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Topics of Professional Nursing II, NRS 438
Dennis Ondrejka, Ph.D., RN, CNS303-577-0387, ext 209Emergencies 303-909-9011 [email protected]
Course Description
Topics explored include the legal aspects of nursing, role of nurse as advocate, US Healthcare System and high quality cost-effective outcomes, models of other health care systems, and the impact of technological developments on nursing practice and role development.
Course Description
Students are encouraged to explore larger global trends in health care and consider disparities from a systems approach. Issues of scope of practice, RBC practice and differentiated practice considerations.
Course AssignmentsApril 10
Text, vii-23, Ch. 1
April 17 Text Ch. 2 Nursing Social Policy p.5-14,
35-46
April 24 today 229-269 Recap Text Ch. 3
May 1 Text Ch. 4 Nursing Scope & Stds of
Practice, ANA p 1-20
May 8 Coile pp. 291-294 and
Goldsmith, pp. 295-308 Mid-term review
May 15 Evidence Based Practice
Day-In class Assignment Mid-term at 10:30
May 22 Text Ch. 5, 6
May 29 Ch. 7, project paper
June 5 Pending
June 12 Pending
June 19 Final is from 9-11
This Class is About Understanding the Difference Between:
1. Nursing Process with assessment, diagnosis, intervention and evaluation
VERSUS
2. Being in connection and knowing that healing or increased disease is an extension of the nurse. YOU, set the stage for healing to begin through RBC. Or YOU set the stage for a less than desired outcome by ignoring RBC.
The nurse as advocate
For care, Presences,Patient, Family.
12 Values Assumptions that guide the process of internal change are
1. The meaning and essences of care is a connection in the moment 2. Feeling connected creates harmony and healing3. Each person on the team plays a part
12 Values Assumptions that guide the process of internal change are (2)
4. Relationship is at the heart of all of this5. Care providers knowledge of self and self-care > quality of care, healthy relationships.6. Healthy relationships among health care member is essential to the quality of care provided to patients.
12 Values Assumptions that guide the process of internal change are
(3)
7. People are most satisfied when in alignment with their personal and professional values8. We must understand and value of Relationship in patient care.9. A therapeutic relationship is essential for quality care10. Patient experiences improve measurably when staff own their own practice
12 Values Assumptions that guide the process of internal change are (4)
11. People willingly change when they are inspired to a shared common vision. When an infrastructure is implemented for it working, when relevant education is provided for personal professional development, and when they see evidence of success (I2E2) 12. Transformational change happens one relationship at a time.
Disconnect Between What Drives a Health Care
Organization and What Matters Most
We want to address patient quality and their perceptions---but we don’t do it very wellWe cannot get out of this chaos unless we truly focus on the patient, but we are system driven
Traditional Drivers of HC
Systems drivenRisk Avoidance drivenHierarchy drivenPower broker drivenPolicy drivenPolitically drivenRe-imbursement drivenCost reduction driven
Disconnect page 2
We understand human behavior as being non-rational most of the time, yet expect to solve these issues with rational interventionsWe realize there is a critical need for the care provider to have a positive relationship to self and we tend to ignore it anyway
Transformational Change
When we speak of “transforming” we are speaking of changing the conditions of what currently exists. Page 6
Formula for Leading ChangeI2E2
I1 is inspiration: They will participate when they believe what they have to offer is valued and they are contributing to a compelling, valuable, life affirming visionI2 is Infrastructure: The infrastructure must support the organizations overall vision (strategic, operational, tactical levels)
Formula for Leading ChangeI2E2
E1 is Education: Priorities are in self-awareness, patient-family experience of care, having healthy relationships, proactive positive com., creative & critical thinking, and leadershipE2 is Evidence: measure results of your actions and support inspiration.
Implementing I2E2 Needs to have the 5 Cs in Place
Clarity Why, benefits, how to, their part, scope or
responsibility and authority frees actions
Competency Know expectations, feel skills, educate
Confidence Empowered to action, self-governance
Collaboration RB work, respect others, know your part
Commitment Ownership, headed for a shared goal
Chapter 1A Caring and Healing
Environment
When crossing the river, remove your sandals. When crossing a boarder, remove your crown. By White Hmong Proverb
I think one’s feelings waste themselves in word; they ought to be distilled in to actions which bring results Florence Nightingale
RBC for the Clinician
Colleagues
Colleagues
Patient & FamilyFirst
Self
“The CORE of the healing Environment is your Relationship to the Patient and Family” p. 29
What Patients Want
Interpersonal skills of staff. They want be a person vs. a diagnosis (Press & Ganey, 1997)To be listened to, treated with respect, cared for gently (Care conf. data)Care providers responding and anticipating patient requests; ability to calm fears, good com., inform them about tests & procedures (Dingman, 1999)RBC is key to quality care (Tresolini, 1994)
The Caring and Healing Environment
Preparation to RBC requires crossing the threshold into the pt’s environmentIt has been called sacred space (Wright and Syre-Adams, 2000)There is a physical element to this space that can be manipulated and promote better healing (room, building, view, sound, colors, traffic flow) (Ulrich, 1984; Bilchik, 2002)At the core of the environment is the intentional caring relationship between health care provider and patient (family).
Development of RBC
It has been developing over 25 yearsWe have researchWe have theoristsWe have it tied to professionalismIt is now found in the science of Quantum Mechanics
Care Theories for This Course
Watson’s Caring-Healing FrameworkSwanson’s Five Caring ProcessesLeininger’s Caring TheoryDingman’s Caring Model
Environment of Care
EC impacts how care is givenEC impacts how care is perceivedResearch on Care Environments Gerteis, 1993 Ulrich, 1994 Bilchick, 2002 Malkin, 1992
Practice Using Care Theories
Watson (1999): the caring moment Interconnectedness Caring and healing are spatially extended Caring and healing are temporally
extended Caring-healing consciousness is dominate
over physical illness & treatment
Practice Using Care Theories
Swanson (1993) Maintaining Belief Knowing Being with Doing for Enabling/Informing
Practice Using Care Theories
Leininger (1994) Care is essential for human growth,
survival & to face death There is no cure without care Expressions of Care vary among cultures Therapeutic nursing care is only
effective if you know the cultural norm for that care
Nursing is a transcultural care profession and discipline
Practice Using Care Theories
Dingman (1999) Introduce yourself and your role Find out what the patient wants to be
called Use touch appropriately Sit at the bedside for 5 minutes each shift
to partner with the patient around their goals for the day. Integrate yours, and set outcomes
Reinforce the mission, vision, and values of your facility and unit when planning care.
Filters We Use to Interpret the Experiences of Others
ONE: Our personal and behavioral background of the care providerTWO: Our own spiritual consciousnessTHREE: Our beliefs about an individuals rights and responsibilities to exercise free will
So How do these filters affect your patient care?
Complementary Therapies
http://www.csh.umn.edu/modules/index.htmlhttp://www.cudfm.org/holistic/National Center for Complementary and Alternative Medicine (NCCAM) http://nccam.nih.gov/http://ods.od.nih.gov/Research/ProductQualityResources.aspx50% of public use it$40 Billion spent on CAM today
CH. 4 Professional Nursing Practiceby Mary Koloroutis
Key Constructs to Professional Nursing The nurse-patient is the cornerstone The two major H.C. drivers can
negatively impact Professional Nursing Financial decisions Technology issues
Magnet Status is positively related to Professional Nursing
Key Constructs to Professional Nursing continued
Aiken Study (1994) > + P. N. Facilitate professional autonomy Nursing control over their practice Positive nurse-physician relations
P.N. numbers/mix impact + patient outcomes by 3-12% (Needleman, 2001) Provides compassionate care to clientsOJT does not normally meet the requirements of a professional occupation.
What is a Profession?
Abraham Flexner (1910) Intellectual vs physical (care plan vs IV) Based on an assessable body of
knowledge Is practical rather than theoretical Can be taught through professional Ed Has a strong internal organization of
members Has practitioners motivated by altruism
Explore the Meaning of a Professional vs. Technical
Practice
Describe the similarities or differences between the chef at the Brown Palace & the cook at the Village Inn?
Chef
Cook
Professional vs. Technicalfor all practice areas
Professional PracticesHave a culture that supports professional activities: frameworks, CE, researchHas a defined body of knowledge gained by formal educationIs a discipline with peer review and a code of ethicsAutonomy in practice with legislative and legal sanctionsIs an organized system of practice-society recognized
Technical PracticesAre more likely to have more OJT than formal education. Are skill focusedHave trade journals or technique trainingsDo not focus on what advances the practiceDevelop through certificationsWant less accountability
Professional vs. TechnicalThinking and Valuing
Professional thinking More is best Specialization in depth
and breadth Evidence-based education Invests energy beyond the
work-associations, research, reading
Expects self accountability Resilient with change and
believes change is valuable
Technical Thinking Least is best Specialization in depth Experience is the
primary educator Conserves energy
beyond the workday Prefers others be
accountable Enjoys consistency and
believes change is disruptive
Professional vs. TechnicalNursing Competencies
Professional Technical
Imagine Nursing as Never Changing-Flat Line
Completely controlled Impact on patient
outcomes Impact on new
nurses Impact on
physicians Impact on quality Impact on staff
What Would it Look Like with Fluctuation and Change?
How is Fluctuation & Change different from Random Chaos?What are the Benefits of Fluctuation and Change?Called Cybernetics II
(as system in constant change—shaping toward improvements)
Imagine Minimal Change
Professionals believe there are: Mind and Body Failures
Limited knowledgeInformation processing barriersEnvironmental barriersMotivational (internal) barriersEmotional barriersPerceptual barriersIntellectual barriersCultural barriers (bias)
KEY RESPONSES ARE:More people need to be
stepping up to critical decisions with
Shared GovernanceWe need practice
theories to keep us on track and tell us when we are lost
We need to practice in an evidence-based care environment
Motivation That Is On Track (C x E) - (T x F) = M
Calmness 1-10 ___Energy 1-10 ___Tension 1-10 ___Fatigue 1-10 ___
Where is your energy going?? Awareness Process Scores from -99 to 99
Perceptual Brain Support
Try to read this. I'm sure you can....very interesting.fi yuo cna raed tihs, yuo hvae a sgtrane mnid tooCna yuo raed tihs? Olny 55 plepoe can.i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at CmabrigdeUinervtisy, it dseno't mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae.
Conceptual Frameworks-Theory Allow You To Organize Your Thinking and Connect it to
PrinciplesIt helps to know what we believe and whyThese are the the building blocks of our knowledge and beliefsThis allows us to move into new territory as if we have a map for the unknown We have less surprises, and then react less stressedIt is an external support for our faulty thinking
Imagine Nursing as Random Practice—Not a Discipline
Inconsistent carePatient confusionEvidence based practices are not encouragedThere is confusion and constant conflictNo accountability
MetaparadigmsBroadest consensus of a disciplineHave general parameters & creates boundariesHave a distinctive domain and cover all of itMost theories include these components Person (humans) Environment (context) Health (ideas of health) Nursing (nursing as a discipline) Caring Quality
Propositions: Linkages & Relationships
Belief regarding person to their own healthBelief regarding person to environmentBelief regarding health to nursing practiceBelief regarding the connection of person, environment, health , and the practice of nursing
Beliefs about caring, quality and practice
The Focus of One’s PracticeImpacts the practice and workplace
Client focusedFamily focusedPerson-environment focusedNursing therapeutic focusedHumanistic focusedSpiritually focusedProcess focused
Models Give you a Picture of How the Parts are Related
A Philosophy Has Your Key Values Presented for Others
Advocacy through Caring
About Quality
Nursing Practice
Patients are the reason we exist and our caring shows that we advocate for them
Quality is the combination of clinical competency and the art of caring
Nursing is at the forefront of our excellence
Other TheoriesImpact the practice and the workplace
Growth and development (Erikson, Piaget)Adult development (Kohlberg, Gilligan, Rest)Aging and death (Kubler-Ross)Chronic Disease (Geriatric Theories)Human Intelligence (Gardner)Psychological development (Psych. Theories)Cause and Effect & Multifactorial (Medicine)Potentiality, Consciousness & Reality (Q.M.)
Definitions of Nursing (ANA)
Provision of a caring relationship that facilitates health and healingAttention to the range of human responses to health and illness, the physical and social environmentsIntegrates objective data and subjective experience.Apply scientific knowledgeAdvance knowledge through scholarly inquiryInfluence social and public policy for social justice
Definition of Nursing (ANA)
“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.”
The Scope of Nursing Practice
Dependent on their educational preparationTheir experienceTheir roleAnd the nature of the patient populationPractice within recognized standards of professional nursing practice (varies with education, experience
Three Realms of Practice
Delegated RNs carry out medical plans of action RN is responsible to confirm safety, and
appropriateness of the order
Independent Focus is on the patients response to actual
or potential health problems
Interdependent Interdisciplinary care, planning, and services
Entry & Levels of Nursing Today
Certified Nursing Assist.Licensed Practical Nurse
PN, LPN, LVN
Professional Entry AD, BSN, (Dip), ND
Advanced Practice Nurses
NP, CNS, ND
Terminal Degrees Ed.D., Ph.D., DNSc, DNP,
DScN,
Creating Boundaries for Practical Nursing:
What is in the Domain of
NOT Practical Nursing
Practical Nursing
Quiz # 1 Name: Date
Beyond LPN
List four things that are in the domain of practical nursing &four things that are beyond the scope of practical nursing
Within LPN
Creating Boundaries for Nursing:What is the Discipline?
What is in the domain
And what is not
NOT NURSINGNURSING
Evaluating the boundaries of Nursing
1. Distinctions between human and non-human (not nursing), 2. Distinctions between living and nonliving (not nursing),3. Nature of environments and human-environmental interactions from cellular to societal levels,4. Illness versus health and well-being5. What you do to or for your clients
Academic Training for RNsAll NursingAssessmentDiagnosisOutcomes IdentifiedPlanningImplementation
Coordination of Care Health teaching,
Promotion Consultation Prescriptive Authority
Evaluation
Professional NursingQuality of PracticeEducationProfessional Prac. Eval.Collegiality /CollaborationEthicsResearchResource UtilizationLeadership
Roles of Professional Nursing
Have a “Voice of Agency”1. Sentry (Watch over, protect others)2. Healer (Care for another’s body, mind, spirit)3. Guide (Leads another through unfamiliar territory)4. Teacher (Imparts knowledge)5. Collaborator (Works with others)6. Leader (Has authority to act on behalf of others)
Essential Functions of Nursing Practice
Assessment of needs through data collection, clinical assessment, plan, implement, & evaluateManage and deliver the care required for the patient’s condition and individual human responseCommunication and coordinate care with others who are interacting with the patientCoordinate the patient transfer or discharge
Benner’s “Novice to Expert” (1984)
NoviceAdvanced BeginnerCompetentProficientExpert
“Quotes” form Ch. 4
There must be a relationship with the patient to know their strengths, weaknesses, hopes and fears… our challenge is to balance tasks with relationship. (Manthey)Within the dominant, modern, Western mindset, the caring-healing practices of nursing have been on the margins—have been repressed and silenced. (Watson)