Barkley/FNP-Practice Issues Part I

Health literacy

1. This is the degree to which patients have the capacity to obtain, process, and understand basic health care information and services necessary to make appropriate health care decisions.

   1. Considered to be the single best predictor of one’s health status.

2. The average adult in America reads at an eighth-grade level.

3. Medical/health information literature should be written at no higher of a grade level than 6th to 8th grade.

Legislative and regulatory processes

1. Accreditation guidelines

   1. Often laid out by the Joint Commission

2. Joint Commission also lays out National Patient safety Goals and areas of concern for health care professionals in accredited institutions.

3. Goals in acute/critical care:

   1. Proper identification of patients and relevant health data (e.g., blood types)

   2. Proper staff communication

   3. Safe use of medications:

      1. Proper labeling

      2. Proper care and mindfulness when treating patients taking anticoagulants

      3. Proper knowledge and patient counseling on medication, including maintaining list of current agents and checking for possible interactions.

   4. Ensuring alarms are easily heard and responded to intimate.

   5. Prevention of infection.

      1. Maintaining set standards of hygiene, including hand cleaning

      2. Use of proven guidelines to treat resistant infections

      3. Use of proven guidelines to prevent infection of blood from central lines

      4. One of proven guidelines to prevent infection after surgery

      5. Use of proven guidelines to prevent UTI from catheter

   6. Prevention of mistakes in surgery via proper marking of surgical areas and pausing to evaluate process.

4. Rules laid out by the institution that may provide further qualifications and restrictions on the role of healthcare staff (e.g., the duties, responsibility, and privileges of AGACNPs).

Economics

1. Resource utilization involves:

   1. How consumers use health care resources and services.

   2. How patients interact with health care providers.

   3. Special concerns in acute care:

      1. Length of stay

      2. Top reasons for hospitalizations

      3. Long-term care

      4. Emergency room and primary care clinic utilization

Multidisciplinary Response Team (MRTs)

1. Team of multiple health care professionals across various disciplines, assembled to deal with emergency situations.

2. Rapid Response Team: Deals with rapid deterioration in health, such as respiratory distress or cardiac arrest:

   1. Physician/AGACNP

   2. Nurse

   3. Respiratory therapist

   4. Others per institutional protocol

3. Institutional disaster: A mass casualty event which MRTs frequently train to intervene:

   1. Pandemic

   2. Terrorist attack/mass shooting

   3. Natural disaster

   4. Large chemical exposures

   5. Large fires/explosions

CAGE-AID

Useful assessment tool

Drug and alcohol use

Wong-Baker FACES Pain Rating Scale

Useful assessment tool

Assesses pain

Self-assessment tool

Patient rates pain by choosing among six faces, ranging in expression from smiling to crying.

Critical-Care Pain Observation Tool (CPOT)

Useful assessment tool

Tool designed to be used in the critical care unit to assess pain.

Assesses 4 behavioral categories:

1. Facial expression

2. Body movements

3. Muscle tension

4. Compliance with the ventilator (intubated patients) OR vocalization (extubated patients)

Each category is scored 0, 1, or 2.

Total range of scores is 0-8.

Confusion Assessment Method for the ICU (CAM-ICU)

Useful assessment tool

Tool designed to be used in the critical care unit to assess for delirium, including altered mental status and disorganized thinking.

Four features:

1. Acute onset of mental status changes or fluctuating course

2. Inattention

3. Disorganized thinking

4. Altered level of consciousness

Should be conducted every day/shift with the ICU patient

Clock drawing test

Useful assessment tools for geriatric populations

To assess dementia and delirium

Used to assess for cognitive impairment

Patient is asked to draw numbers in the circle to make the circle look like the face of a clock and then draw the hands of the clock to read “10 after 11.”

The clock is scored 1 to 6, with a score >3 representing cognitive deficit.

Can also assess with Mini-Mental State Examination (MMSE)

Index of Independence in Activities of Daily Living (Katz Index of ADL)

Useful assessment tools for geriatric populations

Used to assess Functional assessment/ADLs

Can be used to assess the progression of an illness, need for care, and effectiveness of treatment and rehabilitation.

Assess six self-care functions: Bathing, dressing, toileting, transferring, continence, and feeding.

Get-up and Go Test

Useful assessment tools for geriatric populations

To assess gait and immobility/fall risk

Short test that measures a patient’s risk of falling.

The patient is asked to rise from the chair, stand still momentarily, walk a short distance, turn around, walk back to the chair, turn around, and then sit down in the chair.

The patient’s performance is rated 1 to 5, with a score > 3 indicating a risk of falling.

1. 1 = Normal

2. 2 = Very slightly abnormal

3. 3 = Mildly abnormal

4. 4 = Moderately abnormal

5. 5 = Severely abnormal

Pain assessment in Advanced Dementia Scale

Useful assessment tools for geriatric populations

Tool used to measure pain in older patients with dementia.

Five behaviors of the patient are observed: Breathing, negative vocalization, facial expression, body language, and consolability.

Each behavior is scored on a scale of 0 to 2, with 0 indicating no pain.

1. 1-3 = Mild pain

2. 4-6 = Moderate pain

3. 7-10 = Severe pain

Durable medical equipment (DME)

Equipment and supplies ordered by a healthcare provider for everyday or extended use.

What makes medical equipment this?

1. Durable (long-lasting)

2. Used for a medical reason

3. Not usually useful to someone who is not sick or injured

4. Used in home

5. Has an expected lifetime of at least 3 years.

Durable Medical Equipment (DME)

Examples of Medicare-covered these:

1. Beds (air-fluidized and hospital)

2. Sleep apnea and CPAP devices

3. Canes

4. Crutches

5. Manual wheelchairs, power mobility devices

6. Walkers

7. Traction equipment

8. Patient lifts

9. Commode chairs

10. continuous passive motion machine

11. Nebulizers and nebulizer medications

12. Oxygen equipment and accessories

13. Suction pumps

14. Blood glucose monitors and test strips

15. Infusion pumps and supplies

Assistive Devices

Devices whose primary purpose is to maintain or improve an individual’s functioning and independence.

Examples:

1. Wheelchairs

2. Prostheses

3. Hearing aids

Life Support Devices

Devices used by qualified health professionals to support life in critically ill people

Examples:

1. Balloon pump

2. Ventricular assist device

3. Dialysis

4. Transvenous pacers

Complementary and alternative medicine (CAM)

A term that refers to treatments that are used along with, or in place of, conventional medicine.

Focus is on the whole person.

Includes physical, emotional, mental, and spiritual health.

Examples:

1. Natural products

   1. Herbs

   2. Vitamins and minerals

   3. Probiotics

2. Mind and body practices

   1. Yona

   2. Chiropractic and osteopathic manipulation

   3. Meditation

   4. Massage therapy

   5. Acupuncture

   6. Relaxation techniques

   7. Tai chi

   8. Qi gong

   9. Healing touch

   10. Hypnotherapy

   11. Movement therapies

   12. Music

   13. Light therapy

3. Ayurvedic medicine

4. Traditional Chinese medicine

5. Homeopathy

6. Naturopathy

Integrative medicine

Bringing conventional and complementary approaches together in a coordinated way.

Examples:

1. Chronic pain: Incorporating mindfulness meditation with pain management programs

2. Symptom management: Acupuncture and meditation to help manage symptoms and side effects of cancer treatment.

Technology

Goals of this in nursing:

1. Enhance scope of practice and evidence-based practice.

2. Make practice knowledge-driven.

Nursing informatics

A specialty that integrates nursing science, computer science, and information science to manage and communicate date, information knowledge, and wisdom in nursing.

Through the use of information structures, information processes, and information technology, nursing informatics supports consumers, patients, and other providers in their decision-making in all roles and settings.

Roles:

1. Practice

2. Education

3. Government

4. Industry

Informatics

These competencies:

Beginning nurse:

1. Computer literacy

2. Information management

3. Know how to use nursing-specific software

4. Ability to use patient care technologies (e.g., monitors, pumps, medication dispensing)

Experienced nurse:

1. Skilled in information management and computer technology related to specific areas of practice (e.g., on trends of data)

Informatics nurse specialist:

1. Advanced informatics preparation

2. Assists practicing nurses in meeting information needs

3. Possesses skills for conducting informatics research along with theory development.

Benchmarking

Comparison and measurement of a healthcare organization’s services against other national healthcare organizations.

Benefits:

1. Helps leaders understand how their organization compares with similar organizations.

2. Allows for the sharing of best practices and evidence0based practice clinical research outcomes.

3. Four core principles:

   1. Maintaining quality

   2. Improving customer satisfaction

   3. Improving patient safety

   4. Continuous improvement

4. Examples:

   1. All patients who enter the hospital have a medication reconciliation completed upon admission.

   2. Hospital readmission rates for acute-care hospitals.

5. Meeting these:

   1. Management team must support the goal.

   2. Compliance must be measured.

   3. Organization must allocate time and resources for implementation.

Peer review

The process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice (American Nurses Association).

Stimulates professionalism through increased accountability and promotes self-regulation of the practice.

A formalized, systematic peer-review nursing practice is required for Magnet recognition.

Practice principles:

1. A peer is someone of the same rank.

2. Practice focused

3. Feedback is timely, routine, and a continuous expectation.

4. Fosters a continuous learning culture of patient safety and best practices.

5. Feedback is not anonymous.

6. Feedback incorporates the nurse’s development stage.

Therapeutic relationships

Establishing rapport and professional these:

1. Non-judgmental approach

2. Mutual trust

3. Professional boundaries

4. Confidentiality

5. Cultural competence

   1. Respect

   2. Spiritual needs

Therapeutic communication

1. Listen more than talk.

2. Open-ended questions

3. “Tell me.”

4. Never, “Why?”

5. Focus on feelings

   1. Mad, sad, glad, afraid, ashamed

6. Do not mince words; no euphemisms.

   1. “I am concerned about alcoholism.”

   2. “I’m sorry, but she died.”

FIFE Model

Often used to get an understanding of a patient’s concerns regarding illness.

Feelings: Fears, concerns, and other emotions regarding the condition.

Ideas: The patient’s understanding of the nature and cause of the condition.

Functioning: How the condition affects the patient’s everyday life.

Expectations: What the patient thinks/hopes might happen with the course of the condition, the NP’s care, the treatment regimen.

Crisis Intervention

1. Ensure safety/boundaries.

   1. Call security if necessary.

2. Establish trust/rapport.

Crisis/Acute Grief Therapeutic Communication

1. Acknowledge feelings.

2. Offer self.

Advance directive

Written statement of a patient’s intent regarding medical treatment.

The Patient Self-Determination Act requires that all patients entering a hospital should be advised of their right to execute this.

Healthcare Directive

Type of advance directive that may (or may not) include a living will and/or specifications regarding durable power of attorney in one or two separate documents.

Living Will

Written compilation of statements in document format that specifies which life-prolonging measures one does and does not want to be taken if he/she becomes incapacitated.

In the US, most states recognize these as long as the will is specific enough and addresses the problem at hand.

These often include granting durable power of attorney to a significant other to act as a proxy/agent/attorney-in-fact of the patient in making healthcare decisions should the patient become incapacitated. Essentially, the proxy is responsible for articulating the patient’s advance directive.

Power of attorney must usually be in writing before it will be honored by most institutions such as hospitals, banks, etc.

Health Insurance Portability and Accountability Act (HIPAA)

Title I of this protects health insurance coverage for workers and their families when they change or lose their jobs (i.e., Consolidated Omnibus Budget Reconciliation Act [COBRA]).

Title II of this, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

1. The Office for Civil Rights enforces this, which protects the:

   1. Privacy of individually identifiable health information.

   2. This Security Rule, which sets national standards for the security of electronic protected health information.

   3. Confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety.

HIPAA

“Covered entities” required to follow these regulations:

1. Health plans (health insurance companies, health maintenance organizations [HMOs], company health plans, and certain government programs that pay for health care, such as Medicare and Medicaid).

2. Most Health Care Providers (especially those who use electronic billing to health insurers)

3. Health Care Clearinghouses (those that process nonstandard health information data received from another entity into a standard, such as standard electronic formats)

HIPAA

Examples of this Protected Information:

1. Written information in the medical record.

2. Conversations among healthcare providers about one’s care or treatment.

3. Patient information stored in a health insurer’s computer system.

4. Patient billing information stored at a clinic.

5. Without a patient’s written authorization, a provider generally cannot:

   1. Disclose information to one’s employer

   2. Use or share a patient’s information for marketing or advertising purposes

   3. Share private notes about a patient’s health care.

The Privacy Rule: Patients’ Rights

1. See or receive a copy of their health records.

2. Have corrections added to their health information.

3. Receive a notice that tells the patient how their health information may be used and shared.

4. Decide if they want to give permission before their health information can be used or shared for certain purposes, such as for marketing.

5. Receive a report outlining when and why their health information was shared for certain purposes.

6. File complaints with one’s healthcare provider, health insurer, and/or the US government if their rights are being denied or if their health information is not being protected.

Situations for which health information is allowed to be viewed/shared

1. To ensure proper treatment and coordination of care.

2. To pay for healthcare services (e.g., physicians, NPs, hospitals, etc.)

3. With a patient’s family, relatives, friends, or others the patient identifies as being involved with their health care or bill payment (unless the patient objects)

4. To ensure quality care given by healthcare providers (e.g., physicians, NPs, nursing homes, etc.)

5. To protect the health of the public (e.g., reporting disease outbreaks)

6. To make required reports to the police (e.g., reporting gunshot wounds)

Confidentiality vs. “duty to warn”

1. The “duty to warn” supersedes the right to confidentiality if a patient’s condition may endanger others.

2. The duty to protect a patient from harming him/herself supersedes the right to confidentiality.

Invasion of privacy

Damaging one’s reputation as a result of information being shared without the patient’s permission.

The charge cannot be made if the information can be shown to have been accurate, given in good faith, and the receiver had a valid reason for obtaining the information (e.g., a consulting practitioner has a right to know specific patient information)

Health care delivery

General principles:

1. When initiating any change, you always begin at the most local level and then progress upward and outward. For example, you began at the hospital level, then the community, then the region, then the state, then national.

2. In treating patients, medical conditions are always treated first before psychosocial conditions.

3. Remember that the strongest method to evaluate teaching is returned demonstration. That is, “show me,” or “tell me what you understand based on what I just said,” grand rounds, etc.

4. Seriously ill or injured patients may need to be transferred to a tertiary facility, if full range of services are not available at the AGACNP’s current facility. Assess all injuries, stabilize, assess the capabilities of your facility, and then transfer (ship), as appropriate.

   1. Major maxillofacial injuries

   2. Severe Le Fort fractures of the skull:

      1. Le Fort 1: Floating palate

      2. Le Fort 2: Floating maxilla

      3. Le Fort 3: Floating face

5. Always fully educate your patient who is reluctant to undergo diagnostic or procedures about their condition.

6. Do not delay a patient’s discharge from a hospital or acute care facility for primary care screening exams that are not absolutely necessary.

7. Remember that the most powerful data collected from a patient is their subjective data, or data you observed as a nurse practitioner. Caution should be taken with the interpretation of family members, friends, and others.

Healthy People 2030

1. Access to health care and improved health are both major issues for health policy.

2. Continuance of Healthy People 2020 and the fifth iteration of the initiative established by the US Department of Health and Human Services (DHHS)

3. Goals:

   1. Increase the quality and years of healthy life

   2. Eliminate health disparities among Americans

4. Document contains hundreds of health objectives based on numerous focus area.

5. Objectives relate to equal access, availability, cost, quality of care, etc.

6. Used to understand health status of the nation and plan prevention programs.

7. Individuals, communities, and organizations are responsible for determining how to meet the goals of this.

“Reporting” statuses

Require practitioners to report specific health-related information; vary from state to state but commonly involve:

1. Criminal acts and injury from a dangerous weapon (police)

2. In most states, the NP must notify the Department of Health of the following diagnoses:

   1. Gonorrhea

   2. Chlamydia

   3. Syphilis

   4. HIV

   5. TB

   6. COVID-19

3. Animal bites (Animal Control; subsidiary of the DHHS)

4. Suspected or actual child or elder abuse (police via social services)

Collaborative practice

1. Exists to enhance the quality of care and improve patient outcomes.

2. The American Nurses Association’s Nursing: A Social Policy Statement (1995) described collaboration as a “true partnership” in which all players have and desire power, share common goals, and recognize/accept separate areas of responsibility and activity.

Navigating the health care system for patients

1. Social services

2. Psychiatric services

3. Physical therapy

4. Occupational therapy

Issues regarding access to care

1. Home health—Short, focused visits

2. Hospice—death dx of only 6 months or less; CMO order

3. Skilled nursing facilities—Unable to do ADLs; PT included

4. Private duty nursing—$$$

Palliative care

1. Multidisciplinary approach intended to improve quality of life of patients and their families facing a life-threatening illness, through the prevention and relief of suffering.

2. Key elements: Early identification, impeccable assessment, and treatment of pain and other problems (e.g., physical, psychosocial, spiritual)

3. Includes incorporating the skills of physicians, nurses, nurse practitioners, physician assistants, registered dietitians, social workers, psychologists, chaplains, massage therapists, among others.

4. This and hospice care both provide comfort.

5. Remember to ascertain if the patient has an advance directive to guide potential future decisions about this.

6. This can begin at diagnosis and at the same time as treatment.

7. Hospice begins after treatment is stopped and when it is determined that the patient will not survive an illness.

Health care financing

1. Coding: Evaluation and Management (E&M) codes to identify the level of care provided.

   1. Codes match the level of service provided to the complexity of the presenting patient problem.

2. Billing

3. Reimbursement

4. Third party payers

5. Two-thirds of health care expenses are allocated for multiple chronic conditions.

Categories of third-party payers

1. Medicare: Sets the standard for reimbursement and cutting costs.

2. Medicaid

3. Commercial indemnity insurers

4. Commercial management organizations (e.g., health maintenance organizations [HMOs])

5. Businesses or schools wanting health services for employees or students

Problem focused

Appropriate level physical exam documentation to determine levels of E/M services

A limited examination of the affected body area or organ system

Expanded problem focused

Appropriate level physical exam documentation to determine levels of E/M services

A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)

Detailed

Appropriate level physical exam documentation to determine levels of E/M services

An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).

Comprehensive

Appropriate level physical exam documentation to determine levels of E/M services

A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s)

Medicare A

Type of Medicare

Covers inpatient/hospitalization, skilled nursing facility services, home health services and/or hospice associated with the inpatient event; most individuals qualify to receive benefits at 65 years of age.

Medicare B

Type of Medicare

Covers physician services, outpatient hospital services, laboratory and diagnostic procedures, medical equipment, and some home health services.

Supplemental medical insurance requiring recipients to pay a premium

NPs and clinical nurse specialists (CNSs) receive 85% of physician reimbursement for services provided in collaboration with a physician.

Medicare pays 80% of the patient’s bill for physician services and the patient pays 20%.

Medicare C

Type of Medicare

A + B = C

Formerly known as “Medicare + choice”; now known as “Medicare Advantage”

Patients entitled to Medicare Part A and enrolled in Part B are eligible to receive all of their health care services through one of the provider organizations under Part C (e.g., HMOs, PPO, etc.)

Medicare D

Type of Medicare

Limited prescription drug coverage

Plans offered by insurance and other private companies are approved by Medicare.

Monthly premium required.

Co-pay on each prescription is required.

Penalty may be applicable if not enrolled when first eligible; assistance is available for people with limited income and resources.

Medicare rules for NPs

1. To qualify to be a Medicare provider, an NP must:

   1. Hold a state license as an NP

   2. Be certified as an NP by a recognized national certifying body.

   3. Hold at least an MSN degree

2. The practice facility accepts Medicare payment (i.e., 85% of physician schedule rate for bills submitted under the NPs provider number)

Medicare payments

1. Medicare reimburses NPs 85% of the physician fee delineated in Medicare’s Physician Fee Schedule.

2. Medicare pays NPs 80% of the 85% of the Physician Fee Schedule rate.

3. Practices must bill under the provider of the clinician who performs a given service. The exception is “incident-to” billing. When billing “incident-to” a physician’s service, a practice may be reimbursed 100% of the Physician Fee Schedule rate.

Incident-to Billing

Services billed under the physician’s provider number to get the full physician fee (100%) given the following rules:

1. The services are:

   1. An integral, although incidental, part of the physician’s professional service

   2. Commonly rendered without charge or included in the physician’s bill

   3. Of a type commonly furnished in physician’s offices or clinics

   4. Furnished under the physician’s direct personal supervision and are furnished by the physician or by an individual who is an employee or independent contractor of the physician. Direct supervision does not require the physician’s presence in the same room, but the physician must be present in the same office suite and immediately available.

2. The physician must perform “the initial service and subsequent services of a frequency which reflect his or her active participation in the management of the course of treatment.”

3. The physician/other provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is provided.

4. *Incident-to billing is not allowed in the hospital setting; an NP must bill under his/her provider number.

5. An NP may bill for an assistant’s work (e.g., performing an EKG under the NP’s provider number as long as the rules for incident-to billing are followed.

Other rules for billing

1. Physicians and NPs may see a patient on the same day for their services; however, the two must coordinate billing to avoid duplicate payments.

2. For inpatients, physicians and NPs must decide for which party (i.e., the NP or the physician) should bill, given the amount of services rendered by each on given day.

Medicaid

Federally supported, state administered program for low-income families and individuals

1. Benefits vary from state to state

2. These payments are made after other insurance or third-party payments have been made.

Case management

1. Involves a comprehensive and systematic approach to provide quality care.

2. Purpose: Mobilize, monitor, and control resources that a patient uses during a course of an illness while balancing quality and cost.

Quality Assurance (QA)/Quality Improvement (QI)/Continuous Process Improvement (CPI)

1. A management process of monitoring, evaluating, continuous review, and improving the quality in providing health care.

2. Quality Assurance: A process for evaluating the care of patients using established standards of care to ensure quality.

3. Based on the methodology developed by Deming and tested in Japanese industry that quality can be improved by continually monitoring structure, process and outcome standards (CQI)

   1. Structures: Inputs into care such as resources, equipment, or numbers and qualifications of staff.

   2. Process of care: Include assessments, planning, performing treatments and managing complications.

   3. Outcomes: Include complications, adverse events, short-term results of treatment and long-term results of patient health and functioning.

Quality Assurance (QA)/Quality Improvement (QI)/Continuous Process Improvement (CPI)

4. Used to assess, monitor, and improve care provided to patients.

5. Components include monitoring of care, quality, care appropriateness, effectiveness of care, cost of care, self-regulation and peer review to ensure compliance to care standards.

6. Quality and Safety Education for Nurses (QSEN) initiative:

   1. An initiative aimed at providing future nurses with the knowledge, skills, and attitude necessary to ensure continuous improvement in quality and safety of the respective healthcare systems.

   2. Identifies, funds, and promotes education across six key competencies:

      1. Patient-centered care

      2. Teamwork and collaboration

      3. Evidence-based practice

      4. Quality improvement (QI)

      5. Safety

      6. Informatics

Quality Assurance (QA)/Quality Improvement (QI)/Continuous Process Improvement (CPI)

7. Steps of Continuous Quality Improvement (CQI)/Quality Assurance (QA) (outlined by the Joint Commission)

   1. Quality planning (i.e., developing a quality management plan which assigns responsibility for degree of involvement)

   2. Delineate scope of care.

      1. Identify important aspects of care

      2. Identify indicators related to aspects of care.

   3. Establish thresholds for evaluation related to the indicators.

   4. Collect and organize data.

   5. Evaluate care when thresholds are reached.

   6. Take action to improve care.

   7. Assess the effectiveness of the action and document improvement.

   8. Communicate relevant information.

Quality Assurance (QA)/Quality Improvement (QI)/Continuous Process Improvement (CPI)

8. Critical path: Contains key patient care activities and time frames for those activities which are needed for a specific case type or diagnosis-related group (DRG)

9. Care Map: A newer version of the critical path and is a blueprint for planning and managing care delivered by all disciplines.

   1. The Care Map contains a critical path section plus a section that identifies common problems encountered by patients of a specific case type, the day-to-day goals that the patient must achieve, and the final desired clinical outcomes.

   2. Monitoring outcomes of care is a very important goal.

Root Cause Analysis

A tool for identifying prevention strategies to ensure safety.

1. A process that is part of the effort to build a culture of safety and move beyond the culture of blame.

2. Involves and incorporates:

   1. Inter-disciplinary experts from the frontline services

   2. Those who are the most familiar with a situation

   3. Continually digging deeper by asking why, why, why at each level of cause and effect

   4. Identifying changes that need to be made to systems

   5. A process that is as impartial as possible

Sentinel Events

1. Unexpected occurrences involving death or serious physical or psychological injury, or the risk therof

2. Serious injury specifically includes death, permanent harm, or severe temporary harm, among others.

3. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

4. Such events are called “sentinel” because they signal the need for immediate investigation and response.

5. The terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

6. In response to a sentinel event (e.g., falls in nursing homes or a colleague’s behavior that undermines a culture of safety), clinicians and institutions are expected to conduct a root cause analysis.

Scope of practice

1. Based on legal allowances in each State, according to and delineated by individual State Nurse Practice Acts of each State Board of Nursing (State of Licensure)

2. Provides guidelines for nursing practice; varies from state to state

State Practice Acts

1. Authorize Boards of Nursing in each state to establish statutory authority for licensure of registered nurses.

2. Authority includes use of title, authorization for scope of practice including prescriptive authority, and disciplinary grounds.

Prescriptive authority

1. The ability and extent of the NPs ability to prescribe medications to patients is dependent on state nurse practice acts.

2. While the Drug Enforcement Agency (DEA) has ruled that nurses in advanced practice may obtain registration numbers, state practice acts dictate the level or prescriptive authority allowed. The Consolidated Appropriations Act (2023) also requires that all DEA-registered practitioners (except veterinarians) have a one-time, 8-hour training on the treatment and management of patients with opioid or other substance use disorders.

Credentials

1. Encompass required education, licensure, and certification to practice as a nurse practitioner

2. Establish minimal levels of acceptable performance

3. Credentialing is necessary to:

   1. Ensure that safe health care is provided by qualified individuals

   2. Comply with federal and state laws relating to advanced practice nursing

4. Acknowledges the scope of practice of the NP

5. Mandates accountability

6. Enforces professional standards for practice

Licensure

1. Establishes that a person is qualified to perform in a particular professional role

2. Licensure is granted as defined by rules and regulations set forth by a governmental regulatory body (i.e., state board of nursing)

Certification

1. Establishes that a person has met certain standards in a particular profession which signify mastery of specialized knowledge and skills

2. Certification is granted by nongovernmental agencies (American Nurses Credentialing Center [ANCC] and the American Association of Critical-Care Nurses [AACN])

Credentialing and Privileging

1. Process by which a nurse practitioner is granted permission to practice in an inpatient setting.

2. Credentialing with hospital privileges is granted by a Hospital Credentialing Committee comprised of physicians who hold privileges at the given hospital where the NP has made request.

3. Privileges may be granted in part or full; stipulations regarding the allowance of future privileges may be made by the Credentialing Committee (e.g., number of additional supervised hours required before a certain privilege is granted).

Risk management

1. A systematic effort to reduce risk

2. Incident reports: The most common method of documentation

3. Satisfaction surveys: Important form for identifying problems before developing into actual incidents or claims; important to track and analyze just like incident reports

   1. Patient satisfaction surveys

   2. Employee and/or practitioner satisfaction surveys

4. Complaints: A key source of potential risk management information. A risk management plan should delineate tracking, analyzing and managing complaints.

5. Action taking initiatives:

   1. Prevention

   2. Correction

   3. Documentation

   4. Education

   5. Departmental coordination

Medical Futility

1. Refers to interventions that are unlikely to produce any significant benefit for the patient; “Does the intervention have any reasonable prospect of heal thing this patient?”

2. Two kinds of this are often distinguished:

   1. Quantitative futility: Where the likelihood that an intervention will benefit the patient is extremely poor, and

   2. Qualitative futility: Where the quality of benefit an intervention will produce is extremely poor.

Competence (decisional capability)

A state in which a patient is able to make personal decisions about his/her care

Implies the ability to understand, reason, differentiate good and bad and communicate

Informed consent

A state indicating that a patient has received adequate instruction or information regarding aspects of care to make a prudent, personal choice regarding such treatment.

Includes discussing all of the benefits AND risks with a patient in order to make a truly informed decision.

Generally, consent is assumed if the patient’s condition is life-threatening.

Right to refuse care

Patients must be advised at the time of their admission to a federally funded institution such as a hospital, nursing home, hospice, HMO, etc. that they have a right to refuse care (Danforth Amendment, 1991).

Care that may be refused includes any, some, or all, as long as the patient has a decisional capability (competence).

Ethics

The study of moral conduct and behavior which serves to govern conduct, thereby protecting the rights of an individual.

Nonmaleficence

The duty to do no harm

Utilitarianism

The right act is the one that produces the greatest good for the greatest number.

Beneficence

The duty to prevent harm and promote good.

Justice

The duty to be fair.

Fidelity

The duty to be faithful.

Veracity

The duty to be truthful.

Autonomy

The duty to respect an individual’s thoughts and actions.

History of the NP Role

1. The role of the NP developed in the early 1960s as a result of physician shortages in the area of pediatrics.

2. The first NP program was a pediatric NP program, begun in 1964, by Dr. Loretta Ford and Dr. Henry Silver at the University of Colorado Health Sciences Center.

3. Growth of the NP programs soon ensued with distribution of NPs in various practice settings with an emphasis on ambulatory and outpatient care.

4. The historical service of NPs in primary care resulted in part from the availability of federal funding for preventative and primary care NP education.

5. Movement of NPs expanded to the inpatient setting as a result of managed care, hospital restructuring, and decreases in medical residency programs.

6. Four distinct roles for the NP include expert:

   1. Clinician

   2. Consultant/collaborator

   3. Educator

   4. Researcher

Major steps in the research process

1. Formulating the research problem

2. Reviewing related literature

3. Formulating the hypotheses

4. Selecting the research design

5. Identifying the population to be studied

6. Specifying methods of data collection

7. Designing the study

8. Conducting the study

9. Analyzing the data

10. Interpreting the results

11. Communicating the findings

Nonexperimental research

A “no experiment” design; usually includes two broad categories of research, descriptive and ex post facto/correlational research:

1. Descriptive research aims to describe situations, experiences, and phenomena as they exist.

2. Ex post facto or correlational research: Examines relationships among variables

3. Other possibilities:

   1. Cross-sectional

   2. Cohort

   3. Longitudinal

Cross sectional

A type of non experimental research

A type of observational study that examines a population with a very similar attribute but differs in one specific variable (such as age); designed to find relationships between variables at a specific point in time or “surveys.”

Cohort

A type of nonexperimental or observational study; retrospective or prospective; compares a particular outcome (such as lung cancer) in groups of individuals who are alive in many ways but differ by a certain characteristic (e.g., female nurses who smoke compared with those who do not smoke)

Longitudinal

A type of non experimental research

A study that involves taking multiple measures of a group/population over an extended period of time to find relationships between variables.

Experimental research

Includes experimental manipulation of variables utilizing randomization and a control group to test the effects of an intervention or experiment (e.g., RCTs—Randomized Controlled Trials)

Quasi-experimental

This research involves manipulation of variables but lacks comparison group of randomization.

Qualitative

Includes case studies, open-ended questions, field studies, participant observation and ethnographic studies, where observations and interview techniques are used to explore phenomena through detailed descriptions of people, events, situations, or observed behavior.

1. Research bias is a potential problem.

2. Calls into question the generalizability of findings

3. Produces very rich data through no other means of research

PICOT

Useful framework to answer a clinical-based question

P = Patient (e.g., population)

I = Intervention (e.g., treatment)

C = Comparison (e.g., control)

O = Outcome (e.g., result; effectiveness of what is being measured)

T = Timing (e.g., duration of the measure/data collection)

Type 1 error

“False positive”

Incorrectly rejecting the true null hypothesis

Type 2 error

“False negative”

Failing to reject a null hypothesis which is false

Meta-analysis

Tests hypotheses by using numerous quantitative studies to systematically assess the results of previous research