perspectives final

Purpose of state nursing  practice acts 

• Protect the public

• Define the scope of practice 

• Makes nurses accountable 

• Nurse practice acts establish state boards of nursing

Regulatory (authority) powers of nursing

Grant license 

• Deny or revoke (when necessary)

Approve nursing programs

Establish standards for nursing schools

Create specific regulations for nurses and nurse practice acts 

Determine who can use titles of 

• RN

• LPN

• LVN

History of nursing licensure 

Florence Nightingale → first to register graduates of her nursing program 

• Graduates of nursing schools received a certificate of completion 

Permissive license

• Can practice nursing and use the title of RN

• If not, use the title of graduate nurse 

Mid-1800s

• Nursing leaders recognized the need for standardized credentialing and licensing

what is a nursing licensure 

Mandatory licensure requires all persons practicing nursing

• Meet established standards of education

• Pass the standardized examination

• Be licensed in the state where they practice 

Nursing as a regulated practice requires a valid license to practice 

• Function of state boards of nursing 

what is the Licensing exam

The standardized nursing exam did not exist prior to 1945 

The ANA Council of State Boards of Nursing created the first standardized exam

• State board examination 1950

Renamed

• National Council Licensure Exam 

Licensure by endorsement 

• State-recognized passing the NCLEX

Qualifications for the application of the nursing licensure

• Proof of graduation from an accredited program

• Criminal background check

• Proof of passing the NCLEX

good to knows with your nursing licensure

Renewal period

• Varies from state to state 

Continuing competence requirements

• Continuing education units

Legal risk in nursing 

Negligence 

• Failure to act as a reasonably prudent person would do in the same situation 

Malpractice

• Negligent acts by a licensed professional that result in harm

Types of malpractice 

• Commission - doing something that should not have been done 

• Omission - failing to do something that should have been done

Essential elements of malpractice 

The duty of a professional nurse towards a patient was assumed

A professional nurse breached the duty of care; failed to meet the standard of care 

RN failing to provide the standard of care caused harm to the patient 

The injury (harm) is proven

Delegation

Professional nurses become accountable for the outcomes of actions of others when delegating nurses' responsibilities to practical/vocational nurses (LPN/LVP) and unlicensed assistive personnel (UAP)

Nursing practice acts address the delegation process 

5 rights of delegation

Right task

• Is the task appropriate for delegation in a specific care situation 

Right circumstance

• Is delegation appropriate in this situation?

• Patient setting, patient condition 

Right person

• Must verify that the patient delegated to do the task is competent to complete this task 

Right direction/communication

• Has the RN given clear, specific instructions

Right supervision 

• Can the RN or other licensed nurse provide supervision and evaluation of the patient and the performance of the task?

RNs responsibility on delegating nursing responsibilities to other personnel

RN responsible for determining the delegated person is competent to perform the delegated act 

That person is responsible for delegating the act safely 

State nursing practice does not give LPNs or LVNs the authority to delegate 

RN's accountability/legal liability nursing responsibilities delegated to another person, unless that person is a licensed professional

Informed consent by personal

physicians/nurse practitioners' responsibility to obtain 

RNs role

Clarify facts 

Confirm its presence

Verify consent is signed 

Minors 

Three major conditions of informed consent 

1. Consent must be given voluntarily 

2. Consent must be given by an individual with the capacity and competence to understand 

3. The patient must be given adequate information

Confidentiality

Legal and ethical concern. Protection of private information gathered about a patient during the provision of care 

Health/insurance portability and accountability act (HIPAA)

Requires all health care providers, including physicians, hospitals, health plans, pharmacies, public health authorities, insurance companies, billing agencies, information systems sales and service providers, and others, to ensure the privacy and confidentiality of patients

Ask yourself, “Do I need to know this information for my job”?

Assault and battery 

Assault: threat or an attempt to make bodily contact with another person without the person's consent 

Assault always precedes battery 

Battery: assaults carried out: unprivileged touching of one person by another 

Actually, harm may or may not occur as a result of assault and/or battery

Strategies to limit the possibility of legal action

Meet the standards of care 

Carry and understand professional liability insurance 

Promote positive interpersonal relationships, especially with patients and their families 

Practice in a safe setting

qualities of safe agencies 

• Employs an appropriate number of personnel with a variety of skills to care adequately for a number of patients at all levels of acuity

• Has policies, procedures, & personnel practices to promote

quality & safety

• Keeps equipment in good working order

• Provides comprehensive orientation & opportunities to learn

Communicate well with other health care professionals, patients, and families

Accurate documentation - if it wasn't documented, it wasn't done

Basic concepts in ethics: values and morals 

Values → attitudes, ideals, or beliefs that an individual or a group holds and uses to guide behavior 

• Integrity, respect, responsibility, compassion 

Morals → standards of behavior that guide the actions of an individual or social group and are established rules of conduct to be used in situations where a decision about right and wrong must be made 

• Focuses on what to do (good) and what to avoid (harm)

Basic concepts in ethics: ethics and bioethics 

Ethics → term used to reflect what actions an individual should take and be “codified”, as in the ethical code of a profession 

Bioethics → application of ethical theories and principles to moral issues or problems in health care 

Use of morals in ethical decision-making 

Moral reflection

• critical analysis of one's morals,beliefs, and actions 

Moral integrity 

• Beliefs and actions are assessed and analyzed (reflected on) so that professional ethics continue to respond to changes in practice 

• Analysis of actions to reduce inner conflicts between personal values, morals, and professional ethics 

Moral distress

• Response to a decision when nurses are faced with ethical dilemmas, but also encounter institutional constraints that limit their actions 

Moral courage 

• Capacity to overcome fear and stand up for values with awareness, despite potential risk 

Theory of ethics: deontology 

Greek word deon, meaning “obligation or duty”

• To do one's duty is right 

• To do one's duty is wrong 

The act is moral if its motivations or intentions were good, regardless of the outcome

Theory of ethics: utilitarianism 

The moral rightness of an action is determined solely by its consequences 

Maximizing the greatest good for the greatest number of people 

• Triage in ER 

• Allocation of how healthcare dollars are spent 

Theories of ethics: virtue ethics 

Emphasizes the character of the decision-maker 

• Virtues are tendencies to act, feel, and judge that develop through appropriate training but come from natural tendencies 

• Individuals' actions are built on a degree of inborn moral virtue (Burkhardt and Nathaniel, 2002) 

Theories of ethics: principlism 

Uses 6 key ethical principles in the resolution of ethical conflicts or dilemmas 

1. Beneficence

2. Nonmaleficence

3. Autonomy 

4. Justice

5. Fidelity 

6. Veracity 

Ethical principles: beneficence 

Commonly defined as “the doing of good”

Performing a deed that benefits someone

Ethical principles: nonmaleficence

Defined as the duty “to do no harm”

Refraining from doing harm 

examples

•  fall risk patient - set bed alarm 

5 checks and 3 rights in med administration 

1. Right patient

2. Right drug

3. Right dose

4. Right route

5. Right time 

Ethical principles: autonomy 

Asserts that individuals have the right to determine their own actions and the freedom to make their own decisions 

Examples 

• Right to informed consent - decision to have surgery 

• Right to refuse treatment 

Ethical principles: justice 

Equals should be treated the same, and unequals should be treated differently 

Example

• Patients with the same diagnosis and healthcare needs should receive the same care, and those with greater or lesser needs should receive care that is appropriate to their needs 

Healthcare 

• Right?

• Privilege?

• Who gets the resource allocation?

Ethical principles: fidelity 

Faithfulness or honoring one's commitments or promises 

Being trustworthy 

Loyal commitments to patients 

• Honoring patients wishes

• Consistent communication

• Keeping promises 

Ethical principles: veracity 

• Telling the truth, or not lying 

• Accurate information

• Honesty in communication

• Maintaining trust 

• Informed consent

Code of ethics in nursing 

The social contract through which the profession informs society of the principles and rules by which it functions 

• Shapes professional self-regulation

• Serves as guidelines to the members of the profession 

ANA Code of Ethics for Nurses (latest: 2015)

ICN code of ethics for nurses (latest: 2012) 

Respect for persons

Beneficence

Justice

Professionalism ]integrity 

Collaboration

Advocacy 

Commitment to personal and professional growth

Code of ethics in nursing: florence nightingale 

• I pledge myself to consecrate my life to the service of humanity; to care for him who shall have been placed in my care with all the devotion and humanity that I can muster

• I will endeavor to practice my profession with honesty and integrity, and to be faithful in all my work

• I will hold in confidence all personal matters committed to my keeping, and all family affairs coming to my knowledge in the practice of my calling

• I will be loyal to my employer, and I will be true to my obligations to my patients

• I will strive to maintain and improve the standards of my profession, and to uphold the ethics of nursing practice

• Commitment to service 

• Deviation and humanity 

• Honesty and integrity 

• Confidentiality 

• Loyalty and fidelity 

• Professional development

Steps in ethical decision-making 

• Clarify the ethical dilemma

• Gather additional data 

• Identify options

• Make a decision 

• Act

• Evaluate 

What is patient safety?

“How hospitals and other health care organizations protect their patients from errors, injuries, accidents, and infection” (Leapfrog, n.d.)

Regulatory agencies 

• Joint commission

• Centers for Medicare and medicaid services (CMS)

• Institute of Medicine (IOM) 

Patient safety statistics 

The Institute of Medicine (IOM) found 

• 98,000 patients die each year due to medical error

• On average, patients experience at least one error/day

Escape fire

• Overuse of expensive technology 

• Underuse of expensive services

• Error-prone implementation of care 

Leap frog 

• 440,000 people die every year from preventable errors

• 1 out of 25 patients develops an infection while hospitalized every year 

• Medicare patients have a 1 in 4 chance of injury, harm, or death while hospitalized 

• 1,000 people will die today d/t preventable hospital errors

National patient safety goals 

Established by the Joint Commission

Purpose - improve patient safety 

Goals - focus on problems in healthcare safety and how to solve them 

Whose responsibility? the nurse

1. Identify the patient correctly

2. Improve staff communication

3. Use medication safely 

4. Use alarms safely 

5. Prevent infection

6. Identify patient safety risks

7. Improve health care equity 

8. Prevent mistakes in surgery 

NPSG - nursing interventions 

Improve the accuracy of patient identification

• Name and DOB

Improve the effectiveness of communication among caregivers

• Assertive communication

• Communicate critical labs 

Improve the safety of using medication

• Label medications

• Communicate new and or dc’d meds

• Give the patient written info about each med

• Instruct the patient to bring up-to-date lists of meds to each clinic visit 

Reduce harm associated with clinical alarm systems 

• Manage alarms 

• Avoid alarm fatigue 

Prevent infection 

• Hand hygiene

Identify patient safety risks 

• Risk for suicide 

Improve health care equity 

• Identify health care disparities in the patient population

• Written plan to improve health equity 

Prevent mistakes in surgery 

• Correct patient

• Correct surgery

• Make body site

• Time-out in OR

National patient safety goals 

Your role as a nurse:

• Know your institution's policies and procedures 

• Be your patient advocate

• Be involved in your institution 

• Create a safe environment

Creating a safe environment 

Falls

• Everyone's job is to prevent falls

• Use gait belts

• Bed alarms

• Non-skid slippers

• Clean up spills 

Other items 

• Dispose of needles/sharps properly 

• Keep yourself healthy 

Emergencies 

• Know your role in each code situation

• Proper equipment for each scenario (crash cart, fire extinguisher, etc.)

Correct patient identifiers 

• All patients (name and DOB) 

Report an unsafe environment

Near miss = good catch 

• An unplanned event that did not result in injury, illness, or damage, but had the potential to do so

• Often precedes loss-producing events

• May be overlooked, as there was no harm, no injury, damage, or loss

Adverse event 

An event, preventable or non-preventable, that may or may not cause harm to a patient

Examples: falls, medical errors, delays in treatment, lost patient belongings 

Variance report 

• Method of reporting 

• Clear, concise, and timely manner

• What to include: facts of the event

Sentinel event (never event)

An adverse event that results in any of the following:

• Death

• Serious injury

• Or risk of both 

Signals a need for immediate response/investigation 

examples

• Retention of a foreign body in the patient after surgery

• Air embolism

• Blood incompatibility 

• Stage III?IV pressure ulcer

• Fall → serious injury 

• Cath associated with UTI 

• Central-line associated bloodstream infection (CLABSI)

• Surgical site infection

• Poor glycemic control while hospitalized

• DVT or PE post-orthopedic surgery

Patient involvement 

Patients and family 

• Speak up

• Pay attention and be involved

• Know medical condition and medications 

Good patient education by the nurse

Understand patients rights

• Patients have the right to receive safe care

Just culture 

• Organizations are accountable to create safe systems to respond to employees' behaviors in a fair and just manner

• Employees are accountable for their choices and for reporting their errors and system vulnerabilities 

• Human error will occur

• The outcome will not influence how we think about the person involved or how we respond after an event has occurred

Just culture: your role 

Employees

• Accountable for your own performance

• Report adverse events and near misses

• Participate in process/quality improvement to reduce likelihood of error 

Leaders 

• Encourage reporting of events

• Create reliable systems/processes

• Utilize “just culture” algorithm → consistent response to events

Quality and safety education for nurses (QSEN) 

• Created to facilitate change in nursing education

• Robert Wood Johnson Foundation funded this project

• Identified 6 competencies - all nursing and health care education programs need to address

• Incorporated into nursing education standards and the NCLEX

QSEN Standard #1

• Patient-centered care 

• See patients' health care situation through their eyes

• Understand their values and health beliefs 

• Incorporate their preferences and values into the plan of care 

• Allow patients to participate in decision-making

QSEN Standard #2

• Teamwork and collaboration 

• Recognize interprofessional collaboration

• Includes: nurses, physicians, pharmacists, therapists, dietitians, social workers, and others 

• IOM - up to 66% of healthcare errors are related to poor work relationships and poor communication

• Several frameworks can be used - tea, STEPPS, SBAR

QSEN standard #3

• Evidence-based practice (EBP)

• Patient care - based on the best evidence available 

• Nurses base their practice inquiry, asking questions about everything they do 

• Will ensure best practices are used, leading to the best care possible

QSEN standard #4

• Quality improvement 

• Use of data to monitor/improve leads to quality and safety 

• A quality culture encourages inquiry - ask questions about how, what, and why.

QSEN standard #5

• Safety 

• Minimize risk of harm to patients through system effectiveness and individual performance

• Organizations promote learning from mistakes and recognize that even the most competent healthcare professional can make mistakes 

• Consider the individual vs the system approach

QSEN standard #6

Informatics

Use information and technology to: 

• Communicate effectively 

• Manage knowledge 

• Mitigate error and support decisions 

Nurses must play a crucial role in the design, purchase, and implementation of technology 

The healthcare system

Illness care system 

• Focus on treating health problems once they have occurred, rather than focusing on wellness through health habits 

Healthy people 

• Science-based program

• National objectives focuses on health promotion and disease prevention

• New objectives established every 10 years

Major categories of health care services

1. Health promotion and maintenance, including early detection

2. Illness Prevention

3. Diagnosis and treatment 

4. Rehabilitation and long-term care

Health promotion maintenance

These services assist patients to 

• Remain healthy 

• Prevent diseases and injuries

• Detect diseases early 

• Promote healthier lifestyles 

Early detection = less costly treatment with better outcomes

Assumption: patients who adopt healthy behaviors are more likely to avoid certain illnesses

Illness prevention 

Address health problems after factors are identified 

Example

• Illness prevention - promoting cessation of alcohol use in patients with known liver disease 

Note: health promotion services seek to prevent development of risk factors

Diagnosis and treatment 

Modern technology helps refine methods of diagnosing and managing illnesses

• Imaging and detection of certain cancers

• Minimally invasive surgery 

• Nerve block - reduces post operative pain and need for opioid prescription 

High-tech services can lead patients to feel dehumanized when care is focused on machines, computers

Rehabilitation and long-term care 

Rehabilitation services

• Helps restore the patient to the fullest possible level of functon and independence after injury or illness

• Disease managment focus - help patient understand and manage their chornic conditions

Long-term care 

• Provides serves patient/family cannot provide 

• Goal-mantain independence as long as possible

Classification of healthcare delivery agencies 

• Government (public) vs voluntary (private) agencies 

• “Not-for-profit” or “for-profit” agencies 

• Level of health care services provided

Government (public) vs voluntary (private) angencis 

Government (public) 

• Federal agencies 

  • CMS, NIH, CDC

State angencies 

• state dept. Of health, state boards of nursing

Local angencies 

• public health dept.

• Voluntary (private) 

• American red cross

• American cancer society 

• American heart asscociation

“Not-for-profit” vs “for-profit”

Classified by what is done with the income earned 

“Not-for-profit” 

• Uses profits to pay personnel, improve services, advertise services, provide educational programs, or otherwise contribute to the mission of the agency 

“For-profit” 

• Distribute profits earned to partners or shareholders

• 25% of hospitals nationlly are “for profit”

• 50% of hospitals in nevada, texas, flrodia, new mexico

Primary care services

When the patient first endters the healthcare system 

Goals

• Entry into the system 

• Emergency care 

• Healthcare maintenance 

• Monagment of long-term and chronic conditions

• Treatment of temporary health problems that d not require hopsitilizartion 

Secondary care services

Management of a condition by a specialist after being referred by a primary care provider 

Examples 

• Cardiologist, endocrinologist, oncologist, or orthopedic surgeon 

Services

• Management of patient with new diagnosis of complex illness or who need surgery, eveluating patients with chornic illnes,s providing cousnseling or other therapes that are not available in primary care setting

Tertiary care services

Provided to acutely ill, those requiring long-term care, those needing rehabilitation services, and the terminally ill

Involves collaboration with multiple interprofesisonl teams

Examples

• Burn center, pediatric hospitals, skilled rehab center, hospice homes

Subacute care services

Goal-oreinted, comprehensive inpatient care designed for acute illness, injury, or exacerbation of disease process

Care more intensive than skilled nursing; less intensive than acute inpatient care 

Goals 

• Provide lower cost healthcare 

• Create seamless transition of patient mvoing thorugh healthcare system 

Examples 

• Inpatient dialysis, wound clinic, rehab

Organizational structure

How an agency is organized to accomplish its mission

Board of directors 

• Governing body 

• Represent various business and poltiical interests of the community 

• Legally repsoinsible for establishing polciies governing operation

• Ensures policies are executed

• Delegates repsonsibilties for running the agency to the CEO 

Chief executive officer (CEO) 

• Ensures institution runs effecenctly and is cost-effective

• Addresses health care issues in the community 

• Usually sits and reports to board of directors 

Chief operating officer (COO)

• Assistant to CEO 

Chief nurse executive (CNE), chief nurse officer (CNO), vice president for nursing, or director of nursing 

Shared governance 

• Voice of nursing

• Nurses participation in decision-making process

• Partnership between nurses and management 

• Improves staff satisfaction

Nursing care delivery methods: team nursing

Team approach: RN as team leader, LVN/LPN, and UAP

Least skilled an dmost experienced meber care for the patients with the least complex care 

Most skilled and experienced members care for the most seriously ill patients that require msot ocmplex care 

Advantages

• Hard to find RN so team approach you can get away with less RN in hopsital

Disadvantages 

• Ongoing communication so someone could be bad at it and it makes working challenging

Nursing care delivery methods: primary nursing 

Goals 

• Delivery consistent, comprehensive cae by identifying one nurse who is responsible, has authority, and is accountable for patient outcomes 

Role of the primary nurse

• 24-hour accountabilooity for care outcomes 

Advantages

Disadvantages 

• Hard ot higher all RN, it can be expensive

Nursing care delivery methods: case managemnt nursing 

Two models 

• Internal facus - case manager works wihtin facility 

• External focus - case manager oversees patients and the delivery of services 

Use critical path (care map)

Goal - prevent hsipitlaiztion; reduce length of stay 

Advantages

• Try to reduce cost of readmissions 

Disadvanatges 

• Want someone experienced and may be hard to find

Nursing care delivery methods: patient-centered care

A model based on “patient needs have priority over institiutions needs:

Brings traditional and nontraditional components to optimize the healing enviornemnt 

Components include architectural design, educational programs for patient and families, emphasis on beauty, gardens, art, food, and nutrition, availability of complementary therapies, emphasis on spiritualitym and community interaction

Advantages  

• Good patient outcomes

Disadvantages 

• Can be expensive 

Basic economic theory 

Supply and demand 

• Provides goof and services

• Demand and use godds and services 

• Efficient marketplace

Principle of premarket economy 

• Consumption of any good or service is determined by the individuals abilityto pay 

• Most us citizens consider health care to be a right not a privilege - existenc eo medicare and midcaid 

Price sensitivity in healthcare 

• Someone is paying the bill with 3rd party payers, price sensitivity is removed from the consumer 

• Client is paying only a portion fo the bill

Additional influences on the health care market 

• Consumers cannot always control demand for healthcare services 

• Healthcare needs to tend to be immediate 

Economics of nursing care  

No specific bill for nursing care 

Nursing services biled as a “room rate”

• Difficult to determine ration of RNs, LPNs, UPAs

• Difficult financial contritains led to reducing nursing staff 

Patient classification systems 

• Different patients require different amounts of nursing care (ICU)

• Higher nurse to patient ratio, higher the death rate

History of healthcare fincance before WW2

• 90% of americand paid out of pcoket or depende don charity care 

• Few had private insurance 

• Public insurance did not exist (medicare, medicaid) 

History of healthcare fincance after WW2

• Most indivisualized nations began publicly financed healtcare system for all citizens 

• United states continued private, free-for-service system

• Initiatives improved coverage, access and quality but created unforeseen loopholes

• Increased costs 

Retrospective payment 

• Payet after care is provided 

• Deductible and co-pay 

1980’s attempt to control costs 

Prospective payment systems 

• Know the amount tht will get reimbursed before care is provided

Diagnostic related groups 

• Payment categories used to classify hospitalized patients

• Purpose of reimbursing hospitals for each case ina  given category with a fixed fee regardless of actual coasts incurred

Managed care 

• Health maintenance organization (HMO) 

• Preferred provider oragization (PPO)

Affordable care act (2010)

• Requires health insurance

• Requires employers to offer health insurance

• Bans insurance companies from dropping coverage 

• Prevents discrimination against children with pre-exisiting conditions

• Bans lifetime limits on coverage 

• Extends coverage of dependents to age 26

Current methods of payment for health care 

Private insurance (voluntary) 

• Premium 

Medicare or title XVIII of social security act 

• Parts A, B, C, D and medigap 

Medicaid or title XIX of social security act 

Personal (out-of-pocket) paymet 

Workers compensation 

Private insurance 

Premiums 

• Indvisual 

• Employer

• Shared 

Deductile 

• Amount you pay before insurance pays, varies form plan to plan 

Co-payment 

• Percentage of charges you pay

Medicare (titile VII of social security act) 

“You care for the elderly” 65+ or chronic kidney disease 

Does not cover long term care 

Governemnt cover 

Part A - hospital insurance 

• We will pay for admission to a hispital or skilled nursing 

Part B - medical insurance 

• Doctors office visits 

Part C -  medicare advanatge

• Private insurance company 

Part D - prescription drug coverage 

• Cover presciption drug cost 

• Medigap (gap coverage with private insurance

Medicaid (title XIX of social securoty act) 

• “Aiding those in need” 

• State to state 

• Pre existing illness as a child 

• Jointly funded program fo rlow income, elderly, blind, and disabled 

• Adminsited by the state, so varies from state to state 

• No fees to participate 

Personal (out of pocket payment)

• Least common

• Pay out of pocket

• Those without access to insurance 

Workers compensation 

• Small proportion of health care payment 

• Covers workers who are injured on the job

• Varies state to state 

Nursing role in managing health care costs 

1. Become cost-concious 

2. Provide excellent care and be advocates for patients perosnal finances

3. Question unnecessary ro repetitive tests, suggest genetics, and detetcts problems early yo avoid repetitive hospitalizations 

4. Organize and streamline flow of patients for meximum effeciency

Current inittitives to control health care costs 

Hospital readadmission reduction program

Hospitalized acquired condition reduction program 

Examples 

• Catheter associated UTI, bed sore in the hospital 

Value-based care 

Home health care 

Certificate of need

Professional review organizations