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CHAPTER 1 Nursing Today Objectives ●

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Discuss the development of professional nursing roles: Nightingale’s philosophy, training program, and work in Crimean war ○ Philosophy: Florence Nightingale established the first nursing philosophy based on health maintenance and restoration ○ Training Program: She opened the first training program for nurses in 1860 ○ Work in the Crimean War: Work as the first nurse epidemiologist and used statistical analyses to drastically reduce mortality related to cholera and dysentery by improving sanitation. Brought mortality from 42.7% to 2.2% in 6 months Describe educational programs available for professional registered nurse education ○ Associate Degree: 2 years by community college or university, the program focuses on basic science and theoretical and clinical courses related to the practice of nursing ○ Baccalaureate Degree: 4 years, the program focuses on: basic sciences: theoretical and clinical courses and courses in the social sciences, arts and humanities to support nursing theories. The Essentials of Baccalaureate Education for Professional Nursing (AACN) Describe the roles and career opportunities for nurses ○ Nurse researcher ○ Nurse Educator ○ Care Provider ○ Patient Advocate ○ Manager ○ Teacher: Patient teaching Discuss the influence social, political, and economic changes in nursing practice ○ Social Changes: Consumers of health-care are now more informed because of resources access (Internet), media, and publications ○ Political Changes: Lobbyists have begun working on behalf of nursing through organizations such as the AACN, American Public Health Association, and American College of Nurse-Midwives to improve qualities of nursing care ○ Economical Change: Uninsured, new technologies, new medications: mainly trying to reduce health-care cost while maintaining quality patient care

Nursing as a Profession Patient-centered care Professionalism ◆ Administer quality care ◆ Be responsible and accountable Health care advocacy groups ◆ Robert Wood Johnson Foundation (RWJF) Future of Nursing: Campaign for Action ◆ Institute of Medicine (IOM): Publication on The Future of Nursing

Science and Art of Nursing Practice Nursing requires: ◆ Current knowledge and practice standards ◆ Insightful and compassionate approach ◆ Critical thinking Benner’s stages of nursing proficiency: ◆ Novice- No previous level of experience ◆ Advanced beginner- some level of experience. May only be observational in nature ◆ Competent: Same clinical position for 2 to 3 years. Able to establish long-range goals ◆ Proficient: More than 2 to 3 years. Perceives patient’s clinical situation as a whole. Focuses on managing care as opposed to managing and performing skills. ◆ Expert: Nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem. Scope and Standards of Practice ➔ American Nurses Association (ANA)- Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations. International Council of Nurses (Pg.2) Nursing: Scope and Standards of Practice ◆ 1960: Documentation began ◆ Standards of Practice: Competent level of nursing ◆ Standards of Professional Performance: The ANA Standards of Professional Performance describe a competent level of behavior in the professional role ◆ ➔ Goals- to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice. Standards of Practice Six standards of practice: ◆ 1. Assessment: Nurse collects comprehensive data pertinent to the patient’s health and/or the situation ◆ 2. Diagnosis: Nurse analyzes the assessment data to determine the diagnoses or issues ◆ 3. Outcomes Identification: Nurse identifies expected outcomes for a plan individualized to the patient or the situation. ◆ 4. Planning: Nurse develops a plan that prescribes strategies and alternates to attain expected outcomes. ◆ 5. Implementation: Nurse implements the identified plan. ● Coordination of Care: RN coordinates care delivery

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Health Teaching and Health Promotion: RN uses strategies to promote health and a safe environment. ● Consultation: Graduate level-prepared specialty nurse or advanced practice registered nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change. ● Prescriptive Authority and Treatment: Advanced RN uses prescriptive authority, procedures, referrals, treatment, and therapies in accordance with state and federal laws. ◆ Evaluation: RN evaluates progress toward attainment of outcomes. ◆ Nursing Process is the foundation of clinical decision making.

Code of Ethics ➔ Code of Ethics- the philosophical ideals of right and wrong that define principles used to provide care ➔ It is important for you to incorporate your own values and ethics into your practice

Professional Roles ➔ Autonomy and Accountability- the initiation of independent nursing interventions without medical orders ➔ Caregiver- you help patients maintain and regain health, manage disease and symptoms, and attain a maximal level of function and independence through the healing process. Healing through psychomotor and interpersonal skills. ➔ Advocate- you protect your patient's human and legal rights if the need arises ➔ Educator- you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patient’s progress in learning. ➔ Communicator- allows you to know your patient’s, including their strengths, weaknesses, and needs. ➔ Manager- Establish and environment for collaborative patient-centered care to provide safe, quality care with positive patient outcomes.

Career development ➔ Nursing provides an opportunity for you to commit to lifelong learning and career development ➔ Provider of care ➔ Advanced Practice Registered Nurse (APRN): ◆ Clinical Nurse Specialist (CNS)- An expert clinician in a specialized area of practice. Specialty identified by population, setting, disease specialty, type of care, type of problem. ◆ Nurse Practitioner (NP)- Provides health care to a group of patients, usually in an outpatient, ambulatory care, or community-based setting. Provides care for patients with complex problems and a more holistic approach. ◆ Certified Nurse-Midwife (CNM)- Educated in midwifery and is certified by the American College of nurse-midwives provides independent care for women during normal pregnancy, labor, and delivery and care for the newborn. ◆ Certified Registered Nurse Anesthetist (CRNA)- Advanced education from a nurse anesthesia-accredited program. Must have at least 1 year of critical care or emergency experience.

◆ Nurse Educator- Works primarily in schools of nursing, staff development, departments of health care agencies, and patient education departments. Nursing faculty have a Master’s or a doctorate ◆ Nurse Administrator- Manages patient care and the delivery of specific nursing services within a health care agency. Nursing manager positions usually require at least a baccalaureate. Director and nurse executive positions require a master’s degree. ◆ Nurse Researcher- Preferred doctorate’s. At least a Master’s in nursing.

Nursing Shortage Essential skills include: ◆ Time management ◆ Patient education ◆ Therapeutic communication ◆ Compassionate implementation of bedside skills

Historical Influences Nurses: ◆ Respond to the needs of patients ◆ Actively participate in determining best practices ➔ Knowledge of the history of the nursing profession increases your ability to understand the social and intellectual origins of the discipline

Florence Nightingale ➔ First practicing epidemiologist ➔ Organized first school of nursing- Nightingale Training School for Nurses at St. Thomas’ Hospital in London ➔ Improved sanitation in battlefield hospitals ➔ Practices remain a basic part of nursing today.

Civil War to Beginning of the Twentieth Century ➔ ➔ ➔ ➔

Clara Barton- Red Cross (civil war-1980) Mother Bickerdyke- Ambulance Service Mary Mahoney- First trained African-American nurse-focused on cultural diversity Lillian Wald and Mary Brewster- Henry Street Settlement: health needs of the poor people in New York who lived in tenaments.

The Twentieth Century ➔ Movement toward scientific research-based practice and defined body of knowledge. ➔ Nurses assumed, expanded, and advanced practice roles ◆ 1906: Mary  Adelaide Nutting, first nursing professor at Columbia Teachers College ◆ Army and Navy Corps established ◆ 1920’s: Nursing specialization began

Twenty-First Century ➔ Changes in curriculum ➔ Advances in technology and informatics ➔ New Programs address current health concerns

➔ Leadership role in developing standards and policies

Contemporary Influences ➔ Importance of Nurses self-care ➔ Changes in society lead to changes in nursing: ◆ Affordable Care Act (ACA)- President Obama ◆ Rising health care costs ◆ Demographic changes ◆ Medically underserved

Trends in Nursing ➔ ➔ ➔ ➔ ➔

Evidence-based Practice Quality and Safety Education for Nurses- Knowledge, Skills, Attitudes (KSA) Impact of Emerging Technologies Genomics- study of all genes with one another and with that person’s environment Public Perception of Nursing ◆ Hospital Compare- consumer-oriented website that allows people to select multiple hospitals and directly compare performance measure info ◆ Hospital Consumer Assessment of Healthcare Providers Systems- used to obtain info about patient’s perspectives on hospital care ◆ To Err is Human- publication that describes strategies for government, healthcare providers, industry,and consumers to reduce preventable medical errors.

➔ Impact of Nursing on Politics and Health Policy- ANA works for the improvement of health standards and the availability of health care services for all people, fosters high standards of nursing, stimulates and promotes the professional development of nurses, and advance their economic and general welfare.

Professional Registered Nurse Education Registered Nurse Education: ◆ 2 year associate’s- focuses on basic sciences; theoretical and clinical courses ◆ 4 year baccalaureate- focuses on basic sciences; theoretical and clinical courses; courses in social sciences, arts, and humanities to support nursing theory ◆ ➔ Graduate Education- Master’s degree, APRN- emphasizes advance knowledge in the basic sciences and research-based clinical practice ➔ Doctoral degree- (DSN OR DNSC) prepare graduates to apply research findings to clinical nursing. Other programs prepare nurses for more rigorous research and theory development and award the research-oriented Doctor of Philosophy (PhD). AACN recommended the Doctor of Nursing Practice (DNP) as the terminal practice degree and required preparation for all APRN’S Continuing and In-service education: ◆ Continuing education- involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. ◆ In-Service education- Instruction or training provided by a health care agency or institution.

Nursing Practice

Nurse Practice Acts (NPA’S) ◆ Overseen by State Boards of Nursing ◆ Regulate scope of nursing practice ◆ Protect public health, safety, and welfare Licensure and Certification ◆ Licensure: NCLEX-RN Exam ◆ Certification: Requirements vary

Professional Nursing Organizations ➔ Address member concerns ➔ Present educational programs ➔ Publish journals Student organizations: ◆ National Student Nurses Association (NSNA) ◆ Canadian Student Nurses Association (CSNA)

CHAPTER 2 THE HEALTH CARE DELIVERY SYSTEM OBJECTIVES ● Explain the advantages and disadvantages of managed health care. ○

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Advantages: ■ It lowers the costs of health-care for those who have access. ■ People can seek out care from within their network. ■ Information moves rapidly with a network. ■ Prescription management is much easier. ○ Disadvantages: ■ It limits care access for those who do not have insurance or provider coverage. ■ Busy networks can have long wait times. ■ The rules of managed care are extremely rigid. Discuss the types of settings that provide various health care services. ○ Preventive and Primary Health Care: School health, Occupational health, Physician’s office, Nurse-managed clinics, Block and parish nursing, Community health centers. ○ Secondary and Tertiary Care: Hospitals, ICU, Psychiatric facilities. ○ Restorative Care: Home care, Rehabilitation, Extended care facilities. ○ Continuing Care: Nursing centers/facilities, Adult day care centers, Hospice. Discuss the role of nurses in different health care delivery system. ○ Preventive Care: Reduces and controls risk factors for disease. ○ Primary Care: Focuses on improved health outcomes.Requires collaboration. ○ Secondary and Tertiary Care: Diagnosis and treatment disease. ○ Restorative Care: Serves patients recovering from an acute or chronic illness/disability. Helps individuals regain maximal function and enhance the quality of life.

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Continuing Care: Services for prolonged periods of time.

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Explain the impact of quality and safety initiatives on delivery of health care. ○ Safety is a critical part of quality health care. ○ Quality health care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

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Discuss the implications that changes in the health care system have on nursing. ○ Quality Improvement (QI): Improve health-care related processes/ ○ Performance Improvement: (PI): Organization analyze and evaluate current performance and uses results to develop focused improvement actions.

Challenges to Health Care ➔ ➔ ➔ ➔ ➔

Uninsured patients Reducing health care costs while maintaining high-quality care for patients Improving access and coverage for more people Encouraging healthy behaviors Earlier hospital dischargers result in more patients needing nursing homes or home care

National Priorities Partnership ➔ Promote best practices ➔ Promote prevention, treatment, and intervention practices for the leading causes of mortality ➔ Ensure person- and family-centered care ➔ Make care safer ➔ Promote communication and care coordination ➔ Make quality care affordable

Institute of Medicine (IOM) - 2011 ➔ Nurses need to be transformed by: ◆ Practicing to the full extent of their training ◆ Achieving higher levels of education through an education system that provides seamless progression ◆ Becoming full partners with physicians and other health care providers in redesigning the health-care system ◆ Improving data collection and information infrastructure for effective workforce planning and policy making

Health Care Regulation and Reform Regulatory and competitive approaches ◆ Professional standards review organizations (PSROs) ● Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid Utilization review (UR) committees ◆ Review admissions, diagnostic testing, and treatments ordered by physicians who cared for patients receiving Medicare. Prospective payment system (PPS) ◆ Established by Congress in 1993 ◆ It eliminated cost-based reimbursement Diagnosis-related groups (DRGs) ◆ Disease/surgery specific (hospital and rehabilitation ◆ Hospitals receive a set dollar amount for each patient based on the assigned DRG, regardless of the patient’s length of stay (LOS) or use of services Capitation ◆ The providers receive a fixed amount per patient or enrollee of a health care plan ◆ Capitation aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost Resource utilization groups (RUGs) ◆ Long term care Profitability Managed Care ◆ Describes health care systems in which a provider or health care system receives a predetermined capitated payment for each patient enrolled in the program ◆ The focus of care of the organization shifts from individual illness care to prevention, early intervention, and outpatient care. “Never Events” ◆ Sentinel events and requires a root cause analysis following the event (Unforeseen complication- Death) ◆ Organized in seven categories: 1. Surgical 2. Product or Device 3. Patient protection 4. Care Management 5. Environmental 6. Radiological 7. Critical Patient Protection and Affordable Care Act (PPACA) ◆ Access to health care for all ◆ Reducing costs

◆ Improving quality ◆ Provisions include ● Insurance industry reforms ● Increased funding for public programs ● Improved coverage for children

Emphasis on Population Wellness Health Services Pyramid ◆ Managing health instead of illness ◆ Emphasis on wellness ◆ Injury-prevention programs Health Care Settings and Services Box 1. Preventive Care (blood pressure, immunizations) 2. Primary Care (prenatal, family planning) 3. Secondary Care (emergency care, acute medical-surgical care) 4. Tertiary Care (intensive care) 5. Restorative Care (cardiovascular, orthopedic, and pulmonary rehabilitation, sports medicine) 6. Continuing Care (assisted living, adult day care) 1. Preventive Care: Reduces and controls risk factors for disease 2. Primary Care: Focuses on improved health outcomes, requires collaboration a. Health promotion programs lower overall costs: i. Reduces incidence of disease ii. Minimizes complications iii. Reduces the need for more expensive resources 3. Secondary and 4. Tertiary Care: a. Focus: D  iagnosis and treatment of disease b. Disease management is the most common and expensive service of the health-care delivery system c. Postponement of care by uninsured contributes to high costs d. Hospitals i. Work redesign ii. Discharge planning e. Intensive Care f. Psychiatric facilities g. Rural hospitals 5. Restorative Care: Serves patients recovering from an acute or chronic illness/disability. Helps individuals regain maximal function and enhance the quality of life. a. Home Health Care: i. Provision of medically related services and equipment to patients and families in their homes for health maintenance, education, illness

prevention, diagnosis and treatment of disease, palliation, and rehabilitation. ii. Involves coordination of services iii. Focuses on patient and family independence iv. Usually reimbursed by government (such as Medicare and Medicaid in the U.S.), private insurance, and private pay. b. Rehabilitation: i. Includes physical, occupational and speech therapy, and social services ii. Begins on admission iii. Focuses on preventing complications iv. Maximizes patient function and independence c. Extended Care: i. Extended care facility 1. Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities ii. Intermediate care/skilled nursing facility 1. Provides care for patients until the can return to their community or residential care location 6. Continuing Care a. For people who are disabled, functionally dependant, or suffering a terminal disease b. Available within institutional settings or in the home: i. Nursing centers or facilities: 1. Provide 24-hour intermediate and custodial care a. Nursing, rehabilitation, diet, social, recreational, and religious services b. Residents of any age with chronic or debilitating illness 2. Regulated by standards: Omnibus Budget Reconciliation Act of 1987, patient’s rights and quality of care 3. Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs, r...