Professor and Department Chair for Leadership Studies Texas Tech University Health Sciences Center School of Nursing Lubbock, Texas. Professor Emeritus of the University of Tennessee Health Science Center College of Nursing Memphis, Tennessee, Sixth Edition.
WHO WILL BENEFIT FROM THIS BOOK?
At no other time in the history of modern nursing have nurses been presented with such enormous opportunities to improve health care and advance the nursing profession. These important topics include patient safety and quality care, health care reform and the uninsured population, challenges in the nursing workforce, advancing technology, changing legal and ethical concerns, evolving trends in nursing education, rising health care costs, and working in a multicultural society.
ORGANIZATION
The Development of Nursing
Current Issues in Health Care
Leadership and Management in Nursing
Career Management
LEARNING AIDS
Integrated learning outcomes that give teachers and students a clear understanding of what behaviors can be expected after a chapter study is completed. Useful online resources particularly relevant to further exploration of the subject are included at the end of selected chapters.
NEW TO THIS EDITION
Summary at the end of each chapter provides closure and helps students focus on points to remember • References related to chapter content help students.
ANCILLARIES
Student Resources
Instructor Resources
- UNIT 1 The Development of Nursing
- UNIT 2 Current Issues in Health Care
- CHAPTER 7 Paying for Health Care in America: Rising Costs and Challenges, 105 Marylane Wade Koch, MSN, RN
- UNIT 3 Leadership and Management in Nursing
- UNIT 4 Career Management
Barbara Cherry, DNSc, MBA, RN, NEA-BC, received her BS in Nursing from Methodist Hospital School of Nursing, her BSN from West Texas A&M University, her MBA from Texas Tech University, her MSN from Texas Tech University Health Sciences Center, and her Doctor of Science in Nursing from the University of Tennessee Health Sciences Center. Jacob, PhD, MSN, RN, received her BSN from West Virginia University in 1970, her MSN from San Jose State University in 1975, and her PhD from the University of Tennessee, Memphis in 1993.
The Evolution of Professional Nursing
Toba was placed under the care of the Palliative Care Team, an interprofessional team of health care professionals coordinated by an advanced practice nurse who was nationally certified by the National Board for Certification of Hospice and Palliative Nurses. Since its time, nursing has evolved into a profession focused on meeting the needs of the people it serves and preparing providers who can meet those needs.
PREHISTORIC PERIOD
Describe the evolution of professional challenges experienced by nurses of diverse ethnic, racial, and educational backgrounds. This chapter provides a brief insight into health care practice and nursing in the prehistoric period and early civilization and then describes the development of professional nursing practice.
EARLY CIVILIZATION Egypt
1948 Estelle Osborne is the first African-American nurse elected to the ANA Board of Directors. Elizabeth Carnegie, an African-American nurse, is elected president of the American Academy of Nursing.
Palestine
A pharmacopoeia was written to aid in the treatment and management of disease, classifying over 700 drugs (Ellis and Hartley, 2012). As in the case of Shiphrah and Puah, the midwives who saved the baby Moses, kings and other aristocrats used nurses to deliver and care for the young, older adults and the sick.
Greece
India
China
Rome
They were very well organized and dedicated, and for protection they wore armor with the emblem of the Red Cross.
THE MIDDLE AGES
THE RENAISSANCE AND THE REFORMATION PERIOD
THE COLONIAL AMERICAN PERIOD
Benjamin Franklin, who was outspoken about caring for the sick, insisted that a hospital be built in the colonies. Through his efforts, the first hospital, called the Pennsylvania Hospital, was built in the United States in 1751 in Philadelphia (Ellis and Hartley, 2012).
FLORENCE NIGHTINGALE
In 1873, graduates of Nightingale's nursing training program in England migrated to the United States, where they became supervisors in the first of the hospital-based (diploma) nursing schools: Massachusetts General Hospital in Boston, Bellevue Hospital in New York, and New York. Haven Hospital in Connecticut. Until her death in August 1910, Nightingale demonstrated the powerful effect that well-educated, creative, skilled and competent individuals have in the delivery of health care.
MARY SEACOLE
Nightingale had the resources to support her work and the stamina to continue her belief in healthcare.
NURSING IN THE UNITED STATES The Civil War Period
Three African-American nurses made particularly important contributions to the nursing effort during the Civil War: Harriet Tubman cared for the sick as a nurse on the Sea Islands off the coast of South Carolina and later became known as the "conductor of the Underground Railroad." . Rockefeller funded the establishment of the first nursing school for African American women at Atlanta Baptist Seminary—now known as Spelman College (Jones, 2004).
1900 to World War I
World War I and the 1920s
However, as the war continued, the Red Cross nurses also moved into urban areas to provide health care services (Stanhope and Lancaster, 2010). Nurses working for the FNS traveled an area of 700 square miles, often on horseback, to provide services to approximately 10,000 patients (Stanhope and Lancaster, 2010).
The Great Depression (1930 to 1940)
Equally important was her documentation of community nursing outcomes in rural communities. The primary purposes of the Social Security Act of 1935 were to provide (1) a national old-age insurance system, (2) federal subsidies to states for maternal and child welfare services, (3) vocational rehabilitation services for the disabled, (2) 4) medical care for the crippled children and blind people, (5) a plan to strengthen public health care, and (6) a federal unemployment system (Karger and Stoesz, 2005).
The piece of legislation that had the greatest effect on health care in the United States was the Social Security Act of 1935, which set the precedent for the passage of the Medicare and Medicaid laws that followed in 1965. The Social Security Act of 1935 provided opportunities for nursing care and nursing jobs were created.
Post–World War II Period (1945 to 1950)
Nearly 40% of the hospitals built in the late 1940s and early 1950s were built with Hill-Burton funds. In the 1940s, the NACGN began to wage an all-out war against discrimination by the southern components of the ANA.
Nursing in the 1960s
From 1916 to 1948, African-American nurses in the South were barred from membership in the ANA due to segregation laws in southern states. With the establishment of individual membership, African American nurses in the South could bypass them.
Nursing in the 1970s
To receive Medicare reimbursement for home health services, patients were required to have (1) homebound status; (2) the need for partial or intermittent skilled nursing care; (3) a medically reasonable and urgent need for treatment; and (4) a physician-approved plan of care. Home health care was one of the first employment environments that allowed nurses to work only during the week.
Nursing in the 1980s
An increasing number of nurses moved from the hospital setting to the community to practice in programs such as hospice and home health. This decline in enrollment occurred as the complexity of health care rapidly increased and more nurses took on expanded roles.
Nursing in the 1990s
Fifteen percent of the gross domestic product was related to health care spending (this amounts to about $1 trillion per year). The nurse of the 1990s had to focus on providing health care services that (1) included an assessment of health risks based on family and environmental factors, (2) supported health promotion and disease prevention, and (3) advanced counseling and health education. (Nies and McEwen, 2011).
Nursing in the Twenty-First Century
Nurses have the potential to effect meaningful changes in the health care system that will meet the demand for safe, quality, patient-centered, accessible, and affordable care (IOM, 2011). The nursing profession has the ability to effect far-reaching changes in the health care system.
This new demand on the health care system has significant implications for nursing, the nation's largest health care profession with more than 3 million RNs nationwide. This evolution will continue to provide the basis for the scope of practice, educational curricula, scholarship, and research necessary for nurses to lead and manage the healthcare environment of the future (Catalano, 2012).
ADDITIONAL RESOURCES
Gill G: Nightingales: the remarkable education and curious life of Miss Florence Nightingale, New York, 2004, Ballantine Books. Karger HJ, Stoesz D: American welfare policy: a pluralistic approach, 5th ed., New York, 2005, Allyn and Bacon.
The Contemporary Image of Professional Nursing
Antoinette (Toni) Bargagliotti, DNSc, RN, ANEF, FAAN
The contemporary image of professional nursing in the United States is an ever-changing kaleidoscope created by the 3.06 million men and women of all ages, races, and religious beliefs who are registered nurses (RNs). The request for Nightingale's nursing services in Crimea arose from newspaper reports of the devastating health care conditions during the Crimean War.
WHY IMAGE IS IMPORTANT
Second in size to the teaching profession, nurses have been alternately described as either saints or sinners, powerless or powerful, admired or ignored, and most recently, those who dare to care. Although nurses became concerned about their public image and media portrayal, Kalisch and Kalisch's (1995) extensive work detailing the image of nursing in film and media over time permanently etched the image issue into the professional radar screen.
REGISTERED NURSE SUPPLY
NURSING IN ART AND LITERATURE
Antiquity Image of Nursing
Victorian Image of Nursing
24 UNIT 1 The development of nursing was endured because of the lack of other options. Fortunately, Sairy's literary arrival was followed by Longfellow's portrayal of the heroic Nightingale in Santa Filomena (1857).
Early Twentieth-Century Nursing
Reflecting Victorian England's concern for untrained health care providers, Dickens advised Sairy on the benefits of "a little less drink, and a little more humanity, and a little less respect for herself, and a little more respect for her patients." and maybe a little extra honesty.” Nightingale was one of the early adopters of the emerging knowledge called statistics and developed the pie chart that is still in common use today.
The 1930s Nurse as Angel of Mercy
As important as Nightingale was to the improved health care of British soldiers and to the development of modern nursing, the ever-increasing positive images of Nightingale only occurred because she was able to succinctly demonstrate the total outcomes of nursing practice.
The 1940s Nurse as Heroine
Nursing in the Antiestablishment Era of the 1960s
Nursing in the Sexual Revolution of the 1970s
Nursing in the 1980s to 1990s
Millennial Media
Social Media
Nursing’s Response
Media Campaigns for Nursing
THE ENDURING PUBLIC CONCERN WITH NURSING
What the Public Believes About Nursing
THE REALITY OF THE CONTEMPORARY STAFF NURSE
Skechers, Schick, Dentyne Ice, and the Lung Cancer Alliance were persuaded to remove "naughty nurse" TV commercials (Truth About Nursing, 2011). Nursing's heroic and noble public image has been etched in stone and in stained glass windows in larger-than-life proportions.
FACTS ABOUT TODAY’S REGISTERED NURSE
CREATING THE IMAGE OF TWENTY-FIRST CENTURY NURSING
From a very different perspective, McNamara and colleagues (2012) suggested that a powerful image of the discipline of nursing can be found online in nursing school curricula, just as is the case for other academic disciplines at universities. Unfortunately, many faculty are unaware of the image of nursing they project to the public through the way they label nursing education.
THE BASICS
Aiken et al.'s (2011) study of all hospital admissions in the four largest states in the United States in one calendar year found that simply increasing RN levels is not the only answer to reducing patient mortality. Nursing education is important because for every 10% increase in the percentage of BSN nurses, the mortality rate decreased by 4%.
Changing Nurse-Physician Interactions
A meta-analysis of all mortality/morbidity/nurse staffing studies since 1990 indicated that a decrease in the evening nurse-patient ratio was accompanied by a 90% increase in mortality and that 47% of deaths from abdominal aortic surgery were due to nursing staff (Kane et al., 2007). A positive work environment was defined as one where there are positive doctor-nurse relationships, management listens to bedside nurses' patient concerns, nurses are engaged in hospital affairs, and hospitals invest in improving quality and in continuing education. development of nurses.
THE LOOK OF NURSING
A survey of healthcare providers, medical and nursing students (n = 513) found that no respondent group had a positive attitude towards tattooed persons. While there are 79 or more specialty nursing organizations, the main professional association is the ANA.
CREATING A NEW IMAGE
Diers D: The mystery of nursing: Secretary's Commission on Nursing: support studies and background information, volume 2, Rockville, MD, 1988, Department of Health and Human Services, pp VIII-1-VIII-10. Department of Health and Human Services: The registered nurse population: findings from the 2008 national sample survey of registered nurses, Rockville, MD, 2010, author.
The Influence of Contemporary Trends and Issues on
Nursing Education
Create a personal philosophy and plan for ongoing professional development and practice that integrates knowledge of current trends and issues. What are the major current trends in society and healthcare and how do they affect nursing education and practice.
INTRODUCTION
TRENDS AND ISSUES IN
CONTEMPORARY NURSING EDUCATION Knowledge Expansion and Use of Technology
The use of social media has become so common in nursing that guidelines and ethical code statements are being developed by employers and by national nursing organizations (National Council of State Boards of Nursing [NCSBN], 2012; Prinz, 2011). The use of blogs has been cited as a method of increasing communication among nursing students and a forum for sharing medical information (Roland et al, 2011).
Practice-Based Competency Outcomes
American Academy of Nursing aannet.org Information on nursing issues, impact on government, other organizations; research promotion, national leadership. National League for Nursing http://www.nln.org/ Information on all Nursing Testing Schools; educational programs.
Performance-Based Learning and Assessment
Another form is faith-based learning projects with nurses in churches and congregations (Brendtro and Leuning, 2000; Kotecki, 2002). The change in competency outcomes and practice-based learning requires changes in assessment methods that focus on valid, actual performance of required competencies in realistic scenarios; paper-and-pencil tests and inconsistent subjective clinical observations by instructors or teachers are not sufficient.
Sociodemographics, Cultural Diversity, and Economic and Political Changes
Increasingly, health care providers must learn about different cultural values and health practices and integrate them into care as much as possible. It leads to more widespread health problems that strain health care facilities and financial resources.
Community-Focused Interprofessional Approaches
46 UNIT 1 The development of nursing for those who want to learn and the teacher who tries to help them learn. As suggested, an important part of nursing education involves trends in society and the issues that arise from them.
Patient-Centered Care: Engagement, Safety, and Privacy
These experiences promote cultural understanding and appreciation of health conditions outside and within the United States; help students integrate the impact of environment, education, and culture on health conditions regardless of location. Students must learn to manage disease and preventive health care for a variety of clients spread throughout the community and provide critical care to hospital patients who are sicker and go home faster.
Ethics and Bioethical Concerns
These trends challenge students to prepare for a wide range of nursing practice, which relies on competencies such as clinical decision-making (Flin et al, 2008), communication, collaboration and leadership. Other problems arise from the increasing use of alternative medicines outside the mainstream of traditional Western medicine, such as herbs and acupuncture (Anastasi et al, 2009).
Shortage of Nurses and Faculty
Additionally, the number of students in the master of science in nursing (MSN) and doctoral programs is not adequate to meet current needs. For example, many organizations and associations have initiated collaborative partnerships to improve education at all types and levels of nursing education; some are nationwide or regional agreements (Allen et al, 2007; Horns et al, 2007; Hunt, 2007;
Disasters, Violence, and Terrorism
The faculty is aging and retiring, but the number of future qualified replacements is very limited (AACN, 2012). See the chapter on flexible education, mobility and distance learning programs, p. 54) NLN has launched initiatives to improve nursing education and faculty development (see AACN and NLN websites for position statements on innovations and transitions in nursing education).
Increasing Professional and Personal Responsibilities
50 UNIT 1 The evolution of nursing increases the need for nurses to document continued competency for initial licensure, relicensing, and recertification. Changes in state and multistate regulations increasingly focus on the need for initial and ongoing competency (IOM, 2009).
DIVERSITY IN NURSING EDUCATION PROGRAMS
Many states require continuing education, and some require a portfolio approach to validate continuing competency (see websites for NCSBN and specific states, such as California, Kentucky, Oklahoma, and Tennessee). The ANA has identified continuing nurse competency as one of its key concerns since the late 1990s (see the ANA website and back issues of The American Nurse.
Licensed Practical or Vocational Nurse Programs
Hospital Diploma Programs
Associate Degree Programs
52 UNIT 1 Nursing Development to create more respect and recognition for nursing's contribution to community health. ADN education is a living example of how changes in society affect the evolution of nursing education; it was another important "first" in nursing and an important part of the development of the professionalization of nursing as a discipline.
Baccalaureate Degree Nursing Programs
For the first time, it was possible for all RNs to be educated in a post-secondary environment and obtain a higher education. This trend of acceptance and growth of ADN programs, along with slowly increasing 4-year BSN programs and opportunities for progressive mobility, established the educational framework for current nurse education.
Master’s Degree Nursing Programs
As a result of this expanded scope of practice, an increasing number of nurses have earned an MSN degree and Advanced Practice certification. In addition, the Consensus Model for Regulation of Advanced Practice Registered Nurses (APRN): Licensure, Accreditation, Certification, and Education was published in 2008 (AACN, 2008c).
Clinical Nurse Leader
The extraordinary and rapid changes in health care since the early 1990s have emphasized the cost-effectiveness and quality of care brought about by the use of advanced practice nurses in primary care and other specialty areas. Most nurse practitioners, managers, administrators, and educators are now required to have a master's degree or doctorate.
Doctoral Programs
Some nursing leaders believe that introducing a second level of preparation is not in the best interest of nursing and will further exacerbate the faculty shortage (Chase and Pruitt, 2006; Tanner, 2005). Additionally, as of March 2012, 184 DNP programs enroll students in schools of nursing in 40 states nationwide, 65 of which are accredited by the CCNE and 110 of which are seeking accreditation (AACN, 2012).
FLEXIBLE EDUCATION, MOBILITY, AND DISTANCE-LEARNING PROGRAMS
American Association of Colleges of Nursing: Position Statement on the Doctor of Nursing Practice Degree (Website). American Association of Colleges of Nursing: Government affairs, nursing policy beat: Healthcare reform, 2009d (website with several links to shortages and strategies for change).
Nursing Licensure and Certification
International Council of Nursing (ICN): Professional organization representing nurses in countries around the world. Mutual Recognition of Nursing: A Program Developed by the National Council of State Boards of Nursing (2012).
THE HISTORY OF NURSING LICENSURE Recognition: Pins and Registries
Purpose of Licensure
Early Licensure Activities
For example, the NCSBN approved the most recent revision of the model practice law and administrative rules in 2011 (NCSBN, 2012c). Separate sections of the model law provide guidance for state boards of nursing and the necessary requirements for entry into practice.
Mandatory Licensure
State boards of nursing were established with rules for examinations and revocation of licensure. The next major event in licensure efforts occurred in 1982 with the development of the first NCLEX-RN exam.
COMPONENTS OF NURSE PRACTICE ACTS
Like previous versions of licensing exams, the NCLEX-RN exam has evolved over time. For more information on the NCLEX-RN exam, see Chapter 28 of this text.
Purpose of Act
As part of the original activities of UNIT 1 The Development of Nursing, the council advocated for a standardized examination for licensure. The test was revised so that all nursing content could be included in one section of the exam.
Definition of Nursing and Scope of Practice
These varied activities culminated in the National League for Nursing administering the first State Board Test Pool Examination in 1950.
Licensure Requirements
Renewal of Licensure
Mandatory Continuing Education
ROLE OF REGULATORY BOARDS TO ENSURE SAFE PRACTICE
Duties of the Board of Nursing
SPECIAL CASES OF LICENSURE Military and Government Nurses
Internationally Educated Nurses
International Practice
REVISION OF NURSE PRACTICE ACTS
Sunset Legislation
DELEGATION OF AUTHORITY TO OTHERS
CURRENT LICENSURE ACTIVITIES Mutual Recognition Model
In addition, a national database provides information on individual nurses' practice and disciplinary actions taken against nurses. On the other hand, concerns relate to monitoring nurses' practice in multiple jurisdictions, nurse privacy, and due process rights.
Continued Competency
With the increased mobility of nurses, the telehealth movement, and the need to care for patients over long distances, state boards of nursing have recognized the need to provide nurse practitioners with more than procedures of underwriting their initial license. Since changes occur frequently in this area, the most comprehensive and current sources of information are the websites for the ANA, the NCSBN, and the state boards of nursing for individual jurisdictions.
CERTIFICATION History of Certification
The efforts organized nursing has invested in advanced practice nursing certification are further indications of nurses' commitment to protecting the public and the patients they serve. Outpatient Care Nursing Cardiac Rehabilitation Nursing Cardiac Vascular Nursing Case Management Nursing Certified Vascular Nursing College Health Nursing Community Health Nursing Diabetes Management - Advanced General Nursing Practice.
Purpose of Certification
Steps to Certification
Current Issues in Certification
American Nurses Credentialing Centre (ANCC) http://www.nursecredentialing.org/default.aspx Commission on Collegiate Nursing Education. National Council of State Boards of Nursing (2012b): Gesamentlike verklaring oor afvaardiging: American Nurses Association (ANA) en die National Council of State Boards of Nursing (NCSBN) (webwerf).
Theories of Nursing Practice
It is important for nurses to study the development of nursing theory because without an idea of where you have been, how can you know how, why, when or where to go. This chapter in no way reflects the breadth and depth of nursing theorists and their theories.
SCIENCE AND THEORY
Nursing Science
This knowledge guides nursing practice to better serve patients through cure, prevention, education and health maintenance.
Theories, Models, and Frameworks
Nursing Theory
The language of theory is translated into pictorial form, which provides a comprehensive view, or model, of the theory. A model, like a blueprint of a building, allows one to see the layout, including outlines of all features specific to the theory.
Levels of Theory
From the earliest model offered by Florence Nightingale, nursing theory has been described and explained using this medium. While it is not the same as understanding every little detail of the structure, the idea is to provide an overview, which is informative and descriptive at a glance.
FLORENCE NIGHTINGALE: THE FIRST NURSING THEORIST
As her parents talk to Christine's attending physician in a nearby office, you talk to Christine, who goes from smiling and chatting to bursting into tears. Assessment phase: As a result of Christine's concrete experiential interpretation of "sleep", she has applied a negative value to the environmental conditions surrounding her abdominal pain.
Nightingale’s Theory of Practice
Nightingale discusses some of the common substances (porridge, arrowroot pudding, and egg flip) given to the sick. One of her biographers (Cook, 1942) said: "She was not only 'The Lady with a Lamp' who threw light into dark places, but also a kind of galvanic battery who stimulated and sometimes shocked the dull and sluggish public to life and action ." .
SURVEY OF SELECTED NURSING THEORIES
Interpersonal relationship model explores the interpersonal relationship of the nurse and the client and identifies the client's emotions as a predictor of positive outcomes related to health and well-being. Behavioral Systems Model of Nursing; separates the psychological and the physiological aspects of illness; The nurse's role is to provide support and comfort to achieve regulation of the client's behavior.
Sister Callista Roy (1974)—Adaptation Model
Assistance with the Adaptation to Stressors to Facilitate the Integration Process of the
Jean Watson (1978)—Theory of Human Caring: Transpersonal Caring as the Fulcrum;
Philosophy and Science as the Core of Nursing
Margaret Newman (1979, Revised 1986)—
Health as Expanding Consciousness
Merle Mishel (1981, Revised 1990)—
Uncertainty of Illness
FUTURE OF NURSING THEORIES AND THEORISTS
Nightingale F: Notes on Nursing: What it is and what it is not (commemorative edition), Philadelphia, 1992, Lippincott. Johnson BM, Webber PB: An introduction to theory and reasoning in nursing, Philadelphia, 2001, Lippincott.
Nursing Research and Evidence-Based Practice
Phenomenology: A qualitative research design that uses inductive descriptive methodology to describe the lived experiences of study participants. Qualitative research: A systematic, subjective approach used to describe life experiences and give them meaning.
DEFINITION OF NURSING RESEARCH
EVOLUTION OF NURSING RESEARCH
By the 1970s, more doctoral-prepared nurses were conducting research, and there was a shift in studies that focused on improving patient care. Evidence-based practice (EBP) can be defined as the process of finding, evaluating, and systematically using research findings as a basis for making decisions about patient care.
RESEARCH PRIORITIES
With the growing educational emphasis on the doctorate in nursing practice degree, research emphasis on such patient care focuses is likely to accelerate, especially in light of the quality gaps highlighted by recent reports from the Institute of Medicine (IOM, 2001). No longer are nurses and other healthcare professionals simply comparing the outcomes of patient care between units within the same hospital; solutions, choices and results are sought on an international level.
National Institute of Nursing Research
Agency for Healthcare Research and Quality
EPCs conduct research on specific clinical care topics and generate reports on the effectiveness of health care methodologies. Health care providers can then use the evidence in developing site-specific guidelines that guide clinical practice.
Private Foundations
AHRQ also actively maintains the National Guideline Clearinghouse (www.guidelines.gov), a website that makes a wide variety of clinical practice guidelines available to health care professionals for consideration in health care decision-making. Another recent addition to AHRQ's initiatives is the Healthcare Innovations Exchange (AHRQ, 2011b), which provides a public source of information about innovations occurring in healthcare delivery.
Nursing Organizations
Submitted innovations are reviewed for the quality of outcomes achieved, providing evidence as a basis for decision-making by others who may be seeking or considering similar innovations. Although most AHRQ activities are intended to support health care professionals and institutions, the agency supports health care recipients by designing information specifically for dissemination to the lay public (AHRQ, 2011a).
COMPONENTS OF THE RESEARCH PROCESS
STUDY DESIGNS
The researcher chooses the method according to the research question and the current level of knowledge about the phenomena and the problem being studied. Qualitative research is a systematic approach used to describe and advance understanding of human health-related experiences.
Quantitative Designs
Qualitative Designs
A meta-analysis synthesizes quantitative data from several similar studies, thereby increasing the strength of the results and allowing for more confident generalizations than a single study. Phenomenology Phenomenology is designed to provide an understanding of the "lived experience" of participants. This method is a valuable approach for studying intangible experiences such as grief, hope, and risk.
Triangulation
Pilot Studies
EVIDENCE-BASED PRACTICE AND RESEARCH UTILIZATION
Advancing Evidence-Based Practice
Individuals with common interests can form collaborative groups that further strengthen the EBP culture by bonding around specific patient problems and discovering evidence-based solutions. Of particular importance to EBP initiatives is the availability of individuals in clinical settings who have the specific responsibility and expertise to understand and translate evidence into practice (Malloch and Porter-O'Grady, 2010).
Nurse Researcher and Evidence-Based Practice Roles
Given the specified role definitions published by the American Association of Colleges of Nursing (AACN), CNLs and DNPs are potential major contributors to the advancement of nursing research and EBP (AACN. Nurses prepared at the DNP level provide leadership for EBP in nursing and translate evidence-based nursing research into their practice.
About the Evidence
Because of their novelty and the sparse literature describing role development outcomes, the concrete research and EBP effect of individuals prepared for these roles remains to be determined. Regardless of official role definition, point-of-care nurses and nursing unit leaders may increasingly be called upon to lead and contribute to collaborative research and EBP initiatives at the health care agency level (Larrabee, 2009a).
Locating Published Research and Evidence Summaries for Evidence-Based Practice
In addition to CNS and CNR, there are emerging role definitions for those of clinical nurse leader (CNL) and doctor of nursing practice (DNP). In 2010, the focus of the Annual Nursing Research Review was nursing workforce issues (Debisette and Vessey, 2010).
Types and Levels of Evidence
These books are an excellent resource for nurses involved in the development and use of research. Nursing Research Nursing Science Quarterly Qualitative Health Research Research in Nursing and Health Western Journal of Nursing Research Worldviews on Evidence-Based Nursing Health.
Critical Appraisal
One of the roles of the evidence user is to be concerned with the strength of the different types of evidence used to make decisions about care and care processes.
Evolution of Evidence-Based Practice
Some Examples
In the case of pressure ulcers, a significant amount of research evidence is available for the implementation of prevention and management strategies. Based on the three examples, it can be seen that research evidence can play a significant role in healthcare practice.
Clinical Practice Guidelines
Thus, research evidence plays a role in supporting or refuting common and logically held notions. Practitioners must carefully access, digest, interpret, and apply research evidence in the unique contexts presented by individual patients and patient populations.
ETHICAL ISSUES RELATED TO RESEARCH Institutional Review
Federally funded studies must meet strict guidelines to ensure the protection of subjects' human rights, such as self-determination, privacy, anonymity and confidentiality, fair treatment, and protection from inconvenience and harm. The IRB is responsible for reviewing study procedures and the informed consent process to ensure subject protection.
Historical Examples of Unethical Research
Brown S: Evidence-Based Nursing: Linking Research to Practice, 2nd Edition, Sudbury, MA, 2012, Jones and Bartlett. LoBiondo-Wood G, Haber J: Nursing research: methods and critical appraisal for evidence-based practice, ed. 7, St.
Paying for Health Care in America
Rising Costs and Challenges
DRG (Diagnosis Related Groups): Refers to the reimbursement of medical services based on a predetermined fixed price per case or diagnosis. Provider: An individual (such as a doctor or nurse) or an organization (such as a hospital) that receives reimbursement for providing health care services.
HISTORY OF HEALTH CARE FINANCING
1965 Medicare and Medicaid programs are created, making comprehensive health care available to millions of Americans. 1977 Health Care Financing Administration (HCFA) is created to administer Medicare and Medicaid separately from the Social Security Administration.
Health Care Financing Revolution
2010 Enactment of the Patient Protection and Affordable Care Act, comprehensive health care reform to provide universal coverage for Americans. Rising healthcare costs are a dangerous trend that poses a significant threat to the US.
The Development of Managed Care
To control rapidly rising health care costs, a health care financing revolution began in 1983, when Medicare moved from a retroactive (fee-for-service) reimbursement to a prospective payment system (PPS) based on diagnosis-related groups (DRGs). . Medicaid • Health care coverage for low-income persons who are elderly, blind, disabled, or for certain families with dependent children.
ACCESS TO HEALTH CARE—THE PROBLEM OF THE UNINSURED
The Patient Protection and Affordable Care Act (PPACA)
112 UNIT 2 Current Issues in Health Care federal government arguing that requiring individuals to purchase health insurance is unconstitutional. The need for health care reform to provide Americans with affordable health care is paramount.
ALLOCATION OF HEALTH CARE RESOURCES
Other groups oppose the law on the grounds that it forces religious employers to cover objectionable birth control treatments. However, the Supreme Court ruled that the majority of the law was constitutional and will be kept intact.
Health Care Resources
Resource Allocation Questions
Economic Approaches to Allocating Health Care
The health insurance company that makes payments for health care is the most common type of third-party payer in the United States. This shows that insurance coverage, or third-party payment, contributes to the confusion of health care markets.
HOW HEALTH CARE IS PAID
Almost all the health resources in the British National Health Service (eg hospitals, clinics, care homes) are owned and run by the government. Another issue affecting health care markets is "third-party payers," which are entities other than the patient who assume responsibility for payment of health care costs.
Private Insurance
Although the US has a regulated healthcare market system, these healthcare markets are not really competitive and are therefore out of sync with the rest of the US. Once the patient visits the health care provider, that provider is likely to be in charge of several subsequent decisions, so the provider becomes an "agent" for the patient.
Public Insurance: Medicare and Medicaid
These plans offer more flexibility and consumer discretion over their health care dollars and provide a tax-free way to save for future health care needs. These programs are likely to change as the PPACA moves forward in the coming years.
Effect of Payment Modes
The goal of the never-happen payment policy is to eliminate payments for certain medical errors and encourage hospitals to direct resources to preventing errors rather than being paid for them. Never Events include hospital-acquired infections, injuries from falls, wrong-site surgeries, and mismatched blood transfusions.
IMPLICATIONS FOR NURSES: MANAGING COST-EFFECTIVE, HIGH-QUALITY CARE
In an effort to save lives and millions of dollars, Medicare adopted a policy effective October 1, 2008, that it will no longer pay hospitals for the additional costs of treating preventable errors. Commonly referred to as never events, Medicare will no longer pay hospitals for the costs of treating medical errors that are largely preventable and have serious consequences for patients.
Nursing Practice and Health Care Finance Decisions
Payment rules are important as a reflection of the value and worth society places on health services for the public. Funding affects employees because health care providers build employment opportunities based on sources of payment.
Efficiency and Effectiveness of Care
As national health care concerns change, funding rules reflect the attitudes of policymakers and hopefully the general public. Nurses must be proactive and position themselves educationally and professionally to meet the economic challenges of healthcare.
Expansion of Technology
Nurses are most successful when they can demonstrate care efficiency with measurable and effective outcomes. The rewards will come to those health care professionals who can manage the costs of illness and teach the value of good health.
Consumer Empowerment
Recognize early warning signs of illness, and get prompt treatment from your healthcare provider. Changes in the focus of the American health care delivery system bring new challenges for professional nurses.
Legal Issues in Nursing and Health Care
Persons and institutions may be required to obtain a license to provide certain health services. Include fundamental laws and regulations that establish the patient's right to autonomy, self-determination and informed decision-making in the healthcare environment.
SOURCES OF LAW AND NURSING PRACTICE
STATUTORY LAW
Federal Statutes
Facilities should inquire if the patient already has an advanced healthcare prescription, and they should note it in the patient's medical record. Legal considerations related to living wills, durable powers of attorney, and DNR orders are discussed in "The Law and Patient Rights," the last section of this chapter.).
State Statutes
They are not familiar with the administrative rules and regulations adopted by the licensing board. Each nurse should own a current copy of the NPA and the licensing board's administrative rules and regulations.
Nurse-Patient Ratios and Mandatory Overtime Statutes
In 2006, another jury awarded $240,000 in punitive damages (out of a total award of $400,000) against a nursing home because understaffing at the facility was considered an aggravating factor in a patient's death (Miller v. Levering Regional Healthcare Center, 2006). The court records contained sufficient evidence that the institution knew it had a chronic understaffing problem and that the problem directly led to the woman's death (Snyder, 2006).
Reporting Statutes
This case provides sobering evidence of the potential retaliatory reactions the nurse may face when reporting incompetent, illegal, or unethical behavior. The nurse may be liable for damages in a civil lawsuit for not filing a report that results in damages to an individual.
Institutional Licensing Laws
In 2004, the Missouri Supreme Court overturned a lower court decision in the case, and the nurse continued to face felony charges. Although this case settled favorably for the nurse, the nurse spent 2 years defending the charges with the help of lawyers.
COMMON LAW
134 UNIT 2 Current Issues in Health Care Efforts should be made by professional nurses to review case law as it is published and discussed in nursing journals. There has also been a proliferation of nursing journals devoted solely to legal issues in nursing practice.
CIVIL LAW
There has been a tendency to incorporate. legal advice” columns in many practice journals, and journals often contain discussions of nursing law practice. More information on finding nursing case law is available online at http://evolve.elsevier.com/Cherry/.).
Negligence and Malpractice
However, even in the case of a physician's negligence—"I knew about the penicillin allergy, but I forgot"—the nurse has a special and independent duty to the patient to prevent harm. When the negligent act clearly lies within the range of a jury's common knowledge and experience, the doctrine of res ipsa loquitur ("the thing speaks for itself") may apply.
Statutes of Limitation in Malpractice Cases
The statute of limitations also changes if a foreign body remains in the patient's body. The statute of limitations in the case of minors is different and can expire only when the child reaches the age of majority (18 or 21) (Westrick and Dempski, 2008).
Nursing Malpractice Insurance
Fear that disclosure will lead to a malpractice suit is a significant barrier to voluntary disclosure, despite research findings to the contrary (Heimchen et al, 2010). If further clarification is required, the nurse refers to the institution's chain of command or unresolved dispute policy.
Liability
Furthermore, nurses in the study's focus groups admitted to routinely and independently disclosing nursing errors that did not involve serious harm, but believed that when system failure or team failure contributed to the error and harm, the physician should act as the team leader in the disclosure discussion.
Personal Liability
The court ordered the jury to weigh the extent to which the nurses' negligence contributed to the unfortunate outcome. Furthermore, as Snyder (2003) reports, hospitals sued nurses to recover financial losses incurred when they were required to pay damages for the alleged negligence of the nurses named in the malpractice suit.
Personal Liability with Floating and Cross-Training
It is also a prudent practice for the nurse to enter a note in the medical record with the name of the resource or support nurse who will be available and responsible to assist in the planning and evaluation of care. Doe, RN, will co-manage patient and assist with procedures, planning and evaluation of care as needed.”
Personal Liability for Team Leaders and Managers
The nurse in charge also refused to call the patient's doctor until the patient experienced cardiopulmonary collapse. Each consultation with the team leader or manager should be carefully documented in the patient's record to demonstrate that an appropriate chain of command process has taken place.
Personal Liability in Delegation and Supervision of Team Members
The nurse manager failed to call the chief of obstetrics when the primary obstetrician did not respond to a non-reassuring fetal heart rate. The primary nurse asked the nurse manager to personally evaluate the electronic fetal heart rate pattern.
Employer Liability
Inspectors found numerous violations by the nurse regarding the delegation and supervision of care by aides. In addition, there was evidence that the nurse had falsified patient records to indicate that nursing assistants were present when in fact they were away from the home.
Corporate Liability
The hospital had a written policy that required a nurse in the cardiac unit to respond to "codes" called in other areas of the hospital. Although the agency is responsible for ensuring that the nurse has the necessary license, education, experience and certifications, the hospital has direct control and monitoring of the nurse's actions.
REDUCING LEGAL LIABILITY Risk Management Systems
A job-based or unit-based handout, if readily available, can be a useful reference for the agency nurse (TJC, 2006). Team members should have an opportunity to evaluate the agency nurse and provide written feedback on performance.
Incident Reports or Unusual Occurrence Reports
The nurse should never note in the patient's medical record that an incident report has been completed and filed. This brings the existence of an incident report to the attention of the plaintiff's attorney.
INTENTIONAL TORTS IN NURSING PRACTICE
Photocopying of an incident report is generally prohibited by agency policy and may be expressly prohibited in writing on the incident report itself. Advanced practice physicians and nurses do not have to write an order to submit an incident report.
Assault and Battery
152 UNIT 2 Current Issues in Health Care In this case, the nurse intends to carry out the offending act, although most nurses do not normally intend to harm the patient. The nurse lied and told her the medication was indeed Demerol, but gave her the fentanyl instead.
Defamation of Character
Such behavior by the nurse could also lead to disciplinary action by the state licensing board; However, this was not addressed by the court.
False Imprisonment
Intentional Infliction of Emotional Distress
153 CHAPTER 8 Legal Issues in Nursing and Health Care. Demerol) or morphine for pain control during a diagnostic procedure. The court allowed the case to proceed, saying there was evidence of "reckless disregard" for the patient's rights.
Invasion of Privacy
The Nurse and Criminal Law
THE LAW AND PATIENT RIGHTS Advance Directives
Living Wills
Health care law experts recommend that individuals interested in appointing a representative seek legal assistance in executing a durable power of attorney for health care. Nurses may be asked questions about living wills and durable power of attorney for health care by patients and their families.
Informed Consent
Written materials, including consent forms and discharge instructions, should be available in the patient's preferred language. The patient's 17-year-old daughter was not deaf and could sign, but was not a trained medical interpreter.
The Right to Refuse Diagnostic Testing, Treatment, and Care
The value of the document in countering a claim of negligence, should the patient or family later file a lawsuit, will largely depend on the quality of the nurse's charting. These accusations generally arise when well-intentioned nurses try to prevent the patient from carrying out his intention.
Use of Physical Restraints
Provides information on health standards, on-call incident alerts, and related health legislation National Council of State Boards of Nursing. Provides information on a wide range of health care legislation and the Medicare program; offers access to other websites within health legislation.
Ethical and Bioethical Issues in Nursing and Health Care
Everywhere in today's health care delivery system there are potential questions of a different nature – “how. This chapter introduces the nursing student to a different aspect of nursing care—the "right" aspect or, as it is better called, the ethical aspect.
NURSING ETHICS
Is the life of this 80-year-old woman less important than that of the 40-year-old father of four who has just been admitted after a tragic car accident. How should I feel when this 80-year-old patient enters a research study designed to test a new drug for pulmonary edema caused by congestive heart failure that has previously only been tested in a younger population.
BIOETHICS
How do I decide when the availability of one-on-one trauma treatment beds is threatened and the decision has to be made to move someone out of a bed to make room for this 80-year-old woman whose condition is rapidly deteriorating. How should I react when one of the few nurses who report to work on a given day refuses to accept patient care due to insufficient staffing.
Dilemmas for Health Professionals
Because of the diverse society in which healthcare is practiced, there are at least two sides to almost every problem. In every aspect of the nursing profession lie the more subtle and complex questions of how to deliver this care and how to decide when choices conflict.
Dilemmas Created by Technology
Many nursing students do not consider nursing and nursing practice from the personal, truthful, honest, faithful (keeping promises to patients), qualitative and subjective aspects; they prefer to look only from a technical, quantitative and objective point of view. Advances in technology have changed the face of health care in many ways, creating troubling questions that have become central to care delivery.
ETHICAL DECISION MAKING
Answering Difficult Questions
But what is the answer when modern medicine can save or prolong the life of an eight-year-old child, but the child's parents refuse treatment based on religious reasons? What is the answer when an Asian family refuses to allow the doctor to share the news of a terminal illness with their grandmother?
Balancing Science and Morality
Or what is the answer when modern medicine has the life to offer a 30-year-old mother who needs a transplanted organ, but the woman is without the financial means to cover the cost of the treatment. What is the answer when new discoveries allow some prospective parents to choose biological characteristics of children not yet conceived.
VALUES FORMATION AND MORAL DEVELOPMENT
What is the answer when the emergency room is full of acutely ill patients and the nurses are expected to be insufficient for the next shift. At one end of the spectrum there is the obvious; the second is often just uncertainty.
Examining Value Systems
There is no conflict when there is a competent nursing staff, sufficient in number to provide quality care. Just as there is an orderly sequence of physical and psychological development, there is an orderly sequence of right and wrong behavioral development.
Learning Right and Wrong
Forming a worldview and value system is an evolving, continuous, dynamic process that moves along a continuum of development known as moral development. With each biological developmental milestone comes a more mature, expanded physical being; in the same way, with every life experience that involves choices between good and evil, there is a more mature, more virtuous person.
Understanding Moral Development Theory
172 UNIT 2 Current Issues in Health Care own value system leads to a clearer lens through which nurses can see ethical questions in the practice of their profession. A refined value system and worldview can serve professionals when dealing with the meaning of life and its many choices.
Moving Toward Moral Maturity
ETHICAL THEORY
Utilitarianism
Deontology
ETHICAL PRINCIPLES
Autonomy
Although the principle of autonomy may seem basic and universal, there are times when this principle may be in conflict.
Beneficence and Nonmaleficence
Veracity
ETHICAL DECISION-MAKING MODEL
Many ethical decision-making models exist with the goal of defining a process by which a nurse or other healthcare provider can actually move through an ethical dilemma toward an informed decision.
Situation Assessment Procedure
Usefulness and Application of the Situation Assessment Procedure
BIOETHICAL DILEMMAS: LIFE, DEATH, AND DILEMMAS IN BETWEEN
Life
Moving beyond the question of when life begins, health care providers must now address their patients' questions about the right or wrong of designing life itself through the manipulation and engineering of DNA or the right and wrong of new parenting models.
Death
Dilemmas in Between
Should people in need of organ transplants be placed on a first-come, first-served list, or should they enter a lottery. What about challenging the nurse's autonomous right to refuse to work in understaffed settings?
ETHICAL CHALLENGES
The Challenge of Veracity
The Challenge of Paternalism
In the best interest of the patient, paternalism involves actions that are not based on the patient's choices, wishes, and desires. A current threat to healthy patient-provider relationships is the rise of entrepreneurship in medicine, with healthcare providers increasingly being called upon to be business managers.
The Challenge of Autonomy
Paternalism interferes with a patient's right to self-determination and occurs when the provider believes that he or she can make a better decision than the patient. The healthy patient-provider relationship is based on the open communication described earlier, where patient choice and respect for individuality are considered as important as scientific knowledge and sound health care advice.
The Challenge of Accountability
In the end, the profession as a whole will suffer and the well-being of society will deteriorate. Box 9-4 presents online resources available for learning more about ethics, bioethics, and the issues nurses are likely to face in their practice.
