Study Guide Study Guide: Exam 1 Dimensions of Nursing:

Chapter 4: The Process of Educating Nurses (Nursing Schools) • The nurses who graduated from diploma schools were proficient in basic nursing skills and could assume positions in the hospital where they were trained or in home nursing, where they worked on a case-by-case basis without any additional orientation or education. On the job training in the hospital • Because of the 24-hour-a-day, 7-day-a-week socialization process administered by these schools, diploma graduate nurses tended to be very submissive to authority and willing to carry out any duty to please the physician, administrator, or head nurse. Before the advent of licensure examinations and standardization of practice, nurses from diploma schools were often limited to employment in their own training institutions or in home health-care settings. Nursing Programs: What are the 2 degree- granting programs for beginning nurses? ASN degree and BSN degree What are the similarities and differences between the programs? QSEN: • QSEN-Quality and Safety Education of Nurses: A national movement that guides nurses to redesign the “What” and “How” they deliver nursing care to ensure high-quality self-care. Help guided what is being taught it nursing programs • The Robert Wood Johnson Foundation undertook a three-phase project to improve the quality and safety of client care by focusing nursing education on student competency. The project, QSEN, is built on the six competencies developed initially by the IOM. 1. Client-centered care. 2. Teamwork and collaboration. 3. Evidence-based practice (EBP). 4. Quality improvement (QI). 5. Safety. 6. Informatics. Case Management: • As case managers, nurses are responsible for developing clinical pathways and for directing and guiding the overall health care of a specific group of clients. • Case management includes overseeing the clients’ care while they are in the hospital and following them through their rehabilitation at home, long-term follow-up, health-care practices, and developmental stages. • Care management is a general term that refers to a method of coordinating care either with an individual client or on a system-wide basis. • Case management is now a certified specialty; however, there is a lack of qualified nurses trained in case management. Interprofessional Education: • Defined as “two or more students from different professions learning about, from and with each other to enable effective collaboration and improve health outcomes. 1. Values and ethics for interprofessional practice 2. Roles and responsibilities 3. Interprofessional communication 4. Teams and teamwork Chapter 5: Nursing Organizations: Professional Organization: • A group of people banding together to achieve a specific purpose. By working together for a specific purpose, an association or organization amplifies its impact, and by developing a strategic plan, it focuses that impact to achieve certain results. • Professions with just one major organization generally have a great deal of political power. The National League for Nursing (NLN): • Strong force in community health nursing, occupational health nursing, and nursing service activities. • It was the first national nursing organization to provide accreditation for nursing programs at all levels. The primary purpose of the National League for Nursing (NLN) is to maintain and improve the standards of nursing education. The American Nurses Association (ANA): • The American Nurses Association (ANA) grew out of a concern for the quality of nursing practice and the care that nurses were providing. • The major purposes for the existence of the ANA, include; improving the standards of health and access to health-care services for everyone; improving and maintaining high standards for nursing practice; and promoting the professional growth and development of all nurses, including economic issues, working conditions, and independence of practice The National Student Nurses’ Association (NSNA): • Working closely with the ANA, which offers services, an official publication, and close communication, the NSNA consists of state chapters that represent student nurses in those particular states. • The main purpose of the NSNA is to help maintain high standards of education in schools of nursing, with the ultimate goal of educating high-quality nurses who will provide excellent health care Grassroots Organizations: • In reality, all nursing organizations start as the grassroots efforts of local nursing groups that are trying to solve a particular problem • Grassroots organizations usually have relatively small memberships; are localized to a town, city, or sometimes a state; and attempt to solve a problem or deal with an issue that the members feel is not being adequately handled by a large national organization Chapter 14: Health Care Systems and Delivery 3 Levels of Service: Primary Care • In nursing, primary care refers to health promotion and preventive care, including programs such as immunization campaigns. Primary care focuses on health education and on early detection and treatment. Maintaining and improving optimal health is the overriding goal. Secondary Care • In the secondary level, the focus shifts toward emergency and acute care. Secondary services are frequently provided in hospitals and other acute care settings, with an emphasis on diagnosis and the treatment of complex disorders. Tertiary Care • The tertiary level emphasizes rehabilitative services, long-term care, and care of the dying. Nursing services are essential in all three levels of health care, in both the hospital and community settings. What types of facilities fall under applicable categories? Outpatient services, public health departments, and home health care Demographics Affecting Health-Care Delivery Age: • The number of people in the over 65 demographic is rapidly increasing and have medical and health needs that will increase the need for qualified RNs • If the ACA is fully implemented, somewhere between 30 and 50 million new clients will gain access to the health-care system. Traditionally, as the economy grows stronger, fewer students seek nursing as a career, further increasing the nursing shortage. • Between now and the year 2050, the number of persons 65 years or older is expected to double. By 2050, one in five people living in Canada or the United States will be elderly, and their numbers will reach an estimated 80 million. Of this number, many will eventually become more dependent on the health-care delivery system as a result of chronic health problems. Health-Care Systems in the United States: • The highest rate of death by gun violence, by a huge margin • The highest rate of death by car accidents • The highest chance that a child will die before age 5 • The second-highest rate of death by coronary heart disease • The second-highest rate of death by lung cancer and COPD • The highest teen pregnancy rate • The highest rate of women dying due to complications of pregnancy and childbirth This disparity is attributed in large part to the cost of health-care services, not the quality of the services available. Types of Health-Care Systems in the Western World Hospice Services: • Hospice care provides a variety of services in a caring and supportive environment to terminally ill clients, their families, and other support persons. • Hospice care emphasizes physiological and psychological support for clients who have terminal diseases • The central concept of hospice care is not saving life, but improving or maintaining the quality of life until death occurs. MCO (Managed Care Organizations) • Definition: Provide comprehensive, preventive, and treatment services to a specific group of voluntarily enrolled persons. • The goal of capitation is to have a payment plan for selected diseases or surgical procedures that provides the highest quality of care, including essential diagnostic and treatment procedures, at the lowest cost possible. Any expenses in excess of the capitated rate are the responsibility of the MCO • If the MCO spends less on the care of a client than it is given for delivery costs, it can keep the excess as profit, providing it with a strong incentive to reduce the cost of services. • The effectiveness of the MCO plan rests on the theory that health-care costs can be reduced by decreasing the number of hospitalizations, shortening the length of inpatient stays, providing less expensive home-care services, and keeping people healthy through health promotion and illness-prevention services. Box 14.3 Medicare • Definition: Federally funded national health insurance program in the United States for people older than 65 years. • Part A provides basic protection for medical, surgical, and psychiatric care costs based on diagnosis-related groups (DRGs). • Part B is a voluntary medical insurance plan that covers physician and certain outpatient services. • Part D is an unfunded insurance for medications. • Characteristics: Payment for plan deducted from monthly Social Security check; covers services of nurse practitioners (varies by state); does not pay full costs of certain services; supplemental insurance is encouraged. Box 14.4 Medicaid • Definition: Federally funded, state-operated medical assistance program for people with low incomes. • Individual states determine eligibility and benefits. • Characteristics: Finances a large portion of maternal and child care for the poor; reimburses for nurse midwifery and other advanced practice nursing (varies by state); reimburses long-term care facility funding. Independent Nurse-Run Health Centers: • Similar to community health centers, nurse-run health centers tend to focus on health promotion and disease prevention. Historically, they have been service rather than profit oriented and remain so today. Nurses who are interested in autonomous practice often work in these settings. • Community health and institutional outreach centers. Primary care services are generally offered to the medically underserved, and these centers are typically funded by public and private sources. • Wellness and health-promotion clinics are another type of nurse-run clinic and offer services at work sites, schools, churches, or homeless shelters. Many of these centers are affiliated with schools of nursing, providing health-care services while offering educational experiences for nursing students. • A final type of nursing center includes faculty practice, independent practice, and nurse entrepreneurship models. These facilities are owned and operated by nurses and may be solo or multidisciplinary practices. Services are typically reimbursed through fee-for-service plans, grants, and insurance. Origins of Power: The following list includes some of the more accessible and acceptable sources of power that nurses should consider using in their practice: • Referent- doing things you don’t want to do, but do anyways because of the relationship • Expert- This power source is exercised by the individual or group when knowledge, skills, or expertise is either used or withheld in order to influence the behavior of others. (LPN to RN) • Reward- including personal favors, promotions, money, expanded privileges, and eradication of punishments (patient completing all there ROM exercises). • Coercive- The ability to reprimand, withhold rewards, and threaten punishment is the key element underlying the coercive source of power (threatening client with injection if not taking medication) • Legitimate- nurses have access to the legitimate source of power when they are licensed by the state under the provisions in the nurse practice act or when they are appointed to positions within a health-care agency (licensed nurse) • Collective- Professional organizations that can deliver large numbers of votes have a powerful means of influencing politicians Chapter 17: Incivility: The Antithesis of Caring Civility: • Civility is based on recognizing that all human beings are important. A simple definition of civility is for people to treat others as they would wish to be treated (the Golden Rule). • Civility in the profession enables nurses to make caring the focal point of their practice. Being civil to each other, to students, to colleagues, and to clients promotes emotional health and creates a positive environment for learning and for the promotion of healing. Incivility: • The simplest definition of incivility is the lack of civility. Incivility can be viewed as a continuum of impolite behaviors with a lot of overlap between them. (Example “I had my arms full of packages when I arrived yesterday, and not even one of the three or four people standing by the door offered to help.”) • People under stress can potentially lose their sense of civility, which can escalate, turning into outright violence if left unchecked. • Can lead to physical violence if taken to their extremes • It is essential that every individual be committed to eliminating negative, uncivil thoughts and behaviors • Another method to decrease incivility is to avoid escalating uncivil behavior. Bullying: • Type of incivility that is one step beyond impoliteness. It can be defined as any behavior that could reasonably be considered humiliating, intimidating, threatening, or demeaning to an individual or group of individuals. • In the U.S. legal system, physical abuse, emotional abuse, verbal abuse, or any combination of the three are considered bullying and may be punished. Hazing and initiation rites • The goal of bullying is usually to coerce or intimidate another person or group of people into doing something that they do not want to do. However, sometimes the goal is to merely humiliate a person or group because of some perceived difference or weakness • Most people who bully others have low self-esteem along with a poor self-image and use bullying to make themselves feel more powerful. Workplace Violence: • Whether in the form of mere workplace incivility or full-blown workplace violence, these behaviors result in negative outcomes for clients as well as employees and administrators Survey 2013: • A survey conducted in 2013 of 550 nurses’ perceptions of how workplace hostility affected client safety revealed several major concerns. A large number of the nurses indicated the following actions could occur in an environment of horizontal hostility leading to the compromise of client safety and quality of care: • Failing to clarify an unreadable order because of fear of the physician • Lifting or ambulating heavy or debilitated clients without assistance rather than asking for help • Using an unfamiliar piece of equipment without asking for instructions first • Carrying out orders that the nurse did not believe were correct Lateral Violence: Covert Lateral violence: • Covert lateral violence is initially more difficult to identify and includes unfair assignments, marginalizing a person, refusing to help someone, ignoring someone, making faces behind someone's back, refusing to work with certain people, whining, sabotage, exclusion, and fabrication. Overt Lateral violence : • can include name calling, threatening body language, physical hazing, bickering, fault finding, negative criticism, intimidation, gossip, shouting, blaming, put-downs, raised eyebrows, rolling of the eyes, verbally abusive sarcasm, or physical acts such as pounding on a table, throwing objects, or shoving a chair against a wall. Watson’s Nursing Theory: • In Watson's nursing theory, caring can be demonstrated and practiced through interpersonal interactions. Similarly, the consideration of others within interpersonal relationships is a fundamental part of being civil. • The increase of incivility in nursing today contradicts the primary requirement that nurses be caring professionals. • The reason incivility is on the rise can be uncovered by a closer examination of the interpersonal relationships found in toxic work and learning environments “Caring Science is the starting point for nursing (in) relational ontology that honors the fact that we are all connected and belong to Source.” ETHICAL PROHIBITIONS TO INCIVILITY: As of now, there are no federal standards to regulate workplace violence; however, several states have attempted to develop laws to control it. In most cases, these laws are confusing and difficult to enforce. To help fill this void, the Joint Commission (TJC) developed new guidelines under their “Leadership” standard to deal with behaviors that are interpreted as lateral violence. These include the following: • Requiring hospitals and other organizations to develop their own codes of conduct defining behaviors that are considered lateral violence • Requiring hospital administration to develop and implement a process for managing individuals who are displaying disruptive and inappropriate behaviors • Requiring additional standards for medical staff to follow for the credentialing process, including demonstrating interpersonal skills and recognizing inter-professionalism. Mentoring: • High-quality mentoring for new nurses and new faculty helps to build healthy relationships between students and educators. Constructive mentor relationships require respectful listening, focused thinking, maturity, wisdom, and positive energy, all of which help those being mentored correct mistakes and accomplish goals. • Disregarding incivility sends the message that uncivil behavior is part of the norm and something to be tolerated. Denial of problems often leads to bigger and more severe problems down the road. Better to take precautionary measures to prevent incivility and stop it as soon as it starts because it is almost impossible to stop without radical intervention. Examples of Student-to-Faculty Incivility: • Harassing and threatening behaviors by students toward certain instructors over grades • Cutting classes because students consider them boring or the instructor stupid • Cheating on tests and homework assignments to get better grades • Refusing to participate in class activities • Being unprepared for classes by not doing reading assignments or written work • Distracting teachers and other students by asking irrelevant or confrontational questions • Complaining behind the teacher's back to the teacher's superiors It is critical for nursing faculty to deal constructively with disgruntled students in a timely manner. When students’ rude and disruptive behavior is not addressed, it may turn into physical violence. The key to effective education lies in the quality of the interpersonal relationship between student and teacher. Don’t Eat Your Young: • It really is a form of vertical violence since it is based on an inequality of power between the experienced nurse and the new nurse • These initiation rites often involve intimidation and belittling of the student or the new nurse to help them “learn their place” in the organizational chain. Common “eating the young” activities include picking on, chewing out, or ridiculing the new nurse for their lack of knowledge. Using caustic humor or setting up the new nurse by placing them in a situation in which they will likely fail also contributes to the demoralization of the new nurse What are the pros of universities offering specialized degrees in nursing education rather than on the job training? • This teaches students how to teach and explores the political ins and outs of the academic setting. • Graduates come into the field of nursing education with an understanding of curriculum development, evaluation, testing, course preparation, and many other aspects of surviving in higher education, such as yearly evaluations, the rank and promotion system, and the need to publish. Chapter 33: Nursing Leaders: Nightingale: Hampton Robb: Wald: Dock: Goodrich: