RNSG 2138 Professional Nursing Concepts Student

RNSG 2138 Professional Nursing Concepts Student Midterm Blueprint Summer 2018 1- Professionalism/Nursing Organization and Unions Pros/Cons to unions Management of care Planning Analysis Professionalism PowerPoint & Lecture A. Positive • Continuity of care • Continual professional growth • Active in professional organizations • Providing a safe patient environment B. Negative • Unsafe patient care • Negative patient outcomes • Suspension or loss of personal professional license • Consequences in criminal and/or civil law • Violations of current practice standards *When faced with a conflict in the work setting that creates difficulty for a professional nurse to provide safe patient care, the nurse, as a patient advocate, evaluates taking action to resolve the issue either through work-based organizational structures or pursuit of nursing or non-nursing union involvement. 2- Professionalism/Nursing Organization and Unions Managers role during union organizing Pg 593, marquis The Managers’ Role During Union Organizing Because of the health-care industry’s movement toward unionization, most nurses will probably be involved with unions in some manner during their careers. Managers who are not employed in a unionized health-care organization should anticipate that one or more unions may attempt to organize their nurses within the next few years. Because the NLRA provides union protections only to employees, a supervisor has no right under the NLRA to form or participate in a union (Department for Professional Employees, AFL-CIO, 2001–2016). Nurse-managers, as legally defined hospital “supervisors,” are legal spokespersons for the hospital. As such, the NLRB closely monitors what they may say and do. Prohibited managerial activities include threatening employees, interrogating employees, promising employee rewards for cessation of union activity, and spying on employees. This does not mean that these activities do not occur. For example, a complaint was filed with the NLRB in 2014, alleging that employees who participated in a June 2014 picket (a legally protected concerted activity) to draw attention to “potentially unsafe staffing conditions” were either fired, experienced revoked work agreements, or forced to work weekends by the hospital they picketed (“NLRB Hearing,” 2015). Following a 4-day hearing, the NLRB issued a complaint finding that the hospital had engaged in an illegal pattern of harassment and retaliation against hospital staff for their participation in the picketing. 3- Professionalism/Nursing Organization and Unions. National Labor Relations Act Pg. 269 The Nurse as Supervisor: Eligibility for Protection Under the National Labor Relations Act The NLRA establishes certain protections for private-sector employees who want to form or join a labor union. These protections do not, however, extend to supervisors. The NLRA defines a supervisor as “any individual having authority, in the interest of the employer, to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward, or discipline other employees, or responsibly to direct them, or to adjust their grievances, or effectively to recommend such action, if in connection with the foregoing, the exercise of such authority is not of a merely routine or clerical nature, but requires the use of independent judgment” (Matthews, 2010, para. 12). However, several 2006 NLRB rulings deemed that charge nurses might also be considered supervisors because they are responsible for the coordination and provision of patient care throughout a unit (Matthews, 2010). Even part-time charge nurses were so labeled. The 2006 NLRB decisions—collectively known as the Kentucky River cases, after the name of the 2005 Supreme Court decision that sent the issue back to the NLRB—expanded the category of “supervisor” dramatically. The Court found that occasional guidance to other employees was enough to identify someone as a supervisor (Department for Professional Employees, AFL-CIO, 2001–2016). This finding has been contested legally since that time, and several interpretations have occurred. Reinterpretations by the NLRB are expected in the future. In addition, the definition of supervisor in nursing came into question with several administrative and court rulings in the early 1990s. These rulings came about as a result of a case involving four LPNs employed at Heartland Nursing Home in Urbana, Ohio. During late 1988 and early 1989, these LPNs complained to management about what they thought were disparate enforcement of the absentee policy; short staffing; low wages for nurses’ aides; an unreasonable switching of prescription business from one pharmacy to another, which increased the nurses’ paperwork; and management’s failure to communicate with employees (NLRB v. Health Care & Retirement Corp., 1994). Despite assurances from the Vice President for Operations that they would not be harassed for bringing their concerns to headquarters’ attention, three of the LPNs were terminated as a result of their actions. In response to what they perceived to be illegal termination, the LPNs filed for protection under the NLRA. The NLRB ruled that because the LPNs had responsibility to ensure adequate staffing, to make daily work assignments, to monitor the aides’ work to ensure proper performance, to counsel and discipline aides, to resolve aides’ problems and grievances, to evaluate aides’ performances, and to report to management, they should be classified as “supervisors,” thereby making them ineligible for protection under the NLRA. On appeal, the administrative law judge (ALJ) disagreed, concluding that the nurses were not supervisors and that the nurses’ supervisory work did not equate to responsibly directing the aides in the interest of the employer, noting that the nurses’ focus is on the well-being of the residents rather than on the employer. In another turnabout, the U.S. Court of Appeals for the Sixth Circuit then reversed the decision of the ALJ, arguing that the NLRB’s test for determining the supervisory status of nurses was inconsistent with the statute and that the interest of the patient and the interest of the employer were not mutually exclusive. The court said that, in fact, the interests of the patient are the employer’s business and argued that the welfare of the patient was no less the object and concern of the employer than it was of the nurses. The court also argued that the statutory dichotomy the NLRB first created was no more justified in the health-care field than it would be in any other business in which supervisory duties are necessary to the production of goods or the provision of services (NLRB v. Health Care & Retirement Corp., 1994). The court further stated that it was up to Congress to carve out an exception for the health-care field, including nurses, should Congress not wish for such nurses to be considered supervisors. The court reminded the NLRB that the courts, and not the board, bear the final responsibility for interpreting the law. After concluding that the board’s test was inconsistent with the statute, the court found that the four LPNs involved in this case were indeed supervisors and ineligible for protection under the NLRA (NLRB v. Health Care & Retirement Corp., 1994). This same interpretation, at least for full-time charge nurses, was used in another landmark court case in September 2006 to determine whether charge nurses, both permanent and rotating, at Oakwood Healthcare Inc. were “supervisors” within the meaning of the NLRA and thus could be excluded from a unit of nurses represented by a union (Mayer & Shimabukuro, 2012). Upholding the definition that supervisors “assign” and “responsibly direct” employees as well as exercise “independent judgment,” the NLRB concluded that 12 permanent charge nurses employed by Oakwood Healthcare were supervisors. Rotating charge nurses were not if this role was less than 10% to 15% of their work time. The Department for Professional Employees, AFL-CIO (2001–2016) notes that under this ruling, 64 out of 153 nurses at the Salt Lake Regional Medical Center were declared supervisors. For some departments, this meant 10 out of 12 nurses or ratios of 12 supervisors for every 5 employees. Matthews (2010) notes that the Oakwood case has set precedence and figured in approximately 35 subsequent decisions in both health-care and industrial settings, although there have been no further rulings addressing the charge nurse/supervisor status. Hence, the Oakwood ruling is still in effect today, specifying that nurses, on average, with less than 10% to 15% (equal to about one shift per pay period) of their time as charge nurse are considered staff nurses, whereas nurses working more than 15% of their professional time as charge nurses are considered supervisors. 4- Professionalism/Transition to Practice/Benner Level of Nursing Experience .PG 269 marquis DISPLAY 11.2 Benner’s Levels of Nursing Experience Novice • Beginner with no experience • Taught general rules to help perform tasks • Rules are context-free, independent of specific cases, and applied universally • However, rules cannot express which tasks are most relevant in real life or when exceptions are needed Advanced Beginner • Demonstrates acceptable performance • Has gained prior experience in actual situations to recognize recurring meaningful components • Principles, based on experiences, begin to be formulated to guide actions. Competent • Typically a nurse with 2 to 3 years experience on the job in the same area or in similar day-to-day situations • More aware of long-term goals • Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization Proficient • Perceives and understands situations as whole parts • More holistic understanding improves decision making • Learns from experiences what to expect in certain situations and how to modify plans Expert • No longer relies on principles, rules, or guidelines to connect situations and determine actions • Much more background of experience • Has intuitive grasp of clinical situations • Performance is now fluid, flexible, and highly proficient 5- Professionalism/Transition to Practice/Continued Competency. PG. 277 Continued Competency as Part of Career Development Continued competency is also a part of career management. BusinessD (2016b) suggests that the definition of a professional is “a person formally certified by a professional body or belonging to a specific profession by virtue of having completed a required course of studies and/or practice, and whose competence can usually be measured against an established set of standards” (para. 1). Huston (2017) notes that unfortunately, in many states, a practitioner is determined to be competent when initially licensed and thereafter, unless proven otherwise. Yet, clearly, passing a licensing exam and continuing to work as a clinician does not assure competence throughout a career. Competence requires continual updates to knowledge and practice, and this is difficult in a health-care environment characterized by rapidly emerging new technologies, chaotic change, and perpetual clinical advancements. The Institute of Medicine (IOM, 2010) report The Future of Nursing agrees, suggesting that nursing graduates now need competency in a variety of areas, including continuous improvement of the quality and safety of health-care systems; informatics; evidence-based practice; a knowledge of complex systems; skills and methods for leadership and management of continual improvement; population health and population-based care management; and health policy knowledge, skills, and attitudes. One must at least question how many nurses currently in practice would be able to demonstrate competency in all of these areas. Assessing, maintaining, and supporting maintaining continued competence then is a challenge in professional nursing. For example, Huston (2017) notes that some nurses develop high levels of competence in specific areas of nursing practice as a result of work experience and specialization at the expense of staying current in other areas of practice. In addition, employers often ask nurses to provide care in areas of practice outside their area of expertise because a nursing shortage encourages them to do so. In addition, many current competence assessments focus more on skills than they do on knowledge (Huston, 2017). The issue is also complicated by the fact that there are no national standards for defining, measuring, or requiring continuing competence in nursing. Managers should appraise each employee’s competency level not only as part of performance appraisal but also as part of career development. This appraisal should lead to the development of a plan that outlines what the employee must do to achieve desired competencies in both current and future positions. Often, however, competency assessment focuses only on whether the employee has achieved required minimal competency levels to meet current federal, state, or organizational standards and not on how to exceed these competency levels. Thus, competency assessment and goal setting in career planning is proactive, with the employee identifying areas of potential future growth and the manager assisting in identifying strategies that can help the employee achieve that goal. Competency assessment and goal setting in career planning should help the employee identify how to exceed minimum levels of competency. 6- Professionalism/Transition to Practice/Certification pg .279-80 Professional Specialty Certification Professional specialty certification is one way an employee can demonstrate advanced achievement of competencies. To achieve professional certification, nurses must meet eligibility criteria that may include years and types of work experience, as well as minimum educational levels, active nursing licenses, and successful completion of a nationally administered examination (Huston, 2017). Certifications normally last 5 years. Professional associations grant specialty certification as a formal but voluntary process of demonstrating expertise in a particular area of nursing. For example, the ANA established the ANA Certification Program in 1973 to provide tangible recognition of professional achievement in a defined functional or clinical area of nursing. The American Nurses Credentialing Center (ANCC), a subsidiary of ANA, became its own corporation in 1991 and since then has certified hundreds of thousands of nurses throughout the United States and its territories in more than 40 specialty and advanced practice areas of nursing. A few of the other organizations offering specialty certifications for nurses are the American Association of Critical-Care Nurses, the American Association of Nurse Anesthetists, the American College of Nurse-Midwives, the Board of Certification for Emergency Nursing, and the Rehabilitation Nursing Certification Board. Huston (2017) notes that it is middle- and top-level nurse-managers who play the most significant role in creating work environments that value and reward certification. For example, nurse-managers can grant tuition reimbursement or salary incentives to workers who seek certification. Managers can also show their support for professional certification by giving employees paid time off to take the certification exam and by publicly recognizing employees who have achieved specialty certification. Benefits of Specialty Certification The certified nurse often finds many personal benefits related to the attainment of such status, including more rapid promotions on career ladders, advancement opportunities, and feelings of accomplishment. In addition, certified nurses often earn more than their noncertified counterparts. In addition, a great deal of research in the past decade suggests that certification leads to both improved patient outcomes and the creation of a positive work environment. For example, Boyle, Cramer, Potter, Gatua, and Stobinski (2014)examined the impact of specialty nursing certification on patient outcomes in surgical intensive care units and perioperative units and found lower rates of central line–associated blood stream infections when nurses held specialty certification. Fitzpatrick, Campo, and Gacki-Smith (2014) found significant differences in perceived empowerment between emergency department staff nurses who held specialty certification and those who did not. In addition, Boyle, Cramer, Potter, and Staggs (2015) found a small statistically significant inverse relationship between RN national nursing specialty certification rates and total fall rates; increases in specialty certification rates over time tended to be associated with improvements in total fall rates over time. A summary of the benefits associated with professional certification are shown in Display 11.4. p. 279 p. 280 DISPLAY 11.4 Benefits of Professional Certification • Provides a sense of accomplishment and achievement • Validation of specialty knowledge and competence to peers and patients • Increased credibility • Increased self-confidence • Promotes greater autonomy of practice • Provides for increased career opportunities and greater competitiveness in the job market • May result in salary incentives • Improved patient outcomes • Increased levels of perceived empowerment creating more positive work cultures 7- Clinical Judgement/Medication Management/Questioning a medical order. Pg 764 taylor Checking the Medication Order Facility or agency policy specifies the manner in which the medication order is checked. Various systems are used; nurses should be familiar with the system used in the agency where they work and should implement it correctly to minimize errors. The patient’s medication record, often called an MAR (medication administration record) is a complete list of all medications prescribed for the patient. Increasing numbers of health care facilities are computerizing patient records, including medication records (CMAR [computerized medication administration record]). The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original order, depending on the type of system in use. The nurse is also responsible for double-checking the dosage and appropriateness of the medication. 8- Clinical Judgement/Medication Management/Questioning the Medication Order. Taylor pg.764 Questioning the Medication Order Nurses are legally responsible for the drugs they administer. Therefore, it is important to question any drug order suspected to be in error. The suspected error may be in any part of the order. When preparing to administer a medication, ask (Hughes & Ortiz, 2005): Do the patient’s condition, symptoms, and health status warrant receiving this medication? Does it make sense for the patient to have this medication? Is the correct dose and preparation ordered? The legal implications are serious in a situation in which there is an error in a drug order and the nurse could be expected, based on knowledge and experience, to have noted and reported the error. On occasion, the nurse may not think that there is an error in the order but may not understand why the medication has been prescribed. In such instances, ask the prescriber how the order relates to the patient’s plan of care. This may prevent a medication error if the wrong medication has been ordered. Confusion over the placement of a decimal point can lead to a medication error. A zero should always precede a decimal point (e.g., 0.1 mg) for clarity. The use of a trailing zero (e.g., 1.0) is not considered good practice and has been included in the Joint Commission’s “Do not use” list. See Table 16-3 for additional abbreviations included in this list. A drug to which the patient is allergic may be prescribed inadvertently. Best practice is to question the patient about ever having received the medication and ask whether the patient is aware of any reaction to the medication. The patient may describe past adverse reactions with the drug. It is general practice to indicate clearly on the patient’s chart any drug allergies. The drug should not be given and the order should be questioned when, in the nurse’s judgment, the patient is allergic to a drug. In many health care facilities, the patient may also wear a wristband that indicates specific allergies. An allergic reaction can be life threatening to the patient. In addition, a drug may be ordered that would potentially interact with another medication the patient is taking. It is important that nurses verify all medications that they are unfamiliar with before administration to avoid possible drug interactions. If a nurse has difficulty reading an order, guessing is gross carelessness; checking with the person who wrote the order is the only safe procedure. Nurses have the right to refuse to administer any medication that, based on their knowledge and experience, may be harmful to the patient. Although this situation seldom occurs, it is important to understand that the patient’s safety is a primary objective in the administration of medications. Always notify the primary care provider of the refusal to administer any medication. Document any concerns regarding medication orders in the patient’s medical record, and note having contacted the primary care provider, the response of the primary care provider, and any related interventions. 9- Clinical Judgement/Prioritization of Care/time Management. Pg. 207 Time management can be defined as making optimal use of available time. Many people argue that there is not enough time in the day to do everything that must be done. Stone and Treloar (2015) suggest, however, that the problem may not be that these individuals are time-poor; it may be that they are poorly using time. Homisak