NSG 310 FINAL EXAM STUDY GUIDE

NSG 310 FINAL EXAM STUDY GUIDE TOPIC 4: 1. Identify the ethical principles nurses must consider when making decisions regarding client care. • Privacy and confidentiality o Treat information as private o Protect client privacy o Health Insurance Portability and Accountability Act (HIPAA) • Veracity: Obligation to tell the truth and not to lie or deceive others • Fidelity: Obligation to others or to organizations (such as keeping up your CPR training) • ANA Code of Ethics o Code of Ethics which speaks to the nurse’s obligation to: ▪ The Client ▪ To Self ▪ To Colleagues ▪ To the Nursing Profession 2. Describe ethical nursing behaviors that build trust and promote client-centered goals. • Ethics in client care o Respect for autonomy- nurse must find out what the client’s preferences, needs and wants are. o Beneficence- this principle is about doing good for our clients and making sure no harm will befall their care (preventing or removing harm) o Nonmalificence- this principle involves harm to the client but the difference is that the focus is not on inflicting harm, rather than preventing or removing harm as in beneficence. o Justice- this principle is about distributive justice where all care is equal, goods and services equally distributed as well as care for all individuals 3. Examine key elements of management of care, including advance directives, advocacy, client rights, HIPAA, confidentiality, and informed consent. • Board of nursing: State agency legislatively created by NPA in states: o Licensing board for nurses o Establishes entry requirements into the profession o Sets definitions of nursing practice o Establishes guidelines for professional discipline when a nurse fails to obey the law or becomes incompetent • Licensure: Used to protect the health, safety, and welfare of its citizens o State licensure statutes control entry into the profession, the discipline of licensees who fail to comply with minimal standards, and the nursing activity of unlicensed practitioners (“nurse imposters”). o Licensure and protection of health, safety, and welfare of citizens ▪ Entry to practice ▪ Multistate license and telehealth ▪ Advanced practice nurses ▪ Control over nursing practice ▪ Delegation in nursing practice EXAM 2_310 • Nurse Multi-State Licensure Compact: o Approved by the National Council of State Boards of Nursing (NCSBN) in 1998 o Allows a nurse who holds a license in the state of legal residency to practice in other states that have enacted the Compact. Currently, 23 states participate (2009). o Advanced practice nurses are excluded from the Compact and must obtain certification in each state where they practice. • Regulatory power: Authorizes the board to develop rules and regulations for nursing licensure, nursing education, and nursing practice • Adjudicatory power: Authorizes the board to investigate, hear, and decide the outcomes of complaints that involve violations of the NPA and of the rules and regulations promulgated by the board • ROLE OF NURSING BOARDS o As mandated by the NPA, the board must ensure that a licensed nurse continues to practice within the standard of care, behaves professionally and ethically, and obeys all relevant state laws. o The disciplinary action is on the license of the nurse, and that license may be suspended or revoked by the board. o Boards can only limit or deny a nursing license. o Administrative Procedure Act – in each state o A professional license is protected property by the U.S. Constitution. A license cannot be limited or taken away without due process: requires both the right to be heard and notice. A nurse has the right to appeal any decision made by the board. • Know the requirements of the NPA for licensure. • Know the boundaries and definitions of practice, the areas for discipline on practice, and the procedures in place to protect the nurse when the board challenges the license. • NPAs leave public consumers of nursing care dependent to a large degree on members of the profession to control access to nursing services and to maintain the quality of care. • ALL NPAs have commonalities. o A nurse who moves from one state to another or practices in multiple states through the Compact should obtain a copy of each state’s NPA. The differences in state NPAs can be significant. For example, one state may impose no legal duty on a nurse to report the incompetence of a physician. In another state, the nurse may find that failure to report such a physician can result in the loss of license. o The nurse needs to be familiar with the requirements of the NPA for licensure, the boundaries and definitions of practice, the areas for discipline on practice, and the procedures in place to protect the nurse in case the board challenges the license. • Nurses with disabilities o Confidentiality o As long as consistent with client safety o Treatment o Self-reporting o Access to practice ▪ Nurses with disabilities, such as those with drug dependence who are compliant with treatment, those with physical impairments, and those with a mental illness, are granted special confidentiality as long as it is consistent with client safety. This is intended to encourage nurses to seek EXAM 2_310 treatment and self-report, to report other nurses who need treatment, and to ensure nurses with disabilities are not the object of discrimination. • Contract law: Nurses work under contract, a promissory agreement between two or more parties that creates a legal relationship: o Employment at will: The employee has the right to terminate employment for any reason “at will,” and the employer has the parallel right to terminate the employee at any time for any reason, also “at will.” o Labor law: Collective bargaining agreement establishes a contractual agreement between the union and the employer • AN ENFORCEABLE CONTRACT o 1. For performance of legal goods or services. A nurse cannot contract to practice medicine. o 2. The parties must have legal capability to make the contract. For example, they must all have the mental ability to understand their actions and must be old enough to make a legal agreement. o 3. All parties at the time of the contract must agree to do something, and they must agree on what that something is. o 4. There must be “consideration” (i.e., some kind of trade in which each party gets something from the contract). o “Statute of frauds” that limits the enforcement of some contracts not written o State “parole evidence rule.” This rule provides that if oral agreements are made that differ from the written contract, the courts will not allow them to add to or change the written contract. • Contract Termination o Completely performed: Terms met o Both parties agree to a change or annul o Becomes impossible (e.g., death of a party or the destruction of the subject) o Breach: One party fails to meet the terms of the agreement ▪ Other party can sue in civil court for any damages • National Labor Relations Act (NLRA) o Collective bargaining ▪ Bargain with the employer as a group, in good faith, to make an agreement regarding similar interests in wages, hours, and working conditions ▪ Grievance procedures guaranteed to all employees ▪ Protect the nurse employee from discharge except for “good cause” ▪ Cannot bargain individually with the employer o This means they had formed a collective bargaining unit and could bargain with the employer as a group, in good faith, to make an agreement regarding similar interests in wages, hours, and working conditions. Collective bargaining agreements contain grievance procedures guaranteed to all employees. Furthermore, they usually contain a clause protecting the nurse employee from discharge except for “good cause.” Nurses who work in a unionized facility cannot bargain individually with the employer. The employer must bargain with the union, which must represent all employees, whether or not they join the union • Labor Law: Compliance Programs Purpose EXAM 2_310 o Promote conformity to legal requirements within the institution by identifying potential concerns and correcting and preventing the recurrence of any identified problems. Compliance office • Labor Law: Government Employees o Civil Service Reform Act of 1978 o Federal employees, such as nurses who work for the Veterans Administration o Employment rights of state employees are governed by each state’s public employee statutes • TORT: Private or civil wrongs, in contrast to CRIMES, which are wrongs committed against the state (Goldberg, Sebok, & Zipursky, 2012; Schwartz, Kelly, & Partlett, 2010) o Plaintiff files a tort action to recover damages for personal injury or property damage occurring from the negligent conduct or unintended misconduct o Unintentional torts are those in which persons incur harm or injury as a consequence of an unintended, wrongful act by another person: Unintentional tort: Negligence and malpractice, Assault and battery, False imprisonment, Lack of informed consent, Breach of confidentiality o Negligence and the related legal concept of malpractice are examples of unintentional torts (Goldberg et al., 2012; Schwartz et al., 2010). o Several types of torts are often encountered in legal actions against nurses. These include negligence, assault, battery, false imprisonment, lack of informed consent, and breach of confidentiality. o Negligence: Occurs when a person fails to act in a reasonable manner under a given set of circumstances o Malpractice: Unreasonable conduct by a nurse or other professional – which is determined in a court of law ▪ The nurse has the legal duty to provide the client with a reasonable standard of care―that is, “what the reasonably prudent nurse would do under the same or similar circumstances.” ▪ Four Elements of Malpractice • DUTY: A legal obligation toward the client (Schwartz et al., 2010; Scott, 1998). A nurse’s signature in the client’s medical record may be enough to prove that the nurse had a duty to the client. For purposes of establishing the element of duty in a malpractice case against a nurse, the question is, “Did the nurse have a legal obligation toward this client?” • BREACH OF DUTY: Considers whether the nurse’s conduct violated the duty to the client (Schwartz et al., 2010) • To determine whether a breach of duty occurred, the plaintiff must show that the nurse’s conduct did not comply with reasonable standards of care rendered by an average, like-specialty provider under similar circumstances (Schwartz et al., 2010). • A number of methods are used to determine whether the nurse’s care was reasonable. • Expert witness testimony, nursing texts, professional journals, standards developed by professional organizations, institutional procedures and protocols, and equipment guidelines developed by EXAM 2_310 manufacturers can all be used to decide whether the nurse’s care complied with reasonable care (Aiken & Catalano, 1994; Glannon, 2010; Guido, 2013; Schwartz et al., 2010; Sharpe, 1999). • Use of careful documentation techniques, such as those specified in the documentation guidelines, will help the nurse to establish that the care delivered was reasonable (Box 11-2). • CAUSATION: Addresses two issues: whether the nurse’s action or inaction caused the client’s injury and whether the client’s injury was foreseeable (Aiken & Catalano, 1994; Glannon, 2010; Guido, 2013; Schwartz et al., 2010). • To determine whether the nurse’s actions or inaction caused the injury to the client, lawyers frequently use the “but for” test (Schwartz et al., 2010), which asks, “But for the acts or inaction of the nurse, would the injury to the client still have occurred?” • The second part of the causation element looks at whether the nurse could have reasonably anticipated that his or her conduct might lead to client harm (Aiken & Catalano, 1994; Guido, 2013). • DAMAGES: For a client to recover damages from a nurse in a malpractice suit, he or she must have sustained some type of damage (i.e., injury, harm). For example, if the nurse gave the client the wrong medication but the client did not experience any adverse effects, the damage element would be missing, and the malpractice suit would be unsuccessful. • Assault: A deliberate act in which one person threatens to harm another person without his or her consent and has the ability to carry out that threat • Battery: Nonconsensual touching even if the touching may be of benefit to the client • In some circumstances, such as restraint situations, the law allows providers to touch clients without their consent. o Special circumstances and procedural safeguards- special circumstances and procedural safeguards must be adhered to in order to excuse the battery. o Protect the client, others (including health team members) and Protect property o Least intrusive- courts will examine whether restraining the client was the least intrusive method to control the client o Regular assessment for appropriate use of restraints- courts typically inquire whether the health care team regularly reassessed the need to continue using the restraint. If the health care team can demonstrate that it has complied with these requirements and with institutional procedure, nonconsensual touching will be excused. • Informed consent o Informed consent lawsuits focus on whether the client was given enough information before a treatment to make an informed, intelligent decision, including the decision to refuse treatment. o Consent may be express or implied. Express consent is given in spoken or written direct words. Implied consent is consent inferred from the client’s conduct. Even if the client does not sign a consent form expressly consenting to a proposed treatment or procedure, courts sometimes find that the client gave EXAM 2_310 implied consent to the treatment or procedure by coming to the health care facility and submitting to the treatment or procedure. o The client may accept or refuse any treatment, even lifesaving procedures. Nearly all states today treat the failure to provide the necessary information so a client can make an informed decision regarding the risks and benefits of care as negligence under the informed consent doctrine. In other states, the plaintiff files a battery action alleging that the failure to give adequate treatment information constituted nonconsensual touching. The right to informed consent and informed refusal was affirmed at the federal level by the client Self-Determination Act of 1991. o Special circumstances: ▪ Recognized exceptions exist to the doctrine of informed consent. ▪ If a client was admitted to an emergency department with a severe, hemorrhaging abdominal injury that required the immediate removal of his spleen, this would be within the emergency exception to the mandate to provide the usual explanation of the splenectomy procedure and obtain informed decisions about care from the client. ▪ Some courts have allowed a provider to avoid full disclosure to a client if disclosure of information might lead to further harm to the client. This exception is known as therapeutic privilege. For example, if the provider thought a psychiatric client’s knowledge of terminal cancer would lead the client to commit suicide, the provider might exert therapeutic privilege and not reveal the cancer to the client. ▪ -Regardless of the situation, the caregiver does not have authority to stand in the place of the client to provide informed consent for the treatment he or she is providing (Philipsen, 2000). ▪ -Consent must be obtained from the client or the client’s legal representative. ▪ In any exception, the practitioner must seek the best possible substitute for informed consent by the client. ▪ In emergencies, implied consent permits the caregiver to save a life but does not waive the client’s right to informed consent as expeditiously as practical. clients who are unconscious or incompetent or who are minors are unable to provide their own informed consent. The caregiver must locate the person with ▪ The client’s power of attorney for health care ▪ The next of kin designated by state law ▪ The court-appointed guardian who has the power to make decisions for the client, in that order ▪ Parents are generally responsible for making the health care decisions for their minor children unless the parents are not acting in the child’s best interest. The caregiver must inform the client, the client’s guardian, or the client’s surrogate for health care decisions of the client’s care options and must obtain consent for treatment. EXAM 2_310 ▪ A true exception is court-ordered care, for example, drug treatment or psychiatric care ordered during sentencing by a criminal court. When in doubt, the nurse should consult with the facility’s attorney. o Typically, responsibility for the consent procedure rests in the hands of the practitioner who will be performing the treatment, frequently a physician, and the nurse serves as a witness. o When the nurse signs the witness portion of the consent form, he or she is attesting that the signature on the consent form is the client’s. If the nurse witnesses the physician giving the pertinent information regarding the treatment or procedure, the nurse may want to write “consent procedure witnessed” below his or her signature. If a lawsuit later develops concerning whether the provider gave the client information concerning the procedure or treatment, the “consent procedure witnessed” statement can furnish powerful evidence that the client did receive adequate information. o Today’s advanced practice nurses (APNs) often perform procedures and treatments that require consent, such as suturing, obstetrical care, and administration of medications. In these circumstances, the APRN is the practitioner who must ensure the client has enough information to make an informed decision regarding a proposed treatment. • False imprisonment o The confined person must be aware of the confinement or harmed as a result of the confinement. o To prevail in a false imprisonment action, the client must prove that he or she was physically restrained or restrained by threat or intimidation and that he or she did not consent to the restraint (Schwartz et al., 2010). o False imprisonment suits may involve situations in which a client was kept in a mental health facility against his or her will and without a judicial order or a restraint device was applied to a client against his or her will. o The laws on false imprisonment vary from state to state. Most states allow some degree of client confinement if the client poses a serious threat of harm to self, others, or the property of others. o In deciding whether a valid confinement occurred, judges and juries often look at the reasonableness of the decision to confine the client, how long the client was confined, whether the need for the confinement was regularly reassessed, and whether the least restrictive methods for detention of the client were used. 4. Articulate the nurse's ethical and legal responsibility to maintain the confidentiality of client information and records. • It is the duty of health care providers to protect the secrecy of clients’ information, no matter how it is obtained. • State and federal laws provide clients with legal remedies to compensate them for confidentiality breaches. • HIPAA: Health Insurance Portability and Accountability Act (HIPAA) of 1996 o Enacted by Congress in 1996: Governs the privacy of personal health information and the security of such information o Sets a minimum standard governing uses and disclosure of this information EXAM 2_310 o Protects individuals from losing their health insurance when leaving or changing jobs (portability) o Increases the government’s authority over health care fraud and abuse (accountability) o Although the health care provider that created the medical record owns that record, the information it contains belongs to the client. o The HIPAA privacy rule prohibits the release of identifiable personal health information in any form without the client’s permission. o Penalties for failure to comply involve a substantial fine, prison term, or both. • Disaster Nursing o Nurses who respond to disaster are typically volunteer nurses, working either through a recognized nonprofit organization such as the American Red Cross or through a government agency. As long as the volunteer nurse acts in good faith and within his or her scope of practice, he or she is protected from tort actions. o Special provisions in most nurse practice acts permit practice across state borders for emergencies. o The Good Samaritan Acts, which were designed to encourage individuals to volunteer to help in emergencies, also protect volunteer nurses. In addition, special tort laws protect nurses who may be working as disaster volunteers under the coordination of a state or federal government agency in the same way employees of that agency are protected (Howie, Howie, & McMullen, 2012). 5. Identify steps to keep client data secure and professionally manage client information. • 6. Apply professional standards and best practices to compose legally defensible client documentation that is timely, objective, factual, and complete. • Criminal charges filed against a health care provider when a client death has resulted from unintentional error • Rarely occurs in health care; one key element of a crime is that it must include the intent to do wrong • The Institute of Medicine, in its 2004 report, To Err Is Human: Building a Safer Health System, stated: “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system ... when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error. Health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety” (p. 5). • The Committee for Disaster Medicine Reform () is an organization formed in response to the criminal charges following Hurricane Katrina. It promotes legislation and takes other measures to protect health care professionals from “unwarranted criminal allegations and wrongly placed lawsuits”. Nurses and other health care professionals must work together to enforce a policy against the criminalization of error. EXAM 2_310 TOPIC 5: 1. Describe the role of Quality and Safety Education for Nurses (QSEN) in promoting safe client care. • Safety- Freedom from accidental injury • QSEN- “the minimization of risk for harm to patients and to providers through both system effectiveness and individual performance” • Goal of QSEN- meet the challenge of preparing future nurses • Preparation in knowledge, skills, and attitudes (KSA) o Patient-Centered Care o Teamwork and Collaboration o Evidence-based Practice (EBP) o Quality Improvement (QI) o Safety o Informatics 2. Discuss how quality improvement processes contribute to excellence in health care delivery and client safety. • For quality control in healthcare, if you cannot measure it—you cannot improve it (AHRQ, 2017) • Bringing excellence to healthcare decision making, quality improvement, and research. • Quality Indicators (QIs) are standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes. 3. Identify National Patient Safety Goals, core measures, and health care and regulatory organizations that contribute to creating a culture of safety. • Patient safety moved to the forefront in health care with the release in 1999 of the Institute of Medicine (IOM) landmark report, To Err is Human: Building a Safer Health System, which estimated that annually in the United States, up to one million people were injured and 98,000 died as a result of medical errors (IOM, 2000). The report caught the attention of the media, and there were headlines across the nation about the safety (or lack of safety) for patients in healthcare organizations. • National patient safety goals: o Identify patients correctly, improve effective communication, improve the safety of high-alert meds, ensure correct site, correct procedure and correct patient surgery, reduce the risk of health care associated infections, reduce the risk of patient harm resulting from falls 4. Explain the role of client safety primers and quality indicators in promoting safe, quality care. • Nurses play an important role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing countless other tasks to ensure patients receive high-quality care. EXAM 2_310 • Preventable adverse events: those due to error or failure to apply an accepted strategy for prevention; • Ameliorable adverse events: events that, while not preventable, could have been less harmful if care had been different; • Adverse events due to negligence: those due to care that falls below the standards expected of clinicians in the community. • Two other terms are used to describe hazards to patients that do not result in harm: • Near miss: an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome. A patient is exposed to a hazardous situation but does not experience harm (either through luck or early detection). • Error: a broader term referring to any act of commission (doing something wrong) or omission (failing to do the right thing) that exposes patients to a potentially hazardous situation. 5. Define evidence-based practice and its role in ensuring safe, quality care and improving client outcomes. • EBP: problem-solving approach to clinical decision making within a health-care organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence • Quality health care: Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (ANA, 2017). o Include: services provided, consistency with current knowledge and targeted outcomes 6. Describe Just Culture as a concept to promote accountability, transparency, and improvements in providing safe, quality care. • ANA is among the advocates for the use of the “just culture” concept. This concept recognizes that human error and faulty systems can cause a mistake and encourages an investigation of what led to the error instead of an immediate rush to blame a person. Through this process, systems that can be fixed. It gives workers the opportunity to feel more at ease reporting problems, and a sense of accountability for system improvement. • While it discourages blame, it is not a “no-fault” system. It does not tolerate malicious or purposefully harmful behavior and supports disciplinary actions to persons that engage in such behavior. It supports coaching and education if the mistake was inadvertent or occurred in a system that was not supportive of safety. Mandatory overtime or insufficient rest breaks on overnight shifts leading to fatigue might be such systems flaws. o Human error: when people do something wrong not on purpose o At-risk behavior: people choose at-risk behavior, know they are doing something wrong but “have a good reason”, puts patient at risk o Reckless: person consciously disregards policy and practices TOPIC 6: ch. 1, 2, 4 – I 1. Describe characteristics of a positive nurse-client relationship. • Characteristics of a therapeutic relationship – goal is promotion client’s health and wellbeing, not random but instead planned exchange, therapeutic helping relationship vs. social relationship: EXAM 2_310 o Client centered: includes client’s individual preference, values, beliefs, and needs o Partnership: honors client’s right to self-determination giving client and family maximum control over health care decisions – advocate for client and encourage independence o Professional Boundaries: protect functional integrity of alliance between nurse & client, Violations take advantage of client’s vulnerability and represent a conflict of interest o Involvement: degree of the nurse’s attachment and active participation in client’s care, over involvement – loss of essential objectivity need to support client in meeting health goals o Authenticity: requires admitting mistakes, recognizing vulnerabilities o Presence: in the moment o Self-awareness: reflective process seeking to understand one’s values, feelings, attitude, motivations, strengths, & limitations. 2. Identify skills for effective interprofessional communication in the health care setting. • Competencies and Standards of Care – what are standards of care – who tells us what they are? • Professional Licensure - dictates our roles along with agencies that have supervision and oversight for our profession • Professional standards for effective communication set by: o Institute of Medicine (IOM) – 5 reports for safety and quality of health care ▪ Accurate, complete communication is one of it’s goals – standardization for communication tools (such is SBAR) o The Joint Commission (TJC) – regulates hospitals and evaluates safety for accreditation ▪ Effective communication (6 C’s): clear, concise, concrete, complete, courteous and correct o World Health Organization (WHO) – Joint Commission International ▪ Offered 9 solutions for increasing health care safety – includes “correctly identifying the patient” & “better communication during patient handoff” o International Council of Nurses (ICN) ▪ Set expectations for communication in nursing goals, including “ensuring confidentiality” • Recommendations from IOM endorsed by: (1) American Colleges of Nursing (AACN); (2) National State Boards of Nursing; (3) American Nurses Association (ANA) • In the first report (To Err is Human) the IOM identified serious safety issues and up to 98,000 deaths a year in hospitals (IOM, 2000). • The second report identified expected quality performance goals: effectiveness, timeliness, patient-centeredness, efficiency, and equity (IOM, 2001). • The third report calls for restructuring of clinical education with five core areas for competency: o Delivering patient-centered care o Working as part of an interdisciplinary team o Practicing evidence-based medicine o Focusing on quality improvement o Using information technology (IOM, 2003) EXAM 2_310 • The fourth report is bringing together health professionals from different disciplines in tailored learning environments, replace CE’s with a national interprofessional CE institute to foster improvements. • The fifth report is for nurses to practice at the full extent of their education/training, achieve higher levels of education (lifelong education), full partnership with physicians promoted along with other health professionals; better data collection and improved infrastructure of information for workforce planning and policy making; Remove scope of practice barriers. 3. Assess theoretical concepts useful for building effective relationships with clients. • A two-way exchange of information among clients and health care providers, ensuring that the expectations and responsibilities of all are clearly understood. • The Joint Commission description originally with 5 C’s for effective communication is listed here and now we have added in a 6th “C “for “Correct” as we know that communication is a vital part of the nursing process to reduce errors. It is: o Clear o Concise o Concrete o Complete o Courteous o Correct • Communication involves all members of the health care team along with patients and families 4. Relate communication skills to client advocacy and providing safe, quality client care. • Agency for Healthcare Research and Quality (AHRQ)- US Dept. Health & Human Services involved in patient safety by funding research and compiling evidence to publish best evidence-based standards of practice • American Association of Colleges of Nursing (AACN)- Makes recommendations for nursing curricula- standard hand off report (SBAR) • Quality and Safety education for Nurses (QSEN)- Identified essential competencies for nursing education: Knowledge, Skills, and Attitudes (KSA), Patient-centered care, Evidence-based practice, Quality improvement, Teamwork, Safety, & Informatics o QSEN is funded by the Robert Wood Johnson Foundation, aims to prepare future nurses with the knowledge, skills, and attitudes needed to continuously improve healthcare system quality and safety. We saw the six competencies already in previous PPTs: patient-centered care, evidence-based practice, quality improvement, teamwork, safety, and informatics. 5. Explain the importance of shift reports, such as the SBAR, in providing safe, quality care. • Checklists and preprinted orders can provide coverage as long as they are utilized correctly – if checklist is checked off for what was done, it can serve as reminders for what still needs to be done when not checked. If not checked after doing the task, it can cause duplication or error of omission. For example, read-back telephone order (RBTO) checkbox on orders must be checked off if it is the order sheets – if not checked, then considered not done. An agency could get written up in JACHO audit for this. • Preprinted orders then can cover for necessary follow through on treatments most needed, especially PRN orders for care following surgery or for bowel care, for example. However, if a patient has an allergy or other reason for not utilizing part of the pre- EXAM 2_310 printed orders, must be careful to line out and d/c part of the pre-printed order not applicable. • Electronic barcoding, such as scanning armbands with the medication barcodes for medication administration can help with safety in medication dosing. Non-approved work-arounds such as removing multiple doses of medications for multiple patients to give them when due at a specific time, to save the nurse time; versus scanning the patient’s arm band in the client’s room is an example of a work-around. • Transforming Care at the Bedside (2003) • Interdisciplinary Rounds • Huddles • Change of shift reports done at the bedside • Call-outs and time outs (surgery) • TeamSTEPPS Model – formulated to improve team communication “I PASS THE BATON” • Resource management of other team members, including physicians for concise communication that promotes effective communication • Communicating with other healthcare professionals – create a team culture of collaboration and cooperation • Key learning for nursing student is the hand off reporting using SBAR – Situation, Background, Assessment and Recommendations reporting • Use of checklists provide safer practice- if checklist is checked off for what was done, it can serve as reminders for what still needs to be done when not checked. If not checked after doing the task, it can cause duplication or error of omission • Timely documentation • Introduction of standardized tools (such as SBAR) provide better communication • Technology oriented solutions – electronic ID’s, barcoding technology • Avoid work-arounds (non-approved methods) • Understanding interdisciplinary role relationships and nursing role relationship changes • Evidence-based practice research and promotion of safer policies/procedures Safety Incidences • Miscommunication • Errors are usually system problems – multiple smaller errors (Dennis Quaid story) • Fragmented care within complex systems • Most errors are preventable – up to 70% preventable • Fatigue – errors nearly double • Handoff • High financial and human cost • Under reporting medical errors – 90% go unreported (near misses) TOPIC 7: ch. 5, 6, 18, 19 1. Define therapeutic communication. • a dynamic interactive process consisting of words and actions and entered into by a clinician and client for the purpose of achieving identified health-related goals. EXAM 2_310 o The nurse must learn how to maximize their communication skills, understanding of human behaviors and recognize their personal strengths and weaknesses in order to help enhance client’s growth and improve functional abilities. o You cannot tell a client you will be back in five minutes and then not return. o It is imperative to keep your word, be consistent and that boundaries are addressed and followed. o Building a trusting relationship will help enhance client’s ability to communicate and verbalize their thoughts/feelings and feel safe in the environment that is created by the nurse. o The nurse must help the client first learn to trust the nurse so that they can then begin to trust the nurse o Asian cultures show respect by avoiding eye contact. o Native Americans believe it is disrespectful or even an overt sign of aggression to engage in direct eye contact, especially if the speaker is younger. o German Americans expect direct and sustained eye contact. o In Arab cultures, direct eye contact between a man and a woman may imply a sexual interest. o In Greece, staring in public is unacceptable. o Cultural filters are a form of cultural bias or prejudice. Stereotyping = a bias believing every member of a selective group is like all the rest. We all have a frame of reference but must build acceptance and understanding of those culturally different than ourselves and we can use cultural filters to listen to persons in a more unbiased way by recognizing this. 2. Identify how therapeutic communication is used within the health care setting. • Silence can be influencing; helps to encourage client to think; respond when they are ready; to know that you are there for them. • Active listening - observe the client’s nonverbal communication; listen to the message; understand; listen for false notes; provide feedback. • Clarifying techniques - clarifies differences in the frame of reference: • Paraphrasing is restating in fewer words what was said • Restating is echoing feelings; saying the same key words that the client used. “My life is screwed up and has no meaning” NURSE: “Your life has no meaning?” • Reflecting may be a question or mirroring back to the client’s feelings such as “You sound as if your life has had many disappointments?” • Exploring is a way to illicit more information such as “Tell me more”, “Describe . . . ”, or “Give me an example” 3. Demonstrate effective therapeutic communication skills for clients across the life span. • Goal of healthcare providers: o enable individuals to get in touch with themselves and encourage them to discover a full functioning life with meaning and purpose. o as we better understand human growth and development, the more prepared we are to offer therapeutic communication. • Children o Do not fully understand what is happening to them o No comprehension of how medicine or treatment is going to make them feel better EXAM 2_310 o Punishment o Fear of the unknown/understanding o small procedures seem major, explain, establish relationship, speak directly to them, get down on their level, compliment them, give a choice that given their decision will be correct, let them help, do not keep them waiting, listen to their feelings, let them examine tools, show them what you are going to do on a toy, be aware of your own feelingschildren know immediately if you are insecure or you do not like them • Infants (Newborn to 12 months): o Totally dependent on their caregiver o Communicate through crying or smiling o Therapeutic response: ▪ Provide for infant’s physical and emotional needs ▪ By 12 months infants can say 3-5 words with meaning ▪ Swaddle and hold infant in arms o Dependent on caregivers ▪ Physical comfort and safety are primary concerns o Have limited means of communicating needs o Rapid stages of growth from birth to 1 year o Nurse: rub infant’s back; pat infant’s bottom - comforts them; swaddle and hold infant; rocking helps comfort too o Take time to listen to and address parent or caregiver concerns regarding infant care • Toddlers (1 year to 3 years): o Regress to infantile behavior when stressed o Literal with interpretation of words o Therapeutic response: ▪ Use consistency; routines are important ▪ Explain using very basic words ▪ Approach slowly o Nurse: praise; explain what discomfort may feel like (pinch, hug – BP cuff hug arm); build self confidence o Vocabulary is about 300 words o Ability to comprehend and understand speech is greater than number of words the child can say o Books and adult-child conversations contribute significantly to language skills • Preschooler (3 years to 5 years): o Follow simple commands but only one at a time o Literal with interpretation of words o Therapeutic response: ▪ Eye contact ▪ Sit down at their level ▪ Approach slowly o Talk regardless of anyone listening. o Follow simple commands but only one at a time. o Repeat questions until they receive an answer. • School Age (6 years to 12 years): o Transition from home to school o Therapeutic response: EXAM 2_310 ▪ Use terms understandable to the child ▪ Give choices ▪ Provide encouragement and praise ▪ Be honest o Have increased stress from the transition from home to school o Teach parents importance of nutrition and rest, explain procedures in ways the child can understand and be honest o Answer their questions o Do not act with authority o Acting out is a response to stress • Adolescent (13 years to 18 years): o Transitioning from childhood to adulthood ▪ Fight for independence ▪ Need comfort and security o Difficult time ▪ Demands from family, school, peers, society ▪ Body changes ▪ Need something to feel good about ▪ Acne o Difficult time for parents ▪ Transition ▪ Opposing views o Allow adolescents privacy and the right to be exanimated or treated ▪ do not assume parents have told their teen everything they need to know about sex ▪ treat them with respect and dignity ▪ do not take sides between the parent and the adolescent ▪ You have to clearly like and care about adolescents. You cannot hide your feelings from children or adolescents ▪ set the stage for the transfer from pediatric care to adult care ▪ they need to feel a sense of worth, providers can be a positive force o Sense of awkwardness, unsure of themselves o Trying to identify their role in society o Allow adolescents privacy and the right to be exanimated or treated • Adult o Many of the same principles from children and adolescents apply ▪ Recognize characteristics • Working toward career goals, Earning a living, Establishing primary relationships, Making a place in their community, Raising a family ▪ Stress • Information and assistance in parenting and daily living, Extended psychological adolescent period, Still pursuing education, Still living with parents “boomerang generation” o Health care professional: ▪ get to know adult clients EXAM 2_310 ▪ be aware and sensitive to culture, lifestyle, religious beliefs ▪ recognize skills and intelligence, don’t try to impress with medical jargon ▪ emphasize preventative health care ▪ recognize your role as a member of the heath care team ▪ recognize stress caused by accident or serious illness ▪ respect their right to privacy ▪ encourage clients to hope for the best, however, do not promise results. o Women ▪ -child bearing years ▪ -facing menopause around 40-50 years old o Men ▪ “climacteric” period when hormone production slows/diminishes • Older Adult o Fewer acute illnesses o Chronic illness management ▪ Hypertension (HTN); Diabetes; Arthritis ▪ Hearing/vision impairment o More Freedom ▪ Empty nest ▪ Retirement o Final Stage ▪ No longer needed ▪ Bored ▪ Lack energy to participate in activities ▪ Fear for loss of personal safety, financial security, health, loved ones o Interests from younger years tend to remain the same in older years ▪ Active vs. non-active ▪ Social vs. non-social o 2010 Census Bureau ▪ Number of people 85 has increased to more than 1.9 million ▪ Expect to quadruple o New age classifications ▪ “Young-old” 65-74 years old ▪ “Old” 74-84 years old ▪ “Oldest-old” 85 + years old ▪ “Centenarians” 100+ years old (has also doubled each decade) 4. Compare and contrast therapeutic and nontherapeutic communication techniques. • Therapeutic: o Some classic guidelines for conducting an interview include: ▪ Speak briefly ▪ When you do not know what to say, say nothing ▪ When in doubt, focus on feelings ▪ Avoid advice ▪ Avoid relying on questions ▪ Pay attention to nonverbal cues ▪ Keep the focus on the client EXAM 2_310 o Use of silence o Active listening o Clarifying techniques ▪ Paraphrasing ▪ Restating ▪ Reflecting ▪ Exploring o “What if” or miracle questions • Non-therapeutic: o Excessive Questioning o Giving Approval or Disapproval o Giving Advice o Asking “WHY” Questions (better ways than just to ask WHY) o Changing the Subject TOPIC 8: ch. 14, 15 – C, 7 – I 1. Describe the concept of cultural competence. • Culture is a complex social concept that encompasses inherited and shared beliefs, both religious and political beliefs and practices, habits, customs, language, and rituals. • Communication styles include the ethnic identity, rituals, and language used by a particular group of people. • Cultural Diversity can be defined as variations that occur among cultural groups, both within and across cultures but diversity can also be more broadly defined to encompasses differences in age, health status, gender, sexual orientation ,racial or ethnic identity, geographical location or other aspects. • In healthcare, we must understand culture and diversity shapes how people view their world, and how they function in that world where one’s culture can profoundly determine what is perceived as health vs illness. • The United States has increased in diversity and is more of a “mixed salad” than a “melting pot” which is a challenge today to become culturally competent --- how nurses incorporate client’s cultural diversity in plans of care can mean the difference between success for wellness, or failure to achieve optimum outcomes. • Paternalism is a concept where healthcare providers believe they know more about what it best for clients than clients themselves. • Ethnicity is defined as membership of a person in a particular cultural group . . .common racial, geographic, ancestral, religious, or historical bonds. • Ethnocentrism can be defined as the belief that one’s own culture is superior to another’s culture. • Cultural relativism is a concept where each culture is determined to be unique and only judged on it’s own values, standards, and beliefs. • Health disparities can exist where there are margins of society that are underserved for medical care being given. • Acculturation is where a person from a different culture learns behaviors and values of the dominant culture and adopts these norms and values, including language EXAM 2_310 • “Cultural competence is defined as ‘a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals to work effectively in cross cultural situations’ • The process of cultural awareness occurs when the nurse is able to examine his or her own values, biases, and stereotypes. It also requires the nurse to examine the potential cultural biases (racism) that may exist within the health care setting. • The process of cultural knowledge occurs when nurses educate themselves about the worldviews of other cultures and ethnic groups. This cultural knowledge may include learning how disease processes and management may vary depending on the cultural group. • Cultural skill occurs when the nurse can conduct a relevant cultural assessment. Hence, it is achieved when cultural data are used to develop and implement a culturally relevant treatment plan. • Cultural encounters encourage the nurse to engage directly with patients from different ethnic and cultural backgrounds to modify existing beliefs about a cultural group and prevent potential stereotyping. • Finally, cultural desire addresses the motivation of the health care provider to acquire new knowledge about different cultures. This last construct is based solely on the nurse’s intrinsic need to acquire new cultural knowledge and cannot be driven by external regulations or requirements • The standards are composed of eight domains: governance, leadership, workforce, communication, language assistance, engagement, continuous improvement, and accountability. By addressing all eight domains, health care providers and organizations can achieve cultural competence. 2. Describe methods to modify communication patterns and behavior to effectively and respectfully assess diverse clients with unique needs. • Communication Goals o Communicate effectively with individuals of other cultures, while recognizing your own personal cultural biases and prejudices o Actions to promote multicultural communication: o Become knowledgeable – understand theory and culturally congruent, safe, meaningful care o Recognize barriers – interpersonal communication barriers & language barriers o Develop techniques to foster communication and utilize resources • Therapeutic Communication – covered in objective 3 o Must be goal oriented for health care • Diversity ▪ Sensitivity to differences and similarities ▪ Knowledge on expected behaviors ▪ Skill at integrating knowledge and sensitivity ▪ Verify own perception o Identify own prejudices and biases ▪ Self-awareness or cultural awareness ▪ Intrinsic biases • Lack of knowledge- health care professionals must understand and take into consideration cultural differences of patients. EXAM 2_310 • Fear and distrust- Be aware of language or dialect, unfamiliar surroundings may make patients feel subordinate, confusion • Language- Use of interpreters (e.g. clients from Scotland speak English but with a brogue that is incomprehensible to some Americans). Ebonics knows as African American Vernacular English where “Bad” means “Good” • Racism- Implies racial discrimination, segregation, persecution, and domination • Bias- slant toward a particular belief, i.e. favoritism toward certain beliefs, one-sidedness (common biases – preference for Western medicine, providers chosen according to gender) • Prejudice- opinion or judgement formed before all facts are known, preconceived, unfavorable, e.g. Drug addicts are dirty, homeless people are crazy, prejudices related to a person’s sexual preference • Ethnocentrism- reviewed in an earlier slide on belief that one’s own culture and traditions are superior than those of another (e.g. refuse to bow to Japanese businessman/insist on handshake) • Stereotyping- belief that all people or things with particular characteristics are the same, e.g. “All Italians are in the Mafia” or “All Italians talk with their hands” • Health care rituals- Standardized procedures or protocols, consider rationale, make exceptions as appropriate. • Economics – poor and underserved population, vulnerable populations (immigrants, homelessness, mental illness, elderly) • Perception and expectation- becoming aware through senses, exception- we anticipate events based on experience (in Arab countries it is an insult to show the sole of your shoe facing another person). 3. Demonstrate effective therapeutic communication skills for diverse clients with unique needs. • Learn about the cultural traditions of the clients you care for. • Pay close attention to body language, lack of response, or expressions of anxiety that may signal that the patient or family is in conflict but perhaps hesitant to tell you. • Ask the patient and family open-ended questions to gain more information about their assumptions and expectations. • Remain non-judgmental when giving information that reflects values that differ from yours. • Follow the advice given by patients about appropriate ways to facilitate communication within families/between families and other providers. • Listen carefully • Explain what the client needs to understand • Acknowledge cultural differences • Recommend what the client should do • Negotiate mutually agreeable strategies • Hispanic o Family and gender roles- father =head of household o Religion and spiritual practices = catholic o Health beliefs and practices = susto- god and illness, curando = healing o Communication and social interaction patterns = needs to have trust in health care providers and are looking for warmth, respect, and friendliness. EXAM 2_310 • African American o Family and gender roles = Women often viewed as head of household and are considered the “backbone” of this minority group, often assuming responsibility for parents and children. has strong “kinship” networks with value in “caring for one’s own” o Religion and spiritual practices o Health beliefs and practices = There is a history of oppression with more health issues o Communication and social interaction patterns = Trust must be established which is most important for caregivers to build and show respect so that clients are willing to participate in their own treatment and increase self-efficacy. • Asian American o Family and gender roles = May do better male with male, female with female. They can smile in agreement even if they disagree. o Religion and spiritual practices = Eastern religions make up this group and include Hinduism, Buddhism, and Muslim religions that can include rituals for prayer, modesty, and dietary restrictions. o Health beliefs and practices = There may be belief in positive and negative energy known as the “Yin and Yang,” use herbal remedies/medicines and treatments like acupuncture, coining, and cupping which can be interpreted as child abuse when seeing bruising that results from vigorous coin rubbing and suction from cupping. o Communication and social interaction patterns = These cultures appreciate boundaries and formal acknowledgement. They can be seen as stoic and are less likely to request pain medications until pain is very severe. They do not believe in mental health illness that brings shame to the family so do not get this help, often resulting in suicide. • Native Americans o Family and gender roles = There is an egalitarian view for gender roles with equal roles. o Religion and spiritual practices & Health beliefs and practices = Their health beliefs and practices are tied into their spiritual practices. They value nature and earth. Their belief in spiritual ceremonies, including practice of smoking peyote during ceremonies that is legal, will help them in recovery when evil spirits are removed. o Communication and social interaction patterns = They value respect, storytelling and humor can be used, and feel that direct eye contact is disrespectful, are more private and show little to no emotions. Statutory laws- legislated laws, drafted and enacted at federal or state levels Civil laws- developed through court decisions, created through precedents, rather than written statues Situation Patient name, age and room number Attending physician/consulting physician involved in care Diagnosis and admission date Description of the patient’s current situation Background Pertinent procedures/tests completed Allergies, Code Status, Most recent vitals, BS, or other labs Vascular access, fluids, drip/rate, patency & site – changes due or last changed O2 flow if has oxygen ordered Hearing, visual, cognitive, language barriers Patient mobility/fall risk status Isolation/infection control precautions Current meds/relationship to condition Comorbidities affecting client status Cardiac status, telemetry monitoring information Assessment Any change in respiratory status most important (medical) any change in mental status (psych) Any changes in physical/mental status this shift What happened during today’s shift Last pain med given Any medications held/rationale Recommendations Suggestions of actions to be taken, e.g., what is the plan of care, what does the patient need and when, pertinent procedures/tests pending or to be scheduled? Are there any recommendations for discharge? Thinking in terms of discharge begins at admission. EXAM 2_