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Definition of Patient-Centered Care

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care that is respectful of and responsive to individual patient preferences, needs, and values and [ensures] that patient values guide all clinical decisions

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Includes six domains of quality

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SAFETY TIMELINESS EFFECTIVENESS EFFICIENCY EQUITY PATIENT-CENTEREDNESS

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Visions of the Ideal Clinican-Patient Relationship

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In the last 30 years a push to improve quality of patient care. Will require a radical change in the design of the delivery system.

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In 1998 Salzburg Seminar proposed Utopian vision

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Patient a full partner in informed decision-making with the guiding principle of "nothing about me without me" Use of computer-based: Electronic record that patient has full access to E-mail guidance for patient education and monitoring of disease management If no computer, use of small audio/video recorders and phone follow up Patient to complete survey "grading" quality of encounter to guide improved care Patient/Clinician yearly contract to attain specific health goals. Lay persons teach patient perspective in health profession schools. Lay persons on committees to monitor quality standards.

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Patient Involvement

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Their day to day activities, they are the best source of info about their body, co-producer/partner with providers, patient/evaluator in measuring performance of healthcare, INVOLVED PATIENTS HAVE BETTER OUTCOMES

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Defining nursing is an important first step toward professional practice

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Provides framework for nursing practice Establishes the boundaries (parameters) of profession Clarifies the purpose and functions of nurses' work Differentiates nursing from other professions

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Definitions of nursing influence health policy at local, state, and national level

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Definitions of nursing roles are required by nurse practice acts. Definitions aid in developing educational curricula and research agendas.

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Florence Nightingale's definition of nursing

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Contains many concepts that remain contemporary Includes importance of *observational skills*, unique body of knowledge, understanding that patient must be put in best condition possible that nature allows Includes concepts about impact of *patients' immediate environment, nutrition, hygiene, comfort*

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Virginia Henderson's definition of nursing

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Represented emergence of *contemporary nursing*: Service to individual that helps to attain or maintain a healthy state of mind/body

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Post WWII definitions of nursing

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WWII helped *advance technologies* available for nursing, influencing nursing and requiring changed definitions

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Hildegard Peplau's definition of nursing

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Defined nursing in interpersonal terms, reinforcing the idea of the *patient as an active collaborator in his/her care*

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Dorothea Orem's definition of nursing

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Orem's definition hinges on the belief that nurses should do for a person only those things the person cannot do without assistance, emphasizing *patient's active role.*

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The International Council of Nurses (ICN) adopted Henderson's definition

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Assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge

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American Nurses Association (ANA)

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Six Defining Principles: Protection, promotion, optimization of health Prevention of illness Alleviate suffering Advocacy for patient rights

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Royal College of Nursing

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RCN is the United Kingdom's voice of nursing and the largest professional union of nurses in the world Their definition has a core statement supported by six defining characteristics

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International Council of Nurses (ICN)

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ICN is a federation of nurses representing more than 13 million nurses in more than 130 countries Their definition is quite similar to ANA and RCN

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Definition by State Legislatures

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A critical definition of nursing for each nurse is contained in nurse practice act of state in which nurse practices Constitutes the legal definition of nursing in a particular state

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The overarching goal of nursing education is:

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To teach you to think like a nurse To see the world of health care through the lens of nursing To respond to the effects of both educational and clinical experiences by developing professionalism

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Professional socialization

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Nursing requires students to internalize new knowledge, skills, attitudes, behaviors, values, and ethical standards into their own professional identities Professional nursing socialization can be defined as absorbing and assimilating the culture of nursing: its rites, rituals, and valued behaviors

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Formal socialization includes

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Classroom lectures Assignments Laboratory experiences New vocabulary

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Informal socialization lessons that occur incidentally

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This includes unplanned observations, participating in a student nurse association, and hearing nurses discuss patient care Informal experiences are often the most powerful

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Factors influencing socialization

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Adjusting to new roles/expectations Adjusting to new values Learning to cope with negative health behavior of patients Becoming aware of your biases Developing a common nursing consciousness

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Benner's Stages of Nursing Proficiency (Basic Student Socialization)

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Five stages of nursing practice Stage 1: Novice Stage 2: Advanced beginner period Stage 3: Competent practitioner Stage 4: Proficient practitioner Stage 5: Expert practitioner

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Socialization requires active strategies to reduce stress of new learning experiences

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Actively involving yourself in the learning process Keeping your perspective Setting aside preconceived ideas, prejudices, and habits Opening up your creative side, your abstract thinking, and your willingness to engage in hypothetical thinking Being receptive to feedback Developing time management skills Getting a mentor for emotional support Using faculty members as important resources

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Socialization to the Work Setting

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Realizing that ideals taught in school are not always possible to achieve in everyday practice Recognizing that the speed of functioning increases in a work setting, compared to a nursing school setting The need to collaborate with many types of nursing personnel Fatigue and mental and emotional stress Lack of role clarity Integration into a peer group Uncertainty about policies and procedures Sensory overload Developing and contributing to a culture of civility

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"Reality shock"

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Nursing shortages Difficult working conditions Nursing staff retention Older, more chronically ill patients Absence of positive reinforcement Lack of frequent communication

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New nurses "drop out"

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Disengaging mentally and emotionally Driving oneself and others to the breaking point "Job hopping" Prematurely returning to school Burning out Leaving the nursing profession entirely

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Characteristics all professions have in common

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Intellectual as opposed to physical with high degree of responsibility Based on a body of knowledge that is refined with research Is practical in addition to being theoretical Taught through process of highly specialized professional education Has a strong internal organization of members and well developed group consciousness Has practitioners who are motivated by altruism and responsive to public interests

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Kelly's Eight Characteristics of a Profession

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Vital to humanity and welfare of society Special body of knowledge enlarges over time Services involve intellectual activities Education in institutions of higher learning Practitioners relatively independent Motivated by service and importance of work Code of ethics to guide practice Organization supports high practice standards

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Barriers to Professionalism in Nursing

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Varying levels of preparatory education Gender Issues of female-dominated professions Historical influences of religious orders and the military Altruism can devalue autonomy and fair economic valuation External Conflicts-turf battles with other health care professional Internal Conflicts- dissension among subgroups dilute collective power and autonomy

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Florence Nightingale

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In 1854, during the Crimean War, she and a team of nurses improved the unsanitary conditions at a British base hospital called Scutari in Constantinople but the death rate remained very high due to cholera and typhoid. In 1860 she established St. Thomas' Hospital and the Nightingale Training School for Nurses.

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Dorothea Dix

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1844 - Dorothea Dix testifies to the New Jersey legislature regarding the state's poor treatment of patients with mental illness During the Civil War, she served as Superintendent of Army Nurses.

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Clara Barton

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Clara Barton becomes the first President of the American Red Cross, which she founded.

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First three nursing schools founded in 1873

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First nursing school in United States, based on Florence Nightingale's principles of nursing, opens at Bellevue Hospital, New York City. Connecticut Training School for Nurses in New Haven Boston Training School for Nurses at Massachusetts General Hospital in Boston

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Feminization of Nursing

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Requirements for early nursing school applicants were based on Victorian stereotypes of female qualities. "Good breeding" and "ladylike behavior" Submission to authority Sensitivity Intelligence

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Mary Eliza Mahoney

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First African American to study and work as a professionally trained nurse in the United States, graduating in 1879

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Isabel Hampton Robb

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Helped in founding The American Society of Superintendents of Training Schools (precursor to National League of Nursing). Founded Nurses' Associated Alumnae of the US and Canada (precursor to ANA)

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Lillian Wald

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Founder of Henry Street Settlement Visiting Nurse Service on New York's Lower East Side Formalized public health nursing for better living conditions for poor immigrant workers

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Jessie Sleet Scales

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Instrumental in providing excellent nursing care to underserved families despite social challenges of the slums of New York City around 1900

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Margaret Sanger

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In the 1910s, Sanger challenged federal Comstock Laws to bring birth control info and contraceptive devices to women In 1960 she collaborated with Gregory Pincus to bring about Enovid, the first birth control pill

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First Autonomous School of Nursing

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Yale School of Nursing becomes the first autonomous school of nursing in the U.S. with its own dean, faculty, budget

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Mary Breckinridge

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1925-Founded the Frontier Nursing Service Nurses in the FNS traveled by horseback in rural areas of the Appalachian Mountains First midwife program in the U.S.

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The Educational Status of Nursing (1912) by Mary Adelaide Nutting

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Focused on teaching methods, material being taught, and living conditions of students

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The Study of Nursing and Nursing Education, also called "Goldmark Report" (1923)

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Focused on clinical learning experiences, hospital control of education, desirability of university-based schools, funding, and lack of prepared teachers

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Nursing Schools Today and Tomorrow (1934) by National League of Nursing Education (NLNE)

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Focused on schools, curricula, professional collegiate education

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Recommendations of Early Nursing Education Studies (1912-1934)

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Programs should be established within the U.S. system of higher edu Nurses should be highly educated Students should not be used to staff hospitals Standards for nursing practice should be established All students should meet minimum graduation requirements

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Education Pathways

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Diploma program (4%) Hospital-based 2 year program Associate Degree program (53%) Community college based 2-year program Bachelor of Science Degree (44%) University based 4-year nursing program

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Accreditation of Educational Programs

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A supplementary, voluntary review process. Accreditation promotes adherence to standards that: Protect quality of education Protect public safety Protect the nursing profession

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Master's Education

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Emphasis on advanced practice specialization roles: Administration Case management Informatics Health policy/health care systems Education Clinical Nurse Specialist (CNS) Certified Nurse Practitioner (CNP) Certified Nurse-Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA)

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Doctoral Education

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Prepare for teaching as faculty in universities, administrators in nursing schools or large medical centers, researchers, theorists, and advanced practitioners Doctorate of philosophy (PhD): for a research or theory development focus Doctorate of nursing practice (DNP): for practice in advanced clinical roles May provide a solution to shortage of primary care physicians

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Certification Programs

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Certification goes beyond licensure to validate high level of knowledge and proficiency in practice area American Nurses Credentialing Center (ANCC) is largest certification body in U. S. 40 different certification programs for BSN and advanced degrees

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Continuing Education

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Non-degree-seeking ways to maintain expertise in nursing American Nurses Credentialing Center (ANCC) is responsible for: Standards of continuing education (CE) Accreditation of CE programs Transferability of CE from state to state Development of guidelines for states' recognition systems

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Challenges in Nursing Education

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Insufficient clinical sites Faculty shortages due to retirement and low salaries

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Need to transform nursing education for complex U.S. health care needs (IOM, 2003) based on:

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Students not educated to care for elderly and chronically ill Students not educated to work in teams Students not educated to access and use scientific evidence in practice Students unprepared to identify and eliminate errors or problems Students not provided basic informatics training

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Critical thinker

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Raises questions/problems and formulates them clearly and precisely Gathers and assesses relevant information Arrives at conclusions and solutions that are well-reasoned and tests them against relevant standards Is open-minded and recognizes alternative views Communicates effectively about solutions to complex problems

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Nursing Process

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*ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation)* Nursing is not just defined by carrying out doctor's orders but rather an intellectual process that nurses use to address patient problems that are solved by independent nursing interventions Nursing Process is a method of critical thinking focused on solving patient problems Creative approach to thinking and decision making

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Nursing Diagnosis as part of the Nursing Process

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Nursing diagnosis as part of the nursing process: defined as "a clinical judgment about individual, family or community responses to actual or potential health problems which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability" Today, there are 235 approved nursing diagnoses

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Assessment

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Subjective data: obtained through patient's description; called symptoms Objective data: obtained through assessment or observation; called signs

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Diagnosis

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Nursing diagnoses identifies problems the patient is experiencing as a result of a disease process Nursing Diagnoses Statements have 3 parts: 1. Approved NANDA Label—(Impaired Mobility) 2. Related to factors/etiology- (joint stiffness) 3. Defining characteristics/as evidenced by signs and symptoms- (gait changes)

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Planning

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Identify patient goals Determine evidence-based interventions to assist patients to meet goals Goals must be specific to that they can be used to evaluate patient progress Goals should be agreed on by both nurse and patient

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Implementation

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Interventions are performed by the nurse to assist the patient to achieve the stated goal The plan must be individualized to the patient's capabilities

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Evaluation

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Nurse examines the patient's progress Nurse measures progress against goals to determine whether problem is: Met Partially Met Not Met Evaluation is critical; it identifies changes that need to be made to resolve the problem or meet outcomes goals Nursing process is dynamic, continually moving from one phase to another and then beginning the process again

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Acute illness

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characterized by severe, short-lived symptoms Symptoms appear suddenly, progress rapidly, subside quickly May or may not require medical attention Some acute illness can lead to chronic illness

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Chronic illness

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gradual development of permanent changes and disability Altered functioning can disruption of family life & create financial hardship Almost 1/2 of U.S. population has one or more chronic illnesses(CDC 2010)

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Adjustment to Serious Illness

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Stage 1: denial Stage 2: anger Stage 3: attempting to gain control Stage 4: depression Stage 5: acceptance

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Talcott Parsons (1964) identified five attributes of the Anglo-American sick role

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Exemption from social responsibilities Cannot be expected to care for himself/herself Should want to get well Should seek medical advice Should cooperate with the medical experts

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Contemporary Expectations of Sick Role

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People should accept responsibility for their own care People should want to get well and behave accordingly Patients have become increasingly likely to challenge providers and to seek out their own information Internal and external influences can cause wide range of response to the sick role

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Illness Behaviors

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Dependence/independence Coping ability Resourcefulness Resilience Spirituality

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External Influences on Illness Behavior

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Part experiences, culture, stress, physiologic, social and emotional, cognitive

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Stress and Illness

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Stress plays a major role in the development of illness: Exhaustion leads to physiologic breakdown and predisposition to illness Immune response is reduced by stress Healing can be delayed Stress produces greater susceptibility to infectious disorders such as colds and flu

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Coping with Stress

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Indirect/direct, problem solving skills, education

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Factors that affect patient's capacity to learn about their illness

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Physiologic factors (deaf/blind), cultural factors, lack of motivation and readiness, environmental factors.

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Impact of Illness on Families

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Changes in health of one member affect entire family Individual and family coping abilities are critical factors in how well a family tolerates stress Stress is increased whether the ill family member is hospitalized or cared for in the home

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Impact of Caregiving on the Nurse

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Need to find balance between caring for others and self-care

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Dimensions of Caring

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Caring- instinctual empathy for another person Compassion- sincere, deep concern Spirituality- creating environment conducive to free expression of spiritual beliefs Community outreach- health promotion and teaching of disadvantaged patients Providing comfort- providing emotional consolation and physical ease Crisis intervention- assessment/ intervention in critical situations that save lives Going the extra distance- accommodations to make life a little better for a patient

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Theories are beliefs that guide the nurse in:

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Making sound clinical judgement by: Determining which data is important Organizing, analyzing and understanding connections in patient data Planning appropriate nursing interventions Evaluating outcomes of interventions

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Metapradigm

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Refers to the most abstract aspect of the structure of nursing knowledge Consists of the major concepts of the discipline: person, environment, health, nursing, and caring

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Philosophy

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Refers to a set of beliefs about the nature of how things work and how the world should be viewed Nursing philosophy ties together the concepts of nursing's metaparadigm

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Conceptual model

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Framework is a more specific organization of nursing phenomena than a philosophy "Model" or "framework" implies an organizational structure that makes clearer connections between concepts

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Philosophies of Nursing: Florence Nightingale

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Notes on Nursing: What It Is and What It Is Not (1859) Health, illness, and the nurse's role in caring for patients Focused the profession on person, health (as opposed to illness), and nursing (as opposed to medicine) She believed that health was related to patients' environments Clean water and environment, adequate ventilation, balanced diet, etc. She recognized nursing's role in protecting patients Shielding from harm, not discussing upsetting news, not tiring a patient She promoted sensitivity to effect of environment, the foundational work for the theory that changing patients' environments could positively affect their health

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Philosophies of Nursing: Virginia Henderson

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"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge." (1966) She described the nurse's role as a helper or partner to the patient She believed that the function of the nurse was to assist patients if they were unable to perform any of the 14 identified bio-psycho-social needs of the patient

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Philosophies of Nursing: Jean Watson

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Watson's 10 caritas processes guide nurses by specifying the meaning of the relationship of nurse and patient as human beings (1979) Practice loving kindness Decision making Instill faith and hope Teaching and learning Spiritual beliefs and practices Holistic care Helping and trusting relationship Healing environment Promote expression of feelings Miracles

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Dorothea Orem's Self-Care model

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1. Diagnostic: to determine the patient's ability to be in control of their lives and provide effective self-care 2. Prescriptive: nurse formulates plan of care based on self-care deficits 3. Regulatory: nurse provides care ranging from complete assistance to only needing education regarding health

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Imogene King

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Interacting Systems Framework and Theory of Goal Attainment (1971) Nurses and patient have a mutual goal they work together to meet Nurse uses traditional steps of Nursing Process with goal being patient's regaining of health Focuses on three interacting systems: 1. personal (the patient's perceptions of stressors) 2. interpersonal (interactions between patients and others; their roles) 3. social (group social contracts; their outside influences)

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Sister Callista Roy

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Roy's Adaptation Model - Nurses modify the environment to facilitate patient adaptation (1976)

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Grand Theory

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defined as a very broad conceptualization of observed nursing phenomena

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Middle-range theory

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defined as narrower in focus and makes connections between grand theories and nursing practice

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Hildegard Peplau's Nursing Theory of Interpersonal Relations in Nursing

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Relationship between patient and nurse is focus of attention, rather than patient only as the unit of attention Nurse to assist the patient to learn from problems and develop new behaviors

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Ida Orlando's Nursing Theory-The Dynamic Nurse-Patient Relationship: Function, Process and Principles

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Emphasized role of nurse was to determine and meet patients' immediate needs and to improve their situation by relieving distress or discomfort. Theory guides nurses to individualize care for each patient by identifying pressing needs

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Madeleine Leininger's Nursing Theory of Culture Care Diversity

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Goal of transcultural nursing involves planning nursing care based on specific knowledge that is culturally defined, classified, and tested Begin by: Respecting the culture of the patient Recognizing importance of its relationship to nursing care Assessing cultural data to understand its influence on patient

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Middle-Range Theories of Nursing

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Incorporate a limited number of concepts Focus on a specific aspect of nursing Based on first-hand experience research Typically merge practice and research Sometimes developed from other disciplines

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Theory Based Nursing Practice

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Theory-based practice occurs when nurses intentionally structure their practice around a particular nursing theory and use it to guide them as they: Assess Plan Diagnose Intervene Evaluate nursing care

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Theory Based Research

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Theory-based research tests and refines the knowledge base of nursing. Research findings: Enable nurses to improve the quality of care Understand how evidence-based practice influences improved patient outcomes

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Theory Based Education

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Curricula are built on one or more conceptual models. Important for students to understand that their coursework is based on a philosophy or a conceptual model that shapes the way nursing is taught

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Health Promotion and Maintenance

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Services that keep patients healthy, prevent disease and injuries, detect diseases early, and promote healthier lifestyles

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Illness Prevention

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Assist patients in reducing impact of risk factors identified through family history and genetic predispositions

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Diagnosis and treatment

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Traditional goal of medicine; assess symptoms, conduct diagnostic tests, generate formal diagnoses, plan and implement treatment regimens Modern technology allows for refined diagnostic methods

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Rehabilitation and long term care

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Restore patients to fullest possible level of function following illness

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Health Care Agencies

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Public (government funded) or Private (individual citizens donate resources) Not-For-Profit (all profit furthers mission) or For-Profit (profit distributed to shareholder) Type of Health Services Provided

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Two Means of Maintaining Quality Health Care Agencies

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Accreditation by one of two standard-setting bodies approved by Centers for Medicare (CMS) Continuous quality improvement/total quality management

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Team Nursing

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RN team leader with other staff members assigned to defined groups of patients

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Primary nursing

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Patient was assigned one nurse responsible for care for entire hospital stay with a delegated associate nurse caring for the patient during their days off

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Case Management

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Nurse oversees patient's care and manages delivery of services from all health care disciplines

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Patient-Centered Care

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Patient's right to individualized care through multidisciplinary team of professionals

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Nurses can promote cost savings by:

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Using less-expensive alternatives Reducing waste by transferring equipment, medications, supplies Posting costs on shelves Recycling Providing excellent patient care Being advocates for their patients' financial needs regarding health care services

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Affordable Care Act

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Includes comprehensive reforms to improve access and protect consumers from abusive insurance company practices This law does not provide for universal access to healthcare It will be up to each individual state to put in place measures to address reform

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