Final exam -Dimensions of Nursing Ch 12, 13, 14, 15, 16,17, 18, 21, 22, 23, 24, 27

Sentinel Events

"unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury includes loss of limb or function." Sentinel events are not the same as errors. Sentinel events indicate the need for immediate investigation and response. Its goal is to improve the quality of care and prevent future sentinel event occurrences.

What is Quality of Care?

. Safe: Avoiding injuries to clients from the care that is intended to help them. 2. Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. 3. Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. 4. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care. 5. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. 6.Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Developing Cultural Awareness

A nurse develops cultural awareness only when he or she is able to recognize and value all aspects of a client's culture, including beliefs, customs, responses, methods of expression, language, and social structure. However, merely learning about another person's culture does not guarantee that the nurse will have cultural awareness. Nurses must first understand their own cultural backgrounds and explore the origins of their own potentially prejudiced and biased views of others. Several tools have been developed to measure a person's cultural awareness. Cultural awareness begins with an understanding of one's own cultural values and health-care beliefs. To those unfamiliar with a particular culture's health-care beliefs, many of the health-care practices may appear meaningless, strange, or even dangerous.

Root Cause Analysis-for sentinel events

A type of assessment that tracks events leading to error, identifies faulty systems, and processes and develops a plan to prevent further errors.

communication aggressive

Aggressive communication—used to humiliate, dominate, control, or embarrass the other person or lower that person's self-esteem—creates an "I win, you lose" situation. The other person may perceive aggressive behavior or communication as a personal attack. Aggressive behavior and communication are viewed by some psychologists as a protective mechanism that compensates for a person's own insecurities, and others view it as a form of bullying. By demeaning someone else, aggressive behavior allows the person to feel superior and helps inflate his or her self-esteem. Aggressive communication can take several different forms, including screaming, sarcasm, rudeness, belittling jokes, and even direct personal insults. It is an expression of the negative feelings of power, domination, and low self-esteem. Although aggressive people may seem outwardly to be in control, in reality they are merely reacting to the situation to protect their self-esteem.

Nurse Navigator

Although the nurse navigator role is similar to the case manager, it tends to be more focused on only one specialty area, such as cancer clients. The nurse navigator attempts to eliminate barriers and serves as an advocate for the client to make moving through the treatment maze easier. Some of the obstacles that clients must face include lack of transportation, a myriad of confusing insurance forms, change in financial status, lack of knowledge about the disease and its treatment options, and the side effects of powerful medications. The nurse navigator also works with the client's family, caregivers, and employers to help reduce the client's anxiety and/or depression.

Approaches in resolving conflict--Being consistent in your message

Being consistent in your message. This approach is similar to the "walk the tightrope" approach, except now it is directed at resolving the issue of denial. You need to move slowly and let the client determine the pace of the discussion. Agree to disagree but do not waver in your message. The client will insist that there is nothing wrong with them, but you need to make it clear that you believe the lab tests, x-rays, and other objective findings that indicate that they are ill; however, do not argue with them or attempt to overwhelm them with facts and data. They will shut down completely.

communication nonassertive

Communicating in a timid and reserved manner resulting in limited concern for one's own rights regardless of the situation.

Methods to Measure and Improve Quality-- total quality management (TQM)

Continuous quality improvement, also known as total quality management (TQM), is based on the belief that the organization with higher-quality services will capture a greater share of the market than competitors with lower-quality services. This approach emphasizes customer satisfaction, promotes innovation, and requires employee involvement and commitment.

Cultural Belief Systems

Cultural belief systems are highly complex. For example, some Native American groups attributed twin births to witchcraft and believed that one of the twin infants had to die so that the other might live. These beliefs and practices are usually kept as closely guarded secrets among the group's members, and there may even be some type of sanction or punishment for members who reveal the belief.

Methods to Measure and Improve Quality— Dashboards

Dashboards are electronic tools that act as a scorecard. They can provide retrospective or real-time data to assess quality. These informatics technologies assist the process of quality improvement.

Medicaid box 14.4

Definition: Federally funded, state-operated medical assistance program for people with low incomes. Individual states determine eligibility and benefits. Characteristics: Finances a large portion of maternal and child care for the poor; reimburses for nurse midwifery and other advanced practice nursing (varies by state); reimburses long-term care facility funding.

Delegation

Delegation is the designation of a competent individual to the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients.

Disaster Preparation

Disaster planning often does not include any special preparation for the elder population, who may be more profoundly affected because of mobility limitations and chronic diseases that decrease their abilities to cope with major disasters. During evacuations, many elderly leave behind life-sustaining medications and assistive devices that they need for their normal daily activities. planning for the elderly and disabled should include: • Assembling a team of relatives or neighbors who can aid in moving larger immobile individuals safely. Naming one or more of the team members as a legal health-care decision-maker in case the primary decision-maker is injured in the disaster. • Assembling a "to go" emergency kit in a sturdy tool box or small. At least 7 days' worth of items the disabled person routinely uses, such as medications, adult diapers, ostomy supplies, sanitizing supplies, syringes for diabetics, dressings for those with wounds, and sterile water.

Approaches in resolving conflict--Don't ask, don't tell.

Don't ask, don't tell. This approach needs to be used cautiously because it can ruin a trusting relationship; however, if you assess that it might work with your client and nothing else has worked, give it a try. Just quietly walk into the room and hand them a glass of water and the medicine cup with the pill. Don't say anything. Sometimes clients have become conditioned to take pills without really thinking about what they are doing. If not, they'll just tell you they're not going to take it.

Electronic health records— Advantages

Electronic health records (EHRs) have many advantages. Multiple care providers can access them simultaneously from remote sites. They can provide reminders about completing information or carrying out protocols as well as warning of incompatibilities of medications or variances from normal standards. information is captured once and then transmitted to every record requiring the information. EHRs require less storage space, are more difficult to lose, and are much easier to research. Improved communication, increased completeness of documentation, and reduction in error are the most important advantages of the EHR.

Electronic health records— Disadvantages

Electronic health records have some obvious disadvantages. There is a high front-end cost in buying an electronic system and converting from a paper system. Employees may have problems adapting to the new system because of the steep learning curve involved. EHR systems are becoming more portable with the advent of the wireless network; however, they are also subject to all the glitches of electronic systems. Decisions must be made about who can enter data into the system and when the entries should be made. The Health Insurance Portability and Accountability Act (HIPAA) regulations currently creating so many headaches for health-care providers were written specifically to address the many legal and ethical issues involving privacy and access to client information

Approaches in resolving conflict--Establishing a strong trusting relationship.

Establishing a strong trusting relationship. Use the techniques discussed above for trusting relationships. It is particularly important in working with clients in denial.

risk management

Evaluating the risk of clients and staff for injuries and for potential liabilities and implementing corrective and preventive measures.

Forensic Nursing

Forensic nursing is an emerging field that forms an alliance among nursing, law enforcement, and the forensic sciences. The term forensic means anything belonging to, or pertaining to, the law. Forensic nursing, as defined by the International Association of Forensic Nurses (IAFN), is "the application of nursing science to public or legal proceedings; the application of the forensic aspects of health care combined with the bio-psycho-social education of the registered nurse (RN) in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents." 1 Forensic nurses provide a continuum of care to victims and their families, beginning in the emergency room or crime scene and leading to participation in the criminal investigation and the courts of law.

Healthy People 2020 (Chapter 15)

Healthy People 2020 envisions the United States becoming a society in which all people live long, healthy lives. The mission of the project is to work through federal and state governmental agencies to strengthen the policies and practices to make people healthier. -Eliminating preventable disease and death • Achieving health equity by eliminating disparities and improving the health of all groups • Creating social and physical environments that promote good health for all citizens • Promoting healthy habits and behaviors for all ages of the population

Approaches in resolving conflict--I'll be back.

I'll be back. "Ms. Hart, I feel like you have other things on your mind right now. I'll come back in an hour and you can take your medication then."

Methods to Measure and Improve Quality

If you are having problems identifying quality care when you see it, the Leapfrog Group may have a solution. In November 2000, Leapfrog Group was officially launched by larger health-care facilities that worked together to improve the quality and safety of health care and make it more affordable. The resulting movement now serves as the gold standard for comparison of hospital performance on national standards of safety, quality, and efficiency, thereby facilitating transparency and easy access to health-care information.

lateral violence

Is also known as horizontal violence is found in the workplace and can include name calling, threatening body language, physical hazing, bickering, fault finding, negative criticism, intimidation, gossip, shouting, blaming, put-downs, raised eye brows, rolling of the eyes, verbally abusive sarcasm with rude tones, or physical acts such as pounding on a table, throwing objects or shoving a chair against a wall, unfair assignments, marginalizing a person, refusing to help someone, ignoring, making faces behind someone's back, refusing to work with certain people, whining, sabotage, exclusion, and fabrication.

Approaches in resolving conflict--It can't hurt.

It can't hurt. Sometimes called the "humor me" approach. "Ms. Hart, I know you don't think you need this medication, but Dr. Happy wants you to have it. Why don't you take it anyway since it really doesn't hurt anything and if you really do need it, it will actually help." Or "I would really appreciate it if you would take this medication. I want to help you."

mediation

Legal process that allows each party to present their case to a mediator, who is an independent third party trained in dispute resolution.

Approaches in resolving conflict--Let's try it and see what happens.

Let's try it and see what happens. "Ms. Hart, I know you don't believe you need this medication, but if you look at your incision site, you can see how red and tender it is. Why don't you take this medication and see if it helps with the pain? You'll probably need several doses for it to be effective."

The Research Process

Long before graduation, nursing students often notice something in the clinical setting that grabs their attention. They may simply wonder if a different approach would work better in a particular situation or if the best technique is currently being used and what evidence exists to support a particular technique or intervention as "best." As newcomers to the profession, students may question interventions or solutions that seasoned nurses often take for granted. Students may see the experienced nurse's familiar world differently, and their minds may be open to possibilities that those in the field for many years cannot see. Questioning the status quo is a key first step in the research process. Applying critical thinking to a problem often leads to visualization of a research project, the development of a plan, the implementation of that plan, and finally, sharing of the findings with others. This process follows a logical progression from abstract ideas to concrete actions.

The Purpose of Tradition

Many cultural beliefs develop over time from a trial-and-error process that has both benefits and drawbacks. For instance, several Native American tribes that live in the Western desert have developed the practice of keeping infants in cradle boards until they begin walking. This practice, from a safety viewpoint, protects the crawling infant from injury and bites from creatures that are commonly found in the desert, such as scorpions, rattlesnakes, and poisonous insects or lizards. However, the practice tends to delay the leg muscle development of the child and increases the incidence of hip dysplasia because of the child's position in the cradle board. Some cultural beliefs have a primary purpose of explaining unusual or unpredictable events. For example, many traditional Vietnamese Americans believe that mental illness results from some action that offended one or more of the gods. They also believe that a family member who is mentally ill brings disgrace on the family, and thus knowledge of the illness must be kept secret, especially from strangers. As a result, traditional shamans, or priest-doctors, are sought to attempt to appease the offended deity through rituals and prayers. Only with great reluctance will a traditional Vietnamese American family seek therapy or medication for a mental illness.

Health-Care Coverage—Medicaid

Medicaid differs in that it is primarily for low-income families and low-income individuals. There is much variability in who qualifies for Medicaid and the benefits that are available because it is administered and managed by the individual states, which receive matching funds from the federal government.

Health-Care Coverage— Medicare

Medicare not only covers the elderly but also those with disabilities. Medicare is a federal government-sponsored health-care program developed primarily for senior citizens over the age of 65, those with end-stage renal disease, and disabled persons who are eligible to receive Social Security benefits because of their contribution to the Social Security system during their working years. To maintain consistent and uniform coverage across the county, the program is run and maintained by the federal government and is divided into Part A, which covers hospital care; Part B, which covers medical insurance; and Part D, which covers prescription drugs. Participants in the program may be required to pay a deductible and a small co-pay for medical services.

Arbitration

Neutral third party who assesses facts independently of the judicial system. Hear both parties' positions and then make a decision or ruling on the basis of the facts and evidence presented.

A Modern Prophet

Nightingale came to believe that all persons on a mission or quest to become Christlike are given certain gifts and talents. Some say Nightingale was a modern prophet of God and saw herself as a liberated human being. For Nightingale, spirituality involved a sense of a divine intelligence that creates and sustains the cosmos, and she had an awareness of her own inner connection with this higher reality. The universe, for Nightingale, was the embodiment of a transcendent God. She came to believe that all aspects of creation are interconnected and share the same inner divinity. She believed that all humans have the capacity to realize and perceive this divinity. Nightingale's God can be described as perfection or as the "essence of benevolence."

communication nonassertive

Nonassertive communication is also referred to as submissive communication. When people display submissive behavior or use a submissive communication style, they allow their rights to be violated by others. Their requests and demands are surrendered to others without regard to their own feelings and needs. Many experts believe that submissive behavior and communication patterns are a protective mechanism that helps insecure people maintain their self-esteem by avoiding negative criticism and disagreement from others. In other situations, it may be a means of manipulation by way of passive-aggressive behavior.

A Care Coordinator

Nurse case managers act as advocates for clients and their families by coordinating care and linking the client with the physician, other members of the health-care team, resources, and the payer. The goal of the nurse case manager is to help the client obtain high-quality, cost-effective care while preventing the duplication and fragmentation of care. Research data indicate that active participation by a nurse case manager in the care of a client positively affects the client's outcomes. Nurses are uniquely prepared by their education and professional experiences to fulfill the role of case manager. . Factors that indicate the need for a nurse case manager include: 1. A complex treatment plan that requires coordination or a plan that is unclear. 2. An injury or illness that may permanently prevent the client from returning to his or her previous level of health. 3. A preexisting medical condition that may complicate or prolong recovery. 4. A need for assistance in accessing health-care resources. 5. Environmental stressors that may interfere with recovery.

Parish nurses

Parish nurses are in a unique position to exercise their skills as case managers. As nurses, they possess clinical knowledge and skills, understand the health-care delivery system in their communities, and know many of the key health-care providers. As members of their parish, they are intimately familiar with their communities, understand the cultural climate of their clientele, and are familiar with the services that are available. Moreover, as members of the church community they serve, they are likely to be familiar with the spiritual, psychosocial, and financial needs of their clients.23 However, direct reimbursement is not yet available for most parish nurse services. Churches engage parish nurses to: • Serve as health educators and counselors; • Do health assessments and referrals; • Organize support groups; • Visit parishioners who are sick or elderly; • Serve as client advocates or case managers; and • Organize and manage parish health clinics.

Methods to Measure and Improve Quality

Quality assurance (QA) Continuous quality improvement (CQI) Total quality management (TQM) Benchmarking Leapfrog group Quality indicators (QIs)

Methods to Measure and Improve Quality

Quality assurance (QA) in health care attempts to guarantee that when an action is performed by a health-care professional, it is performed correctly the first time and each time thereafter. QA requires that actions and activities are continuously measured and compared to a standard of care established by a professional organization and that process of monitoring be in place to provide continuous feedback to prevent errors. Quality control is focused on health-care outcomes.

Methods to Measure and Improve Quality—quality assurance

Quality assurance initiatives are essential when efforts are being made to cut costs and, at the same time, maintain high standards of care.

Understanding communication.

Several factors can interfere with the encoding process. On the sender's side, these can be factors such as unclear speech, convoluted and confused message, monotone voice, poor sentence structure, inappropriate use of terminology or jargon, or lack of knowledge about the topic. On the receiver's side, factors that may interfere with encoding include lack of attention, prejudice and bias, preoccupation with another problem, or even physical factors such as pain, drowsiness, or impairment of the senses. Effective communication requires understanding that the perceptions, emotions, and participation of both parties are interactive and have an effect on the transmission of the message. Nurses often encounter situations that require clarification of the information for accuracy and encoding.2 The following is an example of client teaching that requires a return demonstration: clients says yes but looks confuse than nurse does extra explanation.

Methods to Measure and Improve Quality—Benchmarking

Standards for benchmarking are used to classify acceptable levels of performance. These may be written for outcomes, processes, or for structures. Outcome standards focus on results of care given, process standards relate to care delivery, and structure standards relate to the organization, management, or physical environment of the organization.

What is Quality of Care?

The Institute of Medicine (IOM) defines quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

Minority Nurses Needed for the Future of Nursing

The last comprehensive study of minority nurses conducted in 2008 shows that there has been only a slight increase in the number of minority nurses since 2000. Although hospitals and health care in general acknowledge the need for more minority nurses, some nurses are experiencing barriers to their career mobility. Although the core issues are not unlike those that all nurses experience—understaffing, frustration with paperwork and regulations, and unappreciative administration and physicians—they also feel that their ethnic background may be hindering their chance for promotion. Sometimes their capabilities are questioned because of their differences, and that is a big deterrent. The role of minority nurses continues to develop as an issue for the future of health care. Not only are they desired employees because of the changing demographics of the population, but also many in the health-care system believe that diversity in their nursing staff will increase the quality of care for the increasing numbers of minority clients. To help recruit nurses and retain those who are already practicing, several organizations have been established that nurses can contact.

Guidelines for Delegation

The primary goals of staffing decisions are to make sure that optimal staffing patterns are in place and to ensure client safety and high-quality client care. Because health-care facilities and agencies are unable to staff with all RNs, client care today requires the use of health-care workers with a mix of skill levels. Delegation is the designation of a competent individual to the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients. the RNs are always legally responsible for supervising that person to ensure that the care given meets the standards of care. Nursing responsibilities when delegating: Assess the client. Know staff availability. Know the legalities in the nurse practice act. Know the job description. Educate the staff member.

Telehealth

The use of electronic information and communications technologies to provide and support health care when distance separates the health care provider and the client including "plain old telephone service" (POTS), highly sophisticated digitized cameras, telemetry, voice systems, and even interactive robots that can be controlled by the practitioner to assess clients and administer treatments.

Methods to Measure and Improve Quality--continuous quality improvement (CQI)

To ensure high-quality care, the health-care industry borrowed the philosophy of continuous quality improvement (CQI) from the business world. According to the CQI philosophy, there are internal customers and external customers. The external customers are clients and their families; internal customers are individuals working within the health-care setting.

Approaches in resolving conflict--Tough love

Tough love (inducing fear as a motivator). (Note: this is to only be used when all else has failed because it is borderline unethical using the Teleological system of ethics. Be careful using this approach, as it has the potential to destroy your relationship with the client.) "Ms. Hart, you have refused all medications and treatments for the last three days. I'm going to get in contact with the people at hospice so that they can make arrangements for your end-of-life care at your home."

Approaches in resolving conflict-Use the communication building techniques.

Use the communication building techniques. The most important ones for the client in denial are: Asking open-ended questions and taking the time to really listen to the responses. Reflecting back emotions that are being expressed. Asking clarifying questions. "Ms. Bell, you said before that you are really okay, but then you just said you were afraid that the pain in your leg might lead to an amputation. Using all the nonverbal and paraverbal techniques. Eye contact, directly facing the client, open posture, quiet tone, head nodding, and light touch.

Approaches in Resolving Conflict:--Walking the tightrope

Walking the tightrope: Approaching clients in denial who are refusing to take their medications or submit to prescribed treatments requires a gentle touch. Providing too much information may overwhelm them, or being too forceful in your approach may result in them stiffening their resolve not to do what you want.7 On the other hand, diminishing or dismissing the issue will also not accomplish your goals.

98,000 Deaths per Year

When the Institute of Medicine (IOM) published its first report in 2000, To Err Is Human: Building a Safer Health System, it estimated that 98,000 people die per year due to adverse events and medical errors in hospitals.3 The report focused on faulty systems, processes, and conditions that led to mistakes. It recommended system changes for advocated strategies to reduce the number of errors and improve the quality of health care. The report recommended a four-tiered approach: 1. Establish leadership, research, tools, and protocols to enhance the safety knowledge base. 2. Develop a public mandatory national reporting system and encourage participation in voluntary reporting systems. 3. Use oversight organizations, health-care purchasers, and professional organizations to increase performance standards and expectations for safety improvements. 4. Implement safety systems at the point of care delivery in health-care organizations.

Appreciating the Older Populations Spirituality

With aging and changes in health status, many of the elderly find new meanings for their existence. They make preparations for their vertical transcendence from life to death. Some nurses have difficulty in their role when managing the needs of the elderly or dying client due to a conflict they may have in coping with their own fears of death. By understanding their own belief systems, nurses may feel more comfortable in addressing the client's spiritual needs Using spiritual strategies improves the individual's self-esteem and relationships with others and with God. There were some educators who were not convinced that a nurse should attempt to deal with a client's spiritual needs. Rather they feel that area of care belongs to the clergy or those who are trained in pastoral services. Nursing has a relatively short history of incorporating spirituality into health care.

Approaches in resolving conflict--You can trust me; I'm the nurse.

You can trust me; I'm the nurse. You can use the trust the client has built up for you due to your compassion and knowledge to change behavior

Assessing Culture

ask about faith and belief systems to understand culture and spirituality relationships the only way nurses can avoid imposing their cultural values and practices on others and develop plans of care based on their knowledge about others' beliefs and customs is to make a concerted effort to obtain this information. Several cultural assessment tools for clients have been developed

communication 3 styles

assertive, nonassertive, and aggressive.

communication verbal

is either written or spoken and constitutes only about 7 percent of the communicated message.

communication assertive

is honest and direct and accurately expresses the person's feelings, beliefs, ideas, and opinions. Respect for self and others constitutes both the basis for and the result of assertive communication. It encourages trust and teamwork by communicating to others that they have the right to and are encouraged to express their opinions in an open and respectful atmosphere. Remember that the goal of assertive communication is to prevent an "I win, you lose" situation and to encourage an "I win, you win" outcome.4 A win-win goal is achieved when both parties have the ability and willingness to negotiate even though they do not get all they want.

communication paraverbal

is the tone, pitch, volume, and diction used when delivering a verbal message. How people say something is often more important than what they are saying. A sentence can have a completely different meaning by placing emphasis on different words. Paraverbal communication makes up about 38 percent of the total message and is often considered part of nonverbal communication.

communication nonverbal

makes up the other 55 percent of communication and includes body language, facial expressions, gestures, physical appearance, touch, and spatial territory (personal space).

Mediation-Arbitration

parties first attempt to settle their dispute through mediation, if no settlement is reached the dispute will be arbitrated

Transcultural Communication

requires linguistic skills, culturally congruent interpretation of behaviors of others, listening, observation skills. -can be defined as communication which are valid across social groups The ability to communicate is the foundation on which culturally competent care is built. The most obvious barrier to culturally competent care for the non-English-speaking client is the lack of a common language -to help use interprete

5 "Rights" of Delegation

• Right task: Do the tasks delegated follow written policy guidelines? • Right person: Does the person have the proper qualifications for the tasks? • Right direction or communication: Are the instructions and outcomes clearly stated? When should the person report changes? • Right supervision or feedback: How can the delegation process be improved? Are the client goals for care being achieved? • Right circumstances: Are the tasks that are being delegated possible without independent nursing judgments?