Unit 6 - Foundations of Nursing Practice

Hildegard Peplau

* 1952 * "mother of psychiatric nursing" * Was a true pioneer in the development of the theory and practice of psychiatric and mental health nursing * Interpersonal relationships theory

Martha Rogers

* 1970 * Science of Unitary Human Beings * Promote health and well-being

Dorothea Orem

* 1971 * Self-care deficit theory

Patient's Bill of Rights

* 1972 (revised in 2003 as the Patient Care Partnership) * Rights and responsibilities of the patient while receiving care in the hospital

Sr. Callista Roy

* 1974 * Adaptation Model * States that the individual is a set of interrelated systems that strive for balance

Madeline Leininger

* 1978 * Transcultural Nursing

Patricia Benner

* 1989 * Novice to Expert * Stages of a clinical competence

Patient's rights

* Able to see and copy their own medical record * Update their health record * Choose how to receive health information * Right to accurate and easy to understand information * Right to choose healthcare providers * Right to respectful care * Right to participate in treatment options * Right to talk privately and have your information protected * Righ to fair, fast, and objective review of any complaint that you have against caregivers * Right to emergency services

Nurses advocacy

* Advocacy: protection and support of another's rights * Represent patients * Facilitate patient's decision making

Code of ethics

* Agency policies, and State and Federal privacy legislation dictate how patient information can be communicated (verbally and in writing) * While most nurses are staunch advocates of a patient's right to privacy and confidentiality, many nurses thoughtlessly violate these rights every day (e.g. talking in elevators) * Change in shift report: avoid gossip

5 professional values identified by the AACN

* Altruism: concern for welfare and well-being of others * Autonomy: right to self-determination; respect patient's right to make decisions * Human dignity : respect for the inherent worth of individuals * Integrity: the quality of being honest and having strong moral principles * Social justice: upholding moral, legal, and humanistic principles

Professional nursing organizations

* American Nurses Association (ANA) * National League for Nursing (NLN) * American Association for Colleges in Nurisng (AACN) * National Student Nurses' Assocation (NSNA)

Principles of growth and development

* Are orderly and sequential as well as continuous and complex * Follow regular and predictable trends * Differentiated and integrated * Different aspects occur at different stages and at different rates, and can be modified * Pace is specific for each person * Physical and psychological skills and maturation vary among people

Principles of bioethics

* Autonomy * Nonmaleficence * Beneficence * Justice * Fidelity

Middle adulthood (40-65): generation vs. stagnation

* Awareness of aging process with some increase of health problems * Maturation and acceptance of family roles, careers, economic responsibilities * Some crises: aging, death of loved ones

Ethical considerations

* Balance between benefit and harm * Informed consent * Family * Relationships between caregivers and patients * Professionalism * Cost * Culture and spiritual * Power

Normal physiologic changes of older adults

* Balance declines * Decreased ability to maintain homeostasis * Integument: wrinkles and sagging skin, change in pigmentation * Decreased sight and hearing * Decrease in SQ tissue and weight, muscle mass, and strength * Bone demineralization * Joints stiffen * Diminished lung capacity and less effective cough * Decreased blood flow and blood vessel elasticity * Less efficient venous return * Fatty plaque deposits * Heart valves thicken * Decreased GI motility and digestive juices * Ab. muscles weaken * Swallowing reflex less effective * Decreased bladder capacity, muscle tone, and prostate gland enlarges * Decrease in response time, balance, coordination, and learning speed * Sleep time at night shortens * Temp. regulation and pain/pressure perception become less efficient

Ethical conduct

* Begins in nursing school * High-quality care based on professional standards of ethics * Nurses identify and become familiar with bioethical standards for professional nursing conduct

Cultural norms of the healthcare system

* Beliefs * Practices * Habits * Likes * Dislikes * Customs

Values

* Beliefs about the worth of something * Formed during a lifetime * Environment * Family * Culture

Types of ethics

* Bioethics * Clinical * Nursing

Culturally competent nursing care

* Care is planned and given in a way that is sensitive to needs * Healthcare system is a culture with customs, rules, values, and a language of its own * Cultural assessment * Guidelines for nursing care

Nursing roles

* Caregiver * Communicator * Teacher/Educator * Counselor * Leader * Researcher * Advocate * Collaborator

Jean Watson

* Caritas Process * Promote & restore health, prevent illness, and caring for the sick * Holistic care: promote humanism, health, and quality of life

Collaboration

* Collaborate with the patient, family, and health care team utilizing evidence-based health information/informatics to achieve quality outcomes

Common nursing virtues

* Competence * Compassionate caring * Subordination of self-interest to patient care * Self-effacement * Trustworthiness * Conscientiousness * Intelligence * Practical wisdom * Humility * Courage * Integrity

Theory

* Composed of a group of concepts that describe a pattern of reality * Statement that explains or characterizes a process, an occurence, or an event and is based on observed facts * Arrange a group of related statements or concepts that give meaning to a series of events

Nurses' role in healthcare reform

* Cost containment * Improved access * Increased quality of services * Political action (Nurses day on the hill)

Legal issues

* Credentialing: way professional competence is ensured and maintained - Accreditation - Licensure

Major losses

* Death of loved ones * Relocation * Job loss/retirement * Depression from social isolation

Caring

* Demonstrate an attitude of positive regard, respect for diversity, empathy and integrity when providing relationship centered care

Theories

* Derived through 2 principle methods: deductive reasoning and inductive reasoning

Nurses need to:

* Develop cultural self-awareness * Develop cultural knowledge * Accommodate cultural practices in healthcare * Respect culturally based family roles * Avoid mandating change * Seek cultural assistance

Nursing theories

* Developed to describe, explain, predict, and control * Ultimate goal is to improve patient outcomes

Frameworks for healthcare delivery

* Different methods are used to ensure continuity of care and cost-effective care as a patient moves through the healthcare system * These methods include managed care systems, case management, primary healthcare

Care team

* Doctors * Nurses * Dietary * Pharmacist * Social worker * Therapist

Secondary level of prevention

* Early detection * Health maintenance * Early intervention

Theory of psychosocial development

* Erik Erickson * 8 stages from infancy to late adulthood * Each stage has major crisis * Lack of resolution prevents aligning to develop fully * Never too late for resolution of any stage crisis

Bill of Rights for Registered Nurses

* Established due to decreased quality of care caused by inadequate staffing and decreased nurse satisfaction * Improve workplace and ensure nurse ability to provide safe, quality patient care * Empower nurses

Florence Nightingale

* Established the first school for nurses that provided both theory-based knowledge and clinical skill building * Stressed the need to create a body of nursing knowledge separate from medical knowledge * Recognized the influence of environment on health * Identified personal needs of the patient and the role of the nurse in meeting those needs * Established standards for hospital management * Established a respected occupation for women * Recognized the 2 components of nursing (health and illness) * Recognized that nutrition is important to health * Stressed the need for continuing education for nurses * Identified that maintaining accurate records is important for nursing research

Ethical decision making

* Ethical dilemmas * Ethical distress

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

* Federal mandated organization * Specifies that nursing care data r/t patient assessments, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the patient record * Each nurse is expected to practice according to local policies and professional standards

Professional values essential for nurses

* Foundation for nursing practice * Guide "nurses interaction" * 1998: The AACN identified 5 values that epitomize the caring, professional nurse

Nursing code of ethics

* Framework (to make decisions): professional expectations * Goals and values of profession * Protects patients * Nursing Standards of Practice: 1991 standards of professional performance and standards of care

Factors influencing growth and development

* Genetic heredity * Prenatal * Individual and caregiver factors * Environment * Nutrition * Health and illness * Culture

Theories of aging

* Genetic theory of aging: genetics and hereditary * Immunity theory of aging: immune system * Cross-linkage theory: chemical reaction that damages DNA and leads to cell death * Free radical theory: free radicals are formed during cellular metabolism which have an adverse effect on adjacent cells

Role of nurse: middle adult

* Health maintenance and promotion * Greater emphasis on both anticipatory guidance counseling * Teaching about illnesses, grand-parenting, retirement, losses, stress reduction

Primary level of prevention

* Health promotion * Illness prevention

Role of the nurse for the elderly

* Health restoration * Health maintenance * Health promotion * Dying with dignity

Political action for healthcare reform

* Healthcare crisis is a societal problem that needs national political attention for a solution * Nurse advocacy for our patient's well-being is an ethical obligation * Political intervention is the key * Nurses need to use their political muscle & credibility

Major health concerns for middle adult

* Heart/pulmonary disease * Cancer/strokes * Diabetes mellitus/obesity * Alcoholism/depression * Accidents

Nursing Theorists

* Hildegard Peplau (1952) * Abraham Maslow (1968) * Martha Rogers (1970) * Dorothea Orem (1971) * Sr. Callista Roy (1974) * Madeline Leininger (1978) * Patricia Benner (1989) * Jean Watson

Community based healthcare services

* Home health care * Hospice: 6 months or less to live * Respite care * Community centers and clinics * Day care programs * Parish nursing * Meals on wheels

Human needs

* Humans are complex organisms, influenced by and responsive to both the internal and external environments * Holistic nuring care allows the nurse to provide individualized and health-oriented care

Healthy People 2020: Leading Health Indicators

* Improve access to healthcare services * Clinical preventative services * Environmental quality * Injury and violence prevention * Maternal, infant, and child care * Mental health and mental disorders

Nursing research

* Improve care of patients by improving quality, cost effectiveness, and safety * Broader study of people and nursing to enhance: education, policy development, ethics, and history

Suicide

* In 2014, the highest suicide rate (19.3) was among people older than 85 * Second highest rate (19.2) was among people ages 45-64 years * Younger groups have had consistently lower suicide rates than middle-aged and older adults (11.6% ages 15-24 in 2014)

Health

* Individually defined * Integrates all the human dimensions * Holistic care is important

Legal safeguards

* Informed consent: confirm * Contracts: exchange of promises (written or oral) * Collective bargaining: unions or other organizations * Competent practice: you're responsible for your own education and updating your practice with continuing educational hours; documentation

Critical thinking

* Integrate evidence-based knowledge, clinical reasoning, and the nursing process to formulate safe nursing judgments when providing quality care

Sentinel event

* JCAHO * An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof * Serious injury specifically includes loss of limb or function * Needs immediate investigation and response * E.g. a baby is stolen from the hospital

Theory of cognitive development

* Jean Piaget * 4 stages of from birth to adolescent * Framework for how children learn rules * Each stage transforms and supersedes the one before * Stages are universal (affects all cultures and people)

Health care delivery: nurses

* Largest employee group in health care * Part of health care team * Practice guided by nursing process

Theory of moral development

* Lawrence Kohlberg * Carol Gilligan

Licensure

* Legal document * Entry level competence * State Board revoke of suspend * NCLEX: National Council Licensure Examination

Risk factors for illness

* Lifestyle * Psychosocial * Environmental * Developmental * Biologic

Accreditation

* Maintain minimum standards * State Board of Nursing

Practices

* Maintenance of health and prevention of illness

Financial aspects of healthcare

* Medicare: part A (pays for hospitalization), part B (supplemental - can buy additional coverage) * Medicaid: state-distributed federal money * Group plans: HMO (health maintenance organization), PPO (preferred provider organization) * Private insurance * Long term care insurance

AACN

* National voice for baccalaureate and higher degree nursing education programs * The organization's goals focus on establishing quality educational standards; influencing the nursing profession to improve healthcare; and promoting the public support of baccalaureate and graduate education, research, and nursing practice * National accreditation for collegiate nursing programs is provided (based on meeting standards) through this professional nursing organization by the Commision on Collegiate Nursing Education (CCNE)

Professional and legal regulation of nursing practice

* Nurse Practice Act: law affecting nursing practice - Protects the public - Lists violations - Excludes untrained or unlicensed people

Evidence-based practice

* Nursing care provided that is supported by reliable research-based evidence * The use of EBP mandates critical analysis and extensive, systematic reviews of research articles and findings to improve nursing interventions/actions

Health promotion

* Nursing interventions done to promote the level of health the patient is currently experiencing * E.g. immunizations, screenings, teachings

Health maintenance

* Nursing interventions that are focused on maintaining the patient's level of health

Health restoration

* Nursing interventions that are focused on restoring the patient back to their previous level of health * Generally done after the patient has become ill * Includes medications, surgery, treatments, etc.

Healthy People 2020: Leading Health Indicators

* Nutrition, physical activity, and obesity * Oral health * Reproductive and sexual health * Substance abuse * Social determinants * Tobacco use

Assessment/teaching for aging adult

* Nutrition: less food, more often, low salt/fat/sugar * Regular exercise * Encourage independence: teach proper use of canes and walkers * Encourage regular socialization * Medications: teach proper use and correct dosage * Protect from injury: falls, hypothermia, assess living situation and remove throw rugs, place furniture safely, look at walking shoes

Laws affecting nursing practice

* Occupational safety and health * National practitioner data bank * Reporting obligations * Controlled substances * Discrimination and sexual harassment * Persons with disabilities * Wills * Legal issues r/t dying and death

Myths about older adults

* Old age begins at 65 years * Most older adults live in nursing homes * Most older adults are sick * Old age means mental deterioration * Older adults are not interested in sex * Older adults don't care how they look * Bladder problems are a problem of aging * Older adults do not deserve aggressive treatment for serious illness

Older adult: integrity vs. despair

* Older than 65 years * By 2030, 20% of the population will be older than 65 * Older women outnumber older men * Reminiscence about life events provides a sense of fulfillment and purpose

NLN

* Open to all people interested in nursing, including nurses, non-nurses, and agencies * Established in 1952, its objective is to foster the development and improvement of all nursing services and nursing education

Legal safeguards

* Patient education * Executing physician orders * Documentation * Adequate staffing * Professional liability insurance * Risk management program * Incident report

Cultural influences

* Peoples' values and beliefs about health, illness, and care for an illness * Develop from cultural and ethnic influences

Nursing interventions

* Perform nursing interventions safely for individuals and families in a variety of settings

Chronic illness

* Permanent change * Remissions * Exacerbations * Slow onset * Requires education/support for rehabilitation * Leading health problems in the world * e.g. heart & lung conditions, arthritis, diabetes, HIV

Culturally competent care

* Physiological characteristics * Psychological characteristics * Reactions to pain * Mental health * Gender roles * Language and communication * Orientation to space and time * Food and nutrition * Family support * Socioeconomic status

5 major components of growth and development

* Physiological: body function * Cognitive: intelligence, thinking * Psychosocial: emotional, reactions with environment and other people * Moral: sense of right and wrong * Spiritual: religious, sense of correctness with inner self

Professionalism

* Practice within the ethical and legal framework of the nursing profession * Identify individual learning goals to promote learning for personal and professional development in a changing healthcare environment

Levels of prevention

* Primary * Secondary * Tertiary

ANA

* Professional organization for RNs in the US * Founded in the late 1800s * Membership is comprised of the state nurses' associations to which individual nurses belong * Establishes standards of practice, encourages research, and represents nursing for legislative actions

RCTC's core integrating concepts

* Professionalism * Critical thinking * Caring * Collaboration * Nursing interventions

Good Samaritan Law

* Protects health practitioners when giving emergency aid

Classification of hospitals

* Public: nonprofit institutions are financed and operated by local, state, or national agencies. Patients admitted may not have insurance so services are provided at no cost or little cost to the patient. Tax revenue of public funds covers the cost * Private: can be for profit or nonprofit, operated by communities, churches, corporations, and charitable organizations * e.g. Mayo is private, nonprofit * e.g. Olmsted is public

NCLEX Analysis

* Questions will have application, analysis, synthesis or evaluation as the level of cognitive ability * You will not get knowledge questions, instead you will get questions that have you apply your knowledge * There is a strategy that can be learned from each question.

Illness

* Response of the person to a pathological problem where level of functioning is changed * Individually defined * Disease: pathologic change in the structure or function of the body or mind

Student Liability

* Responsible for their own acts * Be prepared to know agency policies and procedures

Tertiary level of prevention

* Restoration * Care of the dying

Evidence-based practice

* Review and critique research reports * Identify level and strength of the evidence * Make specific recommendation for practice: validate, change, and examples

Guidelines for Nursing Practice

* Scope and Standards of Practice defines the activities of nurses that are specific and unique to nursing * Standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where healthcare is given * Each nurse is accountable for his or her own quality of practice and is responsible for the use of these standards to ensure knowledgeable, safe, and comprehensive nursing care

Trends in healthcare delivery

* Self-care focus * Knowledgeable consumers * Cost containment * Fragmentation of care * Aging & diversity of America * Nursing shortage

Ethinicity

* Sense of identification * Share unique cultural and social beliefs

Laws affecting nursing practice

* Sentinel events * Good Samaritan Law * Student liability

Theory of psychoanalytic development

* Sigmund Freud * Emphasizes the effect of instinctual human drives on behavior * 4 major components * 5 stages * If not resolution in one stage, fixation follows with arrested development * Ego is defense mechanism

Beliefs

* Standardized definition of health and illness

Factors affecting health in the community

* Support systems * Community health care structure * Environment * Economic resources

Ethics

* Systematic inquiry into principles of right/wrong conduct of virtue/vice and of good/evil as they relate to conduct

Federal & state regulatory agencies

* The Centers for Medicare and Medicaid Services (CMS) * The Joint Commission - National Patient Safety Goals (NPSG) * National Committee for Quality Assurance (NCQA)

Ethical theories: Deontological

* The action is right or wrong and is independent of the consequences

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

* The intent of this initiative is to provide a standardized survey instrument and data collection method to get patients perspective on hospital care * National standard for patient satisfaction * Designed to include public reporting of results

Ethical theories: Utilitarian

* The rightness or wrongness of a particular action depends on the consequences

Habits

* Use of a systematic approach and problem-solving methodology

Nursing as a profession

* Uses an organized body of knowledge that is generated from research/theory and provides rationale for our nursing interventions/actions * Uses nursing theory which is self-generated and draws from other disciplines/fields

Ethical theories

* Utilitarian * Deontological

Professional values

* Value clarification: - Process of understanding your own values and value system - Involves choosing alternatives - Prize which value involve feeling pride and happiness - Acting by combining choice into one's behavior

Virtue of nurses

* Virtues are human excellencies, cultivated dispositions of character and conduct that motivate and enable us to be good human beings

Nursing is recognized as a profession based on

* Well-defined body of specific and unique knowledge * Strong service orientation * Recognized authority by a professional group * Code of ethics * Professional organization that sets standards * Ongoing research * Autonomy

Abraham Maslow

*1968 * Developed a hierarchy of basic human needs that can be used to consider which needs of a person are the most important at any given time

Community based care

*Healthcare provided to people who live within a defined geographic area * Each community is unique and is defined by the people, area, social interactions, and common ties * Centered on individual and family healthcare needs

Sources of knowledge

1) Traditional: passed from generation to generation (e.g. "We have always done it this way" 2) Authoritative: comes from an expert and is accepted (e.g. a senior staff member teaches a new nurse) 3) Scientific: new ideas tested and measured by research (evidence based practice)

4 competencies

1) cognitive abilities/skills 2) technical skills 3) interpersonal skills (communication) 4) ethical/legal skills Nurses rely on these skills to achieve goals of practice

Goals of nursing practice

1) to promote health 2) to prevent illness 3) to restore health 4) to facilitate coping with disability or death Nurses accomplish these goals by using knowledge, skills, and critical thinking

Role as a patient caregiver

4 primary objectives: 1) promote health 2) prevent illness 3) restore health 4) facilitate coping

NCLEX Question: a nursing instructor reviews the goals of Healthy People 2020 with students. Which statement by a nursing student indicates a need for further education? 1) "I know that nurses are key to the health indicator - Clinical Preventative Services." 2) "I would like to know more about the ways nurses can improve access to health services." 3) "I will study the Healthy People 2020 to learn more about how these indicators work." 4) "I know that nurses have a limited impact on the health indicators."

4) "I know that nurses have a limited impact on the health indicators."

Knowledge

An awareness of the reality one acquires through learning or investigation

Stereotyping

Assuming groups are alike

Race

Based on specific characteristics (e.g. skin color, hair color, facial features)

Ethnocentrism

Belief that one's ideas, beliefs, and practice are the best or superior

Health

Defined by the World Health Organization, one's health includes physical, social, and mental components and is not merely the absence of disease or infirmity

Growth

Increase in body size or changes in body cell structure, function, and complexity

Health

Is a subjective state - a person may be medically diagnosed with an illness but still consider himself or herself healthy

Holistic nursing care

Is based on considering all the patient's dimensions that affect how human needs are met in health and illness

Health

Nurses promote this by maximizing the patient's own individual strengths

Inductive reasoning

One builds from specific ideas or actions to conclusions about general ideas

Deductive reasoning

One examines a general idea and then considers specific actions or ideas

Cultural assimilation

One's values are replaced by the values of the dominant culture

Development

Orderly pattern of change in structure, thoughts, feelings or behaviors resulting from maturation, experiences, and learning

NSNA

Prepares students to participate in professional nursing organizations

Stages of illness

Stage 1) experiencing symptoms Stage 2) assume sick role Stage 3) assume dependent role Stage 4) recovery and rehabilitation

Nursing

The care of others

Gerontology

The scientific and behavioral study of all aspects of aging and its consequences

Essence of nursing

caring for, caring with, and caring about people

Art of nursing

skilled application of the knowledge base to help others reach maximum health and quality of life

Science of nursing

the knowledge base for the care that is given