Professional Nursing Issues Final

American Nursing Association (ANA) 1965 position papers
BSN minimum for professional practice and ADN for technical practice (LPN not recommended)
What role does the National League of Nursing (NLN) play in nursing education?
Accreditation – ensuring that educational guildelines are met and upheld
Nurse Practice Act
Usually is the most important law affecting nursing practice within state bounds
Licensing law
Defines the title and regulations governing the practice of nursing
Assists the nurse in staying within the legal scope of nursing practice in each state.
Defines the regulations for practical nursing and includes requirements for an approved school of nursing.
Defines requirements for licensure and conditions for which a license may be revoked or suspended
What 3 functions does the State Board of Nursing (SBN) serve similar to traditional government structure?
Responsible for enforcing the Nurse Practice Act
Publish Rules and regulations that expand the law
Set and enforce minimum criteria for nursing education programs – schools have to be approved
Protect the public from dangerous nurses – **most commonly impaired nurses**
They can CLARIFY, CANNOT change the law
**Executive**: Administers nurse practice act
**Legislative**: Adopts necessary rules to implement act
**Judicial**: Authority to discipline a licensee
Can approve or reject applications for new nursing education programs
OBN – Ohio Board of Nursing
Set and enforce minimum criteria for nursing education programs
Schools of nursing must have state approval to operate

Have the power to discipline a licensee
To protect the public from dangerous practice
Most frequent reason for discipline is for practicing while impaired

National Council of State Boards of Nursing (NCSBN)
Established in 1978 to develop the examination
Primary function is to develop the NCLEX RN & PN licensing exams
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Scope of Nursing Practice
Defines what a practicing nurse can or cannot do
Nursing Social Policy Statement
Code of Ethics
**Is an implied contract with society**
A formal statement of the nursing’s profession’s code of ethics.

The Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) is the most recent revision.

Two requirements:
Nurse (defendant) practices with specialized knowledge and skills
Through this practice caused patient’s (plaintiff’s) injury.
Patient Self-Determination Act
Supports ethical principle of **autonomy**
Uses Advance Directives
**Defined as giving someone authority to act for another**

Nurse’s primary legal and ethical consideration is safe, effective care for patients

Professional nurses retain accountability for acts delegated to another person; never be delegated.

Most debated area of delegation involves medication administration by unlicensed assistive personnel

There are five rights to ensure safe delegation of tasks to unlicensed assistive personnel
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right supervision/Evaluation
Delegation to UAP (basics)
Feed, unless there is paralysis
Take vital signs, unless known to be unstable
Measure urine output from catheter bag, collect urine specimen from bag
Transport/ambulate, unless new ambulation
Do I&O
Delegation to LPN/LVN (basics)
Give meds, including injections
Collect data
Dressing changes
Catheter insertions
REINFORCE previous teaching, NO NEW TEACHING and NO Discharge instruction
Can assist Physician
LPN cannot insert IV (this requires special certification beyond basic licensure) or initiate any step in nursing process.
Defined as threat or attempt to make bodily contact with another without that person’s consent

Precedes battery

Defined as assault carried out
Impermissible, unprivileged touching
Actual harm may or may not occur as a result
Defined as: Failure to act as a reasonably prudent person would act in the same circumstances
Anyone can be found negligent

**Occurs through commission or omission**

Assumed the responsibility for the patient’s care
Found to have failed to meet the prevailing standard of care
Harm to the patient must be shown to have been caused by the failure to meet the standard of care
Injury is proven

6 major causes of negligence
Failure to follow standards of care
Failure to use equipment in a responsible manner
Failure to communicate
Failure to document
Failure to assess and monitor
Failure to act as a patient advocate
Informed Consent
**Three major considerations**
Capacity/competence to understand
Enough information given

**Role of the nurse**
**Witness patient’s signature**
Determine three elements are present to patient’s satisfaction
Provide feedback to provider if patient requires further information or is unable to sign
Make sure the consent form is signed and on the patient’s chart prior to the procedure

Health Insurance Portability and Accountability Act (HIPAA)

First federal privacy standard governing protection of patients’ medical records
Comprehensive legislation providing major patient protections

**Reinforces protection of electronically transmitted information**

Requires all health care providers to ensure patients’ privacy and confidentiality

attitudes, ideals, belief system of individuals/groups that are used to guide behavior.
rules of conduct and standards of behavior: the identification between right and wrong.

**Morals becomes an issue when the choice is no longer clear between right or wrong.**

This is defined as fair and equal treatment for all.
*EX: equal treatment – despite affordability to pay – can’t afford chemo – nurse’s discharge – you advocate for them to be able to stay*
This relates to the quality of doing good and can be described as charity.
Virtue Ethics
Inborn tendencies that develop through training
Emphasizes the character of the decision maker
Character traits regarded as virtues:
Honesty, courage, compassion, fairness, integrity, etc.
This refers to the client’s right
To make his own decisions.
But the client must accept
The consequences of those
Decisions. The client must also respect the decisions of others.
This relates to loyalty and
Faithfulness to the client and to one’s duty.
to do no harm
This refers to being honest when dealing with a client.
Moral rightness is determined by the outcome of the action – weighs pros and cons – right or wrong is based off of what benefits society

**Bring about the greatest good for the greatest number of people.**

Examples: triage, Obamacare

Moral if intent/motive good, regardless of outcome
“Duty”- towards the good of society
Act Deontology – gather facts
Rule Deontology – principles guide
actions – veracity, fidelity, etc.

Example: good Samaritan law

Ethical theory if moral originates from goodwill.

Moral Distress
Pain or anguish of a person who unwillingly participates in perceived moral wrongdoing.
Moral Courage
taking action to do what is right in spite of possible repercussions

The phrase “moral courage” suggests there is danger or fear associated with taking a right action, because of the possible personal sacrifice.

the promotion of a supportive and healthy work environment, cooperation, and recognition of interdependence among members of the nursing profession
Professionalism – Current barriers
**Variability of educational background**

Public perception
“The nurse does what the doctor says”
“The nurse helps the doctor”

Historical issues
1901 men banned from nursing in military
Are gaining their historical position in the profession as nurses

“Obedience” (1868 AMA/Hospital Admin promoted “training”….persisted through 1960’s)
Altruism (less expectation of monetary compensation)
Power of other organizations (AMA, legislation)

Occupation versus Profession
**Occupation – what a person does to make
a living or how one spends time.**
Most of work is manual
Trained on-the-job
No specific value-system associated
No specific career path
Accountability lies with supervisor/

Develops from an occupation that **specializes** in

Professions develop a **collective identity**
Formal education
Evidence based practice
Integrated value-system
Legal protection
**Duty to serve**

College setting
Prolonged education, specialized
Orientation (socialization) to beliefs/values

Part of personal identity “I’m a nurse!”
Transcends expectation of material reward

Which recommendation made by the 1965 American Nurses Association (ANA) position paper and other position papers of national nursing organizations is still an issue today?
Minimum preparation for professional nursing practice should be the baccalaureate degree.
Formal and Informal Socialization
Learning a new role is derived from a mixture of formal & informal socialization.
Through education & the workplace.
The process of a nursing student becoming a professional nurse.

– Classroom Lectures
-Laboratory experiences

-Hearing other people discussions
-Unplanned observation of a person(s)
-Participating in an professional organization

Comes in many forms
Transcultural communication
The lens through which all other aspects of life are viewed.
Holistic Communication
-The art of sharing emotional and factual information
-Active listening and active attention
-Avoidance of analyzing, judging, defensiveness, or problem solving
A complex process that builds on communication
Human Factors – Key components
Organizational Factors
Steps in the collaboration process

Identify stakeholders
Identify problem
Identify barriers
Clarify outcomes
Clarify process
Identify who is responsible

Team Building
An intentional process
Sessions focused on identifying problematic feelings, mis-perceptions and correcting them
Clear/Concise speech
Involve all team members

**Patient Focus**
Build team trust
Goal is patient well-being
Avoid Blame
Supportive practice setting

Data collaboration
Acknowledge disagreement
Welcome healthy disagreement
Question calmly

Ask questions – **Benefits both mentor and mentee**
Be specific about your needs
Be vulnerable and teachable
Take initiative in learning opportunities
Be professional
Reality Shock
Realities of the “real world”
Mentoring & management issues
Nursing shortages / retention
Increased aging population
Increased chronic illness/high acuity patients
Complexity of health care systems
Working conditions / relationships
Time constraints
Zone of Helpfulness
Continuum – Arrow Diagram
Under involvement – far left
Zone of Helpfulness – middle
Over involvement – far right
Burnout/Compassion Fatigue
Ethics code provision #5: “duty to self”
Recognize symptoms of “burning out”
Compassion fatigue
Physical symptoms such as insomnia, diet, and weight changes
Disengagement mentally & emotionally
Job hopping
Professional Boundaries
The space between the nurse’s power and client’s vulnerability.
Boundary violations occur when there is a “confusion between needs of the nurse and needs of the client”
Care for the Caregiver
Avoid isolation
Establish positive relationships
Share thoughts with others
Solicit feedback / reality check with trusted colleagues
Develop self-regulation
Awareness of responses
Be proactive in developing resilience
Focus on self-care
Don’t try to do it all
Healthy foods, exercise, adequate sleep
Recharging of self (coping mechanisms)
**Value contributions you DO make**
Don’t focus on what you are not accomplishing or areas where you feel you do not measure up
Transformational Leadership
Focus is for the manager and associates to unite to work towards shared goals
All members to the team work together
Transactional Leadership
The nurse manager only interacts with associates when something needs to be done or something is wrong
Dynamic Leadership
Modeled after theorist Ida Jean Orlando
Based on the theory that the relationship between the manager and the nurse is ever-changing
Both parties are essential to the success of the unit
The leader offers direction instead of controlling
Autocratic (Authoritarian)
Based on the power of the position

Autocratic: person is task oriented, makes decisions independently without input from the group, motivates with praise, blame and reward
“You know where you stand” with this type of leader

Democratic Leader
focused on individual characteristics and abilities, uses personal and positional power to achieve outcomes, uses group process to make decisions, more willing to share information, no secrets or information kept from the group, each person is an unique person

Based on participation and greater equality

Least amount of leadership control

Laissez-Faire: “let alone”, leaves workers without direction, supervision or coordination in their projects, don’t give praise, criticism, feedback or information
Can be very frustrating with a high level of dissatisfaction
Much chaos

Multicratic or Participative Leader
compromise between autocratic and democratic leader
Processes feedback from the group but makes all decisions. Handles emergencies well
Have a free exchange of ideas
Leader gives directions according to rules
Rely on judgemental decisions from leaders
More reliable and safe from employee and manger abuse because they manage by designed and maintained rules, policies, and procedures designed to ensure quality output with minimal error
Difference between Management and Leadership
Give structure/provide resources
Pursue stability
Focus is doing things correctly
Detail oriented
Has subordinates

Big picture/promote ideas
Pursue innovations
Focus is doing what is right
Change motivated
Have followers

An individual must exercise the care that would be exercised by a reasonable and prudent person under the same or similar circumstances to avoid or minimize the risks of harm to others.
Breach of Duty
A standard of care that is expected in the specific situation but that the nurse did not observe; this is the failure to act as a reasonable, prudent nurse under the circumstances.
Specific Injury
Proximate Cause
Legal cause; exists when the connection between an act and an injury is strong enough to justify imposing liability.
Shared Governance
Gives power, control of practice, authority to act, and influence to the professional.

Four Principles of Shared Governance:
**Partnership**—links healthcare providers and patients along all points in the system; a collaborative relationship among all stakeholders and nursing required for professional empowerment.

**Equity**—the best method for integrating staff roles and relationships into structures and processes to achieve positive patient outcomes.

**Accountability**—a willingness to invest in decision-making and express ownership in those decisions.

**Ownership** – recognition and acceptance of the importance of everyone’s work and of the fact that an organization’s success is bound to how well individual staff members perform their jobs.

Relationship with an experienced person, the mentor, who advises and helps a less experienced person, a protége. Mentors are role models
Provider of Care
The provision of care to clients that combines both the art and the science of nursing in meeting physical, emotional, intellectual, sociocultural and spiritual needs
Patient advocate
-protecting patient’s human, legal, rights, including the patient understanding procedures before signing.
Managed Care
A method of organizing care delivery that emphasizes cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients.
Medicare Part A, B, C, D
Federal government funded

Medicaid (Title XIX of the Social Security Act)
Federal and state government funded

Stages of Illness
1. Disbelief and denial
2. Irritability and anger
3. Attempts to gain control
4. Depression and despair
5. Acceptance and participation
Traditional/Contemporary Sick Role
The **traditional** sick Anglo-American
Guidelines according to Talcott Parsons
Includes behavior that is dependent, passive, and submissive
Taught in medical and nursing schools for decades

The current (**CONTEMPORARY**) sick Anglo-American
Accept responsibility for own care
Consumer oriented approach
Wellness behavior

Influences/Factors Affecting Illness Response
Personality before illness
Suddenness of the illness
Extent of the illness
Duration of required lifestyle changes
Individual and family resources for dealing with stress of illness
Life-cycle of patient and family
Previous experiences with illness or crisis
Social support
Spiritual values / beliefs
A personality trait that enables people to perceive stressors as controllable challenges; made up of three personal qualities- control, commitment, and challenge
(an aspect of coping) a pattern of successful adaptation despite challenges or threatening circumstances
is a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. These providers generally are contracted with a type of health maintenance organization(HMO)
Learned resourcefulness
Spirituality Effects in Healing
inner strength related to belief in and sense of connection with a higher power
founder of transcultural nursing
Definition: “A formal area of study and practice focused on comparative holistic culture care, health, and illness patterns of people with respect to differences and similarities in their cultural values, beliefs, and lifeway with the goal to provide culturally congruent, competent, and compassionate care
Transcultural Nursing
The new patient-centered communication standards are designed to have a positive influence on patient-provider communication and on the quality of hospital care . They focus on all patients having their communication needs met. In particular, standards support communication for the most vulnerable patients: those who have no voice; have hearing, vision, or cognitive impairment; speak a language other than English; have limited literacy or knowledge about health care; or have sexual identity, cultural, or religious differences.
Florence Nightengale
Mother of modern nursing, Improved conditions during the Crimean War. Believed the role of the nurse was to put the client’s body in the best state to remain free of disease or to recover from disease. She wanted to facilitate the body’s reparative processes by manipulating the client’s environment., insisted upon strict sanitary conditions, saved lives during Crimean War, on the British side, helped make nursing a profession of trained middle class women. 1st nursing school
the study of the effects of ethnicity on responses to prescribed medication,especially drug absorption, metabolism, distribution and excretion.
A person who believes his or her beliefs and
practices are best.
Components of Cultural Competence
Defined by the U.S. Office of Minority Health as “services that are respectful of, and responsive to the health beliefs and practices, and cultural and linguistic needs of diverse patient populations “The shared values and beliefs in a culture enable its members to predict each other’s actions and react to behaviors.

-Ask older adults how he or she would like to be addressed.
-Determine the patient’s
preferences for touch.
-Determine the patient’s
preferences for silence.
-Investigate the patient’s
belief about eye contact

Campinha-Bacote Model
Exhibits nursing considerations that make up cultural desire:
cultural awareness
cultural knowledge
cultural skill
cultural encounters

Cultural desire

Agency classifications
-Often referred to as the private sector
-Have shareholders who invest money and expect a return on the investment.
-Taxed by the government

-Often referred to as the public sector.
-Receive tax exemptions based on its benefits to the community.
-Federal, state, or local government agencies govern.
-Operate according to mission statements that usually refer to community service.

Levels of Care
Health Promotion and Maintenance
Includes early detection

Illness Prevention
When risk factors are identified

Diagnosis and Treatment

Rehabilitation and Long Term Care

Voluntary Agency
not for profit, non official health care agencies that complement official health agencies and meet the needs of persons with a specific disease
Private Agency
owned and governed by an individual corporation or organization. Has a board of directors appointed by the owner. Supported by fees paid by the client or his/her insurance company. May or may not participate in medicare/medicaid
Primary Healthcare
Defined as entry into healthcare system care that does not require hospitalization
Secondary Healthcare
Defined as treatment and prevention of complications from disease, evaluation of chronic illness, other therapies
Tertiary Healthcare
Defined as comprehensive and highly specialized care
Sub-acute Healthcare
Defined as comprehensive, but less technical care of patient with complications for stabilization
Economic Influences on healthcare
Rising Health Care Costs:
Aging population
An increase in the use of technology
The rising cost of private health care insurance
The rising cost of medical malpractice insurance
Cost containment (nomeclature)
Governmental budget deficits have reached an all time high.
The nursing profession stands to benefit
Found to be cost effective and a high quality alternative to traditional medicine
As a profession, nursing is expected to benefit from reform by expanding roles in prevention, community-based nursing, advanced practice nursing, etc.
It is predicted that nurses will become increasingly active in the development of health policies that improve access, quality, and value in the delivery of health services.
Barriers to health care use
Structural: shortage of providers and lack of facilities. Financial: insurance, jobs, obstacles. Personal/cultural: sexual orientation, language, education
Healthy People 2020
Federal government program initiated in 1979

Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to:
-Encourage collaborations across communities and sectors.
-Empower individuals toward making informed health decisions.
-Measure the impact of prevention activities.

Health Promotion
Activities aimed at improving health and preventing disease by enabling people to increase control over and improve their health
Health Prevention versus Illness Prevention
Different Nursing Roles
Provider of Care (Direct care)
Patient Advocate

**Ideal role image**
society’s expectations of what a nurse should be.includes obligations and responsibilities, rights,privileges.
CLEAR image of what is expected.Often unrealistic.

**Perceived role image**
an individual’s own definition of nurse’s role.
Often more realistic than the ideal role, but not berealistic, either. This is usually the role with which the nursing student usually graduates.

**Performed role image**
what the nurse actually does.

Workplace violence in Nursing
Bullying – An isolated incident of the behavior described in this definition may be an affront to dignity at work but as a once off incident is not considered to be bullying.

**Overt Bullying**
-Name calling
-Fault finding
-Raised eye brows

**Covert Bullying**
-Unfair assignments
-Refusing to help someone
– Ignoring
-Making faces behind someone’s back
– Refusing to only work with certain people or not work with others

A process by which the thinker improves the quality of her thinking by taking charge of the structures inherent in thinking and imposing intellectual standards upon them
A critical thinker:
-Raises questions/problems and formulates them clearly and precisely (INQUISITIVE)
-Gathers and assesses relevant information
-Uses abstract ideas for interpretation (ANALYSIS)
-Develops conclusions that are well-reasoned, testing against relevant standards
-Is open-minded and recognizes alternative views
-Communicates effectively about solutions to complex problems (EXPLANATION, CONFIDENT in REASONING)
Important strategies for new nurse job hunting
Successful interview techniques
(1) Show up a little early
(2) Show confidence
(3) Keep a positive attitude
(4) Maintain eye contact
(5) Watch your body language

A few additional interviewing tips:
Don’t chew gum or breath mints during your interview and don’t speak in slang as it is unprofessional and rude.
Relate your answers to the specific company or interviewer. This will show that you’ve done your research.
Avoid complaining or bad mouthing previous employers or companies.
Speak professionally.
Don’t ramble or use slang in your answers.

Components of an Incident report
Nursing Care Delivery Models
-One nurse is responsible for total care of a number of clients 24 hours a day, 7 days a week.
-Assesses & prioritizes each client’s needs, identifies nursing diagnoses, develops a plan of care with the client, and evaluates the effectiveness of care.
-Incorporates all aspects of the professional role, including teaching, advocacy, decision making, and continuity of care.

**Case Management**
-Assist clients through the complex healthcare system with the goal of increasing the quality of life in a cost-effective way.
-Enable patient, their families, and their health care providers to be actively involved in providing for ongoing care needs.
-Combine nursing clinical knowledge, communication skills, and nursing process skills to assist clients in a variety of clinical settings.
-The case management nurse integrate a variety of disciplines and services in coordinating care throughout the client’s duration of illness.

**Functional Nursing**
-Is generally no longer used in hospital settings; it may be seen in long-term care settings. One nurse (often an LPN/LVN) administers all the medications on a residential unit

**Team Nursing**
-Delivery of individualized nursing care to clients by a nursing team led by a professional nurse (RN), Consists of registered nurses, licensed practical nurses, and, often, nursing assistants. Responsible for providing coordinated nursing care to a group of clients during an 8- or 12-hour shift.

Continuous quality Improvement (CQI)
Monitor processes involved in the provision of safe, effective quality care for patients

Focuses on excellence and employee involvement at all levels of an organization

Delivery of excellent nursing care to patients

Importance of Evidence Based Practice
-Produces better patient outcomes
-Keeps us current with the latest research
-Prevents us from using outdated information
Involves principles that govern actions directed toward given ends (the means to an end)
Policy statements set forth a plan
Polices may result in laws, regulations, or guidelines that govern behavior in public or private arena’s.
Policy decisions reflect the values and beliefs of those making the decisions.

Health policy refers to public or private rules, regulations, laws, or guidelines that relate to the pursuit of health and the delivery of health services.

Defined as a process that requires influencing the allocation of scarce resources.

Allocation assumes that there are not enough resources.
Who gets what, is determined through the political process.

Stakeholders and individuals are those with a vested interest and who try to influence those with the power to make the final decisions.
Stakeholders are organizations, the community at large served by the organization, and other groups or individuals affected by those decisions

Difference between politics and policy
Policies are the decisions

Politics is what influences those decisions

Importance of politics and policy
Deals with social welfare, governmental economic programs, international cooperation
Political Power
Power in and of itself is latent (not consciously expressed) – it is force that is capable of being exerted.
The ability or legitimacy to enforce power
A person with authority has legitimacy to enforce law
Form of power that is not legitimated through official channels.

The action or process of producing effects on the actions, behavior and opinions of others

Professional Associations (types/purposes/benefits)
Nursing organizations are often the catalyst for involvement in political action.

**Broad-purpose professional associations**
**Specialty practice associations**
**Special interest associations**

Organizations define practice standards; take positions on practice issues, and develop ethical guidelines, practice guidelines and policies.

Position statements serve to guide the organization’s work in both the practice and the policy areas.

**Benefits** of belonging to professional organizations:
Development of leadership skills
Certification and Continuing Education
Political Activism
Access to journals, newsletters, and action alerts about topics that need immediate response.
Eligibility for group health and life insurance opportunities, discounts of products and services
Networking with peers

Future Nursing challenges
Societal challenges
Nursing Practice challenges
Nursing Education challenges
Global health needs
Disaster nursing
Health care disparities
Differences in the quality of health care provided to different populations
Societal Challenges
The six challenges expected to have a major impact on the future of the nursing profession:
Environmental deterioration
Large-scale public health disaster needs
Unhealthy lifestyles with resulting rise in chronic illnesses
Cost containment needs
Governmental regulation of health care
Current healthcare priorities that are currently a focus in nursing education/clinical
Diversity issues
Critical thinking
Health promotion issues
Health care costs
Faculty shortage expected
Fraudulent on-line programs
Adequate and properly supervised clinical experiences
Technology helps some: virtual simulations
Students need to be educated consumers and consider specific options when evaluating programs.
What does it mean to be non-judgemental in professional nursing practice?
Explore other cultures
Value differences
Provide education and support

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