.0 Framework and Competencies Model is displayed in Figure 1-2. (Hinkle 9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Healthy People 2020

The Healthy People initiatives identify important periodic goals that, if reached, could have major impacts on improving the nation's health (U.S. Department of Health and Human Services [HHS], 2014). Healthy People 2020 (HHS, 2014), the most recent of these initiatives, set several goals that are aimed at reducing or eliminating illness, disability, and premature death among individuals and communities. The Leading Health Care Indicators (LHIs) include 26 important goals or indicators that are organized around topics that are aimed at improving access to health services, improving environmental quality, diminishing rates of injury and violence, addressing social determinants of health, improving use of clinical preventive services, improving patterns of nutrition and physical activity while decreasing rates of obesity, decreasing rates of tobacco use, and decreasing rates of substance abuse, among others (HHS, 2014). Enacting the goals set by the LHIs and other health care reforms have contributed to continuous change in health care organization and delivery in the United States. (Hinkle 7) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Evidence based practice bundles

The IHI has developed numerous sets of readily implemented EBP sets for use by hospitals. These bundles include a set of three to five EBPs that, when implemented appropriately, can measurably improve patients' outcomes. Many of these practices are within the scope of independent nursing practice. For instance, the IHI Ventilator Bundle advocates that the head of the bed should be elevated and that oral care should be provided using chlorhexidine for all patients on ventilators (IHI, 2016b) (see Chapter 23). EBP tools used for planning patient care may include not only bundles but also clinical guidelines, algorithms, care mapping, multidisciplinary action plans (MAPs), and clinical pathways. These tools are used to move patients toward predetermined outcomes. Algorithms are used more often in acute situations to determine a particular treatment based on patient information or response. Care maps, clinical guidelines, and MAPs (the most detailed of these tools) help to facilitate coordination of care and education throughout hospitalization and after discharge. Nurses who provide direct care have an important role in the development and use of these tools through participation in researching the literature and then developing, piloting, implementing, and revising the tools as needed. (Hinkle 9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Triple aims of effective healthcare

The Institute for Healthcare Improvement (IHI) is a nonprofit organization that advocates that effective health care systems must effect the Triple Aim, meaning that effective health care systems must do the following (Stiefel & Nolan, 2012): Improve population health Improve the patient care experience Reduce per capita costs Under this model, in order for patients to feel that they have experienced excellent care, they must believe that their care is safe, effective, patient-centered, timely, efficient, and equitable, aims for care that are mirrored in the IOM's Crossing the Quality Chasm report (IOM, 2001). (Hinkle 9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

IOM recommendations future of nursing

The Institute of Medicine's Key Messages and Recommendations for the Future of Nursing Key Message I Nurses should practice to the full extent of education and training. Key Message II Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Key Message III Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. Key Message IV Effective workforce planning and policy making require better data collection and an improved information infrastructure. Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of education and training. Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities to diffuse successful practices. Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses' completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advance practice degree program or when they are transitioning into new clinical practice areas. Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50% to 80% by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan. Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity. Recommendation 6: Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan. Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses. Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Workforce Commissiona, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible. aThe National Health Care Workforce Commission did not receive congressional appropriations to fulfill its mission. Reprinted with permission from the Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. (Hinkle 13) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Joint commission initiatives

The Joint Commission is a nonprofit organization that accredits hospitals and health care organizations. Over the past decade, it has annually updated and published its National Patient Safety Goals (NPSGs)—selected NPSGs include areas of patient safety concern that, if rectified, may have the most positive impact on improving patient care and outcomes. Recently adopted NPSGs revolve around identifying patients correctly, improving staff communication, using medications safely, using alarms safely, preventing infections, identifying patient safety risks, and preventing surgery-related mistakes (Joint Commission, 2016a). Each NPSG has implications for scrutinizing and perhaps changing and improving nursing practices. In addition, the Joint Commission provides EBP solutions for these NPSGs. An evidence-based practice (EBP) is a best practice derived from valid and reliable research studies that also considers the health care setting, patient preferences and values, and clinical judgment. The facilitation of EBP involves identifying and evaluating current literature and research findings, and then incorporating these findings into patient care as a means of ensuring quality care (Melnyk & Fineout-Overholt, 2014). In addition to the NPSGs, the Joint Commission, in cooperation with CMS, has developed sets of performance measures for hospitals called core measures. The core measures are used to gauge how well a hospital gives care to patients admitted to seek treatment for a specific disease (e.g., heart failure) or who need a specific treatment (e.g., an immunization) as compared to evidence-based guidelines and standards of care. Benchmark standards of quality are used to compare the care or treatment that patients receive as compared to the best practice standards (Joint Commission, 2016b). The percentage of the patients who receive the best care or treatment as specified at a given hospital is then calculated and reported so that hospitals can use those results to continue to improve processes and performance until they consistently meet the best practice standards 100% of the time. (Hinkle 8-9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, aims to reform the health care system so that all Americans have access to quality, affordable health care. The ACA aims to improve access to innovative and preventive health care programs and therapies and to expand insurance coverage. Key provisions under the ACA include expansion of insurance coverage for young adults up to the age of 26 under their parent's health insurance plan, elimination of lifetime limits on benefit coverage, elimination of arbitrary withdrawals of insurance coverage, and removal of barriers to use of emergency services. The ACA seeks to establish a more integrated and equitable health care system (HHS, 2016a). (Hinkle 8) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

QSEN

The Quality and Safety Education for Nurses (QSEN) project was initially funded by the nonprofit Robert Wood Johnson Foundation (RWJF) to develop curricula that prepare future nurses with the knowledge, skills, and attitudes (KSAs) required to continuously improve the quality and safety of the health care system. In particular, nurses educated under QSEN concepts demonstrate the KSAs consonant with competency in patient-centered care, teamwork and collaboration, EBP, quality improvement, safety, and informatics (QSEN, 2014). Table 1-1 highlights the QSEN definition of safety and its associated KSAs. (Hinkle 11) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Rapid cycle testing

The credibility of IHI's quality improvement methods has encouraged hospitals to change quality improvement processes and nursing practices. For instance, many hospitals have adopted the IHI's change model (sometimes called the rapid cycle testing model) to more rapidly integrate proven performance improvement processes. The principles and steps that guide the Model for Improvement are shown in Chart 1-2 (IHI, 2016a). This model is commonly used by nurses and other health care professionals to monitor quality and performance improvement processes in US hospitals. (Hinkle 9) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Health Informatics

The sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information, have stimulated advances in health information technology (HIT). Using HIT to improve the quality, efficiency, or delivery of health care is an interdisciplinary field of study called health informatics. Key examples of recent advances in HIT include the ICD-10 coding system, the electronic health record, and the use of telehealth. Nurses must not only be cognizant of advances in HIT, but also become adept in its use as their practice setting and patient population require. The Technology Informatics Guiding Education Reform (TIGER) initiative, now a subsidiary of the Healthcare Information Management Systems Society (HIMSS), provides expert panel reports and guidelines for incorporating HIT into nursing practice (The TIGER Initiative Foundation, 2014). The International Classification of Diseases (ICD) (WHO, 2016) launched its 10th iteration for use in the United States in 2015. The ICD-10 classifies diseases and conditions into nearly 70,000 codes. The Centers for Medicare and Medicaid Services (CMS) (2015) and most other major health insurance programs require utilization of ICD-10 codes when treatment is rendered in order for providers to claim reimbursement. This system provides for common nomenclature and tracking of the incidence and prevalence of various diseases and conditions globally. CMS (2016) also requires that clinicians and health care systems use electronic health records; its final rule for stage 3 of the Electronic Health Record (EHR) Incentive Program requires that providers use EHRs by 2018 or face reductions in reimbursement. In addition to these HIT advancements, telehealth, which uses technology to deliver health care, health information, or health education at a distance, is being utilized by both individual clinicians and health care systems more and more frequently. In particular, home health services use telehealth to develop more individualized care plans for patients (see Chart 1-1: Nursing Research Profile). One type of telehealth application uses real-time communication, characterized by an exchange of information between people at one point in time. For instance, a nurse practitioner in a rural clinic may consult with a specialist on a webcam about a patient's condition. Another type of telehealth application uses store-and-forward, characterized by transmission of digital images that may be retrieved and reviewed at later points in time (HHS, 2016b). (Hinkle 7) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Patient the consumer of health care

The term patient, derived from a Latin verb meaning "to suffer," has traditionally been used to describe a person who is a recipient of care. The connotation commonly attached to the word is one of dependence. For this reason, many nurses prefer to use the term client, which is derived from a Latin verb meaning "to lean," connoting alliance and interdependence. The term patient is used purposely throughout this book; it is most commonly used by clinicians, as evidenced by its usage by the Interprofessional Education Collaborative (IPEC) (2016), whose members include 15 national associations of schools of the health professions, including nursing, allopathic medicine, osteopathic medicine, pharmacy, dentistry, and public health, to name a few (see later discussion of IPEC). The patient who seeks care for a health problem or problems (increasing numbers of people have multiple health problems) is also an individual person, a member of a family, a member of various social groups, and a citizen of the community. Patients' needs vary depending on problems, associated circumstances, and past experiences. Many patients, who as consumers of health care have become more knowledgeable about health care options, expect a collaborative approach with the nurse in the quest for optimal health (van den Hooff & Goossensen, 2015). Among the nurse's important functions in health care delivery are identifying the patient's immediate, ongoing, and long-term needs and working in concert with the patient to address them. (Hinkle 5) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Health promotion

Today, increasing emphasis is placed on health, wellness, health promotion, and self-care. Health is seen as resulting from a lifestyle oriented toward wellness. Health promotion focuses on the potential for wellness and targets appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and well-being (see Chapter 4). People are increasingly knowledgeable about health and take more interest in and responsibility for health and well-being. Organized self-care education programs emphasize health promotion, disease prevention, management of illness, self-care, and collaborative use of the professional health care system. Web sites, chat groups, and social media applications promote sharing of experiences and information about self-care with others who have similar conditions, chronic diseases, or disabling conditions. The advent of mobile wireless computer technologies (e.g., Fitbit™) and novel informatics tools (e.g., Step counts) have had the effect of tailoring health promotion activities to meet individual preferences (Pender et al., 2015). Researchers have begun to take advantage of these popular technological advancements by developing population-based registries. For instance, in 2015, more than 41,000 people consented that specific smartphone application data could be used to study the effects of activity on cardiac health (Keller, 2015; Stanford University Medicine, 2016). (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Wellness

Wellness has been defined as being equivalent to health. Wellness involves being proactive and being involved in self-care activities aimed toward a state of physical, psychological, and spiritual well-being. Wellness is conceptualized as having four components: (1) the capacity to perform to the best of one's ability, (2) the ability to adjust and adapt to varying situations, (3) a reported feeling of well-being, and (4) a feeling that "everything is together" and harmonious (Hood, 2013). With this in mind, nurses must aim to promote positive changes that are directed toward health and well-being. The sense of wellness has a subjective aspect that addresses the importance of recognizing and responding to patient individuality and diversity in health care and nursing. (Hinkle 6) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.