Topic 2: Beyond Professional Socialization and Professional Nursing Roles

Advocate

Passion and Vision Purpose is change - true change requires vision, passion, and agitation Evolution of nurses as ____ - Late 1960s: Patient focused and less institution directed - Patient's Bill of Rights - Global and national health care reform "health for all"

Commission on Collegiate Nursing Education (CCNE)

autonomous accrediting agency, contributing to the improvement of the public's health Commission ensures the quality and integrity of baccalaureate, graduate, and residency programs in nursing assess and identifies programs that engage in effective educational practices

role balance

continuum of segmentation and integration fluctuates over time

RN delegation

delegates to LPN and UAP responsible for all duties of LPN and UAP accountable for all tasks assigned most critical, complex patients, new admission, fresh post op, discharge teaching comprehensive assessment gives all medications (IV, chemo) Blood transfusions Invasive procedures: central line and port asses., assist MD with procedures develops care plan (uses critical thinking to interpret patient findings and labs) collaborates with other members of health team Never delegate LPN and UAP with unstable or tasks that require TAPE

delegations

frees up RN to care for critical pts and complete other tasks different for every state 5 Rights: 1. Right Task 2. Right Circumstance 3. Right Person 4. Right Direction/Communication 5. Right Supervision

American Nurses Association

identifies several components to standards of nursing practice as well as standards of professional performance since 1960, it has defined the scope of nursing and developed these standards - standards in place are in place as a set of practice guidelines for nurses to make significant and visible contributions that improve the health and well being of all individuals, communities, and populations

Institute of Medicine (IOM)

independent, nonprofit organization that works outside of government to provide unbiased authroitative advice to decision makers and the public applies a distinct research process to provide objective and straightforward answers to difficult questions of national importance reports undergo extensive peer review by a second group of experts, which remains anonymous to the authoring committee until the study is published

Role segmentation

possessing clear boundaries among or between roles strict ex. : avoid checking employment related email account from home, avoid making personal phone calls at work- you are avoiding any blending of personal and professional roles

Researcher

Inquiring and Discovering -vital for generating new knowledge to underpin nursing practice, clinical care, and public health. International Council of Nurses (2009): "Care that is continually examined through research" Misalignment between role and identity: Ex: oncology nurse who is not aware or curious about cancer treatment research--the role of the nurse requires a comfort with research and a curiosity with clinical investigation. "Research at the bedside" Grounded in curiosity and the desire for discovery driven by compassion for human suffering: it is about sharing and inspiring new knowledge; ask "how" and "why" questions

Manager

Leading, Inspiring, and Thinking Critically All nurses assume this role! --> end of life care leadership and compassion--> servant leadership and emotional intelligence authentic leadership--> glue to hold together a healthy work environment impediments to compassionate client-centered care--> focus on task orientation, rigid hierarchal structures, and possible disempowerment of staff

Educator

Learning and Guiding patient educator role and scope of practice: essential in addressing local and global health problems-COMMUNICATION IS KEY nursing process and teaching process: commitment to be a learner, to see teaching and learning as the act of guiding, and to understand the essence of the phrase "to educate." lifelong learning: commit to being a learner critical thinking, clinical reasoning, and problem solving skills: emphasize critical thinking; these are acquired through lifelong learning and experience

Nursing Stereotypes

Media and culture impact nursing image 2010: IOM: The need for nurses to be transformational Film and TV - Comedies, harsh disciplinarians, "female profession" and view of women, and expanding roles Obstacles - limited media preparation and training - Gender specific to women (male nurse stereotypes)

Work Environment

Nursing Workforce: 2.5 million in 2008 (nearly 85% of licensed RNs) - nearly one-third of nurses today are older than 50 years of age. Slow increase in diversity (non-whites and men) Advanced specialist nurse practice settings: schools, professional orgs, outpatient clinics, state/local health departments, acute care settings, etc. Clinical ladder: Roles and expectations for promotion- start at lowest level, gain and demonstrate ability for first 1-2 years

Professional Practice Roles

shaped by educational preparation and practice environments Mix of knowledge and skills and the diversity of nursing roles Roles fluctuate with changes in: - Patient needs - Systems of health care delivery - Availability of health care technology

Actual (Multifaceted) Nursing Roles

"I do not pretend to teach her how, I ask her to teach herself, and for this purpose I venture to give her some hints" (Nightingale, 1860 "Notes on Nursing: What it is and What it is Not") Educators often find themselves getting out of the way of nursing students, allowing their wisdom to shine Many nurses do not stop being a nurse, they carry the identity of being a nurse into their personal lives. Role and personal identity: - identity of a nurse is determined by how that individual views, imagines, and experiences nursing

Nursing Social Policy Statement

"Nursing is the pivotal health care profession, highly valued for its specialized knowledge, skill, and caring in improving the health status of the public and ensuring safe, effective, quality care" conceptualizes the framework of nursing practice and provides direction to all registered nurses including nurse educators, administrators, researchers, and students serves interests of society (individuals, families, groups, communities, and populations) 6 essential features: -Provision of a caring relationship that facilitates health and healing -Attention to the full range of human experiences and responses to health and illness within the physical and social environments -Integration of objective data with knowledge gained from an appreciation of the patient's or group's subjective experience -Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking -Advancement of professional nursing knowledge through scholarly inquiry -Influence on social and public policy to promote social justice

Model of Professional Nursing Practice

(pyramid) (top) 1. self determination 2. Institutional policies and procedures 3. Nurse Practice Act and Rules and Regulation 4. Nursing Professional Scope of Practice, Standards of Practice, Code of Ethics, and Specialty Certification Quality, Safety, Evidence *set of nursing standards is comprised of Standards of Practice and the Standards of Professional Performance, with each standard having its own key indicators of competence and all are to be met*

Disciplinary Action

A. if applicant for licensure or certification commits act of unprofessional conduct, board can eny application and take other disciplinary action B. In denial order, board invalidates temporary license or certificate issued to applicant C. Anyone aggrieved by order of board from A subsection can request administrative hearing D. If board finds person guilty, they can take disciplinary action E. Board can limit suspend, or revoke privilege of that nurse to practice in that state if guilty after hearing F. If board finds person guilty, board may serve on the licensee or certificate holder a written notice saying;: 1. there's sufficient evidence 2. rules were violated 3. unless a person submits written request for hearing within 30 days after service of notice by certified mail, board may consider allegations admitted and take disciplinary action without hearing G. If the Arizona state board modifies any registered NP or clinical nurse specialist's prescription writing privileges, itmediately notify Arizona state board of pharmacy of modification

ANA Standards of Nursing Practice

Assessment Diagnosis Outcomes Identification Planning Implementation Evaluation

Nurse Practice Acts

Establish specific legal regulations for practice -Regulate the scope of nursing practice -Protect public health, safety, and welfare Many states have revised these to reflect the growing autonomy of nursing and expanded roles of nurses in practice

ANA Standards of Professional Performance

Ethics: Follow Code of Ethics and apply your own moral principles, values, and ethics into your practice Education: RN attains knowledge and competency that reflects current nursing practice. Nursing is a profession of lifelong learning Evidence-Based Practice and Research: RN integrates EBP and research findings into practice Quality of Practice: RN contributes to quality nursing practice Communication: RN communicates effectively in all areas of practice Leadership: RN demonstrates leadership in the professional practice setting and profession Collaboration: RN collaborates with health care consumer (patient) family, and others in the conduct of nursing practice Professional Practice Evaluation: RN evaluates their nursing practice in relation to professional practice standards and guidelines, relevant statuses, rules, and regulations Resources: RN uses appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible Environmental Health: RN practices in an environmentally and safe and healthy manner

Understanding professional identity of nursing empowers nurses to:

-Assume a professional identity that reflects a more responsible and equitable role -Challenge traditional way nurses perceive themselves an are perceived by others -Develop a more relevant notion of professional identity

ANA Code of Ethics for Nurses

-Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. -Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. -Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. -Provision 4: The nurse has authority, accountability and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care. -Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. -Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. -Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. -Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. -Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Professional Nursing Role and Response

-Role: Less traditional and increasingly diverse and expanded in response to the growing complexity in health care -Response: Nursing examines the nature of the professional role, explores underlying values and identity, and adapts to the dynamic health care system. -Stereotypes: Historical development, types of roles, education and practice environment, role dynamics, role stress, and strategies

Socialization

the processes of learning and incorporating aspects of a profession into one's professional identity. Involves personal change and reformed or redefined professional self-identity BEGINS: in basic program educational setting CONTINUES throughout one's professional nursing career REACTIVATED: - when a new graduate leaves the educational setting and begins professional nursing practice - When an experienced nurse changes work settings, either within the same organization or in a new organization - When a nurse undertakes new roles, such as returning to school or assuming a leadership role

1984 Benner's nursing model

5 levels of proficiency in nursing Novice - beginning nursing student or nurse entering a situation with no prior level of experience. In this stage, the learner learns specific rules or procedures. Also includes nurses who may switch specialties or practice areas, ex. Mesurg to OR, ICU to ED, etc. (task-oriented) Advanced beginner - nurse who has had some level of experience with the situation/practice area. Experience may only via observation in nature, but nurse is able to identify significant aspects or principles of nursing care (task oriented) Competent - Nurse who has been in the same clinical position for 2-3 years. Nurse understands organization and specific care required by type of patients. Nurse is competent practitioner - able to anticipate nursing care and establish long-range goals. Typically in this phase, nurse has had experience with all types of psychomotor skills required for their specific patient population (task-oriented, beginning to expand critical thinking skills) Proficient - Nurses with more than 2-3 years of experience in same clinical position. Nurse perceives a patient's clinical situation as a whole, is able to asses an entire situation, and can readily transfer knowledge gained from multiple previous experiences to a situation. Nurse focuses on managing care as opposed to managing and performing skills (enhanced critical thinkers) Expert - Nurses with diverse experience who have an intuitive grasp on existing or potential clinical problems. This nurse can zero in on the problem and focus on multiple dimensions of a situation. This nurse is skilled at identifying both patient-centered problems as well as problems related to the health care system or perhaps needs of a novice nurse

1. Right Task 2. Right Circumstance 3. Right Person 4. Right Direction/Communication 5. Right Supervision

5 rights of delegation

Essential Role Functions and Characteristics (7)

Caregiver Colleague Researcher Mentor Educator Manager Advocate

Caregiver

Caring, Compassion, and Empathy --> Compassion defined: is an essential identity characteristic that guides the actions of assessment, planning, intervention, and evaluation. -> 2009-National League for Nursing: Caring is central to a nurse's identity and serves to facilitate health and healing: "The culture of caring, as a fundamental part of the nursing profession, characterizes both concern and consideration for the whole person, a commitment to the common good and health of all, and outreach to those who are vulnerable" (National League for Nursing, 2009, para 1). Leininger and culture care theory -> Patients from diverse cultures value care differently than nurses did. This theory defines caring behaviors on the part of a caregiver as those that are congruent with the beliefs, values, and expressions of the care recipient. 2005: Covington --> "Caring presence is mutual trust and sharing, transcending connectedness, and experience. This special way of being, a caring presence, involves devotion to a client's well-being while bringing scientific knowledge and expertise to the relationship" (p. 169). Watson and theory of caring -> It describes the scientific basis of nursing as extending beyond human interaction, to a moral concern for preserving human dignity and respect for the wholeness of the care recipient. -Leininger and Watson show link btw caregiver role and compassion + empathy 2003: Robinson: "No technology in health care replaces the critical thinking of a human mind, the caring of a human soul, the proficiency and skill of a human hand, and the warmth of a human heart in healing the sick and injured. That is nursing, esteemed colleagues; that is you" (p. 200).

Colleague

Collaborating and Connecting A colleague cooperates and collaborates. Gardner (2005): Ten lessons in collaboration: (1) know thyself, (2) learn to value and manage diversity, (3) develop constructive conflict resolution skills, (4) use personal power to create win-win situations, (5) master interpersonal and process skills, (6) recognize that collaboration is a journey, (7) leverage all multidisciplinary forums, (8) appreciate that collaboration can occur spontaneously, (9) balance autonomy and unity in collaborative relationships, and (10) remember that collaboration is not required for all decisions (Gardner, 2005, Section 3). Interprofessional collaboration - Telehealth: Nurse in a remote site leverages nursing expertise and technology to provide quality care

National League of Nursing (NLN)

Dedicated to excellence in nursing, premier organization for nurse faculty and leaders in nursing education offers professional development, networking opportunities, testing services, nursing research grants, and public policy initiatives members represent nursing education programs across the spectrum of higher education First nursing organization in the US found in 1893

Standards of Professional Performance

Describe a competent level of behavior in the professional role comes as assurance to patients that they are receiving high-quality care, and nurses know what is necessary to provide adequate care includes Code of Ethics for Nurses

Standards of Practice

Describe the competent level of nursing care. This is illustrated by critical thinking model known as nursing process Nursing process is the foundation of clinical decision making and includes significant actions taken by nurses in providing care to patients

Role Overload

Role overload refers to situations in which the time and resources allotted for a given role are insufficient to meet the role expectations too much to do and too little time Strategies - delegation - prioritization (create a list and number them on importance) - changing the physical environment (determining where supplies should be so more accessible)

Mentor

Sharing and Role Modeling "Be true to oneself and guide another to greater personal awareness and skill" Experience is critical This is formal or informal process. NLN (2006): _____ is a professional means of passing along knowledge, skills, behaviors and values to a less experienced individual

UAP delegation

Supervised by RN; can't delegate tasks ADL's: - bathing - turning - ambulating - Intake and Output except for IV - Linen change - feeding - toileting - does not give meds - Weights - Vital Signs (on stable patient)

Clinical nurse leader (CNL)

advanced generalist; require master's preparation response to nursing shortage, increasing complexity in health care system, increased patient acuity, recognition that other members of health care team entering postgrad education Nursing licensure + AACN CNL emphasizes systems assessment and leadership skills with the intent of increasing nursing's involvement at a health care systems level. Educational focus: quality and safety systems gap assessment and preparation to lead care for cohorts of patients based on available evidence in the clinical settings

Advanced nursing practice/ Advanced practice nurse (APNs)

advanced specialists "Any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy"

role strain

an emotional reaction when role stress is not resolved greater in shift work than salaried positions unresolved role stress can lead to professionals leaving the work setting

"The Future of Nursing: Leading Change, Advancing Health" Report from Institute of Medicine (IOM)

encourages professional nurses to: - practice fully - achieve higher levels of education - become full partners in providing and reforming health care -develop an infrastructure for workforce data collection every nurse has a professional role and responsibility reinforces: - the need for all nurses to make a personal commitment to lifelong learning and education - each nurse must consider personal and professional goals and find a part of this process that means something to him or her and become involved

role integration

movement between multiple roles is fluid ex.: might use a cell phone or pager to stay in touch with work during a day off, or they might do volunteer work with co-workers, incorporating both collegial and community roles. ex: A nurse regularly checks personal and work electronic mail when either at home or at work.

role conflict

refers to role stress that occurs when an individual feels required to meet obligations of two different roles at once Example: A nurse who also is a parent or a primary caregiver to an aging relative Attending to the needs of the dependent while also meeting the professional expectation to be on time for a shift and free of personal distractions creates role stress and may progress to role strain.; nurses who provide bedside care and have managerial responsibilities Strategies: - combining efforts - finding ways to meet obligations - adjusting nursing shifts Family Medical Leave Act (FMLA) (1993): ensures employees who need time off to provide care for family members can return

role discrepancy

refers to role stress that occurs when an individual's conception of a role is incompatible with the actual obligations of the role "Nurses love nursing, they just hate their jobs" "too little time with patients, more time on documentation" Strategies - debriefing=understand role expectations, address concerns, and share experiences ex: Novice - role advancement program - task analysis

role ambiguity

refers to role stress that occurs when the obligations and privileges of a given role are NOT clearly defined - role transition: entering a new role - role extension: a particular role expands Ideally, both role transition and role extension are temporary causes of role stress that resolve when an individual achieves role mastery, a sense of clarity regarding the role expectations and a firm confidence in the ability to meet those expectations. Example: A new graduate begins a position as a professional nurse. The degree of stress depends on the availability of mentoring, organizational support, and preparation from the educational experience. Strategies: - clear definition of the role -comprehensive structured orientation program - support from peers - mentoring

role stress

refers to when situations affect an individual's ability to carry out the perceived obligations of the role poor relationships with colleagues perceived lack of control over the job time demands lack of employer support ex: nurse may feel obligated to fulfill both professional role and needs of family

State board examination

registered nurse RRN demonstrates ability to practice as generalist nurse Different educational programs prepare nurses for board licensure

LPN delegation

supervised by RN; duties depend on state and facilities can delegate to UAPs in some states can do everything UAP does assigned stable patients w/ chronic and predictable outcomes NOT ASSIGNED: new admissions, education (patients who need extensive education upon discharge), unstable, fresh post-op, comprehensive assessment, interpreting data (only collects data), blood transfusions Gather data to contribute to assessment (listen lung/bowel/heart sounds) and report to RN (no comprehensive assessment) Does routine procedures not requiring too much critical thinking (EKG, glucose checks, insert foley catheters, clean wound, ostomy care assists with implementing nursing intervention can give medications except IV medications

TAPE

teaching, assessment, planning, evaluation

Nursing Practice Act

unique to each state ensures all registered nurses are qualified and competent of doing job at high standard outlines: - definitions - Authority, Power and Composition of the state Board of Nursing (BON) - set out standards for educational programs - set out the standards and scopes of nursing practice outlines the types of titles and licenses, and the protection of these titles and requirements needed for licensure - outlines the grounds for disciplinary action and other violations

Role Incongruity

when obligations of a role come into conflict with an individual's values likely to engender a more severe strain Values guide behavior, direct priorities, and determine how information is perceived Moral distress: an individual feels compelled to act in a manner that she or he believes is morally wrong Strategies: - values clarification - empowerment - whistleblowing: Situations in which unethical or illegal conduct by an organization is reported to an outside authority by a member of that organization (ex: U.S. army reported treatment of war criminals in prison camps to federal authorities) ex: nurses in New Orleans after hurricane Katrina- had to care for patients with limited resources, without adequate rest, and isolation from their families who also needed help