Week 2 PowerPoint and Note

Health -objective process (functional stability, balance, and integrity);relates to disease, illness and wellness

Disease - objective, pertains to ‘ill health’, seen and managed by medical science

Illness - subjective experiences of either loss of health

Wellness - the subjective experience of health

Teleology - study of ends or final causes

Exacerbation of Disease - reappearance of symptoms and reactivation of disease

Healthcare Models

Medical model - healthcare model that views health is absence of disease

Holistic model - healthcare model that considers all parts of the person and focuses on positive aspects of health

Indigenous Wholistic Theory of Health - similar to holistic model of health; considers mental, physical, cultural and spiritual well being, of the person AND community.

Wellness model - builds on medical and holistic models. Emphasizes the ability of individuals/groups to cope with health-related challenges.

Ethical Theories

Deontology - ethical concept of defining actions as right or wrong

Utilitarianism (consequentialism) - ethical concept that the value of something is determined by its usefulness

Bioethics - ethical concept that actions are obligation based, outcome oriented, and based on reason. 4 principles of autonomy, beneficence, nonmaleficence, justice

Feminist Ethics - ethical concept that focuses on continuing injustices between people, being attentive to issues of difference, power dynamics.

Relational Ethics - ethical concept that ethical understandings are formed in, and emerge from, a person’s relationships with others. 4 themes: Environment, Embodiment, Mutuality, Engagement

Virtue Ethics - ethical concept looks at ethical character of making decision rather than their reasoning

Divine Command - ethical concept follows philosophies and rules set out by higher power

Code of Ethics for Nurses

statement of ethical values of nurses and of nurses commitments to person with health care needs

A. Providing safe, compassionate, competent, ethical care

B. Promoting Health and well-being

C. Promoting and respecting informed decision making

D. Honoring dignity

E. Maintaining privacy and confidentiality

F. Promoting justice

G. Being accountable

Ethical Issues

Advance Care Planning - multidimensional process that involves health care providers in discussion with patients to ensure they clearly understand their illness, its trajectory, and treatment options

Medical Futility - medical treatment that is considered impossible or unlikely to receive its therapeutic goal

Moral Distress - inability to act according to moral judgment

Moral Integrity - doing right thing when nobody is watching

Moral Residue - distress that remains when the situation generating the moral. distress ends

Legal Implications in Nursing Practice

Professional Regulation

- nurses must be regulated by professional nursing association

- use of NCLEX

- registration may be suspended or revoked by regulatory body

Standards of Care

- legal guidelines for nursing practice

Nursing Practice Acts - define scope of nursing practice, sets educational requirements, distinguishes between nursing and medical practice

Regulation of Health Care Providers

Title Protection

- legally entitled to use specific designation

- defined scopes of practice

Educational Standards

- exams

- competency-based assessment programs to ensure continued maintenance of practice standard

License to Practice

- annual renewal of licenses

- regulators/educational facilities oversee regulation of their members

Controlled Acts

- must be preformed by registered professional

- may only be preformed in response to order given by physician or nurse practitioner or in accordance with conditions identified in regulation

Exceptions:

- first aid in emergency

- students learning to perform act

- person, such as caregiver, trained to perform act

- appropriate person designated in accordance with religion ( rabbi circumcision)

Delegated Acts

- means by which regulated health professional transfers legal authority or permits another person to carry out a controlled act they are otherwise unqualified to do

- acts that can be delegated defined by provincial regulations

- acts in most jurisdictions cannot be sub-delegated

- delegating health care professional, delegate, facility share responsibility for the act

5 Controlled Acts Authorized to RPNs and RNs

1. Performing a prescribed procedure below the dermis or a mucous membrane.

2. Administering a substance by injection or inhalation.

3. Putting an instrument, hand or finger i. beyond the external ear canal, ii. beyond the point in the nasal passages where they normally narrow, iii. beyond the larynx, iv. beyond the opening of the urethra, v. beyond the labia majora, vi. beyond the anal verge, or vii. into an artificial opening into the body.

4. Dispensing a drug.

5. Treating, by means of psychotherapy technique delivered through a therapeutic relationship

Dimensions of Wellness

Physical, mental, emotional, intellectual, social, spiritual, environmental, intellectual, social, spiritual, environmental, occupational

Week 3 Review

Evolution of Canadian Health Care System

Social Safety Net - network of national, provincial, social programs in place to protect vulnerable members of society

Medicare - Canadian insurance scheme that provides prepaid access to medically necessary hospital/physician services to citizens and permanent residents

Indian Act - identified the federal government’s role in providing healthcare to Indians

Early Healthcare in Canada

- Tommy Douglas of Saskatchewan introduced medical insurance for all in Canada (HIDSA paid 1/2 cost); lead to Medical Care Act of 1966

- Federal government enacted the Canada Health Act in 1984, amalgamated HIDSA and Medical Care Act; banned extra billing and user fees associated with previous 2 acts

* Principles of Canada Health Act *

Public Administration - provincial/territorial plans operate on nonprofit basis

Comprehensiveness - covers medically necessary services (may differ in provinces)

Universality - Free of discrimination based on race, gender, ethnicity, religion

Portability - ability to access healthcare services in another province/territory without cost/penalty

Accessibility - based on medical need regardless of ability to pay

- excludes Canadian Forces, RCMP, Veterans, Federal inmates, Refugees as they are federally covered

* Organization and Governance of Health Care

Federal Jurisdiction

- set/administer Canada Health Act Principles

- Assist in financing services through transfer payments

- Deliver/co-deliver health services to targeted groups

- Provide national policy/programming to promote health/prevent disease

Provincial/Territorial Jurisdiction

- manage, finance, plan insurable health care services

- determine location of healthcare facilities

- Reimburse physician and hospital expenses and provide co-payment with users for rehabilitation

Primary Health Care

- initially envisioned at addressing non-medical determinants of health by connecting health status and social determinants of health

- philosophy/model for improving health with emphasis on principles of health promotion/disease prevention

- building spectrum of programs and services beyond traditional health care system

- distinct from primary care as primary care focuses on personal health and primary health care extends

*Levels of Primary Health Care

Level 1: Health Promotion

- enabling people to increase control over and impact their health

- i.e antismoking efforts, advocacy of healthy public policy

Level 2: Disease/Injury Prevention

- illness prevention services to help clients reduce risk factors

- i.e immunization, support groups, climate control action

Level 3: Diagnosis/Treatment

- recognizing and managing existing health problems

*** Three Levels:**

Primary Care - first contact of patient and leads to decision regarding action to resolve health problem. Physicians + NPs, early detection, routine care, education

Secondary Care - specialized medical service by physician specialist or hospital on referral from PC practitioner

Tertiary Care - Specialized technical care in diagnosing and treating complicated health problems. Specialized hospitals that have sophisticated equipment

Level 4: Rehabilitation

- interdisciplinary effort

- improve health and quality of life facing life-altering conditions

Level 5: Supportive Care

- illness/disabilities that are chronic and progressive

- health, personal, social services provided over prolonged period

Respite care - short-term relief or time off for family care givers by health care providers

Development of Nursing in Canada

First Nurses/Hospitals in New France

- Marie Rollet Herbert confronted notion that Indians needed saving

- Male attendants at “sick bay”

- Jesuit priests, allied mission to convert Indians

Grey Nuns

- 1738 “agreed to combine possessions in a house of refuge for the poor”

- operated several businesses to make funds

- took work in remote areas to treat people

- term “grey nun” is derogatory, referred to their unusual work

Health Care and Educational Reform

Jordan’s Principle - if disagreement between 2 governments for status Indian, government first contacted should pay

* 1932 The Wier Report

- concerns of quality of nursing education and exploitation of nursing students led to nationwide study in nursing education

- Resultant scrutiny of nursing education in Canada: insufficient classroom instruction and lack of variety in clinical experience

- recommended nurse preparation be transferred from hospital to general education system

1965 Royal Commission on Health Services

- Instrumental in transition away from hospital training schools

- First to Colleges as 3 year diploma programs, then they became housed in universities

1974 Lalonde Report

- stated that health is determined by more than just biology

1978 Alma-Alta Conference

- health for all 2000

- expanded on by Ottawa charter for health promotion

Week 4 Review

Fiduciary Relationship - a relationship in which a professional provides services that, by the nature, cause the recipient to trust in the specialized knowledge and integrity of the professional

Legislation – laws developed with a specific intent (such as directing the actions of nursing). Usually provincially  Regulation – the act of being registered in a professional capacity

Sources of Law

- constitution divides areas of responsibility between provincial and federal government

- civil law in Quebec and common law in rest of country

Constitutional Law - relationship between people and government (fundamental freedoms)

Statute Law - created by elective legislative bodies such as parliament/provincial legislators. Federal statues apply throughout the country, provincial only in provinces created.

Regulatory Law - legally binding feature of an act

Tort Law - person/property wrongly harmed by another

Contract Law - private agreements that are generally enforceable by court

Criminal Law - wrongful act or wrongful intent

Legal liability issues in Nursing Practice

Tort - civil wrong committed against person or property

Intentional Tort - willful act to violate patient’s rights. (Assault, battery, invasion of privacy, false imprisonment)

Unintentional Tort - negligence, conduct that does not meet the standard of care established by law

Advance Directive - mechanism enabling mentally competent patient to plan for a time where they may lack mental capacity to make medical treatment decisions

Living Will - document in which person makes anticipatory refusal of life-prolonging measures during a state of mental incompetence

Abandonment, Assignment, Contract Issues

Short staffing - nurses should not walk out (charges of abandonment)

Floating - should not float unless adequately trained in areas

Prescriber’s Orders - obliged to follow physician’s orders unless they are in error, violate hospital policy, or harm patients

Standard Statements

1. Appropriate Health Care Provider

nurses must consider each situation to determine if performance of procedure promotes safe client care, and if it is appropriate for a nurse to perform procedure

2. Authority

nurses ensure they have appropriate authority before performing procedures

3. Competence

nurses ensure they are competent in both cognitive and technical aspects of procedure prior to performing it

4. Managing Outcomes

prior to performing procedures, nurses ensure they are able to identify potential outcomes of procedures, have authority and competence to manage outcomes of procedures, or have resources available to manage outcomes

Nursing Act 1991

* 6 Criteria Nurses Must Meet to Become Registered

(The regulatory body is responsible for enacting the legislation passed for the profession to operate, and ensuring the members are registered and competent. Any regulatory body's mission is to : PROTECT THE PUBLIC)

1. Nursing Education from an approved educational institute

2. Evidence of recent practice (which you get at the educational institution)

3. Passing the jurisprudence exam Jurisprudence examination

4. Proficiency in English / French (only French in Quebec)

5. Past Offenses and Legal Findings

6.  Attestation of Health and Good Conduct

Week 5 Review

Levels of Critical Thinking

Basic Critical Thinking

- concrete, based on rules/procedures

Complex Critical Thinking

- separate thinking process from those of expert others, analyze/examine choices more independently

Commitment

- anticipate need to make choices, assume responsibility + accountability for those choices

Components of Critical Thinking

Specific Knowledge Base

Experience

Critical Thinking Competencies

Diagnostic reasoning - process of determining patient’s health status after you make physical and behavioral observations

Clinical Inference - process of drawing conclusions from related pieces of evidence

Clinical Reasoning - term used to describe cognitive process of thinking about patient issues, making inferences, deciding on action to be implemented in certain scenarios

Nursing Process

Attitudes for Critical Thinking

- knowing when you need more information, recognizing personal biases

Standards for Critical Thinking

Intellectual Standards - thoroughness, precision, accuracy, consistency

Professional Standards - ethical criteria for nursing judgments, evidence-informed criteria, professional responsibility

Developing Critical Thinking Skills

Analytic Interpreting - expand on noticing aspects by focusing on one family member at a time

Intuitive Interpreting - immediate apprehension of clinical situation and is a function of exposure to similar situations

Narrative Interpreting - understanding particular case and is viewed through interpretation of human concerns, intents, morals

Reflection-in-action - consider how planned interventions are having an impact moving toward

Three Factor Framework

- framework used to determine which nurse category need to meet patient needs (RN/RPN)

1 Client Factors

- complexity: variability of client’s condition and care requirements

- predictability

- risk of negative outcomes

2 Nurse Factors

- factors that affect a nurses ability to provide safe/ethical care to client

- limits of individual competence

3 Environment Factors

- practice supports, consultation resources and the stability/predictability of the environment

- less stable the factors, the greater the need for RN staffing

Week 6 Review

Nursing Diagnosis - nurse’s perspective on the appropriate focus for the patient

Metaparadigm - set of concepts that define the important characteristics of a phenomena

Types of Theories

Grand - broad theory, structural focus

Middle-Range - theory that encompasses more middle-scope and less abstract

Descriptive - theory that describes phenomena, speculates on why they occur, describes consequences

Prescriptive - addresses nursing interventions, helps predict consequences of intervention

Metaparadigm Concept

- key bodies of knowledge needed to understand nursing process

Client and Person

- nurses do more than care for hospitalized patients

- use term client rather than patient

Environment

- person is part of and interacts with a complex environmental system

Health

- recognizes as more than just absence of disease; ideal state of optimal health/wellbeing

Nursing

• View of client with understanding of person’s environment, life, health goals

Ways of Knowing

Personal: Understanding of self and others through own our experiences (includes experiential knowing) Empirical: Use of data and scientific methods (Rationalism and scientific inquiry) Ethical: What is morally correct & ought to be versus what is or what is desired. We use this a lot in ethical dilemmas Esthetical: The ‘art’ of nursing. Not the scientific aspect but expressed through art, music, non-linear type activities. Finding a meaning in life.

Emancipatory: socio-political awareness – critical examination of things outside the issue that contribute to the issue. Used in advocacy and ‘standing up’ for your clients. (current push for decriminalization of small amount of drugs, safe injection sites, etc)

Major Theoretical Models

Practice-based theories - theories that reflect issues that shape rate and context of nursing

Needs theories - theories that conceptualize patient as representing a collection of needs

Interactionist Theories - theories that detail the relationships between nurses and their clients

Systems Theories - theories that account for whole of entity (system) and its component parts (subsystems) and their interactions

Simultaneity Theories - Human beings and environmental factors are viewed as energy fields which change continuously

Guiding Ethical Principles for Research in Canada

1. respect for human dignity

2. respect for persons

3. concern for welfare

4. respect for privacy and confidentiality

5. justice

PICOT Questions and Nursing Research

P: patient population of interest I: intervention of interest C: comparison of interest O: outcome T: time

- 3 levels of questions (What? What is relationship? Why?)

- “What” is qualitative

- “What is relationship?” and “Why?” are quantitative

Ethical Values (CNO)

• client well-being;

• client choice;

• privacy and confidentiality;

• respect for life;

• maintaining commitments;

• truthfulness; and

• fairness.

Six Principles of Code of Conduct

1. Nurses respect the dignity of patients and treat them as individuals

2. Nurses work together to promote patient well-being

3. Nurses maintain patients’ trust by providing safe and competent care

4. Nurses work respectfully with colleagues to best meet patients’ needs

5. Nurses act with integrity to maintain patients’ trust

6. Nurses maintain public confidence in the nursing profession.

Code of Ethics For Nurses

statement of ethical values of nurses and of nurses’ commitments to person with health care needs A. Providing safe, compassionate, competent, ethical care B. Promoting Health and well-being C. Promoting and respecting informed decision making D. Honoring dignity E. Maintaining privacy and confidentiality F. Promoting justice G. Being accountable

Social Determinants of Health

• Income and social status

• social support networks

• education and literacy

• employment and working conditions

• physical environments

• biological and genetic endowment

• individual health practices and coping skills

• healthy child development

• gender

• culture

• social environments

Determinants of Health (Lalonde 1974)

• human biology

• health care systems

• environment

• lifestyle