Exam 3 Foundations

Culture

Learned and shared beliefs, values, norms, and traditions of a particular group, which guide our thinking, decisions, and actions

Unconscious Bias

Bias we are unaware of and that happens outside our control, which is influenced by our personal background, cultural environment, and personal experiences

Culturally congruent care

Emphasizes the need to provide care based on a individual’s cultural beliefs, practices, and values

Cultural competence

Professional health care must be culturally sensitive, culturally appropriate, and culturally competent to meet the multifaceted health care needs of each person, family, and community

Culture Assimilation

minorities living within a dominant group lose the characteristics that made them different; values replaced by those of dominant culture

Culture Assimilation Example

moving somewhere new and overtime you start blending in with the people around you

Culture shock

the feelings a person experiences when placed in a different culture; may result in psychological discomfort or disturbances

Cultural Imposition

beliefs that everyone should conform to the majority belief system

Cultural Blindness

ignores differences and proceeds as if they did not exist

Cultural Blindness Example

treating all patients the same and not recognizing cultural differences

Ethnocentrism

belief that one’s ideas, beliefs, and practice are the best or superior or are most preferred to those of others

Ethnocentrism Example

in the US we strongly believe in EBP/western medicine and encourage all patients to accept it as best practice since it is the best

Health Disparity

A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage (ODPHP, 2021)

Social Determinants of Health

The conditions in which people are born, grow, live, work, and age (WHO, 2020)

Marginalized Groups

Are more likely to have poor health outcomes and die earlier

Elements of cultural competence

• Developing self-awareness

• Demonstrating knowledge and understanding of a patient’s culture

• Accepting and respecting cultural differences

• Not assuming that the health care provider’s beliefs and values are the same as the client’s

• Resisting judgemental attitudes such as “different is not as good”

• Being open to and comfortable with cultural encounters

• Accepting responsibility for one’s own cultural competency

ESFT Model

guides provider in understanding the patient’s perception of their illness and identifying potential threats to treatment adherence

E – Explanatory model of health and illness “THINK: explanation of cause”

• What do you think caused your problem?

• Why do you think it started when it did?

• How does it affect you?

• What worries you most?

• What kind of treatment do you think you should receive?

S – Social and environmental factors “THINK: sufficient money? Social factors?”

• How do you get your medications?

• Are they difficult to afford?

• Do you have time to pick them up?

• How quickly do you get them?

• Do you have help getting them if you need it?

F – Fears and concerns “THINK: do they have worries/concerns about medicine?”

• Does the medication sound okay to you?

• Are you concerned about the dosage?

• Have you heard anything about this medication?

• Are you worried about the adverse effects?

T – Therapeutic contracting “THINK: therapeutic – will they be compliant?”

• Do you understand how to take the medication?

• Can you tell me how you will take it?

Guidelines for nursing care

• Develop cultural self-awareness and identify your biases

• Develop cultural knowledge

• Accommodate cultural practices in health care

• Be respectful

• Avoid mandating change

• Seek cultural and linguistic assistance

What is the best method to ensure the patient understands?

teach back—When patient is able to recall and comprehend, they are more likely to adhere to therapy

Campinha-Bacotes model—The Process of Cultural Competence in the Delivery of Healthcare Services

1. Cultural awareness - Examining one's biases towards other cultures.

2. Cultural knowledge - Seeking to understand different worldviews.

3. Cultural skill - Collecting cultural data and performing culturally-based care.

4. Cultural encounters - Engaging in cross-cultural interactions.

5. Cultural desire - Genuinely wanting to become culturally aware.

Josepha Campinha-Bacote (nurse theorist)

created a model that emphasizes that cultural competence is an ongoing process, not an endpoint, requiring a commitment to self-awareness, knowledge, and encounters with diverse patients. Her work has significantly influenced nursing education and practice

Cultural Preference

• Dietary restrictions

• language preferences

• decision-making dynamics (individual vs. family)

• use of traditional/complementary remedies

Cultural Practices

• Health beliefs

• rituals surrounding birth/death

• personal space norms

• modesty practices

• spiritual/religious practices

Cultural Dynamics

• Family roles

• gender roles

• acculturation level

• literacy level

• rural vs. urban background

Ethics

• Ethics is the study of what is right and wrong with our conduct

• Principles that govern a person’s behavior

• Rules of conduct in a particular culture or group

• Study of the ideals of right and wrong behavior

• Ethical issues differ from legal issues

Values

Deeply held personal belief about the worth a person holds for an idea, custom or object

Morals

• Concerns individuals

• The individual’s idea of right and wrong

• Based on personal values or compass

Basic Principles

• Autonomy-freedom from external control (informed consent and pt. education about decisions)

• Beneficence-taking positive actions to help others (prioritizing patient safety over self interest)

• Nonmaleficence- to do no harm or hurt (benefits outweigh the risks)

• Justice- fairnesss and distributionof resources (healthcare reform and access to care)

• Fidelity- agreement to keep promises (providing care as expected) Pre

Professional Nursing Code of Ethics

• Advocacy

• Responsibility

• Accountability

• Confidentiality

What does ANA stand for?

American Nurses Association

Deontology (Duty Based)

An action is right if it follows the rules or set principles, regardless of the consequences

Deontology Example

A patient’s CT scan reveals an aggressive and inoperable brain tumor. The oncologist should inform the patient’s spouse of the poor prognosis, even if it causes them distress, because lying is unethical

Utilitarianism (Consequentialism)

The right action results in the greatest good for the greatest number of people

Utilitarianism Example

The FDA approves a medication that can eradicate a certain disease that will cure millions of people, although the drug has known side effects

Deontology short

the end doesn’t justify the means

Utilitarianism short

the end justifies the means

Ethical Dilemma

An ethical problem is called a dilemma when two opposing courses of action can both be justified by ethical principles

Ethical Dilemma Example

Nurse A confronts Nurse B, who is also her best friend on the unit, about some unsafe behaviors observed. The Nurse B ignores it and gets upset at Nurse A.

• Nurse A is conflicted between reporting her friend and not reporting for the sake of their friendship

Ethical Distress

In moral distress, instead of competing options for action, the nurse feels the need to take a specific action while believing that action to be wrong

Ethical Distress Example

the nurse receives discharge orders for a patient who has prolonged their hospital stay, but the patient has no home, resources or support.

• The nurse knows that the patient must be discharged but feels distressed because of the unfavorable outcome of this action

Steps in solving an Ethical Dilemma

1. Ask is this an ethical problem?

2. Gather information relevant to the care

3. Identify the ethical elements in the situation by clarifying values and recognizing the principals involved. Distinguish among fact, opinion, and values.

4. Name the problem. A clear, simple statement of the problem is not always easy, but it helps to ensure effectiveness in the final plan and facilitates discussion.

5. Identify possible courses of action. Access others for their input and be creative in identifying different options.

6. Create and implement an action plan. Gather support from others and identify an alternative action if the chosen one does not achieve resolution.

7. Evaluate the action plan to determine whether further action is needed or if lessons learned in this experience can be applied forward.

Ethics Committee

An ethics committee involves individuals from different disciplines and backgrounds who support health care agencies with three major functions:

• providing clinical ethics consultation

• developing and/or revising policies pertaining to clinical ethics and hospital policy (e.g., advance directives, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement)

• facilitating education about topical issues in clinical ethics

Who can ask for an ethical committee?

In most agencies, any person seeking ethical advice, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committeee

Issues in Healthcare Ethics

• Paternalism

• Deception

• Privacy and Social media

• Confidentiality

• Allocation of Scarce Nursing Resources

• Valid Consent or Refusal

• Conflicts Concerning New technologies

• Unprofessional, Incompetent, Unethical or Illegal Practices

• Right to Life

Paternalism

Acting in a way that overrides a patient's autonomy, under the justification of promoting their best interests. While well-intentioned, it fails to respect the patient as a decision-making partner

Deception

involves intentionally misleading or withholding information from a patient, which violates principles of honesty, trust, and respect for autonomy (like saying you’ve administered many shots before even though it is your first—-helps decrease patient xiety)

Privacy and Social Media

raise concerns about inadvertently disclosing patient information or crossing appropriate nurse-patient boundaries through online interactions

Confidentiality

requires safeguarding patients' private health information and only sharing it with those directly involved in their care, as mandated by HIPAA regulations

Allocations of Scarce Nursing Resources

like staffing, equipment or treatments must be guided by ethical principles of justice, fairness and maximizing benefits

Valid Consent or Refusal

requires ensuring patients have appropriate decision-making capacity and sufficient comprehension before agreeing to or refusing care

Conflicts Concerning New Technologies

like gene editing, AI, or experimental treatments necessitate ethical scrutiny to uphold principles like beneficence and non-maleficencee

Unprofessional, Incompetent, Unethical or Illegal Practices

Nurses have an ethical duty to report unprofessional, incompetent, unethical or illegal practices by colleagues that risk patient safety or welfare

Right to Life

• Abortion

• Quality of life

• Euthanasia/Physician assisted suicide

Constitutional Law

derived from federal and state constitutions to protect fundamental rights

Statutory Law

enacted by legislative bodies like Congress or state legislatures

Civil Law (nurse practice acts)

that protect individual rights and provide remedies for civil wrongs

Criminal Law

define offenses like felonies (serious crimes) and misdemeanors (less serious crimes)

Administrative Law

regulations issued by government agencies to implement and enforce statutory laws

Federal Statuets Affecting Nursing Practice

• Patient Protection and Affordable Care Act (PPACA)- Consumer rights and protections, Affordable health care coverage, Increased access to care, Quality of care that meets the needs of patients

• Emergency Medical Treatment and Active Labor Act- Prohibits the transfer of patients from private to public hospitals without appropriate screening and stabilization

• Health Insurance Portability and Accountability Act (HIPAA)- Provides rights to patients and protects employees

• Health Information Technology Act- Nurses must ensure PHI is protected

• Americans with Disabilities Act (ADA)- Protects rights of people with physical or mental disabilities

• Uniform Anatomical Gift Act- Provides the foundation for the national organ donation system

• The Omnibus Budget Reconciliation Act (1986)- Altered the way in which health care is provided to older adults

Patient Self Determination Act

Requires health care institutions to provide written information to patients concerning their rights to make decisions about their care, including the right to refuse treatment and to formulate an advance directive

Informed Consent

• Explanation of the procedure

• Names and qualifications of people performing procedure

• Description of the risks that may occur

• Explanation of alternative therapies and the risks of doing nothing

• Client has the right to refuse the procedure or treatment without discontinuing other supportive care

• Client may refuse the procedure or treatment even after the procedure has begun

Nurse Practice Acts

• Texas Board of Nursing

• State laws intended to protect citizens, make nurses accountable and assure that care is consistent with best practice within the scope and standards of nursing

• Responsible for licensure

• Nurse licensure compact

State Statutes Affecting Nursing Practices

• Good Samaritan laws- protect helpers from being sued for unintentional harm during an emergency rescue

• Public health laws- require reporting diseases and ensuring vaccinations to keep communities healthy

• Termination of pregnancy- set rules for when abortions are legal

• Physician-assisted suicide- allow doctors to prescribe lethal medication in some states for terminally ill patients to end their life

Nursing Workforce Guidelines

• Staffing and nurse-to-patient ratios- ensure enough nurses for safe patient care

• Nursing assignments- determine which nurses care for which patients

• Patient abandonment- unethically leaving a patient without ensuring continued care

• Nurse delegation- allows assigning tasks to qualified staff with supervision

• Nursing students- follow rules on permissible activities under supervision

• Hospital guidelines and policies- standardize practices for optimal patient care

Negligence

Conduct that falls below the generally accepted standard of care of a reasonably prudent person

Malpractice

A type of negligence; the person being held liable for malpractice must be a professional

Malpractice Insurance

Contract between an insurance company and a nurse or employer that is intended to cover costs incurred when a patient sues the employer and/or the nurse

Reducing Legal Risk

In addition to being aware of the actions taken at the organizational level by your employer, it is important that you remain involved in the nursing profession to reduce your personal legal risk

Risk Management and Performance/ Quality Improvement

Programs help to reduce a nurse’s legal risk for malpractice and negligence because they help to identify potential hazards and eliminate them before harm occurs

Professional Involvement

• It is important to implement actions in your own practice that will help reduce your legal risk.

• Develop and use clinical judgment to identify patient needs and make sound clinical decisions.

• Remain aware of current issues in healthcare.

• Become involved in professional organizations and committees that define the standards of care for nursing practice

Nurse Experts

When a case that involves nursing care is filed, a nursing expert will often testify about the standards of nursing care as applied to the facts of a case

Documentation

• Key communication strategy

• Produces a written account of patient data, clinical intervention and patient responses

• Available to all members of the healthcare team

• Allows others to track a patient’s clinical course

Purpose of Healthcare Record

• Facilitates interprofessional communication

• Provides a legal record of care

• Provides justification for financial billing and reimbursement of care

• Supports the process of needed for quality and performance improvement

• Serves as a resources for education and research

Legal Documentation

Documenting all aspects of the nursing process is a critical nursing responsibility that limits nursing liability by providing evidence that you maintained or exceeded practice standards while taking care of patients

Interdisciplinary Communication

• The quality of the patient care depends on your ability to communicate with other team members of the healthcare team

• When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur.

Mistakes in Documentation that commonly result in malpractice

• Failing to record pertinent health or drug information

• nursing actions

• medication administration

• drug reactions

• changes in patients’ conditions

• incomplete or illegible records

Confidentiality

• Nurses are legally and ethically obligated to keep all patient information confidential.

• Nurses are responsible for protecting records from all unauthorized readers.

• HIPAA requires that disclosure or requests regarding health information be limited to the minimum necessary.

• Physical security measures include placing computers or file servers in restricted areas or using privacy filters for computer screens (LOG OFF WHEN YOU ARE AWAY/DONE!).

• You must safeguard any info that is printed from the record

• You need to de-identify all patients' data when you write it onto forms or include it in papers (use initials, DO NOT USE THEIR NAME!)

• Shred everything that is printed when the information is no longer needed

• Only members of the health care team who are directly involved in a patient’s care have legitimate access to the medical record.

• Nurses may use health care records for data gathering, research, or continuing education. As long as a nurse uses a record as specified and permission is granted

• You can review your patients’ medical records only for information needed to provide safety and effective care.

• Breaches of confidentiality can lead to disciplinary action by employers and dismissal from work or nursing school

Do’s of Documentation

• Do sign name and follow with title SN for student nurse

• Do use black ink for all entries

• Do assure all forms have patient’s label

• Do use only hospital approved abbreviations

• Do record when physicians are notified and their recommendation

• Do write neatly

• Do use military time

• Do document in a timely manner

• Do note “Late Entry” if out of sequence

• Do draw a single line through a mistake and document “error” above with your initials and date

Don’ts Documentation

• Do not chart your personal opinion

• Do not falsify a record

• Do not chart in advance

• Do not leave blanks

• Do not erase or use white out

• Do not use general words like “appears”

• Do not make assumptions about an accident…only the facts

• Do not put an incident report on the chart

Types of Patient Report

• change of shift

• transfer report

• report to provider

What should you include in the change of shift/hand off report?

• Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians

• Current appraisal of each patient’s health status

• Current orders (especially any newly changed orders)

• Abnormal occurrences during your shift

• Any unfilled orders that need to be continued onto the next shift

• Patient/family questions, concerns, needs

• Reports on transfers/discharges

Incident Reports

• any event that is not consistent with the routine, expected care of a patient or the standard procedures.

Ex. if a patient falls

What is included in the incident report?

1. What you observed

2. Follow-up actions taken, including notification of the patient’s health care

3. Patient response

   • Do not include any reference to an incident in the medical record

Proving Nursing Negligence

1. The nurse owed a duty of care to the patient

2. The nurse breached that duty by failing to meet the standard of care

3. The breach caused injury or harm to the patient

4. Actual damages occurred as a result of the negligence

   • Proving all four elements of duty, breach, causation, and damages is required for a successful negligence claim against the nurse.

What decreases the risk for Catheter Associated Urinary Tract Infections (CAUTI)?

hanging the urinary drainage bag below the level of the bladder

S/S of Congested heart failure

• Shortness of breath (dyspnea)

• fatigue

• edema (swelling) in the legs and ankles

• chest pain or discomfort

• persistent cough or wheezing

• lack of appetite

• nausea

• difficulty sleeping

• Patients may experience weight gain

• abdominal bloating

• confusion (due to the buildup of fluid)

• Listening to lung sounds can reveal crackles or wheezing indicating pulmonary congestion

S/S of Right Sided Heart Failure

• swelling in the legs, ankles, and abdomen due to fluid buildup

• may also be weight gain

• fatigue

• loss of appetite

• jugular venous distention in the neck

• discomfort in the abdomen from enlargement of the liver (hepatomegaly)

• Shortness of breath is not typically a primary symptom unless right-sided failure develops secondarily from left-sided heart failure.

S/S of Left Sided Heart Failure

• shortness of breath (dyspnea)

• fatigue

• dizziness

• confusion due to poor oxygen supply

• coughing, wheezing, crackles in lung bases from pulmonary congestion

• paroxysmal nocturnal dyspnea (waking up gasping for air)

• decreased exercise tolerance

• As the left ventricle fails to pump sufficiently, blood backs up into the lungs, causing breathing difficulties.

How does Left Sided Heart failure lead to Right Sided Heart failure?

Left-sided heart failure, where the left ventricle cannot effectively pump blood out to the body, can ultimately lead to right-sided heart failure as well. As the left side fails, increased pressure backs up into the lungs and pulmonary circulation. This added strain on the right ventricle over time can cause it to weaken and fail, resulting in a cascading effect where both ventricles struggle to pump properly. So left-sided heart failure is often the initial underlying cause that subsequently contributes to failure on the right side as well.

Nightingale (environment)

Meeting the personal needs of the patient within the environment

• Advocated the principles of the cleanliness and nutrition in promoting health

• reformed hospitals, organized and provided nursing care, collected and analyzed statistics

Peplau (interpersonal)

nursing is a therapeutic, interpersonal, and goal oriented process

Henderson (independence)

the patient is a person who requires help to reach independence

Orem (self care)

self care is a human need; deficits require nursing works well in all steps of the nursing process

Roy (adaptive modes)

needs are created within interrelated adaptive modes; physiological, self concept, role function and independence

Newman (stressors)

humans are in constant relationship with stressors in the environment

Leininger (transcultural)

caring is the central theme of nursing care, knowledge and practice…provides the foundations of transcultural nursing care