Professional nursing Practice and Its Influences

(Intro.) What are the roles and responsibilities of the nurse?

Today's nurses have many duties and obligations to meet society's health care needs.

Health care has an increased need for nurses. Nurses are at the forefront of patient care

(Fig. 1.1) and work with other health care providers to manage patient's needs. Recipients

of care include individuals, families, groups, and communities.

What are the roles and responsibilities of the nurse?

• Provide expert care to those suffering from illness or injury.

• Advocate for patients' rights.

• Teach patients to manage their health.

• Assist patients and caregivers in critical moments.

• Help patients navigate the complex health care system.

What are the Health Care Settings?

• Acute care facilities

• Long-term care

• Home care

• Community health

• Public health centers

• Schools

• Ambulatory centers

• Outpatient clinics

How has nursing been defined since Florence Nightingale?

Nursing is described as both an art and a science; a heart and a mind.

• Well-known definitions of nursing show that the basic themes of caring, health, and illness have existed since Florence Nightingale. Nursing is putting the patient in the best condition for nature to act (Nightingale).

• The nurse's unique function is to aid patients, sick or well, in performing those activities contributing to health or its recovery (or to peaceful death) that they would perform unaided if they had the necessary strength, will, or knowledge—and to do this in such a way as to help them gain independence as rapidly as possible (Henderson).

In 2010, the American Nurses Association (ANA) provided a new definition of nursing:

"Nursing is the protection, promotion, and optimization of health and abilities, prevention

of illness and injury, alleviation of suffering through the diagnosis and treatment of human

response, and advocacy in the care of individuals, families, communities, and

populations."

What 7 wellness dimensions contribute to health and quality of life?

Seven interrelated wellness dimensions contribute to health and quality of life:

1. Physical

2. Psychologic

3. Social

4. Spiritual

5. Intellectual

6. Career

7. Environmental

Can an issue in one of the seven dimensions affect others?

Yes. An issue in one dimension can affect others. A person's environment changes constantly.

Meaningful behavior focuses on meeting needs, coping with stress, and growing.

What determines a nurse's scope of practice?

Nursing's core is holistic, patient-centered care which includes:

• Assessment and evaluation

• Various interventions

• Patient and caregiver teaching

• Interprofessional teamwork

A nurse's scope of practice is determined by:

• Educational preparation• Experience

• Role

• State law

What must a nurse complete to be able to do their practices?

a nurse must complete an accredited program and pass the NCLEX-RN, which verifies basic care knowledge. Nurses with associate or baccalaureate degrees are generalists. At this level, nurses provide direct health care to patients in a variety of settings.

What are common certifications for nurses?

Nurses can obtain specialty certifications with experience and study. Many nursing organizations offer certification in specialty practice. Certification and recertification require clinical experience and testing. Common specialty certifications include:

• Critical care

• Women's health

• Geriatric

• Medical-surgical

• Perinatal

• Emergency

• Psychiatric

• Community health

What does APRNs stand for?

Advanced Practice Nurses

APRNs must have master's or doctoral degrees as well as advanced training in:

• Pathophysiology

• Pharmacology

• Health assessment and expertise in a specialized area of practice

Types of APRNs

• Clinical nurse specialists (CNSs)

• Nurse practitioners (NPs)

• Nurse midwives

• Nurse anesthetists

APRNs are crucial to health care delivery. APRNs also educate patients and staff, lead, improve quality, research, and consult.

What does DNP stand for?

Doctor of Nursing Practice

What is Doctor of Nursing Practice (DNP)

It is a practice-focused terminal nursing degree.

• With doctoral preparation for APRNs, nursing joins other health professions with practice doctorates (pharmacy [PharmD], physical therapy [DPT]).

• Nurses with a research-focused doctorate (PhD) typically work in health care settings as nurse faculty, clinical experts, researchers, and health care system

executives.

What is the difference between Standards of Practice and Standards of Professional Performance?

The ANA defined Standards of Professional Nursing Practice to guide nurses in how to perform professionally. There are two parts: Standards of Practice and Standards of Professional Performance

What is Standards of Practice?

It describes a competent level of nursing care

What is Standards of Professional Performance

It describes behavioral competencies expected of a nurse, such as ethics and evidence-based practice

How do expanding knowledge and technology and diverse populations influence professional nursing practice?

Changing technology and expanding clinical knowledge add to the complexity of health

care.

• Increased treatment, diagnostic, and care options change care delivery and

lengthen lives.• Genetic discoveries change how we view cancer and heart disease, such as breast

cancer treatment based on a woman's genetic makeup.

• New scientific knowledge and disparities in patient access to advanced health care

pose ethical dilemmas.

As people live longer, more have chronic illnesses and comorbidities.

• Chronic illness patients have complex needs.

• When patients see multiple health care providers and move between settings, their

care must be managed and coordinated.

When caring for a diverse population, consider the patient's and caregiver's culture:

• Immigrants, especially undocumented immigrants, often lack health care

resources.

• Inability to pay for health care leads to delayed care and may result in serious

illnesses at diagnosis.

Why do patients want to be more involved in their health care, and what is the role of the

nurse in assisting with this involvement?

Patients want to be more involved in their care.

• They want more control and high-quality, coordinated, and affordable care.

• With health care information more readily available, many patients are very

knowledgeable about their health and seek health information from the media and

the internet.

• Health-savvy patients gather information to make better health care decisions.

• Nurses must be able to help patients access, interpret, and use safe health

information (Fig. 1.2).

What are the changes in health care systems that aim to reduce costs and improve quality?

The rise in health care costs has many causes including:

• Aging population

• Increased use of prescription drugs

• Administrative costs

• More expensive products and treatments

Many changes in health care systems that affect nursing care delivery aim to reduce costs

and improve quality.

What is U.S Health System Insurers?

is a mix of public and private insurers and providers. Insurers set their own cost-sharing structures within federal and state regulations.

• Medicare developed the prospective payment system (PPS), which pays Medicare

patients flat fees based on the diseases and problems treated during admission.

• For example, the amount a hospital is reimbursed for a total hip replacement is a set

sum of money for the patient's care, such as $45,000.

What are Managed Care Systems HMOs and PPOs?

Managed Care Systems HMOs and PPOs

• Health maintenance organizations (HMOs) and preferred provider organizations

(PPOs) also use prospective payment system (PPS).

• Managed care systems negotiate charges using fixed reimbursement rates or

capitation fees for medical care, hospitalization, and other services.

What are Value-Based Purchasing Programs?

Quality initiatives have changed health care financing. Those who provide quality care at a lower cost may receive more payment.

Value-based purchasing programs pay health care providers based on quality measures including:

o Clinical outcomes

o Patient safety

o Patient satisfaction

o Adherence to evidence-based practice

As part of value-based purchasing, payments can also be withheld if a patient experiences:

o Events such as developing a pressure injury during a hospital stayo A serious reportable event (SRE) while admitted to the facility. A SRE is considered preventable, such as:

▪ Fall-related injury

▪ Wrong-site surgery

What are the aims of the Affordable Care Act and Accountable Care Organizations?

Legislation affects health care delivery and nursing practice. Nurses must also take on leadership roles in creating health care systems that provide safe, quality, patient-centered care.

Affordable Care Act (ACA)

• Most important health care law since Medicare in 1965

• Aims to expand health care access

• Emphasizes teamwork, care coordination, and quality care in its delivery and

payment models

• Promoted creation of accountable care organizations (ACOs)

Accountable Care Organizations (ACOs)

• Group of physicians, hospitals, and other health care providers who coordinate

Medicare care

• Aim to ensure chronically ill patients get the right care at the right time

• Emphasize avoiding duplicate services and errors

How do professional nursing organizations impact health care, nurses, and the nursing practice?

Nurses join professional nursing organizations to stay current in their nursing practice and network with others in their nursing specialty.

What is the primary professional nursing organization?

The ANA

There are many professional specialty nursing organizations, such as:

• American Association of Critical-Care Nurses (AACN)

• National Association of Orthopedic Nurses (NAON)• Oncology Nursing Society (ONS)

What are the roles of Professional Nursing Organizations

• Promote quality patient care and professional nursing practice

• Develop standards of practice and ethics

• Support research

• Lobby for legislation and regulations

• Research error causes and develop prevention strategies

• Address nursing issues that affect patient safety

What is a program that supports nurses?

the American Nurses Credentialing Center's Magnet

Recognition Program.

Magnet Recognition Program for Nurses

• Health care agencies that achieve Magnet designation have created environments

in which high-quality nursing care is provided.

• They provide a positive practice environment for nurses.

o Nurses who work in Magnet agencies have low turnover and burnout rates.

o There are more professional and personal growth opportunities.

o There is greater career satisfaction.

• The benefits to nurses in Magnet organizations leads to better patient outcomes.

What are the 6 core nursing competencies defined by QSEN?

• Patient-centered care

• Interprofessional partnerships

• Safety

• Quality improvement

• Informatics

• Evidence-based practice

Several high-profile reports in the last 25 years have highlighted issues with health care

quality. The Future of Nursing: Leading Change, Advancing Health discussed how health

care providers, including nurses, are not prepared to provide high-quality care in today's

health care systems. The report recommended changes so nurses can advance health care

and take leadership roles.

Robert Wood Johnson Foundation funded the Quality and Safety Education for Nurses

(QSEN) Institute to address nursing's role in solving these problems. QSEN helps nursespractice safely by defining specific core competencies (Table 1.1). Prelicensure and

graduate nursing education incorporate these core competencies

Table 1.1 Core Nursing Competencies

Patient-Centered Care

Provide holistic, compassionate, and

coordinate care based on respect for patient's

preferences, values, and needs and guided by

a scientific body of knowledge

What are Examples of Knowledge, Skills, and

Attitudes of Patient-Centered Care?

• Provide care with sensitivity and respect

• Consider the patient's perspectives, beliefs, and culture

• Communicate effectively

• Engage the patient in an active partnership that promotes health, well-being, and self-care

management

• Use assessment skills, diagnose health problems, and develop and deliver a plan of care

Table 1.1 Core Nursing Competencies

Interprofessional Partnerships

Function effectively within nursing and interprofessional teams

What are Examples of Knowledge, Skills, and

Attitudes of Interprofessional Partnerships?

• Value the expertise of each team member

• Delegate work to team members based on their roles and competency

• Initiate appropriate referrals

• Follow communication practices that minimize risks associated with hand-offs and care transitions

• Take part in interprofessional rounds

• Manage conflict among team members

Table 1.1 Core Nursing Competencies

Safety

Minimize risk of harm to patients and providers

What are Examples of Knowledge, Skills, and

Attitudes in Safety?

• Follow national safety recommendations

• Appropriately communicate concerns about hazards and errors

• Contribute to designing systems to improve safety

• Be accountable for reporting unsafe conditions and near misses

• Promote policies to reduce workplace violence

Table 1.1 Core Nursing Competencies

Quality Improvement

Use data to monitor the outcomes of care and

to improve the quality and safety of health care

systems

What are Examples of Knowledge, Skills, and

Attitudes in Quality Improvement

• Use outcome data to understand performance

• Participate in implementing practice changes

• Take part in investigating the circumstances surrounding a sentinel event or serious reportable

event

Table 1.1 Core Nursing Competencies

Informatics and Health Care Technology

Use information and technology to communicate, manage knowledge, reduce errors, and support decision making

What are Examples of Knowledge, Skills, and

Attitudes in Informatics and Health Care Technology?

• Protect confidentiality of protected health information

• Document appropriately in electronic health records

• Use technology to coordinate patient care

• Respond correctly to clinical decision-making alerts

Table 1.1 Core Nursing Competencies

Evidence-Based Practice

Integrate best current evidence with clinical expertise and the patient/caregiver preferences and values for delivery of optimal health care

What are Examples of Knowledge, Skills, and

Attitudes in Evidence-Based Practice?

• Read research, clinical practice guidelines, and evidence reports related to area of practice

• Base patient care plan on patient's values, clinical expertise, and evidence

• Continuously improve clinical

practice based on new knowledge

How is clinical judgment used to improve patient outcomes?

Nurses provide compassionate, coordinated care based on each patient's needs,

preferences, and values.

• Nurses partner with patients to make decisions regarding their care.

• Patients and caregivers receive competent and knowledgeable care with patient-

centered care.

What does complex health care environments require?

They require clinical judgment to improve patient

outcomes.

What is clinical judgement?

is the ability to interpret information and make decisions based on the information on hand.

Nursing knowledge is used to:

o Assess situations

o Identify priority problems

o Provide safe patient care

o Understand medical/nursing implications of a patient's condition

Clinical judgment is when the nurse:

o Identifies a change in a patient's status

o Considers the context of issue and the patient and caregiver concerns

o Determines the next course of action to be taken with the patient

Where are clinical judgment skills learned through?

They are learned through experience. Various experiences in nursing school teach nurses how to make decisions regarding patient care. Case studies and simulations are helpful tools for developing clinical judgment.

What are the 5 phases of the nursing process?

assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

What is the most common scientific model used when caring for patients?

Nurses use various scientific methods but the most common one is the nursing process.

What is the nursing process?

• A problem-solving approach to patient care and is the foundation of nursing practice

• Organizes nurses' knowledge, judgments, and actions to improve patient outcomes. The nursing process is continuous and cyclical. Process review helps determine why outcomes weren't met. Nurses may need to revise diagnoses, outcomes, and interventions.

It consists of 5 phases: assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

Assessment

Assessment gathers subjective and objective patient data for care planning.

Diagnosis

Diagnosing is analyzing assessment data and drawing conclusions.

Planning

Planning is identifying nursing interventions to achieve patient outcomes. Planning creates criteria to measure and evaluate the interventions

Implementation

Implementation is the action phase and uses nursing interventions

Evaluation

Evaluating patient outcomes is a continuous process to determine if goals were achieved.

What are two clinical judgment frameworks for nursing practice?

Other clinical practice frameworks include Tanner's Model of Clinical Judgment and the National Council of State Boards of Nursing's Clinical Judgment Model (CJM) (Fig. 1.4).

Tanner's Model of Clinical Judgment includes the processes of:

• Noticing

• Interpreting

• Responding

• Reflecting

NCSBN's CJM is designed to?

test clinical judgment on the NCLEX-RN.

All 3 models—the nursing process, Tanner's Model of Clinical Judgment, and NCSBN's CJM—emphasize?

assessment, decisions, action, and outcomes. Many clinical facilities use Assess, Act, Reassess as a shorter version of the nursing process.

What does ADPIE format help nurses learn?

how to care for patients with certain health problems.

Clinical problems guide nursing interventions to?

achieve accountable patient outcomes.

Clinical problems can be diagnosed based on:

• A single clinical finding (i.e., pain or anxiety)

• A complex decision (i.e., impaired nutrition or musculoskeletal problem)

A nursing intervention is?

a single nursing action, procedure, activity, or service for which the nurse is accountable.

• It includes direct and indirect care interventions.

• The nurse choses interventions based on the patient's clinical problem and desired outcomes.

What components are included in a care plans, concept maps, and conceptual care maps?

Nurses are responsible for developing a plan of care. In clinical practice, electronic care plans follow a standard format that has been adapted for that specific setting. Care plans are patient specific and should be customized to each patient's unique needs and problems.

Care plans include:

• Diagnoses or problems

• Outcomes

• Interventions

What is the nursing process documented in?

in care plans.

• Care plans list clinical problems, in order of priority, along with outcomes and interventions.

• Care plans need to be customized for each patient.

o Nurses practice and learn the nursing process by collecting assessment data, identifying clinical problems, and selecting patient outcomes and

nursing interventions.o In care plans, nurses usually must give rationales for the interventions they

choose

A concept map is?

is another way to record the nursing process.

The concept map records the nursing process by using a?

visual diagram.

The concept map shows patient problems and interventions and relationships...

among clinical data.

Nurse educators use concept maps to?

teach nursing processes and care planning.

Concept maps have?

various formats.

Conceptual care maps blend a?

concept map and a nursing care plan.

Where is the assessment data used to identify the patient's primary health concern?

in the center.

Diagnostic test data, treatments, and medications surround the?

assessment data.

Positioned below are clinical problems or nursing diagnoses that represent the?

patient's responses to the health state.

Listed with those are the supporting assessment data, outcomes, nursing interventions with rationales, and evaluation.

After completing the map, connections are drawn between?

identified relationships and concepts

What is the nurse's role as patients move between health care settings?

Patients often move between health care settings based on their health. Nurses are involved at every point along the health care continuum.

Choosing the best health care setting depends on:

• Cost

• Insurance

• Finances

Patients transitioning between care settings require?

safe care coordination.

Ineffective care transitions can lead to?

drug errors and hospital readmissions.

Communication and collaboration between health care members is?

critical. Transitions allow patients to live or recover in settings that maximize their independence and dignity.

Community-based health care settings include:

• Ambulatory care

• Transitional care

• Long-term care

Community-Based Health Care Settings

- Transitional Care

• Care provided is between acute and home or long-term care.

• Acute rehabilitation facilities may provide transitional care after head or spinal cord injuries.

Community-Based Health Care Settings

- Long Term Care

• Care lasting greater than 30 days

• Long term care is needed for:

o Severely developmentally disabled

o Mentally impaired

o Patients with physical deficits

• Includes nursing homes, assisted living and residential care facilities

How do models of acute care, case management, and telehealth nursing provide patient-centered care?

Nurses provide patient-centered care in collaboration with an interprofessional team and within the framework of a care delivery model. A care delivery model outlines how responsibilities and authority are structured to carry outpatient care. Better outcomes

occur when the number and type of care providers match patient needs, and there is a designated care coordinator.

In acute care settings, two basic models are used:

Team Care and Total Patient Care

Team care:

o Care providers work together to deliver patient care as a team.

o There is a team leader, usually a registered nurse (RN), who manages and coordinates care with others:

▪ Licensed practical/vocational nurses (LPN/VNs)

▪ Assistive personnel (AP)

Total patient care:

o The nurse is responsible for planning and providing all care.

Case management involves:

• Managing the patient's care with other health care members and available resources

• Coordinating patient care across multiple care settings and levels of care

• Promoting cost-effective, quality results

RNs are case managers in?

nursing case management delivery systems.

The nurse's responsibilities as case manager includes:

• Assessing patients' and/or caregivers' need

• Coordinating services

• Making referrals

• Evaluating patient care progress