Topics of Professional Nursing II, NRS 438

Dennis Ondrejka, Ph.D., RN, CNS303-577-0387, ext 209Emergencies 303-909-9011 celld.ondrejka@denverschoolofnursing.org

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)