Professional concepts Exam 2

Information and Performance improvement

EMR (when designed well)* -Improves communication -Increases quality of care -Lowers costs -Performance Improvement -Evidence based practice

Patient Rights and Affordable Care Act

-2010's Affordable Care Act (ACA) -Make affordable health insurance available to more people -Expand Medicaid program -Support innovative medical care delivery methods designed to lower costs of health care Patient rights and the Affordable Care Act In 2010, a Patient Bill of Rights was created when the Affordable Care Act (ACA) was passed and made into a law. The bill was designed to give patient protections in dealing with health insurance companies.

What is informed consent?

-A patient's choice to have treatment based on their full understanding of the treatment -Explicit (direct) consent -It is more than just the consent form- dialogue to establish the "informed" part is key -A patient's choice to have treatment based on their full understanding of the treatment -Every person has the right to accept or reject any treatment, medication, procedure, surgery, or intervention -In order to help each person make the best choice about treatment, we must ensure they understand the risks, benefits, & alternatives Informed consent is a legal right -Explicit (direct) consent- different from other legal terms of indirect consent (provide references with a job application, you can assume reasonably that they will contact your references) and opt out consent (if person does not clearly decline consent, consent is granted) -Informed consent is more than just the consent form- it's the conversation to educate the patient, answer questions Informed consent video

Def of collab

-A process by which nursing, interprofessional teams, and patients interact to foster open communication, mutual respect, and shared decision- making, to achieve high quality patient care and the best possible patient outcomes -Health care professionals assuming complementary roles and cooperatively working together with patients, sharing responsibility for problem solving and decision making to formulate and carry out plans for high quality patient care, aiming for best possible outcomes

Reasons to invoke chain

-A provider has not responded to a deteriorating patient condition -Nurse questions provider order, plan, or care -Nurse believes response does not fully address issue -Nurse assessment differs from provider's -Unprofessional behavior threatens patient safety -Suspicion team member is impaired -Patient's wishes differ from family or provider Premature discharge

ANA code of ethics

-ANA Code of Ethics -Provision 8 -Protect human rights -Protect human dignity -Promote patient equality -Provision 8: the nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities (ANA, 2015) American Nurses Association. (2015). Code of ethics with interpretative statements. Silver Spring, MD. Retrieved from https://www.nursingworld.org/coe-view-only According to life, and ANA code of ethics, There are other vulnerable populations we need to consider. For example, -Alex Wubbels case- classic example Can be SUPER difficult sometimes to maintain equality. For example: Taking care of Victoria martens' mom; The kid who set the bombs in the boston marathon bombing; HSC/state VIPs -Also consider how you would hope your teammates would take care of your loved one if they were in their care. -The other side of equality is intrinsic to the health care system itself, which has faults in design and delivery that result in disparities in access and quality. Media reports recently have discussed how people of color, black people and native americans in particular, are getting covid at higher rates than white people. In NM, according to NM DOH, 42% AI (9%), 35% -Latino (37), 12% white (40). Covid not only disease: black women more likely to die from breast cancer despite getting breast cancer less often than white women, are 3x more likely to die in childbirth.

Cont

-ANA Code of Ethics -Social contract to keep patients safe -Nurses held accountable for actions and competency -Must know the limits of your knowledge and skill When you can't solve the problem, call someone who can -Key point: You must be able to find this policy!

Cont

-Acute care- hospital -Sub acute care- emergency clinics, urgent care, outpatient surgery. -LTAC (kindred, AMG- can do xrays, ventilators, complex wound care, usually require long term care but are stable). SNF step down from -LTAC- less acute, less complex wounds, maybe long term antibiotic treatment, don't always see physician daily. Nursing home more residential. -Assisted living may have a nursing component or not. Respite care- when caregiving gets to be too much for the family, can go to respite care for a few days to get a break. Hospice can be inpatient or at home. Rehab- intensive PT, OT. 3 hours per day.

Who participate of informed consent

-Adult, mentally competent patient -Emancipated minor -Parent or legal guardian of minor child -Legally appointed representative for person deemed non- competent -Health care team members -informed consent can only be obtained from an adult patient who is mentally competent to do so except under some circumstances and situations. -When consent, for any reason including the lack of majority, mental incompetence, and unconsciousness, cannot be obtained, other people can provide legal consent for the patient. -These people include the parent or legal guardian of a minor and unemancipated minor child, a legally appointed representative for a developmentally disabled adult, for example, an emancipated minor, and the person who has been appointed as the client's durable power of attorney for healthcare decisions or their health care surrogate or proxy. -In other situations, the courts have guardianship and the right to give informed consent for a client who is not able to consent on their own. With the exception of emergencies, informed consent must be obtained. -In an emergency, consent is usually implied. But what happens when consent is denied in the heat of an emergency? What about when you have just heard you have cancer? Do you hear what the provider is telling you?

Cont rights

-Annual and lifetime dollar limits to cover essential benefits removed -Able to get health insurance in spite of pre-existing medical conditions -The right to an easy-to-understand summary of benefits and coverage -Some preventive screenings are covered -Adults can stay on a parent's policy until age 26 if they meet certain requirements -If your plan denies payment for a medical treatment or service, you must be told why and how to appeal -The right to appeal the payment decisions of private health plans

Care Conference

-Couple different iterations -Daily multidisciplinary conference meant to review patients and collaborate -Care conference to clear up communication between patient, family, health care team, come up with plan as team -Conference to discuss ethical issues, errors, at any level

Competency 4: Teams and Teamwork

-Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable -Learn to be a good team player -Share everything: decision making, expertise, accountability, leadership, problem solving -Sometimes need to relinquish autonomy to achieve goals -A nurse director of a clinic arranges for the entire clinic team to attend a conflict management course -A nurse resident participates in a process improvement project to use the EMR to alert the nurse when the IV dressing is due to be changed -A multidisciplinary team uses best practices to guide their daily meetings when discussing the POC with a patient.

Chain of command

-Authoritative, step- wise structure to solve problems -Administrative, clinical, patient safety concerns Keep presenting the issue to the next level until find a solution -Standardizes communication process -Keeps patients safer

Discharge planning

-Begins on admission -Interdisciplinary -Continuum of care -Nursing discharge process -Discharge planning begins the moment a patient comes in to a facility, arguably even before admission- at triage. -All players take part. Patient, family, providers, case management, nursing, pharmacy, rehab services, dietician, central supply, pulmonary services... -Continuum of care: whatever we don't fix in hospital will need to be addressed after discharge. -Nursing is part of the process every step of the way. We also review the final paper work process and send them off.

How does it improve outcomes

-Collaborative practice decreases: -Total patient complications -Length of hospital stay -Tension and conflict among caregivers -Staff turnover -Hospital admissions -Clinical error rates -Mortality rates

Conflict of management

-Common conflicts -Bullying "zinging" -Intergenerational conflict -Interdisciplinary conflict -Conflict central to all interactions because humans -Conflict can help us grow, improve, drive change Kilmann's 5 primary styles of conflict resolution -Avoiding- refusal to address conflict -Accommodating- submit to other side by accepting the other side's argument -Compromising- neither party wins but both leave satisfied -Collaborating- thoughtful consideration of each persons views, including discussion of goals; results in mutual understanding -Competing- unwillingness to negotiate

Competency 3: communication

-Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease -Use standardized tools -Consider audience literacy -Its YOUR responsibility to speak up for safety -Give and take feedback Communication comes up over and over. Use a common, standardized language, and tools that everyone is familiar with like SBAR. Literacy for patients is also important- make sure person receiving info is able to understand it; this includes language interpretation. -A Shared Governance committee on an inpatient unit participates in Peer Review once a month to ensure nursing staff are following clinical procedures. Recent examples include: two person Foley insertion, med pass, CVAD charting, Curos cap usage -A nurse uses SBAR to report a medication error to the physician and then completes a Patient Safety Intelligence report to document the error and follow up actions -The Infection Prevention Department uses the Health Literacy Department to edit and design patient education pamphlets on mask use during COVID-19

Attributes of collaboration

-Communication is the core of collaboration -Communication is KEY -Poor communication leads to errors -Need standardized ways to communicate -Chain of command -Crew Resource -Management Training -SBAR -Text Paging Etiquette

Why IPE

-Complex conditions require collaborative response -Improved outcomes & patient safety -Better workplace practices & productivity Educational benefits -Real world experience and insight Well- rounded curriculum development -Learn about other professions - Challenge stereotypes

What can nurses do to improve informed consent

-Consent is a process, not just a signature -Process is collaborative -Nurses offer patient teaching about nursing aspects -Watch for paternalism -Provide written materials in patient's spoken language -Get an interpreter -Verify comprehension- use teach back -Think about consent as a process to assure patient understanding and agreement, not just signing a form. Informed consent should be a collaborative activity between the physician, nurse, and patient. -The physician should have obtained consent before the nurse signs a form. -Nurses can offer what we do best—patient teaching -Assess for paternalism- it means to limit a person's autonomy even while intending to do good for that person, usually coming from an attitude of superiority. - from the physician, from yourself. -We understand so much more than the patient and are trying to help, but we cannot pressure or tell a patient what to do. -Providing Written Materials in the Client's Spoken Language, When Possible Give out oral and written educational material and content at the level with which the client can understand this education. At times, written material in the client's spoken, the native language is beneficial for patients and significant others and, at other times, the assistance and services of a professional translator may be indicated. -Teach back: a way to teach the patient something and then get them to repeat back to you what you taught them. It can feel awkward... Teach back video

What is involved in informed consent?

-Consent may be retracted at any step of the process -Health care team members must accept and support the patient's choices -Consent process vulnerable to complexity of treatment, patient condition, ability to understand Consent may be retracted at any step of the process -Health care team members must accept and support the patient's choices -The consent process can be affected by complexity of the treatment, patient condition and ability to understand information, and if treatment is emergent or elective.

What is the most important idea behind advocacy

-Consider what the pt wants not only what is best for them

Barriers to consent

-Cultural differences -Readability of forms -Demographics -Medical jargon -Reluctance to ask questions

What are the components of informed consent

-Describing the Components of Informed Consent -The components of informed consent include the person's knowledgeable consent to a treatment or procedure after they have been given, and understand, complete, unbiased information about: -The proposed treatment or procedure Who will perform the treatment or procedure -The purpose of the proposed treatment or procedure -The expected outcomes of the proposed treatment or procedure -The benefits of the proposed treatment or procedure -The possible risks associated with the proposed treatment or procedure The alternatives to the particular treatment or procedure -The benefits and risks associated with alternatives to the proposed treatment or procedure -The client's right to refuse a proposed treatment or procedure Again, all clients have the legal right to autonomy and self-determination to accept or reject all treatments, procedures, and interventions without any coercion or the undue influence of others.

Professional nursing identity

-Doing- means skills, institutional roles, tasks; we all know Evidence based research is an essential part of nursing identity. -Another example- New Mexico Nurse Practice Act- for example, an rn in new mexico can assess and form a nursing diagnosis, evaluate outcome of nursing interventions, and delegate tasks to other rns, lpns, and pcts. -Being- personal sense of being a nurse. This might look different for different people, and be different amongst generations and cultures. -Acting Ethically- doing what is right and good Flourishing- positive, transformational growth Changing Identities- recognition of changing identities. -Example is every time you get a new role you revert back to that novice stage; realizing that you are becoming really good at being a student nurse. How to figure out your identity Self-reflect Try new things Listen Actively adopt an identity Be accountable Engage Take care

American Hospital Associations Bill of Rights

-Empower people to take an active role in health care -Advocate for informed consent and decision making -Advocate for the right to have an advance directive -Improve the relationships between patients and their health care providers The Patient Bill of Rights -In the early 1970's, the American Hospital Association drafted a Patient Bill of Rights so people would know what they could reasonably expect when they were hospitalized. -Since then, a number of similar measures have been developed. These are designed to: Empower people to take an active role in improving their health, including making informed decisions and the choice and right to have an advance directive. - Strengthen the relationships that patients have with their health care providers.

Ethical implications of Delegation

-Ethical obligation to protect patient -Ethical obligation to protect delegate -Delegation involves mutual respect -First and foremost, all decisions related to delegation and assignment, are based on the obligation to protect the health, safety, and welfare of the public and our patients. So, as with all things in nursing, we delegate with our code of ethics in mind. -Certainly an ethical consideration in delegation is doing it correctly and with the patient's best interests in mind. If a nurse delegates a task to another nurse, the delegating nurse still maintains accountaibilty for the task, but should not allow a delegate to take on a task that is questionable, particularly if the delegate is a novice nurse -A key principle in delegation, according to the ANA's Principles for Delegation, is that Nurse acknowledges that delegation involves mutual respect. This clues us in to the fact that if we do not delegate appropriately we can diminish another's power and dignity. Specifically, a subordinate's power and dignity. For example, I might delegate ECG lead placement to a UAP. If I say, "go put on the leads right now" versus "the patient needs leads right away, do you have time now?" makes a difference- the second sentence gives value to the UAP's time as well while still expressing urgency. -Another ethical risk with delegation is causing others to experience moral distress.

Attributes ethics

-Everyone comes with their own perspective -Cultural diversity -Expertise -Ethics -Collaboration requires conflict management

Delegation cannot occur interperprofessionaly

-False

You can delegate accountability

-False

Plan, do, study act is process improvement method that involves single cycle of process improvement

-False -One cycle is not enough to get the job done

Getting started

-Find the policy before you need it -Ask for direction if no policy or if the policy is vague -Practice in your head Know critical assessment parameters -When do you call the provider? Know your meds -Indications, adverse effects, reversal agents -Use chain of command Document

Specifics

-Formal policy/procedure -Response time? -Documentation expectations Barriers -egos -poorly trained or incompetent leaders -poor communication

IPE collaborative practice

-Health workers from different professions work together to deliver care "Health worker" is anyone who works to enhance health -Everyone- nurses, doctors, physical therapists, techs, pharmacists, housekeepers, IT, maintenance, clinical engineering, infection prevention, pastoral care, social work, dietary...

Delegation cont

-How to delegate -State name, room number -State/describe task -Validate delegate can perform task -Provide timelines (when, how often) -Detail specific approaches Set reporting parameter (when, how often, under what circumstances) -Say please & thank you Key points to delegation -Know yourself & your team -Strengths, weaknesses, job descriptions, policies -Communicate clearly, completely, constantly Evaluate -Give feedback -Say please & thank you

What's the biggest reason to participate in IPE

-Improve patient outcomes and safety

Begin on admission

-In ED on admission -In clinic pre- op -Anticipate, communicate, act early -Educate early and often -Social worker or Nurse Case Manager see patient in ED on admission Same in Cancer Center clinic pre- op -Wound care nurses pre mark ostomy sites Pharmacy and care management get pre auth for meds and procedures -Admitting office works on insurance auths, medication auths, etc. -Sometimes team doesn't know what future holds but key is to anticipate, communicate, and act as early as possible -As a bedside nurse, you can help by educating and communicate early and often

cont chain of command

-Just Culture -Non- punitive -Fix the system -Learn from mistakes -Just culture- Came out of aviation industry, seeks to create an environment where people are encouraged to report errors and near misses in order to identify systems issues. -People are not punished for mistakes- unless the mistake is due to a deliberate disregard for established rules or safety systems. -In systems like aviation or healthcare, there are so many moving parts that errors are inevitable. Systems need to be designed to minimize the chance that a human can make an error. -Systems issue: heparin vial labels. Couple different issues: graphic here shows old label, only lists how many units per ml, still is a 10 ml vial; see where you could draw up 10 mls thinking it is only 5000 mls?

What is involved informed consent

-Legally, means the patient or proxy understands to the best of their ability the risks, benefits, & alternatives to treatment -Signature indicates legal documentation of consent -Ethically, safeguards patient autonomy -Patient understands and makes choices about treatment based on what's best for him/herself

Pharmaceuticals and DME

-Medicare Part D -Durable Medical Equipment -Partial insurance coverage -Both regulated by FDA -Pharmaceuticals and DME are part of the health care delivery system. -The pharmaceutical and assistive device industries are quite large, with a major impact on healthcare costs and policies. Prescription drug use in particular is growing rapidly with the recent passage of the Medicare D drug benefit. Most facilities have their own formularies, which dictate which drugs from which manufacturers the prescribers at that facility can prescribe. -There are a couple of different immunosuppressant meds for transplant patients, and sometimes one med works better than another- fewer infections, fewer rejection episodes. Sometimes a patient comes from out of state to UNM and has to jump through hoops to get that med if it isn't on the formulary. -More and more durable medical and assistive devices, such as sleep apnea machines and portable oxygen, are being covered at least partially through insurance plans. Both pharmaceuticals and these devices are regulated by the FDA for safety.

Others Patient Bills of Rights

-Mental health bill of rights -Hospice patient bill of rights Rights of people in hospitals -Certain US states have their own versions of a bill of rights for patients Insurance plans sometimes have lists of rights for subscribers

Negotiations

-Negotiation is a two- way communication and decision making process, aimed at reaching a solution to a shared problem -Each party has some authority in making the decision -Each party has something at stake -Each will be affected by the outcome -Key question in negotiation in collaborative problem solving: will this lead to optimal outcomes for the patient?

Pt requires emergency electrical cardioversion for dysthymia. Is informed consent indicated

-No

negotiation cont

-No ultimatums -Paraphrase -Ask questions -Focus on facts -Find points to agree on -Focus on patient DESC -Describe specific situation -Express concerns -Suggest alternatives -Consequences stated

Which type of collaboration working on the NM statue Nursing Practice act

-Nurse-interorganization

What is the key idea behind sphere of nursing advocacy model

-Nurses promote patient self advocacy

Advocacy for vulnerable populations

-Organizational -Professional -Self -Family -Community -Public policy/Legislative -Organizational advocacy- represent clinic at health fair; work the flu shot clinic as a student nurse. Professional- represent nursing at legislative sessions- an example of this is Dean Kasper and some CON faculty and staff went to roundhouse in SF to give a speech and represent UNM CON when working to get Bond C for higher Ed on the ballot. Who is the vulnerable population the dean and co is advocating for here? Self advocacy- participating in evidence based process improvements that impact patient outcomes and improves your workplace, makes it a safer, more ethical place to work. Advocating for the clinical instructor to bring you into the room to watch a procedure if you haven't had the opportunities yet. Family- community- these are the things you'll talk about and research in your discussion postings this week. Public policy/legislative- election is HUGE for how public policy will affect vulnerable populations in terms of health care. Even just leading up to the election, there's tons of examples of advocacy for protecting people trying to vote. Another example of public policy advocacy is mask mandates, no visitor policies in hospitals. Anyone have a loved one in hospital? It is pretty hard to get info when no visitors are allowed, so remember the families!!

What are the roles of informed consent

-Patient's role -Speak up -Ask for second opinion -Self- advocate Provider's role -Provide complete info -Answer questions -Remain unbiased & neutral -Take reasonable steps to confirm patient understands Nurse's role -Act as a witness that the person signed and dated the form -Advocate for the patient if you think they are not fully informed -Explain any aspect of nursing care relevant to the treatment -Support and comfort patient and family Nurse is not responsible for making sure patient understands!!! -Nurse does have an obligation to explain nursing interventions associated with procedure being consented to. -Nurse should advocate for patient if they don't think they understand.

Vulnerable popultions

-People of Color -Low income -Low health literacy -Homeless -LGBTQ -Chronic Illness -Substance Use Disorders -Disabled -Criminal Justice System Health Promotions -Education -Vaccinations -Screening -Nutritional Health -Physical Activity -Pharmacologic Agents -Education: lots and lots of education, tailored to literacy level and language -Vaccinations: young and old and ill. -Disseminate accurate information, correct misinformation -Screening: lots of barriers here, from cost to insurance coverage to trust in health care to access, including transport, ability to take time off work, childcare... -Nutritional Health: myplate.gov Physical Activity: kids, old people too Pharmacologic Agents: smoking cessation, substance use, immunizations,

Cont

-Privacy -Confidentiality -Respect and dignity -Choose their own doctor -Get all info about medical condition and treatments -Make informed decisions about their medical care including their right to accept and reject any treatments -Complete freedom from abuse and neglect -Access to emergency services -Manage and control their finances and personal property -Competent and compassionate care -Religious freedom Social freedom -Accurate bills for the care and services -Express complaints and have concerns addressed Establish patients' rights in dealing with insurance companies and other specific situations related to health coverage and payment of services.he American Hospital Association's Bill of Rights (replaced by the AHA's - Patient Care Partnership) includes the fact that all clients and patients have According to the American Hospital Association, all patients have the right to:

Which type of collaboration team focuses on one-time deliverable and has limited terms

-Project teams

What is the most important intervention to prepare patient for discharge

-Provide frequent education using teach back method

Health care delivery system cont

-Public health department responsible for working with state and local departments to improve health. Examples: disease outbreaks, water quality issues that cause illness, make sure restaurants and child care businesses adhere to safety health standards. Community health programs- health care for homeless, senior affairs, meals on wheels -Primary clinic- primary, generalist provider follows and coordinates patient care, coordinates with specialized care.

Delegation

-Responsibility: liability associated with actual performance of task -Accountability: ownership of the task; includes responsibility -Assignment: the work a staff member is responsible for -Delegation: transferring responsibility while retaining accountability -You can delegate responsibility -You cannot delegate accountability Example- the provider calls and asks you to document a set of vitals in the EMR so he can write DC orders in the next 5 mins. -You delegate to UAP. The UAP does not do it. -You are ultimately responsible, not the UAP. Another example- you ask another nurse to do patient education for you on warfarin. You find out later the nurse never completed the education. You are the one accountable, not the nurse you delegated to. You can delegate to anyone- UAP, another RN, LPN, another professional, anyone who can competently perform the task, who can legally perform the task (within their scope). -The difference between delegation and assignment is an important distinction because UAPs have their own fundamental roles and skills that are part of their jobs- like taking vitals, tracking Is&Os, assisting with ADLs. -Technically, we do not delegate those tasks to them. Delegation comes into play when we task them with doing something that is within their scope but not something routinely performed- one example, is helping with post mortem care; assisting with orthostatic BPs; helping a patient get up and walk. -The tasks and roles are different on different units- for example, on 4W the nurses get the CBGs, so asking a tech to get a blood sugar would be a delegative task.

Which IPE domain? In an ACLS class each participate practices each separate role (leader, med nurses, electricity nurse)

-Roles and responsibilities

Which IPE domain? The nurse asks the PT to recommend appropriate assertive device for non-weight bearing exercises

-Roles and responsibilities

Which organizational structure would you use to improve the discharge process

-Shared governance

patient develops rash and SOB while abc are infusion. What is your first action

-Stop infusion

The phase of group work progression where members may callenge one another is

-Storming

IPE

-Students from different professions learn about, from, and/or with each other - Can happen in classrooms or workplaces -Creates effective collaborative relationships -Leads to optimal health outcomes

ACLS team uses best practices determine the most effective way to divide up the responsibilities

-Teams/ teamwork

Concept definition

-The act or process of pleading or supporting another's cause by promoting the environment in which the human rights, values, customs, and spiritual beliefs of the individual, the family and the community are respected (International Council of Nurses, 2006). -Advocacy means using your communication and skills of persuasion to remove barriers so patients can be involved in decision making. -Advocacy is absolutely necessary in nursing practice. Advocacy often viewed as last line of defense on behalf of patient. -Nurses support a patient's rights and wishes in complex, unfamiliar environment; nurses speak up for quality care. -Key is to teach nursing students to get good at communication to voice their opinions and those of their pts. -We should be able to practice safely and be able to voice concerns without threat of retribution. We should not accept or allow behavior that threatens aynyone's safety. -Basically, you HAVE to have good comm skills to be a good advocate. Skills that make you a better advocate are the ability to speak out assertively and credibly and authoritatively. -Advocacy means the power to remove barriers to enable pt involvement and decision making in plan of care.

Attributes roles and responsibilities

-Understanding one's role, others' roles is KEY -Identify and clarify the roles too -Nurses must practice to the full extent of their scope -Recognize nurse sensitive indicators Roles/Responsibilities: -Understanding one's own role and responsibilities in the collaborative relationship, as well as the roles and responsibilities of others, is key in effective collaboration. -The IOM recommendation that nurses practice to the full extent of their training and licensure, and the recognition of nurse sensitive indicators, is an encouragement for nurses to actively participate in all collaborative efforts. -Clarification and communication of each team members' roles in implementation of any plans or interventions contributes to best possible outcomes. -Instructions re home care -Nurse response to questions/concerns Info given family -CAUTI -CLABSI -VAP -Falls - Restraints -Pressure injuries -Peds PIV infections DVTs -nursing turnover rate Staff mix/structure (how many LPNs, RNs, BSNs, MSNs, certified nurses) Discharge education

Competency 2-Roles / Responsibilities

-Use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of patients and to promote and advance the health of populations -Know your role & be able to articulate it -Know others' roles -Challenge inaccurate perceptions -An ACLS course is taught where each role- code leader, medication, compressions, airway, electricity, documentation- is defined clearly, and each person in the course is expected to practice each role -A patient asks the nurse to help them complete disability paperwork. The nurse responds by saying, "I will call the social worker to come help you. While I know a little about the process, the social worker on our team is an expert in benefits like disability and can give you the best guidance".

Which is NOT a tool to improve communication

-Voice mails These are -SBAR -Chain of command -Checklist

IPE competencies: values and ethics

-Work with individuals of other professions to maintain a climate of mutual respect and shared values -Mutual respect and trust are foundational Collaborative care honors diversity in individual expertise -A nurse consistently reviews ACLS algorithms to be sure she's ready if there is a code -A physical therapist who works in the wound care clinic spends an orientation week following a wound care nurse to learn about their practices and workflow to improve her own practice -A multidisciplinary team that maintains patient confidentiality by holding meetings in a closed door office instead of the cafeteria

NOT and example of informal collaboration

-Working on a CAUTI prevention project togtherter These are informal collaboration -Bouncing ideas of each other -sharing best practice -socializing learning during clinical

Delegation nots

-You cannot delegate -Assessments -Nursing diagnoses, care plans -Interventions that require professional knowledge and skill

You encounter an ethical dilemma with a provider, who do you go to to 1sr in chain of command

-charge nurse

Which style of conflict resolution reflected an unwillingness to negotiate

-competing

In same situation, when is the provider chain of command accessed

-concurrently with the nursing chain of command

example of inter organizational collaboration

-creating NMNEC curricula

The nurse's bill of rights

-is a guideline to facilitate standards

ANA nurses bill of rights

-not a legal doc -can help facilitate discussion -a social contract -Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care. -Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice. -Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the -Code of Ethics for Nurses with Interpretive Statements. -Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution. -Nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional responsibilities. -Nurses have the right to a work environment that is safe for themselves and for their patients. -Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.

Group Dynamics Tuckman and Jensen's Stages of Group Process

1. Forming ‐ Relationship development: team orientation, identification of role expectations, beginning team interactions, explorations, and boundary setting. 2. Storming ‐ Interpersonal interaction and reaction: dealing with tension and conflict or confrontation may occur. 3. Norming - Effective cooperation and collaboration: personal opinions are expressed and resolution of conflict with formation of solidified goals and increased group cohesiveness occurs. 4. Performing - Group maturity and stable relationships: team roles become more functional and flexible. Structural issues are resolved leading to supportive task performance through group directed collaboration and resources sharing. 5. Adjourning - Termination and consolidation: team goals and activities are met leading to closure, evaluation, and outcomes review. This may also lead to reforming when the need for improvement or further goal development is identified.

Delegation rights

5 rights -Person -Task -Circumstances -Directions/communication -Supervision/evaluation -The "right" person- does the skill of the person match the task? is it within their scope? Are they competent to complete the task? Have they been trained? Will they do a good job? Example: a nurse is getting a new admit that sounds unstable; another patient who uses a walker needs to get up to the toilet, and a third patient needs pain meds. -Following this "right", the nurse delegates the toilet to the tech and the pain meds to another nurse. -The "right" task- is the task appropriate to be delegated? For example, I heard a story that a new tech/student was sent to transport a person was really close to dying- that person was an appropriately trained transported but had not had a patient die before, so bad choice of tasks. The "right" circumstances- consider assessment of each patient, equipment availability, supervision, environment: first, it can be hard to delegate, when you are super busy and overwhelmed... you can't give anything away from your precariously balanced pile. Second, when you do give things away, consider your ability to supervise and follow up. For example, patients who are unstable or look unpredictable are not good candidates for delegation. -The "right" directions and communication- be clear about expectations- time frames, reporting when job is finished, reporting adverse events, don't delegate to someone else. When you delegate, be specific about time frames and expectations. Be mindful that the UAP has a plan for their day too, so negotiation is key. -The "right" supervision and evaluation- follow up appropriately, give constructive and instructive feedback

Collaboration and ANA

ANA Code of Ethics -Nurses have a unique contribution to collaboration -We should practice at the top of our scope -Work to ensure everyone has a voice -Informed decision making is key -Intraprofessional collaboration important too -The American Nurses Association Code of Ethics addresses the importance of collaboration. -The code states that nurses have a unique contribution to collaboration, including our unique scope of practice, and relationship with other health care professionals. -Nurses, by virtue of being the logistical center of patient care, are well positioned to work to ensure all parties have a voice in informed decision making and patient care issues. -This means patients too. The code also addresses the importance of intraprofessional collaboration. Specifically, civility between nurses.

ADOBE popultions

Adobe program provides wraparound services for previously incarcerated youth, including primary medical care, psychiatric care, substance abuse treatment and services, case management, educational liaison. -Legal advice, can refer to outside psych services if adobe services not the right fit. Help with things from legal services to housing and keeping the electricity on. Lots of mental health diagnoses; get the kids treatment and counseling, get them connected and engaged back in school, get their families stabilized too. HUGE success rate to keep kids out of criminal justice system- 90% success rate! Expensive.

After you stop the infusion, what your next action

Assess the pt

Delegation cont 1

Challenges -Time -Conflict -Lack of confidence in delegates -Misconceptions about delegation -Lack of time- delegation is a skill that takes practice, you get better at it over time. It will save you time! -Conflict... strategies coming. -Lack of confidence in delegates- part of being a nurse is being a leader, part of being a good leader is growing your team mates. If you ensure they have the training, resources, and authority, and give feedback, they will grow. -Misconceptions about character of delegation- you not passing off work to another, you not "dumping"; think of it as a source for development of another person's professional and clinical skills. -People who are good at delegation are the people who get promoted!

Nurse chain

Days: -You Charge Nurse Unit Director/Nurse Manager Executive Director Chief Nursing Officer -Nights/Weekends/Holidays: -You Charge Nurse House Supervisor Admin On Call

Education and Research

Education heavily subsidized -Medicare funds graduate medical school -Loan forgiveness =Direct funding Medical Research -NIH -Private foundations -American Cancer Society -Autism Speaks =Industry =Pharmaceuticals =Medical devices -Education is heavily subsidized through a mix of private and public funding. -Undergraduate nursing, medical and PA programs are funded through a mixture of direct funding and enhanced patient care reimbursement to training institutions. -Graduate medical education is funded publicly through Medicare. Medicaid funding is available in most states, as are HRSA grants. -The US does not actively manage providers' specialty choices or the distribution of the physician workforce. The government is the major funder for basic medical research, particularly the National Institutes of Health. Private foundations are also key funders. For example, the American Cancer Society, Alzheimer's Association and Autism Speaks are major funders of research projects. Industry is the major funder for clinical trials of drugs, medical devices and continuing medical education.

Types of collaboration

Formal -Committee working on CAUTI prevention -Ethics Committee -A nurse running a diabetes program for patients and families -Mentorship -Preceptorship Informal -Socialized learning during clinical -Bouncing ideas off each other -Sharing best practices -Patient/family interactions

Why we need collaboration

Incivility and lack of teamwork leads to increased costs, worse outcomes -Medical errors -Increased mortality and morbidity -Poor patient experience -Burnout -Worker turnover Want to be safer? -Develop conflict resolution skills -Foster environment of open communication Standardize communication, use existing tools

Provider chain

Intern=Resident= Chief Resident = Attending = Medical Director Or Resident Fellow Attending Medical Director

Population health

Medicare -Emphasize value via programs (clinics with these programs earn more Medicare dollars) -Patient Centered Medical Home -Accountable Care Organizations New roles for nurses -Informatics -Health coaches -Transitional care Nurse's role is to assess and develop long term care plans, and collaborate with multidisciplinary team, to improve care transitions, prevent physical and cognitive decline, and help older people live longer in their community. Do this through intensive following of patients. -The problem is making the leap in funding, staffing, and actually getting patients to participate- the reactionary hospital system is overwhelmed, and faces shortages of staff and funds. The tiny steps from a reactionary health care system to a preventative system are like an endless climb uphill. Requires more support and funding.

Examples

National Center for Interprofessional Practice and Education -Agency for Healthcare Research and Quality (AHRQ) has a program called -TeamSTEPPS. TeamSTEPPS is a training program to foster teamwork across disciplines. Some of techniques are standardized communication, like SBAR; the two- challenge rule- if you express a concern to someone who brushes it off, you are responsible to assertively voice your concern at least 2 times AND ensure it has been heard; specific feedback guidelines including timeliness, respectfulness, specificity, directed, and considerate; guidelines for conflict management. Lobowings Patient Safety Training- half days training session taught by hospital teaching participants communication tools and teamwork strategies to improve communication in teams and decrease errors. Biggest takeaway from training is assigning EVERYONE the responsibility to speak up when they see a patient safety issue. The class covers some confidence building exercises and role playing to empower the participants to actually be able to speak up. LoboWings training is given to nurse residents, medical residents, pharmacy residents, students, leaders, and is available to take on a voluntary basis. Has been shown to decrease medical errors and increase employee satisfaction. Code teams- teaching ACLS using team based approach to be sure everyone understands each role. At the start of a code, each person actually gets a card on a lanyard that outlines the duties of that role. Very clear.

collaboration categories

Nurse-Nurse -Plan of care -Process improvement -Shared Governance -Mentoring/Preceptorship Nurse-Patient -Education -Discharge planning -Medication Administration -Advocacy Nurse-Intraorganizational -Between departments Nurse-Interprofessional Teams -Daily organization -Multidisciplinary teams -Discharge planning Nurse-Interorganizational -State Nurse Practice Act -Healthcare for the Homeless -NMNEC -ANA -Unions -Emergency Operations

Theoretical link 2

Orlando's Nursing Process Theory (Currentnursing.com, 2012) -Patients express distress that signifies a need for help -The distressed behavior may not reflect the true need -Role of nurse is to find the true nature of the distress and meet their immediate need for help -Nurse must be sure their reaction aligns with the patient's experience In advocacy, nurses must be sure any action conforms to the patient's wishes and is in the best interests of the patient -Orlando's theory basically outlines the steps whereby a nurse discovers and resolves a problematic situation. Yes, we need a theory to describe everything. -First the Patient expresses distress that signifies a need for help -The distressed behavior may not reflect the true need -Role of nurse is to find the true nature of the distress and meet their immediate need for help Nurse must be sure their reaction aligns with the patient's experience - Nurses do not assume that any aspect of their reaction to the patient is correct, helpful, of appropriate until they check the validity of it in exploration with the patient you ask questions, check in with the patient to be sure your perceptions are correct. If not, revise your thinking and retry. -In advocacy, nurses must be sure any action conforms to the patient's wishes and is in the best interests of the patient. If our response to the patient's distress expression is incorrect, and we advocate for that anyway, we are doing the wrong thing for the patient. -Really important that the nurse drops any judgements or biases -I had a hard time coming up with a life example of this one, all I can think about is the kid who had a meltdown because he broke his whoopee cushion but really he is just hungry

ANA nurses Bill of rights cont

Safe Harbor Act: Nurses can invoke safe harbor, in good faith, to protect their licenses if they find themselves in compromised practice situations where it is not in the best interest of patients for them to accept an assignment, e.g. working mandatory overtime, accepting expanded patient assignments, etc. Violence Against Nurses

Theoretical links

Sphere of Nursing Advocacy Model (Hanks, 2005) -Nurses provide a protective sphere of advocacy for vulnerable clients -Nurses should allow clients to self advocate if they are able -Nurses provide advocacy in the areas where the client is unable to self- advocate -One nursing theory that applies to advocacy is the sphere of nursing advocacy model. Key components: nurses provide a protective sphere of advocacy for vulnerable clients Nurses should allow clients to self advocate if they are able -The diagram shows the model- the client is in the middle, the nurse sphere is the web around; the client can advocate through the gaps in the web, and the nurse advocates in the sections where the client cannot. -Roles of nurse as advocate: supporter and informer. Nurse provides a supportive atmosphere for the clients decision making in health care, and gives them back up when they need it. -Clients may have varying degrees of belief in their ability to self advocate, and this ability may change depending on the environment and circumstances. -Example of this is teaching nursing students in clinicals. I am providing a protective sphere for the students to practice; I will support them to let them do things on their own; and will fill in the gaps where they are not quite competent.

Conflict management cont

Strategies -Recognize conflict early -Be proactive -Actively listen -Remain calm -Define the problem -Seek a solution -Use "I" messages "I felt my messages were brushed off" instead of "You brushed off my messages" Recognize conflict early. Recognizing the early warning signs of conflict is the first step toward resolution. Pay attention to body language and be cognizant of the moods of the team. Be proactive. Address the issue of concern at an early stage. Avoiding the conflict may cause frustration and escalate the problem. Actively listen. Focus your attention on the speaker. Try to understand, interpret, and evaluate what's being said. The ability to listen actively can improve interpersonal relationships, reduce conflicts, foster understanding, and improve cooperation. -Remain calm. Keep responses under control and emotions in check. Don't react to volatile comments. Your calmness will help set the tone for the parties involved. -Define the problem. Clearly identify and define the problem. A clear understanding of the issues will help minimize miscommunication and facilitate resolution. -Seek a solution. Manage the conflict in a way that successfully meets the goal of reaching an acceptable solution for both parties. -Use "I" messages: "I felt my messages were brushed" off rather than "you brushed off my messages" It takes practice but takes the fault off the other person, diminishes the negative response of the other person, and helps us reframe how we think about the conflict.

Ethical Implications of Interprofessional Collaboration

Threats to patient centered care -Financial incentives -Interpersonal factors -Team dysfunction -Confidentiality breaches -Groupthink -Differing professional ethics Strategies to address potential threats to patient centered care -Always place patient at center of care plan Remember our ANA Code of Ethics -Remember the IPEC competencies -Consult ethics team

Which IPE domain? A team works hard to protect patient info by only using secure email even when gmail is easier

Values/ Ethics

Vulnerable popultions

What can I do Ensure safety Give patients a voice Educate Protect patients' rights Connect patients to resources Educate yourself Remember your idealistic nursing student self

Attributes teams

Work teams -accomplish tasks on an ongoing basis in a specific organizational setting (primary care, surgical team, emergency department team). Parallel teams -address shared challenges, such as responding to a cardiac arrest or aiding the transition of patients from hospital to ambulatory care, and typically draw participants from several work teams, wound care to surgical unit Project teams -focus on a one‐time deliverable and have limited terms (an electronic health record implementation team). Management teams -oversee all the others

The IPEC purpose is

improve interprofesional ed& collaboration for optima health outcomes

A preceptor. new grad nurse relationship is what type of collaboration

nurse-nurse

Health care delivery system

pA health care delivery system is an organization of people, institutions, and resources to deliver health care services to meet the health needs of a target population.