Nursing Exam 3

Healthcare is a business

• A hospital must stay in the black (make a profit) in order to pay its employees, buy new equipment, and keep the doors open

• The nursing department often has the largest number of employees

Healthcare organizations

• Acute care hospitals

• Nurse-managed clinics

• Ambulatory care clinics

• Family practice

• Dermatology clinic

• Home healthcare agencies

• Hospice care

• Long-term care facilities

• Occupational health clinics

• Rehabilitation centers

• Urgent care centers

• School health clinics

• Skilled nursing facilities

• Pediatric hospital

• Psychiatric-mental health facility

• Substance use disorder center (inpatient and outpatient)

for-profit hospitals

• are owned by private stockholders and must pay them back a portion of what they make

• hospital must always have funds to pay stockholders/owners:

  • Methodist Hospital (San Antonio)

  • CJW Medical Center – Chippenham Campus (Richmond, Va.)

  • Henrico Doctors’ Hospital (Richmond, Va.)

  • Medical City Hospital (Dallas)

  • Sunrise Hospital & Medical Center (Las Vegas)

non profit hospitals

• are owned by communities, religious-affiliations, etc.

  • Make no mistake, a non-profit hospital is still making a profit, they just don’t have to pay it back

most community hospitls are

not for profit

Many hospitals are part of a network Health Care Organization just like MaineHealth

community hospitals

The AHA (2022) defines a community hospital as all non-federal, short-term, general or specialty hospitals – including teaching hospitals.

2022 most hopsitals are community

Other terms to classify hospitals

• Bed-size

  • Less 100

  • 100-150

  • 150-250

  • 250-500

  • More than 500

• Teaching versus non-teaching

• Length of stay

• Multi-hospital system

• Critical Access

What is a Critical Access Hospital?

• Small hospitals in rural areas that support emergency care of a public

• 24-hour ED

• Up to 25 inpatient beds

• Average length of stay less than 96 hours

• More than 35 minutes from another hospital, more than 15 miles over mountainous terrain and secondary roads, or certified by the State to be a necessary provider of healthcare services

• In general, critical access care sites are medical facilities that offer healthcare services to rural communities. In some situations, they will stabilize the patient and then transfer them to a higher level of care facility

Critical Access Hospitals (16) examples

• Northern Light Blue Hill

• Brighton Hospital

• Calais Regional

• Northern Light C.A. Dean Hospital

• Down East Community Hospital

• Houlton Regional

• Lincoln Health

• Northern Light Mayo Hospital

• Millinocket Regional Hospital

• Mount Desert Island Hospital

• Penobscot Valley Hospital

• Redington-Fairview Hospital

• Rumford Hospital

• Northern Light Sebasticook Hospital

• Stephen’s Memorial Hospital

• Waldo County General Hospital

maines hospitals

• According to the Maine Hospital Association (2022), Maine has 36 hospitals:

  • 33 non-profit general hospitals

  • Two private psychiatric hospitals

  • One acute rehab hospital

• PLUS, the State government run facilities:

  • Dorothea Dix Psychiatric Hospital in Bangor

  • Riverview Psychiatric Hospital in Augusta

• One Federal facility:

  • The VA Hospital in Togus

• Cary Medical Center in Caribou, Maine is owned by the Caribou Hospital District – owned by the municipality of Caribou.

where do nurses work

• While most nurses work in acute care, there are many other settings where nurses can care for patients and many different roles a nurse can fulfill

  • About 30% work in hospitals

  • 15% outpatient

  • 12% in home health

  • 9% in long term care

  • 7% in physician offices

hospital departments

• Administration

• Nursing

• Medical staff

• Admission and Discharge

• Social services

• Medical records

• Information management

• Quality improvement

• Infection control

• Research and Evidence-based practices

• Staff development

• Environmental services

• Dietary

Healthcare providers

• Registered Nurse

• Licensed Practical Nurse

• Patient Care Assistant/Technician

• Certified Nursing Assistant

• Advanced Practice Registered Nurse

• Clinical Nurse Specialist

• Clinical Nurse Leader

• Certified Nurse Midwife

• Certified Registered Nurse Anesthetist

• Doctor of Nursing Practice

• Physician

• Physician Assistant

• Pharmacist

• Occupational Therapist

• Physical Therapist

• Registered Dietician

• Respiratory Therapist

• Social worker

work place culture-consonant

• Functional / effective

workplace culture dissonant

• Nonfunctional / ineffective

• Culture has an impact on nursing staff and the care they provide

$$$ spent – Macro view

• National Health Expenditures increased to $4.9 TRILLION in 2023

• That’s $14,570 per person!

• Medicare spending increased to $1,029.8 BILLION in 2023

• Medicaid spending increased to $871.7 BILLION in 2023

• Private insurance spending increased to $1464.6 BILLION in 2023

• Out-of-pocket spending increased to $505.7 BILLION in 2023

• Prescription drug spending increased to $449.7 BILLION

$$$ spent – Micro view

• Considers financial needs of individual hospitals and health care organizations

• THE BUDGET – made to manage financial issues for a specified period (usually a year)

  • Salaries and benefits

  • Equipment, supplies, utilities

  • Pharmaceutical needs

  • Facility maintenance

  • Dietary needs

  • And more!

• Nursing management must have an active role in planning the budget

• It takes about $40,000 to on-board a new nurse!

Reimbursement

• Payment of the patient’s bill for healthcare services provided, which in turn, covers the cost of care (salaries, benefits, drugs, supplies, equipment, etc.)

• One move changed everything

  • In 1965, Title XVIII amendment to the Social Security Act created Medicare – the federal health insurance program for people over 65 years old, people with disabilities, and people with end-stage renal disease

  • Also in 1965, Title XIX amendment to the Social Security Act created Medicaid – the federally funded STATE insurance program for people who met certain income restrictions, children, disabled, the blind and others depending on your state of legal residence

• Remember, there is also third-party insurance (employer)

Insurance

• If your employer does not offer insurance, you must either purchase your own private insurance, apply for Medicare or Medicaid, or go without insurance (complicated with the ACA)

• Patient receives healthcare services through a fee-for-service reimbursement model, then pays:

• deductible and copayment

deductible

• the part of the bill that the patient must pay before the insurer pays the rest of the bill (annual limit)

copayment

• the fixed amount that the patient may be required to pay per service

Changes in healthcare delivery

• Must focus on meeting the needs of the public

• Develop new processes with better financial models

• Improve efficiency and flexibility

• Clear communication

• Have a voice in decisions that affect nursing

IOM 5 Core Competencies For Health Care Professionals

Provide Patient-Centered Care

Work in Interprofessional Teams

Employ Evidence-based Practice

Apply Quality Improvement

Utilize informatics

patinet centered care

• Identify, respect and care about patient differences and expressed needs

• Relieve pain and suffering

• Coordinate continuous care

• Listen to the patient!

• Clearly inform, communicate with, and educate patients

Patient Centered Care:
Three levels

Individual … frame the plan of care to meet the specific needs of the patient

Organizational … environmental and broader impacts on care that impact patient-centeredness

MACRO – the Health Care System…regulations, expectations, and support factors

Patient Centered Care Theories

dorothea orem

jean watson

madeleine leininger

hildegard peplau

dorothea orem

Self-Care Theory

Help the patient learn how to help themselves and how to manage their life and challenges

Empower!

jean watson

Transformational Caring

The reciprocal relationship we have with patients impacts both patient and nurse

Madeleine Leininger

Transcultural Caring Theory

Focuses on cultural competence, seeking understanding, and providing individualized culturally appropriate care

Hildegard Peplau

Interpersonal Relations Theory

Focuses on the unique nature of nurse-patient therapeutic, professional relationships

Patient Centered Care: 
What is the nurse’s role?

• Advocate for the patient

• Help the patient to care for self

  • Address health literacy and provide education

    • Involve appropriate participants

    • Seek feedback

  • Increase sense of self-efficacy

  • Increase resilience and confidence

• Create a therapeutic nurse-patient relationship

PCC: Coordinate Care

• Create the Plan of Care (POC) through clinical reasoning, critical thinking, and clinical judgment

• Collaboration and interdisciplinary communication (team management, teamwork, communication!)

• Post-Discharge follow up plans (easy contact info, easy instructions, medications, etc.)

• Effective delegation (assigning responsibility of a task to someone else)

PCC: Must Consider disparities, patient priorities, diversity

• Inclusion of patient’s cultural and spiritual values

• Consideration of health disparities

• Respect patient needs and preferences as they are

• Sensitivity to spiritual dimensions of care… they matter!

• Assess access to care past and future

• Assess patient resources- financial and human

Roles of the nurse – We have many

• Provider of care

• Educator

• Counselor

• Manager

• Researcher

• Collaborator

• Change agent

• Entrepreneur

• Patient advocate

• Leader

nursing process

Method for how we provide patient care

nursing process acronym

assement, diagnosis, planning, implementation, emulation

assessment

subjective: current complaiment, history, medications

objective: vital signs, intake and output of fluids, height and weight

diagnosis

rns clinicals judgment about acual or potential health problems to help prioritize and plan care

planning

goals and outcomes formulated personalized to indvisuals unqiue needs

implementation

carrying out interventions outlined like a cardiac monitor or o2, medication and standard protocols

evaluation

evulated implenation to ensure desired outcome has been met, continuous reassesment may be needed

Strategies to encourage patient participation

• Talk to patients in their room, not from the doorway

• Pay attention to your body language

• Use open-ended questions “Tell me about…”

• Therapeutic touch

• Collaborative thinking language “Let’s think this through”

• Don’t sound like the pt’s case is very unusual

• Address patients respectfully “Mr.” “Mrs.”

• Be direct and honest

• Don’t look at your watch

consumerism

Patients expect to be active in their own care at all levels

Micro consumers = patients

Macro consumers = government and insurers who are the major purchasers of care

Macro consumers have influence over the care provided since they pay the majority

Patient rights

• Can’t be denied health care coverage, even if they have a pre-existing condition

• Right to choose their own doctor

• Right to fair treatment and emergency care

• Insurance policies cannot be cancelled unfairly

• Ended annual and lifetime limits for coverage/benefits

• Enhanced access to preventative services

• Right to appeal health plan/insurer decisions

• Ensure health coverage for young adults (up to age 26)

• Privacy

• Informed consent

• Patient Self-Determination Act of 1990

Patient satisfaction (HCAHPS)

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHP) – national survey to assess patient satisfaction

• Sent out to randomly selected patients that were discharged from the hospital each month

• Patients are asked about:

  • Facilities – cleanliness of the room, food, room temperature, noise levels

  • Nurses and physicians – communication, interactions, attentiveness, pain management, care provided, discharge instructions, instructions about medications, and coordination of care

HCAHPS

• 29 item questionnaire to measure patient’s perceptions of their hospital experience

• Allows valid comparisons to be made across hospitals (locally, regionally, nationally)

National Database of Nursing Quality Indicators (NDNQI)

• Another external organization that tracks patient harm:

  • Falls

  • Pressure ulcers

  • Catheter-associated urinary tract infections (CAUTI)

  • Central line-associated blood stream infections (CLABSI)

  • Ventilator associated pneumonia (VAP)

• The care quality information is available to the public

• NDNQI also provides an employee survey that many hospitals administer yearly to track employee satisfaction – this information stays within the organization

Leapfrog

• 

• Data is available to health care consumers (patients) regarding patient satisfaction scores and quality of care provided at hospitals across the USA through a public website called Leapfrog.

Patient Advocacy and the role of the nurse

Help the patient understand

Help the patient find their voice

Work with the patient to assure the best possible outcome based on what they want, even if what they want is to do nothing – even if you disagree

Capacity for self-management and the role of the nurse (education)

• Health literacy – 90 million Americans do not understand

• Results in patient harm, readmissions, and overuse of EDs

• Language barriers have to be addressed – medical interpreters, more diverse staff

• Where do the problems arise?

  • Inadequate assessment, diagnoses, planning

  • Bad planning– lack of money, not realistic they can follow it or will, lack of resources, lack of awareness

  • Timing stressors – interruptions, understaffed, not evaluating patient understanding

Care coordination through
Nurse-patient communication/
interaction

Make care transitions seamless

Improve quality of life for patients with chronic illness

Work with others to improve quality of care and reduce health disparities

Therapeutic use of self = maintaining an effective, professional relationship

Therapeutic communication techniques

• Use silence effectively

• Accept others for who they are

• Use broad openings; offer general leads

• Make observations

• Encourage perceptions

• Restate

• Seek clarification

• Present reality

• Voice doubt with a positive tone

• Assess/evaluate with the patient

Cultural competence

• When a healthcare provider develops the ability to function within the context of the cultural beliefs, behaviors, and needs of patients and communities

  • Justice

  • Equity

  • Diversity

  • Inclusion

culture

Shared values, ideas, attitudes, beliefs, norms, understandings, symbols, and practices of a group of people

Inclusion of patient’s culture/diversity

• Respect for patient needs and preferences

• Sensitivity to spiritual dimensions of care

• Assess how they define health and wellness

• Assess access to care

• Assess patient resources – financial and human

• Awareness and recognition of health care disparities

  • Racial & Ethnic

racial adn ethnic minorities

• minorities experience more disease, disability, and premature death compared to non-minorities. Infant mortality, CV disease, DM, HIV/AIDs, immunizations, cancer and cancer screening rates are examples where disparities exist in USA.

Disparities exist because of:

• Legal/regulatory issues which make it difficult for people to receive equal care

• Socioeconomic issues

• Lack of facilities to provide care

• Discrimination at the patient-provider level related to race/ethnicity

  • Bias – predisposed to a point of view

  • Ethnocentrism – belief that one’s group is superior to others

  • Prejudice – assumptions / negative attitudes of others

  • Stereotyping – unfairly labeling groups

• None of this is new… it is just being brought to attention more

US is a diverse pop…

• (race, ethnicity, gender identities, age, abilities, cultural background, religious and spiritual beliefs)

• Some say … until “we” look more like the overall population of the United States, it will be difficult to serve the public and provide patient centered care

Core competency # 2: 
Work in interprofessional teams

Caregivers should “cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable”

The Core Competency: Work in Interprofessional Teams. In order to ensure that care is continuous and reliable:

• Communicate

• Coordinate

• Collaborate

• Delegate effectively and appropriately

• Manage change

• Apply principles of conflict resolution

• WE HAVE TO WORK TOGETHER

What do we know about teamwork and the work environment?

• We know health care is growing more and more complex

• Patients are sicker and care requires input from all disciplines

• Not all teams are created equal – we must be able to work together

• Job satisfaction is about more than just money – you need to feel appreciated, supported, and valued – feel like you make a difference

Organizational structure

• Can be horizontal – flat – decentralized – considers input from staff

• Can be hierarchal or bureaucratic – more likely to have top-down decision-making

• Newer:  Matrix organizational structure – focuses of departments and providing services within that department like cardiovascular service line that includes ICU, the Catheterization Lab, Respiratory Therapy, the Electrophysiology Lab, and Outpatient CV Rehabilitation services.

Nursing Organizational structure

Upper level = CNO or CNE or VP of Nursing Services

Middle level = Directors who supervise multiple units with a common function – Director of Critical Care Services

First level = Unit manager or supervisors

teamwork

why is teamwork hard?

• We have PT, OT, SW, RN, NA, MD… all expected to work together when one discipline may not even fully understand the functions of the other

• The more we understand each other’s role and what they bring to the table, the more teamwork shines and works in our favor

• COMMUNICATION…

  • How many times do we ask the patient the same question?

  • How much work are we duplicating unnecessarily?

  • Poor Communications is 3^rd root cause for sentinel event

sentiel event

unexpected harmful event in healthcare setting that results in psychological or physical harm (or death), not related to the natural course of the patient’s illness.

Examples of sentinel events…

• Wrong-site surgery

• Foreign body retention

• Falls

• Administering wrong medication due to ordering error

• How could communication effect these events?

Occupational Therapist

• This team member provides important services for patients who have impaired function and difficulty performing activities of daily living after a stroke, traumatic brain injury, or other serious injury.  This team member helps the patient work within their disability to gain back function and independence. 

Physical Therapist

• This team member provides important services for patients who have impaired mobility and strength after a stroke or serious injury, as well as after many types of orthopedic surgery.  This team member may teach a patient how to ambulate safely with a walker or cane or how to transfer safely from bed to chair. 

Respiratory Therapist

• This team member provides important services for patients who have trouble with breathing and airway clearance.  This team member is trained to provide oxygen therapy, inhalation therapy (inhalers or nebulizers), ventilatory support, and even mechanical ventilation. 

Physician’s Assistant

• This team member can perform physical examinations, order diagnostic tests, diagnose and treat diseases, assist with procedures, and write for some prescriptions - but must always perform these care activities under the supervision of a physician. 

Communication = sharing a message

• Sender - Message – Receiver- Feedback

• Mindful communication

  • Process by which actively aware individuals engage in meaningful communication (text vs email vs phone vs in-person)

• One thing worse than poor communication, NO communication!

• We must LISTEN more than we talk

Improving Team Communication

• Effective communication takes practice and awareness

• Structured communication methods

  • Improves team communication

  • Reduces communication barriers

  • Reduces communication errors

• Organizational culture will have an impact

• Respect is critical

Dissonant culture

Consonant culture

• Functional

• Effective – care, communication

• Accept new staff/students/visitors, friendly, welcoming

• Positive

Tools to help with communication, collaboration, and coordination

• Evidence-based clinical pathways/Care bundles

• Checklists

• TeamSTEPPS

• SBAR and CUS communication strategies

TeamSTEPPS

Communication: structured, clear and accurate exchange of info

Mutual Support: anticipate and support team members’ needs through accurate knowledge about their responsibilities/workloads

Leadership: maximize team actions by ensuring members are understood, information is shared, and resources are available.

Situation Monitoring: Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support the team

SBAR

• Situation – what is going on with the patient?

• Background – what is the clinical context?

• Assessment – what do I think the problem is?

• Recommendation – what would I do to correct it?

sbar not effective

use CUS

concerned

uncomfortable

safety issue

Improving Team Communication

Formal meetings

• Should be held in a private place conducive to communication

• Steps for conducting meetings

  • Attendance

  • Minutes

  • Pre-posted agenda

  • Goals of the meeting

  • Votes or consensus making

  • Start and end on time

  • Assigned tasks with due dates and people responsible

  • Opportunities to speak

Debriefing: Open discussion about nursing care.

Setting the stage

Description

Analysis

Take aways

Improving Team Communication

• Assertiveness

  • Standing up for what you believe in

  • Not pushing / controlling

  • Confused with aggression

  • Use “I” statements

  • Nonverbal messages matter too

Listening

• To patients, families, team members

• Barriers to effective listening

  • Anxiety, stress

  • Distractions and interruptions

  • Workload

  • Fatigue and hunger

  • Lack of confidence

  • Burnout/Frustration/Upset

Healthcare Team Members:
Knowledge and Competencies

Key competencies:

• Work with individuals of other professions

• Use knowledge of one’s own role and roles of other professions to appropriately assess patient care needs

• Communicate with patients, families, and communities

• Apply relationship-building values and principles to perform effectively

Teamwork : Leadership

• Effective leader:

  • Recognizes that work of team is critical

  • Should not focus on personal success or on success of any member

  • Emphasizes entire team effectiveness

• Designated team leaders

  • Nursing team = leader is a RN

There does have to be a leader

• A good leader:

  • Keeps the team on point – ID timeline/time constraints

  • Clarifies the purpose and the rules/guidelines of the team

  • Selects and/or orients and trains team members

  • Keeps the team focused on the task at hand

  • Reports up or down and updates the team as needed

  • Recognizes individuals and the team’s work

  • Is open to and supports other’s ideas

  • Resolves conflicts when they arise

  • Evaluates the outcomes of the team’s work

  • Accepts and provides constructive feedback

  • Facilitate group collaboration, communication, and delegation

Formal and informal roles
within a team

Evaluating the effectiveness
of a team

Team size and composition

Team processes – clear goals and expectations, communication, conflict resolution strategies, leadership

Team tasks assigned appropriately

Ability to obtain resources and recognize the strengths of the team

Teams and Decision-Making

• What is the issue?

• What type of data are needed?

• How complicated and substantial is the issue?

• What are the solutions, and how many are there?

• Can the outcome be acceptable with all standards?

Must consider pros/cons, ethical implications, and legal implications

Is the plan feasible?

collaboration

everyone has input, and decisions are made together

• Requires compromise

• Everyone has a say in the outcome

• Requires mutual respect and good working relationships

• Need quiet, private, neutral meeting place

• Goal:  Arrive at the best possible decision

• Integral part of patient-centered-care

Tools to Improve Coordination

Use of Evidence-Based Practice guidelines for clinical protocols/pathways

INTERPROFESSIONAL ROUNDING with inclusion of the patient

An understanding of roles within the team

Support good documentation that is easy for others to locate

Delegation

Part of nurses’ daily work

• Sharing responsibility by assigning tasks to others

Key terms

Supervision

Assignment

Transferring

Delegation how to

The delegated activity must be within the other persons scope of practice

The other person must be competent/able to perform the delegated task

Who can the RN delegate to?

• Another RN

• LPN/LVN

• Unlicensed Assistive Personnel (UAP = CNA, PCA, PCT)

delegation for nurses

What is power?   

• When one healthcare provider has an advantage over another person

What is empowerment?

• A feeling of increased personal achievement and autonomy

power type- Legitimate

(formal position like team leader or nurse manager)

Referent -type of power

(informal, from others’ recognizing leadership qualities)

informational type of power

(from having info others need)

Expert type of power

(expertise that is useful to guide others)

reward type of power

able to reward others if they do something)