NSE 407 NURSING PROFESSIONAL ISSUES AND TRENDS

NSE 407 NURSING PROFESSIONAL ISSUES AND TRENDS Content: - Public policy - Health policy - Nursing involvement in health policy and impact on nursing profession-current RNAO position WHY STUDY NURSING ISSUES? - Effective support for political action within the profession - Encourages nurses to speak in unison on issues and organize themselves to act provincially/territorially, nationally, and internationally - To articulate a professional nursing issue goes beyond the individual nurse - To have greater impact nurses need to articulate issues as a large collective/organization of nurses - Issues should be explored fully and critically assessed in order to challenge pre-conceived views - To articulate an issue fully means to consider the political, historical, social, and economic realities on and through which issues are constructed - Help build a stronger cohort of nurses who have the knowledge to have an influence - Create RNS who have the knowledge to advocate for ourselves as a profession (i.e. RNS being replaced with RPNS, RNAO is standing up for RNS and why they are necessary and require approp staffing for better patient outcomes, esp complex patients) GETTING TO THE POLICY AGENDA (THIS IS A CYCLE) 1. Values and Belief (if threatened) 2. Problem or issue emerges 3. Knowledge development and research 4. Public awareness 5. Political engagement 6. Interest group activations 7. Public policy deliberation and adoption 8. Regulation, experience and revision WHAT IS PUBLIC POLICY? - Our federal and provincial governments are responsible for creating policy, laws and legislation - Public policy is “a statement of direction resulting from a decision making process that applies reason, evidence and values in public or private settings” - Public policy can include a choice to: o Take action o Take no action o Maintain the status quo WHAT IS HEALTH POLICY? - Health policy is a form of public policy - Includes principles, plans and actions related to the health care system including the behavior and actions of organizations and institutions - Many health policies fall under the jurisdiction of other government ministries and require government collaboration: transportation (seat-belt safety), housing (affordable housing), and justice (health care among the incarcerated) - Health policy is not a private issue concerning just the ministry of health DIFFERENT TYPES OF POLICY: KINGDON’S POLICY WINDOW: - Problems - process of persuading policy decision makers to pay attention to one problem over others. - Proposals - process by which policy proposals are generated, debated, revised, and adopted for serious consideration. Sometimes proposals are successful if they are seen as technically feasible, compatible with decision maker values, reasonable in cost, and appealing to the public. - Politics - political factors that influence agendas, such as changes in elected officials, political climate or mood and the voices of advocacy or opposition groups 3I FRAMEWORK (IDEAS, INTERESTS, AND INSTITUTIONS): - This framework relates to followings parts of the policy cycle: o Values and beliefs stage (Interests i.e. interests and values of the policy maker or stakeholder) o Problem or Issue emerges stage (Institutions i.e. structure of government) o Knowledge, development and research stage (Ideas i.e. types of evidence being used to drive policy formation) o Public awareness and political engagement stages (Interests) o Public Policy deliberation and adoption and regulation, experience and revision (Institutions) - Consider external factors – events that occur to create an opportunity for policy (i.e. death of a child features in the news to create opportunity for changes to child protection policy) NURSING INVOLVEMENT IN SHAPING HEALTH POLICY: - Historically nurses have been involved in initiating & shaping health policy, mainly through nursing professional organizations (eg. CNA, RNAO) - Nursing involvement in policy is critical since policies determine the context in which nurses provide care - Policies influence nursing role at various levels – individual level, within health care organizations, professional associations, provincial/federal HOW NURSES CAN INFLUENCE THE AGENDA: - The “policy agenda” is a list of issues/ problems with which senior government politicians pay attention to 1. Hence getting on the ‘agenda’ is very important for an issue to be carried forward into health policy 2. Nurses can play a role in agenda setting by bringing forward issues to government to consider and providing evidence to policymakers so that they can make decisions (eg. Use of policy products such as position statements, briefing notes, fact sheets and media releases) Week 1 – Nursing Issues and Trends Readings: Nurse Manifest- A call to conscience and action: - An article that asks nurses to stand up against the 2017 U.S Executive Branch’s decision that negatively impacts health and well-being of U.S citizens and people worldwide - Seven pledges: - (1) We believe that health and well-being of mind, body and spirit is a fundamental human right o Nurses are committed to provide care for all people- care that promotes high level wellness and restoration of health that considers the mind, body and spirit as a whole - (2) We believe the integrity of our environment is integral to human health and well-being o Nurses oppose actions that damage the environment and the physical structures. Nurses stand up for sustainable and healthy structural environment for Earth - (3) We believe that all people deserve access to affordable quality care o Nurses care for all patients and families regardless of: economic status, sexual orientation/gender identities, immigration status, age, financial status, religious beliefs - (4) We oppose all forms of oppression and discrimination o Nurses commit to protect and care for those whose safety and well-being is threatened based on attributes that are “different’- SDoH. Nurses fight for policies that assure equity and justice - (5) We oppose intimidation and violence in our homes and communities o Nurses protect victims of violence, especially victims of violence due to factors such as race, sexual orientation, gender identity, or religion. Nurses advocate for peaceful resolution of conflict and intervene in dangerous situations - (6) We believe that the health of women must be protected o Nurses act to assure that all women receive the full range of care respect of their own reproductive choices and women’s health care services for good health - (7) We trust scientific knowledge that supports a holistic approach to nursing care o Nurses examine all sources of evidence and ensure the public that practice is based on reliable scientific evidence Nursing issues: A call to political action. - the times of irresolvable issues in health care delivery, nursing practice, and education. How can we understand problems that nurses encounter in practice differently? How can we solve problems in a complex and interrelated method? o A way that a nursing situation is understood by nurses have implications on how likely the issue would be addressed ▪ Many issues in nursing can be understood at political issues that influences the quality of patient care o Dissonance between what the nurse believes the kind of care they should be able to provide and the environment that supports versus the reality of practice - Deepened frustration and dissonance when the issues are unheard and invisible to others o One of the most important preparation for political action for nurses is the : ability to articulate issues o E.g.) TB increase in a community suspected by nurses but public health did not agree with the increase according to the statistics. Nurses asked the TB screening to be conducted in homeless / drop-in shelters but Public Health refused. The nurses took the following steps to press the health department to initiate a screening program: ▪ Calling a meeting with other healthcare workers, shelter and drop-in staff, and ▪ homeless people ▪ Forming an action group ▪ Educating group members about TB ▪ Researching the experiences of other cities ▪ Making representations to health departments ▪ Offering to assist with screenings Canadian Nurse Association and Intersectional Council of Nurses: - Topic: Overview of the CNA and the ICN; their roles and functions and the issues confronting them CANADIAN NURSES ASSOCIATION – SINCE 1908 - WHO: o A federation of 11 provincial and territorial professional associations and regulatory colleges o All the provincial and territorial nursing organizations have at one time been members of the CNA – the face of CNA continues to change o Some Ontario nurses, B.C nurses, and Quebec nurses are missing from CNA federation ▪ ONTARIO: mandatory for RN’s to be registered with the CNO that has mandate to protect the public; RNAO is voluntary but nurses become members of CNA - ICN through RNAO ▪ QUEBEC: QIIQ (both regulatory and professional mandates) withdrew from CNA due to political separatist movement in 1985; Nurses in Quebec may join Nurses Association of NB or Yukon to become CNA/ICN members ▪ BC: Nurses can join ARNBC (Registered Nurse Network of British Columbia) to become CNA/ ICN members ▪ Student Members: nursing students eligible to become CAN members If they are enrolled in an education program for entry to practice as a RN o Annual general board meeting to fulfill fiduciary responsibilities such as election, auditing, changing bylaws, and giving guidance through voting o Board of directors decide on: policy directions, priorities, and resources - What: VISION, MISSION, AND GOALS o Representing some 147,000 Canadian RN’s and NP’s- more than half of Canada’s 268,000 employed RN’s o Various mandates to protect the public, speak on behalf of the profession, or both o Speaks for Canadian RN’s and represents Canadian to nursing to other organizations and to governments nationally and internationally - a strong national association for RN’s o Two nursing-led divisions at an operations level: ▪ 1) Policy and Leadership • Efforts to advance nursing, health and health system policy by establishing strategic working relations with various levels of government (Canada and International) • Government and initiatives to support nursing leadership advance evidence-informed policy • Grounded in two fundamental values: o 1) Primary Health Care - Health promotion, Prevention of disease and injury, accessibility, public participation, intersectoral collaboration, and appropriate technology o 2) Canada Health Act - Universality, Portability, Accessibility, Comprehensiveness, and Public administration o An example of their work can be found in the area of leadership in health human resources planning - shortage of nurses - lobbying efforts with provincial jurisdictions to press for action ▪ 2) Professional Practice and Regulation • Articulates the voice of nursing on a variety of current practice issues, maintains and promotes practice supports such as the Code of ethics • Connects nurses with each other and experts • Variety of supports to optimize the role of RN’s and NP’s • Regulatory Policy work such as: o Testing, Specialty Certification, Code of Ethics, mutual recognition agreement, entry to practice, and nursing legislation o Goals of CNA (). ▪ To promote and enhance the role of registered nurses to strengthen nursing and the Canadian health system ▪ To shape and advocate for healthy public policy provincially/territorially, nationally, and internationally ▪ To advance nursing leadership for nursing and for health ▪ To broadly engage nurses in advancing nursing and health ▪ To transform CNA governance structure and processes. THE INTERNATIONAL COUNCIL OF NURSES - WHO: Represents more than 120 countries worldwide and has more than 1million members - WHAT: o Goal: Unite nurses worldwide by forming a confederation of national nursing organizations, while supporting national nursing organizations in their efforts to influence national health and nursing policy o Committed to world health- since the early decades of the 20th century and WWI o Position statements such as activism on human rights o Enforce standards for nursing education and practice o Develop strategies for a global shortage of nurses The road less traveled: Nursing advocacy at the policy level. ADVOCACY AND NURSING - Advocacy is the philosophical foundation to all nursing practice but also the question of paternalistic assumptions by healthcare professionals when acting on behalf of clients - Advocacy can have self-serving professional motivations MODELS OF ADVOCACY - Nurse advocate focuses on : empowerment, preservation of client values and autonomy in decision making - Can also be seen as a decisional counselling - nurses need to draw on knowledge of the client’s situation, current best evidence and communication skills to support and empower client decision making - 1) Relational and existential model o Advocacy explores the meaning of the health care experience and preserving the client’s right to self-determination in that experience - 2) Advocacy founded on respect for persons model o Advocacy is a moral act of shared humanity that acknowledges common human needs and rights - 3) Advocacy as social justice model Advocacy informs a moral and ethical imperative to advocate assertively for the marginalized, address inequities in health o care and disparities in health, and insist on change ▪ “Critical caring” to address the gap between the marginalized, which recognizes the sociopolitical embeddedness of health and health care and the priviliges ▪ Downstream care = meeting the needs of clients ▪ Upstream advocacy= influence change in the structures and relationships that contribute to the poor health of groups and populations INTIMACY AND ADVOCACY: - Common belief that the nurse’s connectedness to the patient motivates the feelings of responsibility to take action on behalf of the client - however, this is a paternalistic view - Need to take into consideration of the risks for nurses as an employee when acting on behalf of an individual client ADVOCACY AND NURSING KNOWLEDGE: - Empirical knowing: a resource for advocacy, embedded in notions of advocacy as thoroughly informing and supporting clients in their health- related decisions - Personal knowing: drawing on the individual human qualities and experiences that define who the nurse is in terms of advocacy - Aesthetic knowing: the artful, empathic act of nursing informs discussions of relational-existential advocacy as a unique and important role of nursing POLICY ADVOCACY: - Knowledge-based action intended to improve health by influencing system-level decisions - A use of critical theory as a framework for policy analysis; understanding the politics of oppression and marginalization in matters of health - Challenges to Policy Advocacy in Nursing: o Nurses often believe that policy is out of their scope of influence and feel it is too overwhelming to re-create policies o Nursing education does not sufficiently equip nurses to play a role in policy advocacy o Heavy workloads, understaffing, powerlessness in institutional settings and lack of time for nurses to participate in policy change ▪ Lack of free time to participate and also a lack of personal self-efficacy for policy change o A perceived risk for nurses in advocacy that they are putting themselves out there o Ideational discourse: communicates and constructs the substance of policy and frames he empirical and normative arguments o Interactive discourse: communicative and coordinating functions and consist of discursive exchanges between and among coalitions, advocacy communities, and broader political system Influencing policy and leading change: Essential steps in successful transformations: - Public policy directly impacts the way that nurses practice and the outcomes of that practice POLICY: WHAT IS IT AND WHY DOES IT MATTER? - POLICY: A statement of direction resulting from a decision-making process that applies reason, evidence, and values in public or private settings - PUBLIC POLICY: directives that document government decisions the process of taking problems to government agents and obtaining a decision or reply in the form of a program, law, or regulation - HEALTH POLICY: the principles, plans, and strategies for action guiding the behavior of organizations, institutions, and professions involved in the field of health, as well as their consequences for the healthcare system - NURSING POLICIES: exist as part of the everyday practice of nursing arising from sources of - public sources, organizational sources, and professional sources POLICY AND POLITICS - Politics is reactive while policy is proactive: needs negotiation - Politics shapes the process of policy development NURSES AND POLICY - Part of a professional obligation and ultimate reason for enhancing nurses’ political influence is to contribute to the delivery of care and the health status of the population - Can help in ways such as: o Expertise in a range of health-related topics and issues o Explain individuals’ and communities’ needs o Conduct health research that contributes evidence to policy development INFLUENCING POLICY - Policy cycle: There are 8 steps in policy o 1) values and cultural beliefs o 2) emergence of problems or issues o 3) knowledge and development of research o 4) public awareness o 5) political engagement o 6) interest group activation o 7) public policy deliberation and adoption o 8) regulation, experience, and revision TWO PHASES OF THE CYCLE: - PHASE ONE: getting to the policy agenda: o Any policy issues must be grounded in a supportable set of values and cultural beliefs o A) VALUES AND BELIEFS ▪ Identification of beliefs are a must to continue moving forward with policy initiative ▪ Examples of values) • Nurses matter; they are valuable to and highly respected by citizens. • Nurses are an essential part of the healthcare delivery system, necessary to delivering access and quality care. • Nurses should be treated fairly and work in healthy work environment o B) EMERGENCE OF PROBLEM ▪ Issue must exist but also needs urgency. Visible and important to others as well rather than just the people immediately impacted ▪ Identifying the issue: • About the problem: What is the problem and whom does it affect? • About the policy solutions: What are the various options for action? • About the current context: What will happen if the problem is not addressed? • About the relationship to our organization: Does this issue fall within our mandate? o C) KNOWLEDGE AND DEVELOPMENT OF RESEARCH ▪ Once the issue is clearly identified and is seen as pressing, use research and evidence to provide solid support for the desired outcome  Information gathering, research, situational analyses o D) PUBLIC AWARENESS ▪ Last step of the first phase ▪ Creating broad-based awareness for both the issue itself and potential solutions and strategies ▪ Exposure and coverage with mass media: • Get their attention (be strategic!). • Write an engaging news release. • Think like a reporter. • Prepare for and conduct successful interviews. - PHASE TWO: moving into action o E) POLITICAL ENGAGEMENT ▪ For an issue to be placed on a political agenda, it must be softened up, meaning: having people to get used to the idea so that acceptance for the proposed solution or strategy can be built • Know the government structure, committees, caucus, and key members of Parliament (those in power, those in opposition, and the non-elected players who have informal power). • Target individuals with interest, information, passion, or influence regarding your topic • Utilize carefully considered, person-to-person contacts. • Customize the message for each contact person. • Keep these individuals regularly updated regarding your activities, your progress, and your specific needs for ongoing support. o F) INTEREST GROUP ACTIVATION ▪ Deliberately exploit every opportunity to repeat the message and build it into a wave of interest by others • Direct mail from the office (e.g., “Here is the basic message; please spread and respond.”) • Publications (e.g., the ONP electronic newsletter, and pieces in other publications); • Word of mouth (e.g., speeches, regional visits, and interviews); • Bringing key people together (e.g., a National Policy Forum hosted by the ONP in February 2003 immediately following the release of Health Accord 2003) o Direct dialogue with key nursing and other health organizations. o G) PUBLIC POLICY DELIBERATION AND ADOPTION ▪ Move the agenda deliberately to the tables where it can be debated and policy can be formulated ▪ Potential solution and policy formulation should be deliberated thoroughly at this point ▪ Five criteria for a political agenda to survive: • technical feasibility • value acceptability within the policy community • tolerable cost, • anticipated public agreement • a reasonable chance for elected officials to be receptive to it. o H) REGULATION, EXPERIENCE, AND REVISION ▪ Final step ▪ Proposed action becomes a formal policy, law, or regulation ▪ Routinely revised until the next issue comes along ▪ Implementation of the policy and evaluation take place FRAMEWORK FOR LEADING CHANGE - Being Strategic: Aligns with – steps 1,2,and 3 from policy cycle - Engaging People: Aligns with- Steps 4,5,and 6 from policy cycle - Managing the change: Aligns with –steps 7 and 8 from policy cycle Week 2 – Sustaining Self-Care and Self-Management of Diseases Power Point Notes: Content: - Infra-structure for development of client’s skills + abilities - Accountability for self-care outcomes - System of periodic monitoring and evaluation of self-management SELF-CARE: HEALTH PROMOTION AND MAINTENANCE - Self-care agency as a matter of human power to become engaged in self-care or dependent-care as agents, performers and doers of care. - Three major dimensions of self-care: 1. The nurse does for the patient/client (if possible with his/her assistance); 2. The nurse guides/teaches the patient/client to perform the care; 3. Someone else (family/significant one) does for or with the client/patient. WHEN SHOULD TEACHING FOR SELF-CARE BE INITIATED? - Teaching for self-care to promote health and maintain the good health conditions should be a target objective during the first contact between a nurse and client/patient/family/significant other. MAJOR ISSUES IN PROMOTING SAFE SELF-CARE: - Safety in under-supervised self-care at community settings/home care context. - Ethical and legal responsibilities of nurse as a self-care educator. - Extensive training of individuals and dissemination of self-care related information within the client/patient social environment. - Design a cost-effective self-care teaching program. TEACHING FOR SELF-CARE: NURSE AS A HEALTH EDUCATOR: - Mobilize multiple sources of knowledge as clinical specialist and expert. - Be skilled in using multiple educational strategies appropriate to the setting of teaching-learning activities (classroom, hospital bedroom, health facility conference room, community facility, home settings, occupational health setting, etc). - Be knowledgeable about the particularity of process of learning under experiencing disease-related stress/threat, as well as major life changes/challenges. - Be time-sensitive and time-aware: How long it would take to learn and master the required skills under lack of health-related theoretical knowledge? - Master diverse teaching methods according to the level of the complexity of the self-care task to be learned. - Co-create with the « learner », a simple, user-friendly system of self-evaluation for learning, performance and outcomes achievement. - Design with the help of the « learner » a feasible track system of self-assessment and self-monitoring of clinical conditions that would require adjustment in self-care plans. ACCOMMODATION AND SOCIALLY INCLUSIVE SELF-CARE TEACHING APPROACH - Age - Education level - Learning style and preferences (individual, group, online, discussion, lecture, etc.) - Level of functional health literacy (use of sources, decode information, use for decision making) - Reading proficiency - Ability of dealing with mathematical information (numeracy to deal with percentage, calculations, etc…) - Access to informational resources - Spoken languages - Physical and learning disabilities and special learning needs - Computer literacy SUSTAINING EFFECTIVE SELF-CARE: - Participate to (associate with, develop and/or maintain) an integrative network of nursing experts from your own specialty. - Build a list of specialists from nursing and other disciplines to consult with for professional advice, support and guidance. - Identify the major issues, challenges or barriers related to the successful implementation of self-care within a system of referral and contra- referral of clients/patients among health care and social services professionals. SELF-MANAGEMENT: CLINICAL RELEVANCE - Emphasizing patient responsibility, and acting in concert with the provider community, self-management represents a promising strategy for treating chronic conditions—moving beyond education to teaching individuals to actively identify challenges and solve problems associated with their illness. Self-management also shows potential as an effective paradigm across the prevention spectrum (primary, secondary, and tertiary) by establishing a pattern for health early in life and providing strategies for mitigating illness and managing it in later life. SELF-MANAGEMENT: CONCEPTUAL CONSIDERATIONS: - It is a concept introduced in the medical literature in the 1970s - It is seen within the following perspectives: 1. the process of self-management 2. the self-management intervention programs 3. the description of outcomes gained by engaging in self- management practices SELF-MANAGEMENT: PROCESS AND ACTION: - Process: problem solving, decision-making, resource utilization, partnerships with health care providers, and taking action - Action: medical management of the condition, behavior management, and emotional management WHAT IS EVIDENCE FOR SELF-MANAGEMENT? - In long-term self-management: family emphasis on self-reliance and personal achievement, family cohesion, and attentive responses to symptoms have been associated with better patient outcomes. - Relevance of professional, informational and educational support. - Self-management intervention programs: Enhancement of the ability of individuals to improve their health status. - Self-management: is a force behind the 3 processes—primary, secondary, and tertiary prevention—that span efforts to maintain wellness and control symptoms and illness progression. - Improve the quality of care and control cost in healthcare. KNOWLEDGE TRANSLATION ACTIONS INTO CLINICAL PRACTICE - Enhance evidence to improve clinical care. - Identify self-management interventions most likely to improve health outcomes. - Emphasize evidence-based professional training curricula. - Incorporate self-management into primary care. - Engage patients to share self-management experience. - Serve as a resource for local self-management support information. - Tailor self-management to individual needs. - Consider cultural norms and traditions. - Engage patients as to their functional goals. - Transition health care system policies and practices to incentivize and promote self-management. - Use self-management programs as a way to decrease or stabilize costs to payer. - Reimburse providers for prescribing proven self-management techniques. - Use interprofessional approach to develop self-management intervention programs. Week 2 – Case-management, Sustaining Self-care and Self-management of Diseases Readings: Case Management and Self-Management Support for Frequent users with Chronic Disease in Primary Care: a Pragmatic Randomized Controlled Trial - Abstract: Chronic diseases (CD) are major challenge for health care and social services d/t them requiring more services which increase their vulnerability - Intervention: case management by a nurse with group support meetings encouraging self-management - Discussion: the integration of case management by nurses and self management support in primary practice has the potential to impact patient empowerment and QOL & reduce burden on health care - Background: o People with CD need more care because of personal characteristics that increase their vulnerability o Especially true for people with low SES, comorbid mental health conditions or 2+ CDs o People with CD have low QOL, higher risk of social isolation which leads to problems adopting healthy behaviour/managing their health/following treatment o Family Medicine Groups (FMG) were implemented in Quebec to improve accessibility, continuity and coordination of health care in Quebec - Objective: Document the implementation and effects within 4 FMG in Quebec involving case management by a nurse to promote interdisciplinary person-centered follow-up and group self-management support for frequent users of hospital services for CD - Discussion: Case-management intervention delivered by nurses and self-management support has potential to positively impact patient empowerment and QOL and reduce the burden on health care Nursing Informatics: A growing Field of Science and Practice (pp. 215-229) - Nursing informatics: design, use and study of information and communication technologies (ICTs) to support nursing practice What Really is Nursing Informatics About? - Nursing informatics/ICTs are also known as; eHealth, digital health, biomedical informatics, health informatics - Informatics: use of information in a technologically enabled environment; applied through computers and health information systems (HISs) COMMON ICTS - Health Informatics, eHealth, & Biomedical Informatics: Collaboration across the field of information science, computer science, management and organizational science, cognitive science and design science - Digital Health: Same as above and includes the use of genetic information and mobile devices for healthcare activities - Bioinformatics: Use of ICT in genomics/genetics Health Informatics and Health Information Systems: - Goal of informatics according to Canada’s Health Informatics Association (COACH): to help Canadians achieve better health - HIS allows for health information to be entered only once with the ability to be retrieved at any later time - HIS benefits - information can be accessed by more than 1 person at a time, includes individual-based data (what meds are my patient taking) and unit-based data (what is the unit’s fall rate) - Unit-based data can be used for quality improvement - Information entered into the system must be “computer codable” each term has its own code that is to be entered into the system otherwise o the term is not understood by the system Nursing Informatics, a Sub-Field of Health Information: Systems capable to documenting nursing care COMPUTER-CODABLE DOCUMENTATION SYSTEMS FOR NURSING - Most prominent documentation system used globally → International Classification for Nursing Practice (ICNP) developed by the International Council of Nurses (ICN) - ICNP includes areas of concern, why nursing must be involved, nursing activities, interventions and nursing outcomes - Areas of concern include; physiological, psychological, spiritual, and cultural domains - Canadian healthcare records are organized through the use of a multidisciplinary terminology standard called SNOMED-CT (Standardized Nomenclature of Medicine-Clinical Terms) - SNOMED contains 300,000 clinical concepts COMPUTERIZED NURSING ASSESSMENT TOOL: C-HOBIC - C-HOBIC is an assessment tool that includes 24 assessment outcomes organized under 4 categories: functional status, symptom status, safety, and therapeutic self-care - Implementations of the tool; provides nurses education regarding the use of assessment data and tracking change over time, created outcome reports to support pt transitions to different levels of care, raised consideration of the need for C-HOBIC data in the Discharge Abstract Database NATURAL LANGUAGE PROCESSING - NLP is a process where a computer program can identify words and meanings of words/phrases - NLP can automatically convert nursing narratives to standardized nursing knowledge representations Clinical Information Systems (CIS) and the Electronic Health Record - The CIS is used interchangeably with the HIS o Both refer to computer systems that store information that can be retrieved - The EHR is used to access and input information to the CIS/HIS - Data in CIS can be reused for real-time presentation of patient data, interaction with a clinical decision support system, and retrieval of data for quality/research REAL-TIME PRESENTATION OF PATIENT DATA - Patient data is entered into several categories; administrative data, nursing data, clinical data, medical data, lab data, pharmacy data, and radiology data - Once info is entered, EHR collects this info and it becomes immediately available to anyone looking at the patient’s record - EHR provides graphing data so HCPs can observe changes over time CLINICAL DECISION SUPPORT - CDS is the application of evidence using computer logic to the HER - Information is filtered through a system to alert the provider and patient to possible issues and actions to take o This means that the EHR holds both normal values as well as patient results - Computerized Provider Order Entry (CPOE) accesses drug, knowledge, and patient databases to prevent errors such as med errors COMPUTERIZED RECORDS AS A MANAGEMENT TOOL - Nursing executives and management oversee the EHR data - The front-line nurse needs to have the opportunity to document nursing assessment, judgments, actions and outcomes that become a permanent part of the record - The nurse manager needs a system that can document these assessments and is able to track changes over time The Current State of Nursing Documentation - ICN defined an International Nursing Minimum Data Set (iNMDS) that includes minimum data elements to be collected throughout the course of providing care and includes categories such as; setting, pt demographics, and nursing care BARRIERS TO EHR ADOPTION IN NURSING 1. Lack of knowledge among nurses in both practice and academia about how documentations can be done a. Many nurses are unaware of special terms like ICNP b. Nurses working with such systems do not understand the rationale and benefits of it c. Cannot move forward until there is a critical mass of nurses who understand the issues 2. Philosophical stance that rejects post-positivist thinking such that any attempt to name an issue does not “tell the full story” is considered inappropriate a. Many nurses worry that the standardized nursing terms represent a reductionist approach to care which goes against their holistic way of thinking 3. Movement toward interprofessional practice has served to obscure disciplinary perspectives and contributes to invisibility of nursing a. Each profession’s disciplinary perspective can be lost and nursing is particularly at risk 4. Complexities related to the change required to move toward electronic systems a. Failures of implementation are often the result of change planned from “top down” with end-users less involved than what is ideal The Way Forward - To create systems that honour nursing and that accept the reality that electronic environments are becoming the only method of documentation - The lack of critical mass of nurses is the major set back in the movement towards electronic databases Considerations for a new definition of health literacy. Discussion paper. - Health literacy used to be focused on individual skills/deficits and specific products (brochures) - Health literacy is multidimensional o Includes: system demands/complexities, skills/abilities of individuals o Individuals can be patients or family members o Providers of information may be HCP, protocol developers, insurance organizations, pharmaceutical companies - “Oral Health Literacy” or “Environmental Health Literacy”: a term created to personalize and attach the study of health literacy to different disciplines o These terms help connect specific content to central concept - The authors believe it should reflect today’s understanding of health literacy as its multidimensional - Health literacy has many settings and mediums o The definition should include the settings, modes, media and unique psychological impact of health literacy on empowerment and health decisions o Should also be tangible and testable - Limitations of Current Definitions o Since there are multiple conflicting definitions of health literacy, it may be confusing for researchers and the like to choose which is most appropriate o Defines health literacy as an individual skill or ability o The majority of existing definitions specify or do not specify the outcomes of health literacy - no objective indicators of health or health literacy o Definitions should consider the idea of using or applying information (understanding vs. acting) FOUR COMPONENTS THAT SHOULD BE CONSIDERED IN A DEFINITION OF HEALTH LITERACY 1. Include system demands and complexities as well as individual skill/ability - Multidimensional - The components of information exchange must be addressed together--the literacy skills of individuals and system demands and complexities (i.e. consider the context, text, and talks) o E.g. one cannot assess reading literacy without having determined the difficulty of the texts in use - No current instruments that measure health literacy have assessed the oral, numeracy, or writing skills of the professionals themselves - Literacy does not take place in a vacuum → context or systemic factors influences the application of skills (i.e. illness, fear, norms, expectations, and regulations can inhibit skills) 2. Include measurable components, processes, and outcomes - Health literacy is being increasingly considered as a process or pathway they follow to gain more health literacy and create informed health behaviours - Process monitoring is critical to improve performance - Measurable outcomes should be part of the definition 3. Recognize potential for an analysis of change - Definition should be open to the idea that health literacy is malleable and can change for each person, health professional, or health system for a variety of reasons - Doing so will support and allow researchers to explore how and why this change occurs 4. Demonstrate linkage between informed decisions and action - Definition needs to consider the relationship of informed decisions to actions taken RNAO Best Practice Guidelines: Strategies to support self-management in chronic conditions: Collaboration with clients. GUIDING PRINCIPLES - Self-management is a client-led, nurse facilitated process (client sets the agenda) o Client and family participation is paramount - Care strategies need to be tailored towards beliefs, culture, preferences of client - Shift of power must occur from HCP to client o Established through therapeutic relationship and client centered care o Therapeutic relationship = goal directed, focused on advancing the best interest of the client o Client centered care = “meeting people where they are at”/”starting where the client is” BACKGROUND CONTEXT - ⅓ individuals across the lifespan is living with a chronic health condition - In canada most prevalent = cancer, CVD, diabetes, COPD, asthma, depression & anxiety, and arthritis - The incidence of those living with chronic diseases is greatest among those 65+ - Burden of these diseases falls on the economy (and people’s families) - Self-management = addressing behavioural risk factors through 1. Monitoring and managing the signs and symptoms of the disease 2. Engaging in health and lifestyle behaviours and taking medication appropriately 3. Maintaining regular contact with HCP - Self-management is defined as: “...the task that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management, and emotional management of their conditions” - The goal of self-management support = increased confidence in the ability to change, rather than compliance with a caregiver’s advice - Self-management support helps clients become informed about their conditions and take an active role in treatment - Client education and collaborative decision making are needed o Moves away from didactic model of client education DELIVERING SELF-MANAGEMENT SUPPORT - Encourages the client to assume a leadership role o Can be difficult for HCPs who have been trained to be leaders o Less instructions for clients, they have a more proactive role - Strengthens self-efficacy of clients CLIENT EDUCATION AND SELF-MANAGEMENT EDUCATION - Self management = improves QOL, positive outcomes and reduces costs - Behavioural strategies are important in self management o setting goals, collaboratively, with clients, using templates that can be modified based on the client’s context; o assessing clients’ readiness for self-management, based on tools that the client can use in the future; o helping clients to break down goals and tasks into small steps as part of an action plan, using specific tools and templates that can be modified based on the client’s context; o providing personalized feedback and helping the client learn how to ask for, and receive and use feedback; o teaching self-monitoring, using tools and templates; o helping clients obtain social support; o informing clients of and linking them to community resources; o helping clients assess their ‘ commitment to key tasks; and o building in follow up processes to help clients measure their progress and milestone attainment WHY IS LEARNING HOW TO PROVIDE SELF-MANAGEMENT SUPPORT IMPORTANT TO NURSES? - Successful management of chronic health conditions, based on mutual respect, rapport, trust, and effective interventions, is best addressed through a therapeutic client nurse relationship based on the philosophy of client centred care. Practice Recommendations: Multiple Self-Management Strategies. - Nurses utilize the “5 A’s” behavioural change approach of assess, advise, agree, assist and arrange, to incorporate multiple self-management strategies when supporting clients with a chronic illness to assist in improved outcomes. - Nurses establish rapport with clients and families. - Nurses’ screen for depression on initial assessment, at regular intervals and advocate for follow-upG treatment of depression. - Nurses establish a written agenda for appointments in collaboration with the client and family, which may include: o Reviewing clinical data o Discussing client’s experiences with self-management o Medication administration o Barriers/stressors o Creating action plans o Client education - Nurses consistently assess client’s readiness for change to help determine strategies to assist client’s readiness for change to help determine strategies to assist client with specific behaviours. - Nurses encourage clients to use health risk appraisal instruments; model the use of such tools, and discuss the results of the risk assessment with them at regular follow up. - Nurses combine effective behavioural, psychosocial strategies and self-management education processes as part of delivering self-management support. - Nurses utilize the “ask-tell-ask” (also known as Elicit-Provide-Elicit) communication technique to ensure the client receives the information required or requested. - Nurses use the communication technique “Closing the Loop” (also known as “ teach back”) to assess a client’s understanding of information - Nurses assist clients in using information from self-monitoring techniques (e.g., glucose monitoring, home blood pressure monitoring) to manage their condition. - Nurses encourage clients to use monitoring methods (e.g., diaries, logs, personal health records) to monitor and track their health condition. - Nurses collaborate with clients to: o Establish goals o Develop action plans that enable achievement of goals o Monitor progress towards goals. - Nurses who are appropriately trained use motivational interviewing with their clients to allow clients to fully participate in identifying their desired behavioural changes. - Nurses teach and assist clients to use problem-solving techniques. - Nurses are aware of community self-management programs in a variety of settings, and link clients to these programs through the provision of accurate information and relevant resources. - Nurses arrange regular and sustained follow-up for clients based on the client’s preference and availability (e.g., telephone, email, regular appointments). Nurses and clients discuss and agree on the data/information that will be reviewed at each appointment. - Nurses use a variety of innovative, creative and flexible modalities with clients when providing self-management support such as: o Electronic support systems o Printed materials o Telephone contact o Face-to-face interaction o New and emerging modalities - Nurses tailor the delivery of self-management support strategies to the clients’ culture, social and economic context across settings. - Nurses facilitate a collaborative practice team approach for effective self-management support. - Nursing academic programs integrate principles of self-management support education throughout their core curriculum and in continuing education - Organizations provide self-management support education through a variety of ongoing professional development opportunities to support nurses in effectively developing skills in self-management support - Organizations provide opportunities for nurses to take leadership roles in the provision of self-management support. - Organizations integrate self-management support values and principles related to fostering client-centered care and therapeutic relationships in the delivery of care and services, through inclusion in strategic plans and organizational goals. - Decision makers (Chief Executive Officers, Directors, Managers, Stakeholders) within organizations ensure adequate funding is available for self- management support initiatives such as technology to provide education to clients and nurses. - Nursing best practice guidelines can be successfully implemented where there are adequate planning strategies, resources, organizational and administrative support and appropriate facilitation of guideline uptake among clinicians. An effective organizational plan for implementation includes: o An assessment of organizational readiness and barriers to implementation, taking into account local circumstances. o Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. o Ongoing opportunities for discussion and education to reinforce the importance of best practices. o Dedication of a qualified individual to provide the support needed for the education and implementation process. o Ongoing opportunities for discussion and education to reinforce the importance of best practices. o Opportunities for reflection on personal and organizational experience in implementing guidelines. Processes of Self-Management in Chronic Illness (pp. 136-144) - Chronic illnesses are the primary reason adults seek health care Self-Management: - Self-management: the ability of the individual, in conjunction with family, community, and healthcare professionals, to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions - Optimal self- management entails the ability to monitor the illness and to develop and use cognitive, behavioral, and emotional strategies to maintain a satisfactory quality of life EMERGING DEFINITION OF SELF-MANAGEMENT PROCESSES - The three tasks of self- management: o Medical management, such as taking medications and attending medical appointments o Behavioral management, such as adapting lifestyle or life roles o Emotional management, including processing emotions that arise from having a chronic illness - Several processes of self-management; problem solving, decision making, utilizing resources, partnering with healthcare providers, taking action, and improving self-efficacy Findings: FINAL CONCEPTUALIZATION OF SELF-MANAGEMENT PROCESSES - Three categories of self-management processes identified 1. Focusing on illness needs - Represents the self- management tasks and skills necessary for individuals to take care of their bodies and illness-specific concerns of a chronic illness - Individuals learn about the chronic illness, take ownership of their health needs, and perform health promotion activities - Tasks and skills of learning about self-management include acquiring information about the illness and learning requisite regimens, skills, and strategies, in order to manage daily illness needs 2. Activating resources - Resources that are integral to optimum self- management include individuals and community resources and services - Self-management tasks and skills related to activating resources include communicating with healthcare providers, coordinating services, identifying and benefiting from psychological resources, being part of a spiritual community, obtaining and managing social support, and addressing social or environmental challenges 3. Living with a chronic illness - Living with a chronic illness is a self-management process - This process includes skills related to coping with the illness and growing as a person, and focus on the context of the individual’s life. - Four tasks were identified: processing emotions, adjusting, integrating illness into daily life, and meaning-making - Addressing emotions is an important aspect of self-management FACTORS AFFECTING SELF-MANAGEMENT - Demographic factors (socioeconomic status and culture), - Clinical factors (comorbidities and complexity of the treatment regimen), - System factors (quality of relationships and communication with providers) DISCUSSION - An individual does not necessarily progress from a focus on illness needs, to activating resources, to successfully living with a chronic illness - The overall experience of living with a chronic illness changes over time, which can impact an individual’s self- management - The trajectory of the illness as well as the development of complications or comorbidities can significantly alter well-established self- management routines CLINICAL RELEVANCE - Nurses and other healthcare providers that provide self-management support for adults may consider developing an assessment form based on the proposed tasks and skills - This form could be used in the clinical setting to identify strengths and limitations of current self-management efforts to prioritize care - The proposed tasks and skills might also form the basis of a patient-oriented guide to educate patients about various aspects of self-management and to help them monitor their self- management activities Chapter 6: Canadian Health Care (pp. 85-104) The Importance of Understanding Canada’s Healthcare System - Medicare began between the late 1960s and mid-1970s - Canada’s health insurance programs are ~55 years-old - CHA banned physician charges to patients for medical services The Canada Health Act - 5 principles of the CHA: comprehensiveness, universality & portability, accessibility, public administration COMPREHENSIVENESS - Original draft of comprehensive health and social insurance plan included unemployment insurance, health insurance, services for prevention, diagnosis, treatment, and care - The plan was created in response to WWII and the exceeding needs that surpassed the scope of comprehensive health care - The plan was not approved by parliament and instead a less organized implementation of programs and services was used with the original draft as a guide - There are 4 myths of Canadian healthcare in the 21st century 1. The aging population will bankrupt Medicare 2. Canada has the best health system in the world 3. Canada is stuck with the current system in place 4. More money is the only answer NATIONAL HEALTH GRANTS AND THE PUBLIC’S HEALTH - The fed. government offered cost-sharing grants to the provinces to enhance health services - Each province needed to agree to pay ~50% of the costs in order to accept the offer from the fed. Government - Annual grants included general public health, venereal disease control, mental health, tuberculosis control, cancer control, crippled children funds, professional training, public health research, and grants for hospital construction PRIMARY HEALTH CARE - PHC: basis for the delivery of health services, involving a philosophy and an approach in the way the care is delivered - Includes health promotion, disease prevention, curative services, rehab care, supportive/palliative care - Between WWI and WWII (before there was PHC), nurses were especially providing health services which threatened many physicians - In the 90s, the fed. government attempted to develop PHC however the funding was utilized in services provided by physicians - The CAN responded by developing a submission called “Putting Health Back into Health Care” which recommended that insurance programs, legislation, and salary be revised; better health education programs be implemented; and the reinstitution of a national health survey to gather needs of Canadians CARE OF THE CHRONICALLY ILL - An issue of Healthcare Papers in 2007 suggested that the healthcare system address the multiple chronic diseases endured by Canadians - This paper also stated that much of the healthcare budget was supplied to hospitals physicians and prescription meds rather than prevention and management of chronic illnesses THE RISING COST OF STAYING HEALTHY IN CANADA - Canada lacks in providing social security to all of its citizens - Delivery system integration: approach to maximizing the benefit of existing social services THE RESURGENCE OF COMMUNICABLE DISEASES AND PUBLIC HEALTH SERVICES - The outbreak of SARS gave Toronto a wake up call to restore public health services - The Zika virus is allowing international researchers to work collaboratively - Funding for research is the key to supporting public health issues moving and keeping them in the media - Trudeau government responded to calls for more leadership in healthcare directives and supplied 37.1 billion dollars to the provinces for health care - Public Health Agency of Canada (PHAC) was created in 2004 to “promote and protect the health of Canadians through leadership, partnership, innovation, and action in public health” UNIVERSALITY AND PORTABILITY - One challenge in maintaining Canadian healthcare is the difficulty the fed. government encounters in influencing national policy and standards - Universality and portability cannot easily be enforced by the fed. government BARRIERS IMPOSED BY THE BRITISH NORTH AMERICA ACT - The Fathers of confederation did not know much about future health care needs - Most responsibility was left to the provinces - Provinces have a choice about joining cost-shared programs FRAMEWORKS FOR HEALTH PROMOTION - “The gift of Our Neighbors and Surroundings” (J.W. McIntosh) → describes the disabilities affecting many Canadians (hereditary, personal, self- imposed, environmental) - A New Perspective on the Health of Canadians (The Lalonde Report) → considered heredity, environment, lifestyle, health services - “Achieving health for all: A Framework for Health Promotion” (Jake Epp) → identified three key areas (health challenges, health promotion mechanisms, and implementation strategies) ACCESSIBILITY (AND SUSTAINABILITY) - In Alberta, patients were billed extra because Medicare funds restricted adequate compensation for the physicians Government Studies and Agreements - In Feb 2003 a Healthcare Renewal Accord was passed which called for a standard of care that includes; - Access to healthcare provider 24/7 - Access to dx procedures and tx - Reduction in duplication pt hx and testing for every provider they visit - Access to quality home and community care services - Access to quality care no matter where they live - Healthcare system that is efficient, responsive, and adapting to changing needs Nurse Practitioner - NP role emerged in 1960 and 70s - NP role increases accessibility of primary care practitioners to Canadians Public Administration - Canada has a mix of public and private for-profit care - 70% of total health expenditures in Canada are paid by public sector funding - Major challenges faced by Canadian system: extended pt waits for non-emerg surgical services; lack of appropriate fiscal incentives when reimbursing their hospitals; resident physicians currently completing approved programs in gen surg What does this Mean? - Our current situation in healthcare and the need for change: • We operate under BNA act provisions for determining federal and provincial responsibilities • We talk about SDoH but don't really deal with these determinants • Medicare has a high level of public support • Canada implements publicly appealing programs rather than adopting a comprehensive approach • Most nurses work in hospitals or places where their autonomy is more limited than their counterparts in the community • The promise of health reform has yet to be realized • Canada has failed to manage growth of med technology in a rational way • We have yet to develop primary healthcare services, to make better legislative provisions, or promote better use of qualified health personnel • Canada’s healthcare still marginalizes some populations including; Indigenous people, the poor, the elderly, the young • Its necessary to assess socioeconomic barriers that prevent patients from taking responsibility for their health Nurses Leading to Influence Change WHAT NURSES NEED TO KNOW - They need to know about the development of Canadian healthcare - They need to know updated information to keep up to date with public debates - Other information they need to know includes; influence of trade agreements on health care and practice as well as basic needs of the public WHAT NURSES NEED TO BE - Well-educated, good listeners, sensitive caregivers - They must see and respond to the marginalized - They must see and critically think about the dominant players in health care and understand their views WHAT NURSES NEED TO DO - Willing to work together to reach good outcomes for their patients and themselves - Use the knowledge gained through education and nurse-patient relationships to focus attention on the SDoH - Must work collectively toward the goal of primary healthcare - Must be ready to speak, question and spread hope Week 3: Transition to new graduate role & Developing clinical and administrative leadership Readings Content: - Managing changes - Working with merging health care units - Mobilizing resources in levels of communication - How new graduates use available resources - Entrepreneurship in nursing The impact of entrepreneurial leadership on nurses’ innovation behavior. Journal of Nursing Scholarship PROBLEM - There is little knowledge on the type of leadership that focuses on enhancing the innovation work behaviour (IWB) of employees and shapes and directs innovation in the organization - Guo (2009, p. 28) also postulated that previous leadership practices focusing on “directives and control mechanisms are no longer effective,” and healthcare organizations urgently require leadership styles focusing on innovation and new opportunity recognition. AUTHOR’S HYPOTHESIS - Entrepreneurial leadership (EL) has long been suggested to be effective in inspiring innovation and change among nurses (Ballein, 1998). This leadership style also enables leaders to effectively overcome the ever-changing and more serious challenges of healthcare organizations (Guo, 2009). - However, empirical research on the impact of leadership style on fostering the IWB of healthcare professionals and particularly nurses is in the early stages of development (Cummings et al., 2010; Malik et al., 2016; Xerri, 2013). - Essentially, author is trying to determine the impact of EL on nurses’ innovation work behaviour; older leadership styles (i.e. transformational) have been focal in research but there is very little on EL and how it may have an impact on IWB (specifically in Iran) - Hypothesis 1: EL has a significant positive impact on nurses’ IWB. - Hypothesis 2: EL has different significant effects on dimensions of nurses’ IWB (idea exploration, idea generation, idea championing, and idea implementation). WHAT IS IWB AND WHY IS IT IMPORTANT? - Creating and fostering innovation have long been a main concern of different organizational leaders, regardless of the size, nature, or structure of the organization - In particular, leaders of organizations with highly challenging and complex environments such as health care have been struggling with inspiring employees’ IWB and creating the appropriate environment for innovation - Innovation has also been a critical component of employees’ effective job performance and their contributions to organizational success - Dimensions of IWB: IWB, idea exploration, idea generation, idea championing, and idea implementation - Scholars have mostly defined IWB as the intentional initiations and efforts led by individual employees to generate new ideas, get support, and implement ideas to improve the performance of their tasks - “Implementation of a novel idea so that it creates value” WHAT IS EL? - Prior research has suggested EL as an influential leadership style and behavior for stimulating and improving IWB, as well as for consequently fostering competitiveness, effectiveness, and the growth of organizations of all sizes and natures - To achieve the vision, entrepreneurial leaders improve employees’ attitudes toward and self-efficacy in creating novel ideas and direct them to implement new ideas - Such leaders also create an environment and culture in the organization that encourage and support employees to face the challenges of engaging in innovation efforts (Karol, 2015). STUDY FINDINGS - Our findings confirmed the hypothesized significant impact of EL on nurses’ IWB. - Entrepreneurial leaders play a significant role in improving nurses’ IWB through encouraging and supporting them to abandon the traditional ways of executing their tasks and change their perceptions towards their capabilities to create and implement new ideas - Entrepreneurial leaders also advance nurses’ IWB through acknowledging their efforts and contributions in the process of innovation, offering them the required information and resources for innovation and practicing and valuing innovation - In addition, healthcare entrepreneurial leaders develop effective strategies and approaches to facilitate innovation and new opportunity recognition activities - Previous researchers argued that a single leadership style cannot be effective in improving employees’ IWB. Therefore, healthcare leaders and supervisors should also learn how to incorporate EL competencies with other leadership styles to better promote innovation among employees. Issues in contemporary nursing leadership INTRODUCTION - The premise of this chapter is that leadership is about the potential to make a difference and this potential is present in every nurse. - “Complexity science provides a constellation of concepts that are informing critical thinking and research scholarship in multiple disciplines and professional groups - Main concepts in this chapter: complex adaptive systems (CAS), emergence, unpredictability, and relationships. - Bottom-line—there are no simple answers in complex situations. Leaders cannot control nurses and nurses cannot control patients. - However, leaders can inspire and enable nurses to rally around a goal or purpose that they care about and nurses can inspire and enable patients to rally around a goal or purpose that they care about. - Complexity theory eliminates either–or and right–wrong thinking.