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Chapter 1 Nursing Today
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Historical Perspective Highlights
Nurses:
Respond to needs of patients Actively participate in policy Respond and adapt to challenges Make clinical judgments and decisions about patients’ health care needs based on knowledge, experience, and standards of care
Nursing:
Care is provided according to standards of practice and a code of ethics.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Development of a Profession
Nursing has struggled with its definition, its image, and its role in the healthcare delivery system – –
Due in part to its history Fact that it has both theoretical and practical aspects
Role of the nurse in the healthcare delivery system has probably never been more important than it is today.
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Historical Influences on the Development of Nursing
Healthcare in ancient cultures Historic perspectives and early images of nursing
Folk image Religious image Servant image
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The Beginning of Change
Early providers of nursing care − −
Sisters of charity in France and the United States Sisters of the holy cross in France and the United States − Catholic religious orders in Mexico and South America − Ursuline sisters in Canada − Deaconesses at Kaiserwerth, Germany and Pittsburgh, Pennsylvania − Nursing sisters in England and Ireland
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The Nightingale Influence
Dramatically changed the form and direction of nursing Set standards for nursing education and made significant recommendations for changes in how hospitals operated and how nursing was practiced Many of her recommendations are valid today Wrote Notes on Nursing
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Florence Nightingale’s Basic Principles of Nursing Education
Trained teaching hospitals are associated with medical schools Nurses reside in nurses’ houses School matron is final authority in: − −
Curriculum Living arrangements − All aspects of the school
Education includes theoretical material and practical experience Teachers are paid for instruction Records are kept on students Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Florence Nightingale
First practicing epidemiologist Organized first school of nursing Improved sanitation in battlefield hospitals Her practices remain a basic part of nursing today.
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Civil War to the Beginning of the Twentieth Century
The growth of nursing in the United States: Clara
Barton founded the American Red Cross. Dorothea Lynde Dix Mother Bickerdyke Harriet Tubman Mary Mahoney Isabel Hampton Robb Lillian Wald and Mary Brewster: Henry Street Settlement
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The Establishment of Early Schools
Nursing services provided by most hospitals during the 1860s were disorganized and inadequate. In 1869 the American Medical Association established a committee to study the issue of training for nurses. The New England Hospital for Women and Children is often credited with being the first hospital to establish a formal 1 year program to train nurses in 1872.
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Characteristics of the Early Schools
Primarily apprenticeships Long hours during which students provided much of the workforce of the hospital with little time left for study Job description 1887
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The Twentieth Century
Movement toward scientific, research-based practice and defined body of knowledge 1901: Army Nurse Corps established 1906: Mary Adelaide Nutting, first professor of nursing at Columbia University 1908: Navy Nurse Corps established 1920-1923: Study of nursing education 1940s and 1950s: Associations emerged 1970: Emergency Room Nurses Organization
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Nursing Image
Struggle with image Groups waging campaigns to:
Improve image Attract individuals to profession
Critical issue because of nursing shortage A positive image is needed to attract qualified individuals into the profession
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The Twenty-First Century
Nursing code of ethics Changes in curriculum Nursing in multiple care settings Advances in technology and informatics End-of-life care Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Influences on Nursing
Changes in society lead to changes in nursing:
Health care reform Demographic changes Medically underserved Threat of bioterrorism Rising health care costs Nursing shortage
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Nursing as a Profession
A profession has characteristics: Requires an extended education Requires a body of knowledge Provides a specific service Has autonomy Incorporates a code of ethics
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Scope and Standards of Practice
Nursing: Scope and Standards of Practice
1960: Documentation began Standards of Practice Standards of Professional Performance
Goal
To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice
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Standards of Practice
Nursing standards provide the guidelines for implementing and evaluating nursing care. Six standards of practice:
Assessment Diagnosis Outcomes identification Planning Implementation Evaluation
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Standards of Professional Performance Ethics
Quality of Practice
Professional Practice Evaluation
Education
Communication
Resources
EvidenceBased Practice and Research
Leadership
Environment al Health
Collaboration
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Code of Ethics
A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care. It is important for you to incorporate your own values and ethics into your practice. Ask yourself: How do your ethics, values, and practice compare with established standards?
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Quick Quiz! 1. Nursing is defined as a profession because nurses A. Perform specific skills. B. Practice autonomy. C. Utilize knowledge from the medical discipline. D. Charge a fee for services rendered.
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Programs that Prepare Graduates for RN Licensure
Three major avenues to preparation for licensure as a registered nurse exist in the United States:
Diploma or hospital-based diploma Associate degree College-based baccalaureate degree
Master’s and doctoral prelicensure programs Nontraditional prelicensure programs
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Nursing Practice
Nurses practice in a variety of settings. Nurses: Protect,
promote, and optimize our patients’
health Prevent illness and injury Alleviate suffering through the diagnosis and treatment of human responses Advocate for the care of our patients
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Nursing Practice
Nurse Practice Acts Licensure and certification Science and art of nursing practice Benner’s stages of nursing proficiency: Novice Advanced
beginner Competent Proficient Expert
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Professional Responsibilities
Nurses are responsible for obtaining and maintaining specific knowledge and skills. In the past: To
provide care and comfort
Now: To
provide care and comfort and to emphasize health promotion and illness prevention
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Professional Roles Autonomy and Accountability Caregiver Advocate Educator Communicator Manager
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Career Development
Nursing provides an opportunity for you to commit to lifelong learning and career development.
{Fig 1-2 here}
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Professional Nursing Organizations
National League for Nursing (NLN) American Nurses Association (ANA) International Council of Nursing (ICN) National Student Nurses Association (NSNA) or Canadian Student Nurses Association (CSNA) Other professional organizations focus on specific areas.
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Quick Quiz! 2. The NLN and the ANA are professional organizations that deal with A. Nursing issues of concern. B. Political and professional issues affecting health care. C. Financial issues affecting health care. D. All of the above issues.
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Forces for Change in Nursing Education
Incorporation of computer technology in nursing education
Computer technology in the classroom Computers in the hospital environment Distance learning options
Establishment of programs that provide for educational mobility Increase in community-based practice experiences Increase in emphasis on research Education supporting evidence-based practice
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Additional Nursing Trends
Genomics Public perception of nursing Impact of nursing on politics and health policy Future trends
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Chapter 2 The Health Care Delivery System
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Challenges to Health Care
Reducing health care costs while maintaining high-quality care for patients Improving access and coverage for more people Encouraging healthy behaviors Earlier hospital discharges result in more patients needing nursing homes or home care.
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Emphasis on Population Wellness
Health Services Pyramid
{Fig 2-1 here}
Managing health instead of illness Emphasis on wellness Injury prevention programs
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National Priorities Partnership
National Priorities:
Patient and family engagement Population health Safety/eliminating errors as possible Care coordination Palliative care for advanced illnesses Overuse/reducing waste
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Institute of Medicine (IOM)
Nurses need to be transformed by:
Practicing to the full extent of their education and training Achieving higher levels of education and training through an improved education system that provides seamless progression Becoming full partners, with physicians and other providers, in redesigning the health care system Improving data collection and the information infrastructure for effective workforce planning and policy making Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study
Amy Sue Reilly is a 15-year-old white female of Irish descent. She is a freshman at a Catholic high school. Although her parents are divorced, Amy Sue reports that her family (she has two brothers and lives with her mother) is very close, and that her parents work together to meet all their children’s needs. Amy Sue has had asthma since she was 5 years old. She has been able to control her asthma by taking oral medications and by using inhalers when needed.
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Health Care Regulation and Competition
Regulatory and competitive approaches
Professional standards review organizations (PSROs) • Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid
Utilization review committees (URs) • Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare
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Health Care Regulation and Competition (cont’d)
Prospective payment system (PPS)
Diagnosis-related groups (DRGs) Capitation Resource utilization groups (RUGs)
Profitability Managed care
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Health Care Regulation and Competition (cont’d)
Patient Protection and Affordable Care Act
Access to health care for all Reducing costs Improving quality Provisions include • Insurance industry reforms • Increased funding for community health centers • Increased primary care services • Improved coverage for children
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Health Care Settings and Services
1. Preventive
2. Primary
3. Secondary
4. Tertiary
5. Restorative
6. Continuing
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Health Care Accreditation/ Certification
Reasons:
Accreditation earned by the entire organization
To demonstrate quality and safety To evaluate performance, identify problems, and develop solutions
Specific programs or services within an organization earn certifications.
The Joint Commission and others
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Preventive and Primary Health Care Preventive Care Primary care Focuses on improved health outcomes for an entire population Requires collaboration among health professionals, health care leaders, and community members
Health promotion lowers overall costs: Reduces incidence of disease Minimizes complications Reduces the need for more expensive resources Occurs in home, work, and community settings Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Secondary and Tertiary Care
Also called acute care Focus: Diagnosis and treatment of disease Disease management is the most common and expensive service of the health care delivery system. 20% require 80% of health care spending. Fastest growing age group of uninsured? Postponement of care by uninsured
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Secondary and Tertiary Care (cont’d)
Settings Hospitals
Rural Hospitals
Intensive Care Units Psychiatric Care
Resource efficiency, word redesign Discharge planning—nurses’ role
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Restorative Care
Serves patients recovering from an acute or chronic illness/disability Helps individuals regain maximal function and enhance quality of life Promotes patient independence and self-care abilities Requires multidisciplinary approach Settings:
Home Care
Rehabilitation
Extended Care
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Restorative Care: Home Care
Provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation Involves coordination of services Focuses on patient and family independence Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay sources
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Restorative Care: Rehabilitation
Focus: To restore patients to their fullest physical, mental, social, vocational, and economic potential Includes physical, occupational, and speech therapy, as well as social services Occurs in many health care settings, both inpatient and outpatient
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Restorative Care: Extended Care
Extended care facility
Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities
Skilled nursing facility (intermediate care)
Provides care for patients until they can return to their community or residential care location
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Continuing Care
For people who are disabled, functionally dependent, or suffering a terminal disease Available within institutional settings or in the home: Nursing Centers or Facilities Assisted Living Respite Care Adult Day Care Centers Hospice Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Continuing Care: Nursing Centers or Facilities
Provide 24-hour intermediate and custodial care
Nursing, rehabilitation, diet, social, recreational, and religious services Residents of any age with chronic or debilitating illness
Regulated by standards: Omnibus Budget Reconciliation Act of 1987 Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Continuing Care: Assisted Living —Offers a long-term care setting with a home environment and greater resident autonomy
—Provides services such as laundry, assistance with meals, personal care, housekeeping, and 24hour oversight —Allows residents to live in their own units Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Respite Care
The service provides short-term relief or “time off” for persons providing home care to an ill, disabled, or frail older adult. Settings include home, day care, or health care institution with overnight care. Trained volunteers allow family caregivers to leave the home for errands or social time.
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Quick Quiz! 1. A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care setting. C. Assisted-living center. D. Respite center.
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Adult Day Care Centers
Provide a variety of health and social services to specific patient populations who live alone or with family in the community May be associated with a hospital or nursing home or may operate independently Offer services to patients such as daily physical rehabilitation and counseling
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Hospice
Family-centered care that allows patients to live and remain at home Focuses on palliative (not curative) care: comfort, independence, and dignity Provides patient and family support during terminal illness and time of death Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family.
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Case Study (cont’d)
Recently, Amy Sue has had some difficulty breathing, especially during gym class. Corrine is a 45-year-old African American nurse, who recently accepted a job as a school nurse for the four Catholic schools in the area. Three of the schools are grade schools, and one is Amy Sue’s high school. Before she took this job, Corrine worked at a pediatrician’s office.
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Issues in Health Care Delivery
Nursing shortage Competency Evidence-based practice Quality and safety in health care/ Patientcentered care Health care organizations are being evaluated on the basis of outcomes such as prevention of complications, patients’ functional outcomes, and patient satisfaction.
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Issues in Health Care Delivery (cont’d)
Magnet Recognition Program
Nursing-sensitive outcomes
Nursing informatics and technological advancements Globalization of health care
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Case Study (cont’d)
Amy Sue’s difficulty managing her asthma is significant for Corrine because Corrine’s oldest daughter has asthma. In addition, because of her job in the pediatrician’s office, Corrine has had experience with caring for children with asthma and with helping patients access the health care delivery system.
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Quick Quiz! 2. Technological advances in health care A. Make the nurse’s job easier. B. Depersonalize bedside patient care. C. Threaten the integrity of the health care industry. D. Do not replace sound personal judgment.
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The Future of Health Care
Change opens up opportunities for improvement. Health care delivery systems need to address the needs of the uninsured and the underserved. Health care organizations are striving to become better prepared to deal with these and other challenges in health care. The solutions necessary to improve the quality of health care depend largely on the active participation of nurses. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Chapter 3 Community-Based Nursing Practice
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New Stimulus for Community-Based Nursing Practice
Because patients spend less time in acute care settings, there is a growing need to have organized health care services where the population lives, works, and learns. As community health care partnerships develop, nursing is in a strategic position to play an important role in health care delivery and to improve the health of the community.
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Focus of Community-Based Nursing
Health Promotion
Disease Prevention
Restorative Care
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Community-Based Health Care
A model of care to reach all in a community
Focuses on assisting individuals and communities with achieving a healthy living environment
Occurs outside of traditional health care facilities Provides services for acute and chronic conditions
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Challenges
Public health problems influenced by:
Social lifestyles Political policy Economic initiatives
Current medical and social problems
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Achieving Healthy Populations and Communities
Healthy People Initiative (by USDHHS)
Establishes ongoing health care goals
Healthy People 2020
Goals are to increase life expectancy and quality of life, and to eliminate health disparities through improved delivery of health care services
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Improved Delivery of Health Care
Improved delivery of health care occurs through 1. Assessment of health care needs of individuals, families, and communities 2. Development and implementation of public health policies 3. Improved access to care
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Assessment
Examples:
Systematic data collection (such as incident rates) on the population Monitoring the health status of the population Accessing available information about the health of the community
Examples of program results:
Adolescent smoking prevention Sex education Proper nutrition
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Public Health Policy Development + Implementation
Health professionals provide leadership in
Developing public policies to support the health of a population
Strong policies are driven by community assessment:
Example: Assessment of level of lead poisoning in young children Example: Assessment of the number of people in the community who need end-of-life care
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Improved Access to Care
Ensures that community-wide health services are
Available to the total community Accessible to the total community
Example: Five-level Health Services Pyramid Role of community services near acute care services Healthy environments
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Case Study
Kim Callahan is a student in a community health nursing course. She is working in a community nursing service within a large city. Most of the patients in this agency are Bosnian immigrants. A major care initiative in this agency is to provide well-child examinations and immunizations to get children ready to enter the public school system.
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Community Health Nursing
Nursing practice in the community Primary focus is on health care of individuals, families, and groups. Similar to public health nursing Requires
Understanding the needs of a population A set of skills and knowledge
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Community Health Nursing (cont’d)
Essential public health functions:
Community assessment Policy development Access to resources
Goal is to preserve, protect, promote, or maintain health. Provides direct care services to subpopulations in a community Competencies needed
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Nursing Practice in Community Health
Expert community health nurses:
Understand the needs of a population or community Use critical thinking skills to apply knowledge Understand resources
Needed skills:
Patient advocacy Communicating people’s concerns Designing new systems that cooperate with existing systems
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“Double Vision”
Community health nurses:
Care for the Assess the individual or community as a family within the context of whole the community
Successful practice involves:
Building relationships with the community Being responsive to changes within the community
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Community-Based Nursing
Occurs in community settings Involves acute and chronic care Enhances individuals’ capacity for self-care Promotes autonomy in decision making Uses critical thinking skills Reduces costs for the patient by providing care near homes Requires knowledge of family theory, communication, group dynamics, and cultural diversity Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Vulnerable Populations
Examples:
Immigrants Poor and homeless Abused Substance abusers Mentally ill Older adults
Special needs of vulnerable populations are a challenge.
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Multilevel Intervention
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Case Study (cont’d)
Kim and her classmates conducted an assessment of the community’s health care needs and practices. This is a close community that is facing many challenges, although chronic disease is absent in this population. General preventive health care practices, including well examinations and basic screenings, are lacking.
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Competency in Community-Based Nursing
Competency is based on decision making at the level of the individual patient.
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Competency in Community-Based Nursing (cont’d)
Nurses utilize a variety of skills and talents:
Caregiver Change Agent Collaborator Educator
Case Manager Patient Advocate Counselor Epidemiologist
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Quick Quiz! 1. Vulnerable populations of patients are those who are more likely to develop health problems as a result of A. Living at home. B. Abusive habits. C. Immigration. D. Middle age.
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Case Study (cont’d)
Many members of the Bosnian community are suspicious of free/low-cost care. Kim attends community meetings with her community nurse preceptor to assess the beliefs and concerns of the community. Misunderstandings and fears about health care services in this country are identified. Kim uses beneficence—wanting to do the most good for the most people. Kim respects the community’s beliefs. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Community Assessment
Assesses the community at large Nurses care for patients from diverse backgrounds and settings, but all communities have three components: Structure or Locale People Social Systems Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
One single-parent family in the community is 30-yearold Katrina Dudek and her two children (aged 3 years and 6 months). Kim and the community health nurse work with Mrs. Dudek to determine the health care needs of her children and herself. So far, Mrs. Dudek and her children have not received any care. Kim and Mrs. Dudek discuss the need for immunizations of the children and set that as a goal.
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Quick Quiz! 2. In identifying needs for health policy and health program development and services, a community assessment focuses on which of the following elements? A. Structure B. People C. Social systems D. Environments E. All of the above
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Changing Patients’ Health
Nurses need an accurate assessment of patients to design interventions that promote health and prevent disease. Patients are more likely to accept a change if it is:
More Advantageous Compatible Realistic Easy to Adopt
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Case Study (cont’d)
Kim identifies community leaders to serve as key persons in educational programs. Kim spends 12 weeks working with the community agency and leaders to explain how the clinic provides services and the confidentiality of these services. Kim presented information in three homes as well. A gradual increase was noted in the use of services, including fewer “missed” appointments.
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