x Nursing 108 Flashcards
Transition to the Professional Nurse Role
Florence Nightingale (1860)
act of utilizing envt of pt to assist him in recovery
Virginia Henderson (1966)
the unique fx of nurse is to assist individual, sick or well, in the performance of those activities contributing to his/her health or recovery or to a peaceful death.
ANA (2016)
states nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through dx and tx of human response and advocacy in care of individuals, families, communities and populations
Endings
Letting go of old identity, move forward inwardly and outwardly
- Disengagement - separate from familiar
- Dis-id - let go of who you were
- Disenchantment - old way no longer good enough
- Disorientation- confusion during transitions
Phases of Role Transistion
Endings
Neutral Zone
Beginnings
Neutral Zone
in between state where critical psychological realignments occur.
- Surrender: giving in to the emptiness, not fighting uncertainty of transition
- sense of renewal, second wind
- changed perspective about identity
Beginnings
change has occurred. Old ID is gone. New sense of purpose, renewed energy.
Role Conflict: Intrapersonal
internal conflicts, btwn family, work, academic
Role Conflict: Interpersonal
when 2 indiv have diff expectations about same role.
Intrapersonal Conflict
Ideal Role: society’s ida
Perceived Role: your idea
Perfomed Role: actual
Marlene Kramer
Reality Shock
Types of Change
- Developmental
- Unplanned (forced/unforced)
- Planned
Types of Planned Change
- Incremental
- Rapid
- Transactional (mutual benefit)
- Transformational
Kurt Lewin - 3 stages of Planned Change
- Unfreezing: recog need for change
- Moving
- Freezing: process developed, new system in place
McWhinney Walzlawick -Reframing Model
First Order Change: less intense
Second Order Change: radical
Clinical Ladders
1972, developed to start recognizing nurses for their acheivement
Patricia Benner (1980s)
Novice - Expert model
Dalton’s Theory
Apprentice - Independent Colleague - Mentor - Sponsor
SBAR
created in Navy to improve communication on nuclear submarine fleet.
4 steps of SBAR
- What is going on? ID client, me, describe problem
- background, key info, short summary of client dx, phys and mental status.
- Assessment, allow nurse to analyze situation and isolate problem.
- Recommendation: Id what action to resolve, urgency, next stepps
Sunset Laws
require agencies to be abolished unless they are proved necessary
NLRB (National Labor Relations Act)
related to rights and privileges of the worker
Changes in the family structure
.Single parent families
. two career fam
.alterative fam
.teen pregnancy
Change of LIfestyle
.Physical/Psych health progs
.Nurses role and job options
.Immigrant population
.
RUG (Resource Utilization Group)
categories used to determine prospective papyment for nursing home clients
each RUG represents group of residents who reauire similar daily care and similar cost (i.e. nursing home)
Managed Care
system for financing and orgaznizing delivery of health care inwhich costs are contained by controlling provision of services
(HMOs)
HMO (Health Maintenance Organization)
-1st to offer managed care
-
HMO (Health Maintenance Organization)
- 1st to offer managed care
- 1st to provide payment for care aimed at prevention
- basic/supplemental health services
- keep subscribers health to reduce costs
- co pays, in network etc
PPO (Preferred Provider Organization)
- higher premiums, more choices
- group of providers forms a company with health care agency to an insurance company or employer at discounted rates
- physician can belong to more than one PPO
Capitation
healthcare plan allow payment of flat fee for each patient covered. HMO or Managed Care will pay fixed amount of money for its members to health care provider.
-Provider bear some or all risk.
P4P - Pay for Performance
Value Based Purchasing
Medicare, Affordable Care Act
- more than 40 P4P programs exist. largest and longest California Pay for P program.
- provide financial incentives to clinicians or better health outcomes.
Medicare, 1965
Amendment to SSA Title XIX, establishing national and state health insurance program for elderly
- requires enrollment to have hospital state of at least 3 consecutive days.
- Insurance for hospital care, extended care, home health care.
- updates in 1993
Medicaid, 1965
- healthcare for people on welfare and low income.
- any age covered by supplemental security benefits
Afordable Care Act
- Expand access to Insurance Coverage: by 2015, 16.9 mill more americans were covered by health insurance
- Improve Quality and System Performance
- Promote Health Workforce Development
- Curb Rising Health Care Costs
- Increase Consumer Insurance Protections
- Emphasize Prevention and Wellness
Healthcare Settings
.Public Health .Home Health Care .School-based Services .Community Health Centers .Physicians' Office/General Clinic .Occupational Health Clinics .Hopitals .Long Term Care Fac .Retirement/Assisted Living
Functional Nursing Care
functional nursing. an organizational mode for assigning nursing personnel that is task- and activity-oriented, using auxiliary health workers trained in a variety of skills. Each person is assigned specific functions performed for all patients in a given unit, and all report to the head nurse.
Team Nursing
Team nursing is a model in which a group of healthcare professionals, including nurses, care for a group of patients in the acute care or inpatient setting. Acute care, also known as critical care, is when nurses help patients confronting life-threatening issues.
Patient Centered Leadership
-everyone develops skills
-nursing leadership inspires others
-
3 Leadership Styles
- Laissez-faire
- Democratic
- Authoritarian
Laissez Faire Leadership
permissive, nondirective, passive
.allow group to determine own goals
.little planning and decision making
.can lead to frustration re no direction
Democratic Leadership Style
supportive, participative, transformational
.goals shared by group
.moderate freedom, moderate control and hi leader activity
.style works best when members have equal status
.this style require Trust, Collaboration, confidence and autonomy
Authoritarian Leadership
controlling, directive, autocratic
. final decision with leader.
. works best in emergency situations
Situational Leadership
a leadership style that has been developed and studied by Kenneth Blanchard and Paul Hersey. Situational leadership refers to when the leader or manager of an organization must adjust his style to fit the development level of the followers he is trying to influence.
Situational Leadership: 4 Leadership Styles
S1. Directing (hi directive, lo supportive)
S2. Coaching (hi direc, hi support)
S3. Supporting (Hi support, lo direct)
S4. Delegating (lo support, lo directive)
Relationship - Task Oriented
- Hi Relationship - Lo Risk: consider group feelings, may sacrifice task for group
- Hi Task - Lo Relationship: authoritarian, little regard for group, leaders use various forms of punishment
- Lo Task - Lo Relationship: worst type leader, laissez-faire
- Hi task - Hi relationship: best type leader, collaborate, get things done
Types of Leadership Theories
SITUATIONAL: no one approach works in all situations, leaders adjust style to situation
TRANSFORMATIONAL: leaders need t inspire excitement and commitment in group
Theory X
Theory X leaders maintain control, direct employees because they believe motivation is result of reward/ punish. leader perception is employees dislike work, must threat or coerce
X yuck
Theory Y
Theory Y leaders remove obstacles because believe that employees have self control and discipline to perform and receive reward from involvement in their work. leader perception is most people want to do well
Y uplift
Key Leader Behaviours
.Establish trust .Acknowledge good work .Show respect .Promote sense of direction .promote higher level of performance .resolve conflict . foster cooperation .reinforce goals . develop staff strengths .motivate personnel
Transition to Decision Maker
.must gain clinical skill before moving to mgmt
.if promoted from within, social aspects to negotiate
.critical for new mgr to clearly establish professional boundaries and prioritize career in prof envt.
.those who require acceptance by friends have diff in transition from RN to Nurse Mgmt.
QSEN Competency
The Quality and Safety Education for Nurses (QSEN) project addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work.
6 Competencies .Patient Centered Care .Teamwork and Collaboration. .Evidence-Based Practice. .Quality Improvement. .Safety. .Informatics.
Functional Nursing
Head RN assigns tasks to staff members for all pts on unit.
.intro in 1930s
.allowed for care of more pts
.Pros: all members utilized
.Cons: pts don’t have single nurse. nurses don’t own 1 pt, multiple for one task.
Team Nursing
team provides care for a group of pts.
.intro 1950s after WWII
.RN heads team of licensed and unlicensed, each using their skills, coordinated by team leader
.Cons: leader must have good leadership skills, communication, delegation and conflict resolution mgmt
Primary Nursing
one RN rsponsible for all care for group of pats 24/7 and directs care coor by other health care providers.
.popular in 80s
.great continuity of care
.Pros: hi job satisfaction, lo complication rate, better pt outcome
.Cons: $$$$$
Practice Partnership
.Sr partner and Jr partner, work together with group of pts.
RN/LPN, RN/CNA, Experience RN/novice RN
Pro: lo $
Con: success rely on commitment of members
.Care Pairs: RN/CNA
Case Method
.used in early 20th cent when nurses did home care
. Total Pt Care, one RN responsible for a pt for a period of time.
.intro attending RN (ARN). 5x8hr shift per wk. to build relationship w pts and caregivers
.Pro: pt care continuity, autonomy of RN
.Con: $$$$$$
Conflict Management
most important factor
Civility
.based on recognition that all human beings are important
.basics of nursing
.be civil to all promotes emotional health and create pos atmosphere for healing
. helps develop empathy for others and key to underpinning of emotional intelligence
Emotional Intelligence
awareness of both thoughts and feelings of others using behavioral cues.
EI skills correlate with professionalism and expert practice
4 factors of Emotional Intelligence (EI)
- correctly ID emotions in self and others
- use emotions to reason (think/feel)
- understand emotions
- managing emotions
EI involves
.Self awareness
.self mgmt
.social awareness
.relationship mgmt
Lateral Violence
aka Horizontal Violence.
btwn nurses, usually new grads.
“Nurse’s eat their young”
Conflict Mgmt
.Determine if both parties aware of conflict
.Assess
Methods of Conflict Mgmt
- Accommodation
- Avoidance
- Competition
- Compromise
- Collaboration
Is supervision required during delegation and assignment?
YES
RNs remain accountable for delegated task
LPNS can NOT delegate.
Guidelines for Delegation
.Assess the client
.Know staff availability
. Know the job description
. Educate staff member. UAP should be educated and observed doing task delegated
** 5 rights of Successful Delegation
. right task .right circumstances . right person . right direction /communication .right supervision and eval
** Delegation Decision Tree
10 questions.
- laws in place supporting rules of delegation?
- task w/in scope of ln, rn or new grad?
- assess of client needs?
- UAP, LPN, new grad competent?
- ability of caregiver match needs of client?
- task done w/out nursing judgement?
- result predictable?
- easy directions?
- task done w/out repeat assessment?
- supervision available?
Evidenced-based teamwork improves what?
comm among health profs and impact patient care.
TeamSTEPPs
an evidenced-based system aiming to improve teamwork and communication skills w goal of optimizing pt outcomes and improving pt quality and care by implementing evidence based practice.
focus on planning, staff pd, putting EPB into practice
sustain and spread improvements re teamwork
Comm in teams
. Clear Communications
. Positive approach
. Active listening
QSEN
https://www.youtube.com/watch?v=Z3pR-pzutZE
addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work.
Quality and Safety competencies? .Patient Centered Care. .Teamwork and Collaboration. .Evidence-Based Practice. .Quality Improvement. .Safety. .Informatics.
Teamwork and Collab QSEN Competency
.function properly within nursing and inter-professional teams fostering open comm, mtual respect, shared decision making for quality patient care.
.value contributions of othrs
.fx within own scope of practice
.act w integrity, consistency, respect for diff views
.value diff styles of comm
Nursing Research and Evidenced Based practice
-systemic process for improving pt care thru discover of new info
Goals of Nursing Research
. discovering most efficient /cost effective approach to nursing
. clarify/expand body of knowledge unique to nursing
. can be use to shape health policy in direct client care w/in org and at local, state, federal lev
. understand/address cultural issues in nursing care
Goals of EBP
. provide practicing nurses w best evidence based data
. resolve probs in clinical setting
. achieve excellence in care delivery
. promote effective nursing interventions
.assist w efficient and effective decision making
.reduce variations in nursing care
5 As of EBN Process
.Ask .Acquire .Appraise .Apply .Assess
Evaluating an Evidence Report
.best available evidence?
Types of Qualitative Research
.Phenomenology (interviews to know person)
.Ethnography
. case studies (investigation of culture)
. life histories (learn about pt life to understand their illness better)
Qualitative Research
primarily exploratory research. It is used to gain an understanding of underlying reasons, opinions, and motivations. It provides insights into the problem or helps to develop ideas or hypotheses for potential quantitative research
Quantitative Research
study in which items can be counted, measured and statistics can be used to analyze.
Types of Quantitative Research
. Randomized Controlled Trial aka double blind randomized controlled trial (giver nor receiver know if they have med or placebo)
. Longitudinal Study (study sample people across time)
. Descriptive studies (naturally data, i.e. deaths, births etc
. Methodological Research, collective term for structured process of conducting research
Nursing Theories and Models
a systematic view of phenomena by designing specific relationship among concepts or purposes of describing, explaining, predicting, and /or prescribing.
Uses of Nursing Theories
.understand, organize, analyze pt data .make decisions .plan pt care .predict outcomes of care .eval pt outcomes
Paradigm
a MODEL or pattern of shared assumptions about reality
4 paradigms of nursing
. Client - receiver of nursing care
. Nursing - inter btwn nurse, pt and envt
. Health - degree of well being
.Envt - surroundings other than people and inanimate thing that can affect client.
Types of Theories
. Descriptive, describe phenomenon, event, situation or relationship
. Prescriptive, addresses nursing interventions
. Development, outlines process of growth/develop of humans from beginning to end of life
. Systems, learns how the parts of the whole work.
Hildegard Peplau (1952-1980)
Interpersonal relations model.
.Goal to develop interpersonal interaction between nurse and client.
.Focus on person/client, envt, health
Virginia Henderson (1897 - 1996)
Definition of Nursing
.Goal to help client gain independence as rapidly as possible
.Patient is whole, complete independent being w 14 fundamental needs (breath, eat, drink, eliminate, move and maintain posture, sleep/rest, dress/undress, maintain body temp, keep clean, avoid danger, communicate, worship, work, play, learn
. Health is being able to perform these tasks unaided.
Madeline Leininger ) 1925-2012)
Cultural Care Diversity and University Theory
Goal to provide nursing care based on understanding and respecting clients culture.
.Care is essence of dominant, distinctive and unifying feature of nursing.
Dorothea Orem (1914-2007)
Self-Care Theory
Goal to care or and help client attain self-care
5 methods of helping
- acting or doing good
- guiding
- teaching
- supporting
- provide envt promoting ind abilities to meet current and future demands
Martha Rogers (1914 - 1994)
Science of Unitary Human Beings
.Goal to help client achieve max level of wellness
.nursing is use of intellect and knowledge to interact w pts and promote health patterns of living in harmony
** Sister Calista Roy (1939 -
Adaptation Model
. Goal to identify types of demands placed on client and client’s adaptation to them
.main task to maintain integrity in face of envt stimulus
4 Adaptive Models .Physiologic .self concept .role function .interdependence
Jean Watson (1940 -
Philosophy and Science of Nursing
goal to promote health, restore clients to health and prevent illness
. Caring central to nursing threatened by tasks and tech.
. Caring is universal phenomenon only effective when practiced interpersonally
Imogene King (1923 - 2007)
Theory of Goal Attainment
Goal to use interaction w client to help client attain goal of recovery and health.
Betty Neuman (1924 -
Health Care Systems Model
Goal to prevent client stress, reduce existing stress, prevent new problems
** Florence Nightingale (1820 - 1910)
Environmental Theory
.goal to manipulate envt to allow bodies reparative process
. focus on nursing and pt/envt relationship.
. 5 envt factors (pure water, fresh air, sunlight, cleanliness, efficient drainage)
Dorothy Johnson (1919 - 1999)
Behavioral System Model
.goal to foster correct behavioral function in client to prevent illness as well as during and following illness.
7 subsystems: Attachment, affiliative, dependency, achievement, aggressive, eliminative, sexual.
Myra Levine (1920 - 1996)
Conservation Model
Goal to promote adaptaion and maintain wholeness using principles of conservation
. nurse accomplishes goal of model thru conservation of energy, structure and personal and social intergrity
Nola Pender (1941 -
Health Promotion Model
.goal to promote optimum health thru lifestyle changes
RNs DO NOT DELEGTE…
Nursing Process
ASSESSMENT (can not delegate primary, only secondary assessments)
D
PLANNING
I
Eval/Educate (LPNs can only reinforce, not teach)
Collaboration (needs wound consult, dietary services etc)
Patient Safety
the prevention of harm to patients.
emphasis on a system of care delivery that
.prevents errors
.learns from errors that do occur
.is built on culture of safety that involves health care professionals, organizations and patients.
QI
Quality Improvement
activities aimed at improving performance and is an approach to continuous study and improvement of processes of providing services to meet needs of indiv and others.
QA
Quality Assurance
refers to broad spectrum of evaluation activities aimed at ensuring compliance w minimum quality standards. Primary aim to demonstrate that a service or product fulfills or mets a set of requirements.
QA
-Focusing on “outcomes”
CQI (continous quality improvement)
-focus on “processes” and “outcomes”
Continuous Quality Improvement (CQI)
ongoing effort to improve organizations approach to managing performance, motivating improvement and capturing lessons learned.
GOAL: exceed expectations of client
Process of doing, eval, improving, doing again, recycling
4 Basic Elements:
- Teamwork
- Include pt perspective
- measure processes
- insure adequate resources for implementation
Quality Improvement is not about “naming, blaming and shaming” instead
seeks to fix the system to decrease chance of error.
Members of QI team
optimal size 5-8 ppl.
.should be diverse
.include input from “end user”, patient.
.i.e. nurse, MD, therapist, med records, pharmacy, utilization review, community and pt rep.
QI Cycle
PLAN: set goals, predict, plan data collection
DO: test plan, document, reassess, revise
STUDY: complete data analysis, review lessons, decide action
ACT: implement, evaluate, decide next cycle
Peer review
informal feedback. systematic review process, look at nurse’s practice, used for rewards and punishment, only look at evidence affecting nurses’s practice
Outcome achievement
outcome criteria or outcomes mgmt. includes clinical pathways, cost attainment, pt access to services, degree of clinical outcomes, variance from stated goals
Record Audit
records reviewed, measured according to criteria. collect pt outcomes to evaluate care.
Utilization Review
determine whether
patient’s care was appropriate and whether
resources were appropriate.
The Joint Commission: State Health Dept
formerly JCAHO, survey most hospitals and health care orgs for quality of care.
satisfactory survey qualified institution to receive funding from medicaid/medicare
CHAP, Community Health Accreditation Program
independent evaluating body. qualifies for Medicare funding
Documentation
document only what was done, no subjective statement, conclusions or summaries.
Sentinel Event
An unexpected occurrence involving death or
serious physical or psychological injury, or the risk
of serious physical or psychological injury
ten most reported sentinel events:
Patient suicide Operative/postoperative complication Wrong-site surgery Medication error Delay in treatment Patient fall Patient death or injury in restraints Assault, rape, or homicide Transfusion error Perinatal death/loss of function
number-one root cause of sentinel
events
Inadequate communication among healthcare
providers
Root Cause Analysis
Focuses on finding flaws and opportunities for
improvement in the health care environment.
RCAs are NOT used to evaluate the performance
of individual health care providers
Hospital Quality Measures
improving the
quality of care provided to hospital patients and bringing
value to stakeholders by focusing on the actual results
Never Events
29 specific negative occurrences in healthcare that have
serious adverse patient outcomes and are reportable
events
- blood incompatibility, stage 3 and 4 pressure ulcers,
falls and trauma injuries, air embolism, foreign object
retained after surgery, and surgery involving wrong site,
wrong patient, or wrong procedure
Ventilator-associated pneumonia (VAP)
Iatrogenic pneumothorax (caused by a therapeutic
intervention such as mechanical ventilation or tracheostomy)
Deep vein thrombosis/pulmonary embolism (when not
related to orthopedic procedures)
Delirium in critically ill patients
QSEN
Quality and Safety Education for Nursing
Competency – Safety
◦ Minimizes risk of harm to patients and providers through
both system effectiveness and individual performance
