Nursing Chapter 1: Nursing Today

Nursing as a Profession

• To act professionally, a nurse must use critical thinking skills, administer quality patient-centered care, and be responsible and accountable.
• Nursing requires current knowledge and practice standards, an insightful and compassionate approach, and critical thinking and clinical judgment.

Benner's Model of Nursing Practice

• Benner's model describes the stages of nursing development, from novice to expert.
• The five stages are:
• Novice: Beginner nurse student with no nursing experience.
• Advanced Beginner: Some level of experience, maybe only observational.
• Competent: A nurse who has been in the same clinical position for 2-3 years.
• Proficient: A nurse with more than 2-3 years of experience.
• Expert: A nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem.

American Nurses Association (ANA)

• The ANA is the professional organization for nurses in the United States.
• The ANA publishes standards of practice and performance for nursing, including:
• Standards of Professional Nursing Practice.
• Standards of Professional Performance.
• Code of Ethics.

Nursing Process

• Also known as the "Nursing Process," a model for clinical decision making.
• The six stages of the nursing process are:
  1. Assessment.
  2. Diagnosis.
  3. Outcomes Identification.
  4. Planning.
  5. Implementation.
  6. Evaluation.

Professional Responsibilities and Roles

• Autonomy and accountability.
• Caregiver.
• Advocate.
• Educator.
• Communicator.
• Manager.

Historical Influences

• Florence Nightingale:
• Established the first nursing philosophy (Nursing Theory) based on health maintenance and restoration.
• Organized the first program for training nurses.
• First practicing epidemiologist.
• Improved sanitation in battlefield hospitals.
• Practices remain a basic part of nursing today.
• Other historical figures, such as Clara Barton, Dorothea Dix, and Mary Mahoney, contributed to the development of nursing.

Contemporary Influences

• Quality and Safety Education for Nurses (QSEN):
• Patient-centered care.
• Teamwork and collaboration.
• Evidence-based practice.
• Quality improvement.
• Safety.
• Informatics.

Professional Registered Nurse Education

• Prelicensure education:
• 2-year associate's degree.
• 4-year bachelor's degree.
• Graduate education:
• Master's degree, advanced practice RN.
• Doctoral preparation.
• Continuing and in-service education.

Nursing Practice

• Nurse Practice Acts (NPAs):
• Regulate the scope of nursing practice.
• Protect public health, safety, and welfare.
• Licensure and certification.
• Requirements vary by state.

Health Care Delivery System

• Four challenges facing nursing:
• Aging baby boomer generation.
• Shortage and uneven distribution of physicians.
• Rate of nurses' retirements.
• Uncertainty of health care reform.
• Traditional levels of health care:
• Preventative.
• Primary.
• Secondary.
• Tertiary.
• Restorative.
• Continuing health care.
• Integrated health care delivery:
• Primary and preventive health care services.
• Secondary and tertiary care.
• Restorative care.
• Continuing care.

Health and Wellness

• Healthy People 2030:
• Provides evidence-based, 10-year national objectives for promoting health and preventing disease.
• Identifies leading health indicators which are high-priority health issues in the United States.
• Definition of Health:
• A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.
• A state of being that people define in relation to their own values, personality, and lifestyle.
• Models of Health and Illness:
• Health Belief Model.
• Health Promotion Model.
• Maslow's Hierarchy of Needs.
• Holistic Health Model.
• Variables Influencing Health and Health Beliefs and Practices:
• Internal variables.
• External variables.

Illness

• Definition of Illness:
• A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired.
• Acute illness.
• Chronic illness.
• Illness Behavior:
• Involves how people monitor their bodies and define and interpret their symptoms.
• Variables influencing illness and illness behavior.
• Impact of Illness on the Patient and Family:
• Behavioral and emotional changes.
• Impact on body image.
• Impact on self-concept.
• Impact on family roles.
• Impact on family dynamics.

Caring for Yourself

• Eat a nutritious diet.
• Get adequate sleep.
• Engage in exercise and relaxation activities.
• Establish a good work-family balance.
• Engage in regular nonwork activities.
• Develop coping skills.
• Allowing personal time for grieving.
• Focus on spiritual health.
• Find a mentor.

Legal Implications in Nursing Practice

• Legal Limits of Nursing:
• Sources of law.
• Scope and standards of nursing.
• Standards of nursing care.
• Federal Statutes Affecting Nursing Practice:
• Patient Protection and Affordable Care Act (PPACA).
• Emergency Medical Treatment and Active Labor Act.
• Health Insurance Portability and Accountability Act (HIPAA).
• Health Information Technology Act.
• Americans with Disabilities Act (ADA).
• Mental Health Parity and Addiction Equity Act.
• Patient Self-Determination Act.
• Uniform Anatomical Gift Act.
• The Omnibus Budget Reconciliation Act (1986).
• State Statutes Affecting Nursing Practice:
• Nurse practice acts.
• Health care acts and informed consent.
• Good Samaritan laws.
• Public health laws.
• Termination of pregnancy.
• Physician-assisted suicide.
• The Uniform Determination of Death Act.
• Nursing Workforce Guidelines:
• Staffing and nurse-to-patient ratios.
• Nursing assignments.
• Patient abandonment.
• Nurse delegation.
• Nursing students.
• Legal Implications and Reducing Your Legal Risks:
• Torts.
• Negligence.
• Malpractice.
• Malpractice insurance.
• Nurse experts.
• Reducing legal risks.
• Risk management and performance/quality improvement.
• Professional involvement.### The Need for Evidence-Based Practice
• Evidence-based practice (EBP) is a problem-solving approach to clinical practice that combines the best evidence with a clinician's expertise, patient preferences and values, and healthcare resources in making decisions about patient care.
• The best scientific evidence comes from well-designed, systematically conducted research studies found in scientific, peer-reviewed journals.
• Steps of evidence-based practice:
  • Cultivate a spirit of inquiry
  • Ask a clinical question in PICOT format
  • Search for the best evidence
  • Critically appraise the evidence
  • Integrate the evidence
  • Evaluate the outcomes of practice decision or changes
  • Communicate the outcomes of the evidence-based practice decision
• Cultivating a spirit of inquiry involves constantly questioning current practices, leading to consistent use of EBP.
• Asking a clinical question in PICOT format involves identifying the patient population, intervention, comparison, outcome, and time.
• Searching for the best evidence involves using sources such as agency policy, procedure manuals, quality improvement data, existing clinical practice guidelines, and journal articles.
• Critically appraising the evidence involves synthesizing or combining the findings, considering the scientific rigor of the evidence, and determining the value, feasibility, and usefulness of the evidence.
• Integrating the evidence involves applying the research in a patient's plan of care, using evidence as rationale, and incorporating the change into policies and procedures.
• Evaluating the outcomes of practice decision or change involves determining whether the change was effective, if modifications are needed, and if the change should be discontinued.

Scientific Method

• The scientific method involves:
  • Making an observation
  • Asking questions and gathering information
  • Analyzing the literature and forming a research question or hypothesis
  • Conducting a study using scientific rigor
  • Analyzing the data and drawing conclusions
• Types of research studies:
  • Quantitative research: Experimental research, nonexperimental research, surveys
  • Qualitative research: Inductive reasoning

Nursing Research

• Nursing research is a way to identify new knowledge, improve professional education and practice, and use resources effectively.
• Many professional and specialty nursing organizations support the conduct of research for advancing nursing science.
• Translation research phases:
  • Preclinical and animal studies: Basic science research
  • Phase 1 clinical trials: Testing safety and efficacy in a small group of human subjects
  • Phase 2 and 3 clinical trials: Testing safety and efficacy in a larger group of human subjects and testing for comparison to standard treatment
  • Phase 4 clinical trials and outcomes research: Translation to practice
  • Phase 5 population-level outcomes research: Translation to community
• Outcomes research helps patients, healthcare providers, and those in healthcare policy make informed decisions on the basis of current evidence.
• The conduct of nursing research involves studying nursing questions and problems in greater depth within the context of nursing.

Performance Improvement

• Performance improvement (PI) is a formal approach for the analysis of healthcare-related processes.
• PI reviews how existing interventions within a process function.
• PI combined with EBP is the foundation for excellent patient care and outcomes.
• Performance improvement programs focus on processes or systems that significantly contribute to outcomes.

The Relationship Among EBP, Research, and PI

• Although EBP, research, and PI are closely related, they are separate processes.
• EBP uses information from research and other sources to determine safe and effective nursing care with the goal of improving patient care and outcomes.
• Research involves systematic inquiry that answers questions, solves problems, and contributes to the generalizable knowledge base of nursing.
• QI improves local work processes to improve patient outcomes and health system efficiency; results are usually not generalizable.

Caring in Nursing Practice

• AONE Guiding Principles for Future Care Delivery
• Theoretical views on caring:
  • Leininger's Transcultural Caring
  • Watson's Transpersonal Caring
  • Swanson's Theory of Caring
• Common themes among nursing caring theories:
  • Caring is highly relational
  • Caring is obvious when it is absent
  • Enabling is an aspect of caring
  • Knowing the context of a patient's illness helps choose and individualize interventions that will actually help the patient### Patient's Perspective of Caring
• Patients value the affective dimension of nursing care
• Caring Assessment Tool measures patients' perceptions of caring
• Patients become active partners in the plan of care when they sense healthcare providers are sensitive, sympathetic, compassionate, and interested in them as people

Ethic of Care

• Caring is an interaction of mutual respect and trust
• An ethic of care is concerned with relationships between people and a nurse's character and attitude toward others

Caring in Nursing Practice

• Caring is one of the human behaviors that can be given and received
• Recognize the importance of self-care and use caring behaviors to reach out to colleagues and care for them as well

Providing Presence

• Providing presence is a person-to-person encounter conveying a closeness and sense of caring
• Presence involves "being there" and "being with"
• Nursing presence is the connectedness between a nurse and a patient
• Establishing presence strengthens the ability to provide effective patient-centered care

Touch

• Provides comfort and creates a connection
• Types of touch: noncontact, contact, task-oriented, caring, and protective touch
• Use touch with discretion as it conveys many messages

Listening

• Necessary for meaningful interactions with patients
• True listening leads to knowing and responding to what really matters to a patient and family
• Listen effectively by silencing yourself and listening with an open mind
• Through active listening, truly know your patients and what is important to them

Knowing the Patient

• The core of clinical decision making and patient-centered care
• Two elements that facilitate knowing are continuity of care and clinical expertise
• Factors of knowing include time, continuity of care, teamwork of the nursing staff, trust, and experience

Spiritual Caring

• Spiritual health is achieved when a person can find a balance between life values, goals, and belief symptoms and those of others
• Spirituality offers a sense of intrapersonal, interpersonal, and transpersonal connectedness

Relieving Symptoms and Suffering

• Reducing symptoms and suffering requires caring nursing actions that give a patient comfort, dignity, respect, and peace
• Convey a quiet, caring presence, touch, or listen to assess and understand the meaning of a patient's discomfort

Family Care

• Caring for an individual includes their family
• Help family caregivers be active participants
• Understand the stress a patient's illness places on family members

The Challenge of Caring

• Challenges: task-oriented biomedical model, institutional demands, time constraints, reliance on technology, cost-effective strategies, and standardized work processes
• Health care must become more compassionate to make a positive difference

Scientific Knowledge Base

• Environmental safety: basic human needs, common environmental hazards, transmission of pathogens
• Factors influencing patient safety: developmental stages and risks, individual risk factors, and risks in health care agencies

Nursing Knowledge Base

• Factors influencing patient safety: developmental stages and risks, individual risk factors, and risks in health care agencies
• Risks in health care agencies: procedure-related accidents, equipment-related accidents, chemical exposure, falls, and workplace safety

Nursing Process

• Assessment: through the patient's eyes, nursing history and examination, psychosocial and cultural background, health care environment, and patient's home environment
• Analysis and nursing diagnosis: examples, risk for injury, impaired cognition, lack of knowledge, and risk for poisoning
• Planning and outcomes identification: patient participation, setting priorities, selecting priorities based on risk and patient characteristics, teamwork, and communication
• Implementation: health promotion, developmental interventions, environmental interventions, acute and restorative care
• Evaluation: through the patient's eyes, are the patient's expectations met?, patient outcomes, monitoring care by the health care team, and continually assessing needs for additional support

Nursing as a Profession

• To act professionally, a nurse must use critical thinking skills, administer quality patient-centered care, and be responsible and accountable.
• Nursing requires current knowledge and practice standards, an insightful and compassionate approach, and critical thinking and clinical judgment.

Benner's Model of Nursing Practice

• Benner's model describes the stages of nursing development, from novice to expert.
• The five stages are:
• Novice: Beginner nurse student with no nursing experience.
• Advanced Beginner: Some level of experience, maybe only observational.
• Competent: A nurse who has been in the same clinical position for 2-3 years.
• Proficient: A nurse with more than 2-3 years of experience.
• Expert: A nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem.

American Nurses Association (ANA)

• The ANA is the professional organization for nurses in the United States.
• The ANA publishes standards of practice and performance for nursing, including:
• Standards of Professional Nursing Practice.
• Standards of Professional Performance.
• Code of Ethics.

Nursing Process

• Also known as the "Nursing Process," a model for clinical decision making.
• The six stages of the nursing process are:
  1. Assessment.
  2. Diagnosis.
  3. Outcomes Identification.
  4. Planning.
  5. Implementation.
  6. Evaluation.

Professional Responsibilities and Roles

• Autonomy and accountability.
• Caregiver.
• Advocate.
• Educator.
• Communicator.
• Manager.

Historical Influences

• Florence Nightingale:
• Established the first nursing philosophy (Nursing Theory) based on health maintenance and restoration.
• Organized the first program for training nurses.
• First practicing epidemiologist.
• Improved sanitation in battlefield hospitals.
• Practices remain a basic part of nursing today.
• Other historical figures, such as Clara Barton, Dorothea Dix, and Mary Mahoney, contributed to the development of nursing.

Contemporary Influences

• Quality and Safety Education for Nurses (QSEN):
• Patient-centered care.
• Teamwork and collaboration.
• Evidence-based practice.
• Quality improvement.
• Safety.
• Informatics.

Professional Registered Nurse Education

• Prelicensure education:
• 2-year associate's degree.
• 4-year bachelor's degree.
• Graduate education:
• Master's degree, advanced practice RN.
• Doctoral preparation.
• Continuing and in-service education.

Nursing Practice

• Nurse Practice Acts (NPAs):
• Regulate the scope of nursing practice.
• Protect public health, safety, and welfare.
• Licensure and certification.
• Requirements vary by state.

Health Care Delivery System

• Four challenges facing nursing:
• Aging baby boomer generation.
• Shortage and uneven distribution of physicians.
• Rate of nurses' retirements.
• Uncertainty of health care reform.
• Traditional levels of health care:
• Preventative.
• Primary.
• Secondary.
• Tertiary.
• Restorative.
• Continuing health care.
• Integrated health care delivery:
• Primary and preventive health care services.
• Secondary and tertiary care.
• Restorative care.
• Continuing care.

Health and Wellness

• Healthy People 2030:
• Provides evidence-based, 10-year national objectives for promoting health and preventing disease.
• Identifies leading health indicators which are high-priority health issues in the United States.
• Definition of Health:
• A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.
• A state of being that people define in relation to their own values, personality, and lifestyle.
• Models of Health and Illness:
• Health Belief Model.
• Health Promotion Model.
• Maslow's Hierarchy of Needs.
• Holistic Health Model.
• Variables Influencing Health and Health Beliefs and Practices:
• Internal variables.
• External variables.

Illness

• Definition of Illness:
• A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired.
• Acute illness.
• Chronic illness.
• Illness Behavior:
• Involves how people monitor their bodies and define and interpret their symptoms.
• Variables influencing illness and illness behavior.
• Impact of Illness on the Patient and Family:
• Behavioral and emotional changes.
• Impact on body image.
• Impact on self-concept.
• Impact on family roles.
• Impact on family dynamics.

Caring for Yourself

• Eat a nutritious diet.
• Get adequate sleep.
• Engage in exercise and relaxation activities.
• Establish a good work-family balance.
• Engage in regular nonwork activities.
• Develop coping skills.
• Allowing personal time for grieving.
• Focus on spiritual health.
• Find a mentor.

Legal Implications in Nursing Practice

• Legal Limits of Nursing:
• Sources of law.
• Scope and standards of nursing.
• Standards of nursing care.
• Federal Statutes Affecting Nursing Practice:
• Patient Protection and Affordable Care Act (PPACA).
• Emergency Medical Treatment and Active Labor Act.
• Health Insurance Portability and Accountability Act (HIPAA).
• Health Information Technology Act.
• Americans with Disabilities Act (ADA).
• Mental Health Parity and Addiction Equity Act.
• Patient Self-Determination Act.
• Uniform Anatomical Gift Act.
• The Omnibus Budget Reconciliation Act (1986).
• State Statutes Affecting Nursing Practice:
• Nurse practice acts.
• Health care acts and informed consent.
• Good Samaritan laws.
• Public health laws.
• Termination of pregnancy.
• Physician-assisted suicide.
• The Uniform Determination of Death Act.
• Nursing Workforce Guidelines:
• Staffing and nurse-to-patient ratios.
• Nursing assignments.
• Patient abandonment.
• Nurse delegation.
• Nursing students.
• Legal Implications and Reducing Your Legal Risks:
• Torts.
• Negligence.
• Malpractice.
• Malpractice insurance.
• Nurse experts.
• Reducing legal risks.
• Risk management and performance/quality improvement.
• Professional involvement.### The Need for Evidence-Based Practice
• Evidence-based practice (EBP) is a problem-solving approach to clinical practice that combines the best evidence with a clinician's expertise, patient preferences and values, and healthcare resources in making decisions about patient care.
• The best scientific evidence comes from well-designed, systematically conducted research studies found in scientific, peer-reviewed journals.
• Steps of evidence-based practice:
  • Cultivate a spirit of inquiry
  • Ask a clinical question in PICOT format
  • Search for the best evidence
  • Critically appraise the evidence
  • Integrate the evidence
  • Evaluate the outcomes of practice decision or changes
  • Communicate the outcomes of the evidence-based practice decision
• Cultivating a spirit of inquiry involves constantly questioning current practices, leading to consistent use of EBP.
• Asking a clinical question in PICOT format involves identifying the patient population, intervention, comparison, outcome, and time.
• Searching for the best evidence involves using sources such as agency policy, procedure manuals, quality improvement data, existing clinical practice guidelines, and journal articles.
• Critically appraising the evidence involves synthesizing or combining the findings, considering the scientific rigor of the evidence, and determining the value, feasibility, and usefulness of the evidence.
• Integrating the evidence involves applying the research in a patient's plan of care, using evidence as rationale, and incorporating the change into policies and procedures.
• Evaluating the outcomes of practice decision or change involves determining whether the change was effective, if modifications are needed, and if the change should be discontinued.

Scientific Method

• The scientific method involves:
  • Making an observation
  • Asking questions and gathering information
  • Analyzing the literature and forming a research question or hypothesis
  • Conducting a study using scientific rigor
  • Analyzing the data and drawing conclusions
• Types of research studies:
  • Quantitative research: Experimental research, nonexperimental research, surveys
  • Qualitative research: Inductive reasoning

Nursing Research

• Nursing research is a way to identify new knowledge, improve professional education and practice, and use resources effectively.
• Many professional and specialty nursing organizations support the conduct of research for advancing nursing science.
• Translation research phases:
  • Preclinical and animal studies: Basic science research
  • Phase 1 clinical trials: Testing safety and efficacy in a small group of human subjects
  • Phase 2 and 3 clinical trials: Testing safety and efficacy in a larger group of human subjects and testing for comparison to standard treatment
  • Phase 4 clinical trials and outcomes research: Translation to practice
  • Phase 5 population-level outcomes research: Translation to community
• Outcomes research helps patients, healthcare providers, and those in healthcare policy make informed decisions on the basis of current evidence.
• The conduct of nursing research involves studying nursing questions and problems in greater depth within the context of nursing.

Performance Improvement

• Performance improvement (PI) is a formal approach for the analysis of healthcare-related processes.
• PI reviews how existing interventions within a process function.
• PI combined with EBP is the foundation for excellent patient care and outcomes.
• Performance improvement programs focus on processes or systems that significantly contribute to outcomes.

The Relationship Among EBP, Research, and PI

• Although EBP, research, and PI are closely related, they are separate processes.
• EBP uses information from research and other sources to determine safe and effective nursing care with the goal of improving patient care and outcomes.
• Research involves systematic inquiry that answers questions, solves problems, and contributes to the generalizable knowledge base of nursing.
• QI improves local work processes to improve patient outcomes and health system efficiency; results are usually not generalizable.

Caring in Nursing Practice

• AONE Guiding Principles for Future Care Delivery
• Theoretical views on caring:
  • Leininger's Transcultural Caring
  • Watson's Transpersonal Caring
  • Swanson's Theory of Caring
• Common themes among nursing caring theories:
  • Caring is highly relational
  • Caring is obvious when it is absent
  • Enabling is an aspect of caring
  • Knowing the context of a patient's illness helps choose and individualize interventions that will actually help the patient### Patient's Perspective of Caring
• Patients value the affective dimension of nursing care
• Caring Assessment Tool measures patients' perceptions of caring
• Patients become active partners in the plan of care when they sense healthcare providers are sensitive, sympathetic, compassionate, and interested in them as people

Ethic of Care

• Caring is an interaction of mutual respect and trust
• An ethic of care is concerned with relationships between people and a nurse's character and attitude toward others

Caring in Nursing Practice

• Caring is one of the human behaviors that can be given and received
• Recognize the importance of self-care and use caring behaviors to reach out to colleagues and care for them as well

Providing Presence

• Providing presence is a person-to-person encounter conveying a closeness and sense of caring
• Presence involves "being there" and "being with"
• Nursing presence is the connectedness between a nurse and a patient
• Establishing presence strengthens the ability to provide effective patient-centered care

Touch

• Provides comfort and creates a connection
• Types of touch: noncontact, contact, task-oriented, caring, and protective touch
• Use touch with discretion as it conveys many messages

Listening

• Necessary for meaningful interactions with patients
• True listening leads to knowing and responding to what really matters to a patient and family
• Listen effectively by silencing yourself and listening with an open mind
• Through active listening, truly know your patients and what is important to them

Knowing the Patient

• The core of clinical decision making and patient-centered care
• Two elements that facilitate knowing are continuity of care and clinical expertise
• Factors of knowing include time, continuity of care, teamwork of the nursing staff, trust, and experience

Spiritual Caring

• Spiritual health is achieved when a person can find a balance between life values, goals, and belief symptoms and those of others
• Spirituality offers a sense of intrapersonal, interpersonal, and transpersonal connectedness

Relieving Symptoms and Suffering

• Reducing symptoms and suffering requires caring nursing actions that give a patient comfort, dignity, respect, and peace
• Convey a quiet, caring presence, touch, or listen to assess and understand the meaning of a patient's discomfort

Family Care

• Caring for an individual includes their family
• Help family caregivers be active participants
• Understand the stress a patient's illness places on family members

The Challenge of Caring

• Challenges: task-oriented biomedical model, institutional demands, time constraints, reliance on technology, cost-effective strategies, and standardized work processes
• Health care must become more compassionate to make a positive difference

Scientific Knowledge Base

• Environmental safety: basic human needs, common environmental hazards, transmission of pathogens
• Factors influencing patient safety: developmental stages and risks, individual risk factors, and risks in health care agencies

Nursing Knowledge Base

• Factors influencing patient safety: developmental stages and risks, individual risk factors, and risks in health care agencies
• Risks in health care agencies: procedure-related accidents, equipment-related accidents, chemical exposure, falls, and workplace safety

Nursing Process

• Assessment: through the patient's eyes, nursing history and examination, psychosocial and cultural background, health care environment, and patient's home environment
• Analysis and nursing diagnosis: examples, risk for injury, impaired cognition, lack of knowledge, and risk for poisoning
• Planning and outcomes identification: patient participation, setting priorities, selecting priorities based on risk and patient characteristics, teamwork, and communication
• Implementation: health promotion, developmental interventions, environmental interventions, acute and restorative care
• Evaluation: through the patient's eyes, are the patient's expectations met?, patient outcomes, monitoring care by the health care team, and continually assessing needs for additional support