Prof Nursing 2 - content before finals

QI in healthcare

systematic approach to making changes that lead to better pt outcomes and stronger health system performance, involves application of QI science

QI

quality improvement

QI science

provides structure, tools and processes to assess and increase efforts for the testing, implementation, and knowledge spread of QI practice

responsible for quality

academic preparation, hc organisations, provincial and federal organisations, professional organisations, professional staff, support staff, pts and families

To Err is Human

US- 1999, pivotal publication bringing pt safety to the forefront of healthcare

• almost 98,000 people die from medical errors in hospitals

• provides agenda for improving pt safety by designing safer healthcare system

• asserts that problem is not with people, but the system

IHI

institute for healthcare improvement (2004), launched campaign to save 100,000 lives by reducing morbidity or mortality in hospitals by using 6 best practice interventions: rapid response teams, improved care for acute MI, medical reconciliation, preventing central line infections, preventing surgical site infections, preventing ventilator associated pneumonia, now aiming for 5 million lives (not just over America)

Canada 2002, building a safer system

outlines a national integrated strategy for improving patient safety in the Canadian health care system, Canada needs collaboration across all sectors, formed CPSI (canadian pt safety institute) (no longer used), using federal funding for improving healthcare errors- annual 2 million given to CMIRPS or Canadian Medication Incident Reporting and Prevention System

CPSI

Canadian patient safety institute- identified gaps in pt care: impact of workload pressure and complexity of care, difficulty in coordinating and sustaining pt safety initiatives, need for stronger safety culture, need to focus on systems focusing on safety, need to support leaders across continuum

nurse’s role in quality

largest group of hc providers and spend that most time with patients, nurses are in ideal situation to observe and address quality gaps, nurses participation in quality improvement process can be critical efforts to improve quality and efficiency of hc system

steps: be aware of quality standards of care, speak up to colleagues when standards aren’t followed, speak up when quality gaps are found, participate in pt care development, include pt and family, become involved in unit based or organisation wide initiative to improve quality

Strategic goal for hc graphic

Safer Healthcare Now

Canadian version of 100,000 lives campaign, using same 6 interventions: rapid response teams, improved MI care, med reconciliation, preventing central line infections, preventing surgical site infections, preventing ventilator associated pneumonia

HQO- health quality Ontario

provincial agency that advises government and providers strategies to support high quality care, received mandate through the ECFAA - excellent care for all act, identified 6 elements of quality care- Safe, Effective, Patient Centred, Efficient, Timely/accessible, Equitable

guiding principles for successful engagement

partnership (btwn hc staff), learning (about other perspectives), empowerment (ppl need to feel empowered to express their own thoughts), transparency (disclose all mistakes, good or bad), responsiveness (respond to needs), respect (for patients and others you work with)

Patient safety linked to?

Quality (they go hand in hand)

systems thinking and quality improvement

SYSTEMS THINKING AND QUALITY IMPROVEMENT - tools for this: health care systems are highly complex (systems thinking, many staff and choices, look in bigger picture), safety analysis or safety improvement techniques such as RCA (root cause analysis) or FMEA (failure mode and effect analysis), RNAO toolkit for best practice implementation, human factors (incompatibility btwn ppl, tools and environment), interdisciplinary teamwork and communication

Lean six sigma in healthcare

LEAN- make overall processes more efficient by eliminating waste (organising stock room so supplies are more easily to find)

QUALITY- manage care processes by standardising and controlling them (standards of care)

SIX SIGMA- make processes more effective by focusing on eliminating defects (why are people falling- recognise deficits)

HQO (quality improvement framework)-

1. get started, create team and determine goals and timeframe

2. define problem, analyse info, explore problem from multiple viewpoints

3. understand system, collect and analyse data gathered, learn abt performance of system and identify barriers and areas of improvement in system

4. design and test solution, try new things, creative in planning, test using Plan-Do-Act cycles

5. implement and sustain changes, incorporate into everyday practice, monitor to ensure it is effective

6. spreading improvement

HQO

health quality ontario- brings transparency into hc so ppl can see flaws

HQO QI themes

1. team development- work together and cooperate

2. voice of the costumer- incorporate pt voice

3. implementing and sustaining change

4. change management

5. measurement- methods for gathering info and promote long term sustainability

patient engagement

patient centred, meet their unique needs, individualised and applicable, get to know pt, family goals and context, listening, learning and empowerment important bc- improved pt experience and self management, better health outcomes, decreased cost of care

direct care- what care works for patient?

Program/organisational level- how should care be designed for patients similar?

System level- what services should be available for whom in what way?

model for improvement

PDSA- Plan Do Study Act

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

***these allow for trying an improvement idea before fully implementing change, 90-120 days

PDSA Plan

state purpose of pdsa, 5 Ws

PDSA do

90-120 days, conduct test, document results, challenges etc

PDSA study

alanyse data and study results, compare, summarise and predict

PDSA act

refine change and plan for next test

outcome measures

did QI initiative make an improvement, (wait time or infection rates, voice of pt and costumer)

process measures

is the process or steps for QI initiative being followed (did staff comply? voice of staff or workings of the system)

structure measure

changing and fixing equipment in system

balancing measure

dud QI change cause other problems in the system (increased staff satisfaction but not for patients)

Example

research focus, research abstract, findings, evidence informed practice,

choosing wisely canada

recommendations and guidelines to help with decisions

quality and patient safety

Canadian National Steering committee on patient safety: building a safer system (2002)

quality of care- ability of hc services to increase likelihood of desired health outcomes, incorporates accesibility, effectiveness, efficiency, patient safety, patient centred care, equity, efforts to reduce and prevent unsafe acts, use of best practice for best outcomes

adverse events

an event or circumstance that could have or did result in unnecessary harm to a patient (could have been preventable)

most common errors

medications (biggest issue), transfusions, surgeries, restraints, falls, burns, pressure injuries, patient mix ups

adverse event

harmful incident, near miss, no harm incident

stopped at 5 goals of the Canadian quality and patient safety framework

1. people centred care

2. safe care

3. accessible care

4. appropriate care

5. integrated care

just culture

in some healthcare cultures- safe care is a core value, increases knowledge and skills, opportunities to improve are embraced, justice, shared commitment, interest of both patients and providers are protected, aims to make system idiot proof and doesnt blame workers

nurse’s responsibility in just culture

patient safety culture, work in teams, communicate effectively, manage safety risks, optimise human and environmental factors, recognise and respond to adverse events, ensure own safety, be aware of common precautions, critical thinking during pt safety hazard, be familiar with patients

healthcare organisation responsibility in just culture

focus on performance improvement programs, act on risk management findings and safety report, provide reliable and current technology, integrate evidence informed practice into procedures and policies, design safe environment and atmosphere, provide continuing education and access to resources

ppl responsible for patient safety

acedemics, professional organisations, provincial government, federal government, healthcare professionals, support staff, patients and families

factors influencing safety

patient and provider factors, task factors, technology factors, environmental factors, organisational factors

systems thinking and quality improvement

core principle: multiple factors involved in failure, errors are caused by systems and are complex, not just caused by one person FINISH, systems can be engineered (bar code scanner) or people dependant (2 patient identifier), policies and procedures depend on individual attention

swiss cheese model

each slice is a barrier put in place to stop an error, holes represent weaknesses in barriers, holes are continuously moving, when holes line up- hazards find their way to patient, termed active failures

safety analysis or safety improvement techniques

RCA- root cause anaylsis

FMEA- failure mode and effective anaylsis

Lean Six sigma

RCA-

RCA- root cause anaylsis, go into past to determine issue

FMEA

FMEA- failure mode and effective anaylsis, anticipate future issues and engineer solutions and safeguards

Lean 6 Sigma

eliminate waste, eliminate defects

human factors

address incompatibility btwn ppl, tools, environment, improves human performance

interdisciplinary teamwork, communication and feedback

teamSTEPPS used to improve communication and teamwork, program developed to provide team with teechniques and trategies to support teamwork FINISH

nursing knowledge base

experience with care, nursing and scientific knowledge, practice standards, critical thinking

Patient safety organisations

CPSI, HQO, Accreditation canada, canada’s hand hygeine challenge, CIHI, institute for health improvement

patient safety reporting

when actual or potential adverse event occurs, confidential report, organisation can identify pattern or trends, focuses on root cause, undergrad students will complete incident report for hospital and academic institution

staff safety

environmental risks, ipac, violence

patient safety top risks

falls, procedure related accidents (wrong person (med, surgery etc), equipment related accidents (malfunction, misuse or electrical hazards)

fall risks

age, history, mobility risks, patients attempt to get out of bed, hip fracture is serious injury, extend length of stay and increase risk of other complications

nursing interventions for patient safety

assessent and patient communication, staff assignmnets, signage, improved patient hand offs, nursing comfort and toilet rounds, involves patient and family

potter and perry 877-878

risks per developmental stage activity

individual risk factors

lifestyle, impaired mobility, sensory or communication impairment, lack of safety awareness

safety during assessment

health history, pt home environment, health care environment, risk for falls, risk for medical errors, patient expectations

health promotion passive vs active strategies

passive- implemented through public health or government legislative interventions

active- individual is actively involved through changes in lifestyle and participation in wellness programs

fall prevention interventions

safety bars near toilets, non slip footwear, educate on assistive devices, use of restraints, side rails or bed alarms, frequent nursing rounds

restraints

physical, chemical or environmental means of controlling individuals behavior, controversial, understand legal factors, require psychological adjustment for pt and family, could lead to patient injury

side rails

may increase pt mobility and stability in bed or during transfer, keeps pt from falling, are considered restrain if pt can’t operate them, could cause injury

precautions

electrical hazards, seizure precautions, radiation safety

what is a theory

purposeful set of assumptions or propositions that identify relationships btwn concepts, provides systematic view for explaining predicting and prescribing phenomena

what is a nursing theory

knowledge abt nursing organised for nurses to use in a professional and accountable manner, perspective for viewing clients situations, a way to organise data, and a method of analysing and interpreting information, theories are one aspect of disciplinary knowledge and create visual linkages to how inquiry is approached- view client situations, organise data, analyse and interpret information, bring about coherent and informed nursing practice

Table 5.1 terminology

theoretical model vs conceptual framework

theoretical- someone tells u steps to make a basic cake, basic steps

conceptual framework- being able to make a variety of different cakes, specific variations

emergence of nursing theory

Nightingale created early theoretical and conceptual model for nursing

nursing science- unique body of knowledge abt the practice of nursing

Florence Nightingale

modern nursing practice, formalised what nursing looks like as a profession and discipline, descriptive theory- provided nurses witha way to think abt nursing practice in a frame of reference that focuses on patients and environment, created systems for nursing education and practice,

since Nightingale- nursing practice has paralleled that of authority of women in society, after ww2- major developments in science and technology influenced healthcare including nursing, from then- nursing science came into its own and became a unique body of knowledge

nursing theory class inn 1960

led by nurse educators, (used to be led by physicians until 1960),

change → answering theoretical and philosophical questions

what is focus and scope of nursing? how is nursing different from other hc? what is appropriate disciplinary knowlege for nursing? conceptual frameworks, scientific language in dissemination

Ida Jean Orlando

developed problem solving approach known as nursing process (ADPIE)

the conceptual frameworks

goal is to understand how effective nurses systematically organise knowledge about nursing to understand individual pt’s situation, frameworks and models depict theoretical structures to help nurses grasp clinical situation within larger context, often referred to as nursing theory

nursing metaparagigm

called the worldview in context of nursing theory, metaparadigms are the most general statement of discipline and functions as a framework in which the more restricted structures of conceptual models develop. 4 concepts used frequently in relation to others, each nurse theorist’s definition varies by their orientation, nursing experience and different factors, person is main focus, by each theorist defines nursing metaparadigm uniquely

metaparadigm- person

public health/community health nurses, intervene with communities, families, individuals and populations, each have physical, psycological, social, spiritual and cultural characteristics, recognise empowerment as active process

metaparadigm- health

basic resource for everyday living, pblic health/community health nurses participate as active parteners with communities, families and individuals, everyone has the right to information to base decisions and essential healthcare

metaparadigm- environment

nurses are proactive, leaders in promoting public health policy, vulnerable to nature of environment, aware that many variables affect health

metaparadigm- nursing

nurse attributes, characteristics and actions provide care on behalf of or in conjugation with the client, goal of nursing theories is to improve patient care

Imogene King’s theory of nursing (go through summaries instead)

theory of goal attainment - maintain health so ppl can function in their roles, focuses on aiding nurses in pt nurse relationships and helping pt meet goals for their health

person- patient is a social being with 3 needs (need for health info, need for care that seeks to prevent illness, need for care when pt is unable to help themselves)

health- involving life experiences of patient and also takes into consideration the internal and external environment

environment- background for human interactions involves internal environment which transforms energy to enable people to adjust to external environmental changes, which is formal and informal organisations

nursing- considered part of patient of environment

different nursing theory charts- Nightingale, Orem, Henderson, Peplau, Rogers, King, Watson

theory evolution types

grand theory

middle range theory

descriptive theory

prescriptive theory

***some theories work together

nursing theory evolutions

when nurses first began developing frameworks and models, nurses understood the process of building a knowledge base as a matter of science and discovery

grand theory

abstract phenomena, bunch of aspects, broad, conceptual framework, provide structural framework and sometimes called paradigms

martha rogers- theory of unitary human beings- views nursing as both science and art, purpose of nursing is to provide health and well being, believed that patient cannot be separated from the environment

middle range theory

looking at one specific phenomena or concept, limited scope, less abstract,

orems theory - adaptation model of nursing- viewed person as a biopsychosocial being in constant interaction with a changing environment- depicted 4 models of adaptation

descriptive theory

describes why phenomena occurs and describes consequences of it, can be interrelated with the concepts of grand or middle range theories, often considered first level in theory development with aim of detailing components of a nursing phenomenon

ex- nightingale said that ppl were getting more sick bc of the dirty environment

prescriptive theory

stupilates what people must do to attain a goal, uses actions

wiedenbach’s prescriptive theory- multiple realities in which a person exists, depending on the reality of the pt you see- your nursing interventions are different

ways of knowing- barbara carper 1978

nursing is not only science (empiric) byut also art- ethical, personal and aesthetic knowing,

later, theorists added- sociopolitical knowledge, emancipatory knowledge and critical thinking

model bashing

frustration resulting for overly formal and rigid approaches- How does a nurse organise and make sense of all available knowledge and apply it intelligently to the challenges that arise in an individual clinical case?

begin to recognise that older theories are philosophical statements- started to categorise theories as 2 different paradigms

paradigms debated

nursing as art and science, practical and applied, totality paradigm frameworks, simultaneity paradigm frameworks

how was the nursing diagnosis formed

bc conceptual framekworks were less explicit abt how to plan, implement and evaluate nursing care- clinical judgement relating to actual or potential health processes- discrete focus of theorising about nursing care

major theoretical models (+ example)

practice based theory, needs theories, interactionist theories, systems theories, simultaneity theories

practice based theories

theory to improve nursing practice, (prescriptive theory), can draw inspiration from theory,

ex- florence nightingale, dr moyra allen, mcgill modell

needs theories

conceptualising patients as collection of needs, common thinking in 1960s

ex- maslows hierarchy of needs, henderson (14 basic needs, self care theory), orems theory (ways ppl are responsible for meeting the following universal self care requisites)

interactionist theories

look at relationships btwn nurse and client

ex- peplau (described relationship as interactive and therapeutic), joyce travelbee’s human to human relationship model (nurse must provide hope to pt, communication), evelyne adam (nurse respects pt, nurse supports pt strength, knowledge and will)

systems theories

identify subsytems and systems that work together to create a whole, (grand theories)

ex- dorothy johnson (individual is behavioral system with seven subsystems, if one system doesn’t work- dont neglect other systems), UBC model for nursing (individuals made of 9 subsystems), neumans model (looks at stresses and how u react to them),

simultaneity theory (martha rogers)

presents client not just as a person, but in constant interaction with the environment,

ex- Parse theory (person not seen as individual), Jean watson (caring- caritas- how a nurse provides care)

simultaneity vs totality

both are paradigms

totality- views human-universe relationship as cause and effect, considers mind body and spirit as separate entities

simultaneity- human-universe relationship is a mutual process, as entities recognised through patterns

theorising in the future

nursing theories advance over time and build on each other, brings old and new concepts together, shapes concepts into new configurations- adds meaning to human experience

what is community health nursing

a model of care, occurs outside of traditional healthcare facilities, challenges include: social lifestyles, political policy, economic initiatives (not as well funded as acute care)