Chapter 1 - Evolution of Nursing Thought and Action Flashcards
1854 - Crimean Conflict
Russia
Florence Nightingale and her staff of 38 nurses prove their worth by improving facility conditions and heal wounded soldiers decreasing mortality from 47% to 2%.
The Institute of Medicine (IOM) 2003 Core Competences for healthcare providers
Now the National Academies of Science, Engineering, and medicine. These core competencies are the basics for safe, effective nursing care.
- Patient-centered care
- Teamwork and collaboration
- Evidence-based practice
- Quality improvement
- Informatics
Florence Nightingale
Known as the “Founder of modern nursing” transformed nursing into a widely respected profession.
In the Crimean Conflict at the Scutari hospitals, soldiers were dying due to poor environmental conditions, poor nutrition, and lack of quality care.
Persisted to address the care the soldiers needed. Visited nightly with lamp called “Lady with the lamp”.
Decreased mortality, length of hospital stay, and rate of nosocomial infection.
Used clinical judgment, political connections, and social standing to ensure that nursing was recognized as a respected profession.
Other influential leaders in Nursing
Nursing presence on the battlefield became more common during the Civil War when the gov. established the Army Nursing Services to organize nurses and hospitals. Two of the nurses that were important are:
Dorothea Dix - served as Superintendent of the U.S. Army Nurses.
Clara Braton - provided care in tents set up close to the fighting. When the war was over, Barton continued this universal care through the establishment of the American Red Cross.
Others:
Lillian Wald and Mary Brewster - pioneers of public health nursing, founded the Henry Street Settlement in New York to fight the spread of diseases among poor immigrants.
Edward Lyon - first male nurse to receive a commission as a reserve officer.
Mary Mahoney - first African American graduate nurse in the United States, cofounded the National Association of Colored Graduates in 1908
Lavinia Dock - a nurse, feminist, and social activist, compiled the first manual of drugs for nurses in 1890.
Institute of Medicine (IOM)
- 2003
- Now the National Academies of Sciences, Engineering, and Medicine
- Identified quality and safety competencies that all health professionals are expected to demonstrate in their practice
- Provide client-centered care
- Work in interprofessional team
- Employ evidence-based practice
- Apply quality improvement
- Utilize informatics
Safe, Effective Nursing Care (SENC) Competencies
To implement full-spectrum nursing, a nurse must demonstrate the model concepts (thinking, doing, and caring) that are aspects of every competency.
- Provide goal-directed, client-centered care
- Collaborate with the interprofessional healthcare team
- Validate evidence-based research to incorporate into practice
- Employ evidence-based practice
- Provide safe, quality client care
- Embrace/Incorporate technological advances
Nursing today
- Nurses are competent and caring professionals.
- The complexity of healthcare delivery requires that nurses use critical thinking, communication, organization, leadership, advocacy, and technical skills to ensure that clients receive safe and effective care.
Nursing thinking skills
To be safe providers, nurses must carefully consider their actions and think carefully about the client, the treatment plan, the healthcare environment, resources, and safety.
Nurses use clinical judgment, critical thinking, and problem-solving as they care for clients.
- Clinical judgment
- Critical thinking
Clinical judgment
- Requires a strong, solid knowledge base. It involves a process that consists of recognizing and analyzing the cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes of the client’s condition to determine whether change has occurred.
- Careful consideration of the client’s condition, medications, and treatment in the evaluation of his health status
- Make decision
Critical thinking
- A reflective thinking process involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action.
- Nurses use critical thinking in every aspect of nursing care.
- Putting the dots together
Problem-solving
Considers an issue and attempts to find a satisfactory solution
Nursing is
- In 1980, the ANA defined nursing as “the diagnosis and treatment of human responses to actual and potential health problems”
- Nurses are a widely varied group of people with varying skills. They perform activities designed to provide care ranging from basic to complex in numerous healthcare environments. Therefore, it is not easy to describe the boundaries of the profession.
- In 2010, the ANA acknowledged five characteristics of registered nursing:
- Nursing practice is individualized. - person-centered care
- Nurses coordinate care by establishing partnerships (with persons, families, support systems, and other providers). - most important is patient
- Caring is central to the practice of the registered nurse.
- Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumers.
- A strong link exists between the professional work environment and the registered nurse’s ability to provide quality healthcare and achieve optimal outcomes.
The ANA as of 2015 defines professional nursing as follows:
- Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.
Why define Nursing
- Helps the public understand the value of nursing
- Helps differentiate activities of nursing from those of medicine
- Helps students understand what is expected of them
Roles and Functions of a Nurse
- Direct care provider
- Communicator
- Client/family educator
- Client advocate
- Counselor
- Change agent - Advocating for change on an individual, family, group, community, or societal level that enhances health.
- Leader
- Manger
- Case manager
- Research consumer
Important Qualities for Nurses
- Critical-thinking skills
- Monitor the client, note changes, and take actions to ensure safe and effective care.
- Caring and compassionate
- Show kindness, concern, and sincerity that convey to clients that you care about their well-being.
- Detail-oriented
- Pay attention to details to prevent and identify potentially harmful errors in care.
- Organizational skills
- Prioritize and meet the needs of the most critical clients first.
- Speaking skills
- Communicate correct and pertinent information to clients and members of the healthcare team.
- Listening skills
- Listen to clients’ concerns and feedback from the interprofessional healthcare team.
- Patience
- In stressful situations in the work environment, think clearly and take the correct actions.
- Competence
- Obtain the knowledge and skills to ensure safe, quality client outcomes.
- Emotional stability
- Develop the ability to cope with human suffering, emergencies, and other stresses.
- Physical stamina
- Perform physical tasks and endure long hours walking and standing.
Nursing: Profession, Occupation or Discipline?
One strategy used to describe a field of work is to categorize it as a profession, a discipline or an occupation
- Profession - meets criteria
- Technical and scientific knowledge; be evaluated by a community of peers; have a service orientation and a code of ethics (Starr, 1982).
- More autonomous in controlling the practice environment
- Discipline - meets criteria
- Scientifically based and self-governed
- Driven by aspect of there and judgment
- A profession must have a domain of knowledge that has both theoretical and practical boundaries.
- The theoretical boundaries of a profession are the questions that arise from clinical practice and are then investigated through research.
- The practical boundaries are the current state of knowledge and research in the field—the facts that dictate safe practice (Meleis, 1991)
- Occupation - Nursing often described as well
- Most nurses are hourly wage earners.
- The employer, not the nurse, decides the conditions of practice and the nature of the work.
- Nurse practice acts do not prevent nurses from functioning more autonomously. - There are things you can and cannot do
How Can Nursing Improve its Recognition as a Profession?
- Standardizing educational requirements
- Uniform continuing education requirements
- Increased participation of nurses in professional organizations
- Educating the public about the true nature of nursing practice
Formal Education
- To legally use the title nurse, a person must be a graduate of an accredited nursing education program and have successfully passed the National Council Licensure Examination (NCLEX®). Other personnel might respond to the client’s call, but they cannot legally be considered nurses.
- Students may enter nursing through two paths: as a practical nurse or as a registered nurse.
Practical and Vocational Nursing Education
- Practical nursing education prepares nurses to provide basic care to clients under the direction of a registered nurse (RN) or primary care provider.
- Practical nurses are known as licensed practical nurses (LPNs) or licensed vocational nurses (LVNs).
- NCLEX-PN® exam
Formal Education
Various educational pathways lead to licensure as a registered nurse (RN).
- Graduates of all these programs must successfully complete the NCLEX-RN
- Diploma programs
- 3-year program, hospital-based
- Associate degree (AD) programs
- 2-year program, community college
- Baccalaureate degree programs
- 8 semesters, colleges and universities
Entry into practice
Five levels of education for entry into practice
- Diploma
- ADN
- BSN
- RN to BSN
- Master’s
- Doctorate
Advanced Practice: Masters
- Master’s degree programs
- Prepare RNs to function in a more independent and autonomous role, such as nurse practitioner, clinical specialist, nurse educator, nursing informatics, or nursing administrator. It typically takes 2 years to complete the master’s degree.
- Direct entry master’s degree
- At the program’s completion, the student is eligible to take the NCLEX-RN and is awarded a master’s degree in nursing.
Advanced Practice: Doctoral
- Doctoral programs in nursing
- Doctor of Nursing Practice (DNP): A practice degree - translational research
- Doctor of Nursing Science (DSN/DNSc): A degree with a focus on research and practice
- Doctor of Philosophy (PhD): A degree focused on scholarly research and knowledge generation
- Direct entry doctoral degree: Designed for second degree students who seek an accelerated path to the doctorate degree
Other forms of Formal Education
- Continuing education (CE)
- Professional strategy to maintain current clinical knowledge
- Many states require CE courses for renewal of a nursing license.
- In-service education
- Programs offered at the worksite
Informal Education
Pat Benner came up with a process for how you become a Nurse.
Socialization is the informal education that occurs as you move into your new profession. It is the knowledge gained from direct experience, real-world observations, and informal discussion with peers and colleagues.
KEY POINT: Professional socialization begins when you enter the educational program and continues as you gain expertise throughout your career.
Stage 1: Novice
Stage 2: Advanced beginner
Stage 3: Competent
Stage 4: Proficient
Stage 5: Expert
Regulation of Nursing Practice
Laws, standards of practice, and guidelines from professional organizations regulate nursing practice.
Each state has very specific laws.
- Nurse practice acts
- In the United States, each state enacts its own nurse practice act, a compilation of laws that govern the practice of nursing
- State board of nursing
- Empowered to oversee and regulate nursing practice
- Standards of practice
- Guided by standards of practice, which “describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process
Professional Organizations
Numerous organizations are involved in the profession of nursing. These are some of the most influential:
- American Nurses Association (ANA)
- National professional organization
- National League for Nursing (NLN)
- Establishes and maintains a universal standard of education
- International Council of Nurses (ICN)
- Federation of national nursing organizations
Recipients of Nursing Care
Individuals, groups, families, or communities
- Direct care involves personal interaction between the nurse and clients
- Indirect care is working on behalf of clients to improve their health status (e.g., ordering unit supplies or serving on an ethics committee).
Purpose of Nursing Care
- To achieve the goals of health promotion, illness prevention, health restoration, and end-of-life care.
- Together these aspects of care represent a range of services that cover the health spectrum from complete well-being to death.
- Health promotion
- Illness prevention
- Health restoration
- End-of-life care
Models of Nursing Care
- Case method
- One-to-one care; one nurse provides all aspects of care for one client during a single shift
- Functional nursing
- Care is compartmentalized, with each task assigned to a staff member with the appropriate knowledge and skills
- Team nursing - collaborators
- Efficient. It maintains the cost savings of functional nursing while limiting fragmentation.
- A licensed nurse (RN or LPN/LVN) is paired with unlicensed assistive personnel (UAP).
- The team is then assigned to a group of clients.
- Primary nursing
- One nurse manages care for a group of clients
- Associate nurses deliver care and implement the plan developed by the primary nurse when the primary nurse is not available.
- Differentiated practice
- Each unit has the expertise
- Individual nurses develop a portfolio of their competencies and are assigned to clients who need those particular competencies.
Healthcare Delivery System
What type of care is provided?
- Acute care
- The goal is to prevent deterioration and restore health.
- Long-term support services
- “human assistance, assistive technologies and devices, environmental modifications, care and service coordination” on a regular or intermittent basis
- Hospitals
- Extended care facilities
- Assisted living facilities
- Rehabilitation centers
- Ambulatory care centers
- Home healthcare agencies
- Community or public health centers
Type of Care
Acute care - sudden, often unexpected, urgent or emergent episodes of injury and illness
Long-term support services (LTSS) - provided in a variety of nonhospital settings, such as extended care facilities, ambulatory care centers, and home healthcare agencies.
Clients are classified based on their admission status:
Inpatient refers to a client who has been admitted to a healthcare facility. The length of stay is limited to the amount of time that the client requires 24-hour care.
Outpatient refers to a client who receives treatment at a healthcare facility but does not stay overnight.
Categories of Healthcare
Healthcare is categorized by the degree of complexity
- Primary - Health-promotion activities
- Individual level—Counseling
- Group and family level—Teaching about nutrition
- Community level—Advocating for prominent billboards
- Societal level—Working with international partners to establish worldwide standards
- Nursing and Illness Prevention
- Teaching the importance of hand hygiene
- Advocating for and administering immunizations
- Promoting smoking cessation
- Promoting adequate nutrition
- Individual level—Counseling
- Secondary
- Early diagnosis and treatment of illness, disease, and injury.
- Increasingly these services are being performed in surgery centers, offices, and outpatient centers.
- Health restoration
- Tertiary
- After hospital
- Prevent complications of current health issues
- Long-term rehabilitation services and care for the dying
Interprofessional Healthcare Team
The composition of the team varies depending on the healthcare needs of the client
- Physicians (MDs or DOs)
- Advanced practice nurses (APNs)/nurse practitioners (NPs)
- Physician assistants (PAs)
- Registered nurses (RNs)/licensed practical nurses (LPNs)
- Unlicensed assistive personnel (UAPs)
- Pharmacists
- Therapists
- Technologists
- Registered Dietitians/Licensed Nutritionists
- Social Workers
- Spiritual Care Providers
- Alternative Care Providers
Financing Healthcare
- Individual
- Individual private insurance
- Employment-based private insurance
- Government - CMS Center for Medical Services (lookup)
- Medicare - federal
- Medicaid - state, called different names in each state and qualifications differ between states
- Charitable organizations
Medicare and Public Policy
- Initially, health services were reimbursed using a retrospective system that paid hospitals based on the actual cost of providing services to individuals
- Payments to hospitals went from $3 billion to $37 billion by 1983
- Prospective reimbursement system was created under the Social Security Amendments of 1983.
- Hospitals were reimbursed on a per-case, flat-rate basis determined by client groups having similar needs.
- These groups were called diagnostic-related groups (DRGs). If the client’s hospital costs were greater than the reimbursed (“set”) amounts, the hospital lost money. If the costs were less than the rate set by Medicare, the hospital made a profit.
- Private insurance companies, following the lead of Medicare, reimbursed in the same manner.
Medicare and Public Policy after DRGs
- The length of stay in hospitals decreased as care moved into the community and home.
- The cost of delivering nursing care became an expenditure. As a result, team nursing with UAPs replaced the comprehensive care provided by RNs
- Fewer hospitals and nursing homes in a community).
- Reduced staffing and higher client acuity produced a more stressful work environment for nurses.
- Insurance premiums and cost-sharing increased, while availability of services decreased.
Managed Care
Managed care, designed to control healthcare costs, is a competitive approach to healthcare pricing.
A managed care organization (MCO) contracts with medical providers to provide services at discounted rates or based on a predetermined fixed payment per individual covered under the plan
An employer contracts with the MCO and selects a type of health plan for its employees. The most common types of managed care plans are as follows.
- Health maintenance organizations (HMOs)
- Providers receive fixed amount per client regardless of care provided
- Primary care provider coordinates all care, including referrals to specialists
- Least costly
- Preferred provider organizations (PPOs)
- Client pays more in premiums, deductibles, and coinsurance; however, the client has greater choice among in-network providers (including specialists), medications, and devices
- Point of service (POS)
- Ability to select physician from a list of in-network and referrals. There is limited out-of-network coverage at a higher
- Integrated delivery systems (IDNs)
- Consolidation of services into one healthcare system.
- Providers see only IDN clients, facilities, pharmaceuticals, etc.
- The system is designed to promote a culture of collaboration, safety, and teamwork
Healthcare Reform Issues: ANA Recommendation
- Universal access to a standard package of essential healthcare services
- Adequate supply of a skilled workforce to provide quality healthcare services
- Healthcare services that support individuals who have limited resources to share in the cost
- Optimization of primary, community-based, and preventive services that integrate the economical use of innovative, technology-driven, acute, hospital-based services
Healthcare Reform Issues: Work Redesign
Looking at the level of care required and the mix of personnel necessary to achieve the best client outcomes
- Critical pathway - is an interprofessional approach that outlines the direction of client care. Based on scientific evidence, critical pathways allow the interprofessional team to implement best practices that yield the desired outcomes in the quickest manner
- Case management - is the coordination of care across the healthcare system.
Healthcare Reform Issues: A Right or a Priviledge?
Question raises more questions.
- If healthcare is a right of all citizens, should noncitizens be offered coverage?
- What responsibility does an individual have to preserve her own health through lifestyle changes (e.g., diet, exercise)?
- Should extensive and/or expensive therapies be offered if they have little likelihood of success?
- If you believe that healthcare should be affordable for all, are you willing to limit your salary and benefits to help control the costs of care? Are you willing to pay higher taxes?
Ensuring Quality Care
- Continuous quality improvement (CQI) programs -focus on quality (excellent) care as an ongoing goal that identifies problems, develops solutions, implements corrective plans, and evaluates their effectiveness
- Process reviews
- Look at issues related to guidelines, policies, or procedures related to the delivery of care
- Outcome reviews -
- Conducted to determine whether the desired outcome was achieved
- Structure reviews -
- Investigate the adequacy, availability, and quality of resources (e.g., nursing personnel, supplies, bed capacity) on processes and outcomes
- Process reviews
Societal Trends That Influence Nursing Practice
- National economy - insurance linked to emplyment
- Growing proportion of older adults in the United States - keeping people alive longer with chronic illnesses that were not planned for
- Changes in healthcare consumer
- Legislation - consumer interest HIPPA, MOLST, Informed consent, patient rights
- Women’s movement
- Collective bargaining - wages, benefits, working conditions
Trends in Nursing Practice
- Increased use of complementary and alternative medicine (CAM)
- Treatments or services outside the traditional healthcare system
- Holitisic care
- Expanded variety of care locations
- Interprofessional collaboration
- Expanded career roles for nurses
- Increased use of unlicensed assistive personnel
- Influence of nurses on health policy
- Divergence between high-tech and high-touch
