Transcript Trends and Issues Affecting Nursing Practice by Brenda McMillan

Trends and Issues in Nursing
Practice
Brenda McMillan RN, MS
Hinds Community College
Associate Degree Nursing Program
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The minimal educational
qualification/preparation necessary for a
nurse to enter into the profession of
nursing.
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* Over the last 100 years the environment in which
healthcare is practiced has changed considerably, as
has the need for strengthening nursing education.
Several factors, such as an aging population, an
increasing awareness of economics, and more
complex technologies, have contributed to these
changes. In this rapidly changing environment
technological competence alone is no longer
adequate; rather a broader knowledge base is
required (American Association of Colleges of
Nursing, 2005; Association of California Nurse
Leaders, 2000).
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http://nursing.connectwithmhs.org/wp-content/uploads/2013/04/CC041213-BSN_Legislating-entry-into-practice_Tina-Barnes3.pdf
* This broader knowledge base includes the
creative decision-making, critical-thinking, and
managerial skills needed for dealing with a
diverse and multicultural workforce and
patient population. Additionally, today’s nurses
should also be familiar with such broad ranging
topics as cost-benefit analysis and ethical
decision making.
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In most states, basic nursing education is provided at the following levels:
Licensed Practical Nurse (LPN) Diploma Program: A technical/vocational
nurse training program administered at the Junior College or vocational
school level that ranges, by state, from 9 to 18 month
Registered Nurse (RN) Diploma Program: These programs are typically a 23 year experience leading to professional entry into nursing practice.
Before the 1970s there were more than 800 diploma schools in existence;
today there are less than 100
Associate Degree Nurse (ADN) Program: A two-year educational program
administered at the Junior College level leading to professional entry into
nursing practice
Baccalaureate Degree Program, generally a Bachelor of Science in Nursing
(BSN) Program: A four year nurse education program administered at the
upper college level leading to professional entry into nursing practice
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* Currently all state boards of nursing require each
nursing graduate to pass the National Council
Licensure Examination (NCLEX), developed by the
National Council of State Boards of Nursing (NCSBN).
The NCLEX is a standardized exam that determines
whether or not a candidate is prepared for entry-level
nursing practice (NCLEX, 2008). The NCSBN has
developed two licensure examinations to test the
entry-level nursing competence of candidates for
licensure, namely the NCLEX-RN for registered nurses
and the NCLEX-PN for licensed practical/vocational
nurses. In addition, credentialing programs are offered
by the American Nurses Association and a number of
specialty organizations.
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* Nursing theory is the body of knowledge that
explains the profession of nursing.
* Nursing theory is an organized and systematic
articulation of a set of statements related to
questions in the discipline of nursing.
* "A nursing theory is a set of concepts, definitions,
relationships, and assumptions or propositions
derived from nursing models or from other
disciplines and project a purposive, systematic view
of phenomena by designing specific interrelationships among concepts for the purposes of
describing, explaining, predicting, and /or
prescribing."
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Nursing theory aims to describe, predict and explain the phenomenon
of nursing.
It should provide the foundations of nursing practice, help to
generate further knowledge and indicate in which direction nursing
should develop in the future.
Theory is important because it helps us to decide what we know and
what we need to know
It helps to distinguish what should form the basis of practice by
explicitly describing nursing. The benefits of having a defined body of
theory in nursing include better patient care, enhanced professional
status for nurses, improved communication between nurses, and
guidance for research and education
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* Assist nurses to describe, explain, and predict everyday experiences.
* Serve to guide assessment, interventions, and evaluation of nursing
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care.
Provide a rationale for collecting reliable and valid data about the
health status of clients, which are essential for effective decision
making and implementation.
Help to describe criteria to measure the quality of nursing care.
Help build a common nursing terminology to use in communicating
with other health professionals.
Ideas are developed and words are defined.
Enhance autonomy (independence and self-governance) of nursing
through defining its own independent functions.
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* Anne Casey - Casey's model of nursing
* Betty Neuman - Neuman systems model
* Boykin & Schoenhofer
* Callista Roy - Adaptation model of nursing
* Carl O. Helvie - Helvie Energy Theory
* Dorothea Orem - Self-care deficit nursing theory
* Helen Erickson
* Hildegard Peplau - Theory of interpersonal relations
* Ida Jean Orlando (Pelletier)
* Imogene King
* Isabel Hampton Robb
* Katharine Kolcaba
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Katie Eriksson
Madeleine Leininger
Margaret A. Newman - Health as expanding consciousness theory
Martha E. Rogers - Science of unitary human beings
Paterson & Zderad
Ramona T Mercer - Maternal role attainment theory
Rosemarie Rizzo-Parse - Human becoming theory
Virginia Henderson - Henderson's need theory
Dr. Jean Watson
Erickson, Tomlin & Swain - Modeling and Role-Modeling
Moyra Allen - McGill model of nursing
Nancy Roper, Winifred W. Logan, and Alison J. Tierney - Roper-LoganTierney model of nursing
Phil Barker - Tidal Model
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* Purposely omitted from this list is that most
famous of all nurses, Florence Nightingale.
Nightingale never actually formulated a theory
of nursing science but was posthumously
accredited with same by others who
categorized her personal journaling and
communications into a theoretical framework.
* Also not included are the many nurses who
improved on these theorists' ideas without
developing their own theoretical vision.
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Nursing research is research that provides
evidence used to support nursing practices.
Nursing, as an evidence-based area of practice,
has been developing since the time of Florence
Nightingale to the present day, where many
nurses now work as researchers based in
universities as well as in the health care setting.
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* Nurses use research to provide evidence-based
care that promotes quality health outcomes for
individuals, families, communities and health
care systems. Nurses also use research to shape
health policy in direct care, within an
organization, and at the local, state and
federal levels. Nurses conduct research, use
research in practice, and teach about research.
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Evidence-based practice begins with questions that arise in practice settings.
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Nurses must be empowered to ask critical questions in the spirit of looking for opportunities to improve
nursing practice and patient outcomes.
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In any specialty or role, nurses can regard their work as a continuous series of questions and decisions.
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In a given day, a staff nurse may be called to ask and answer questions, such as “Should I give the
analgesic only when the patient requests it, or should I encourage him to take it every 4 hours?
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Will aggressive ambulation expedite this patient’s recovery, or will it consume too much energy?
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Will open family visitation help the patient feel supported, or will it interrupt her rest?”
A nurse manager or administrator might ask, “Who is the most qualified care provider for our sickest
patient today? What is the optimal nurse-to-patient ratio for a specific unit?
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Do complication rates and sentinel events increase with less-educated staff?
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Do longer shifts result in greater staff fatigue and medication errors?
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Will higher quality and more expensive mattresses decrease the incidence of pressure ulcers?
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What benefits promote nurse retention? How does the use of supplemental (or agency) staffing affect
the morale of existing staff?
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Can this population be treated on an outpatient, rather than an inpatient, basis?
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What is the optimal length of time for a comprehensive home care assessment?
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How many patients can a nurse practitioner see in 8 hours?” Likewise, a nurse educator may ask, “Is it
more effective to teach a procedure in the laboratory or on an actual patient?
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What are the most efficient methods of documenting continued competency?
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Do web-based students perform as well on standardized tests as students in traditional classrooms?”
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* Each type of question can lead to important
decisions that affect outcomes, such as patient
recovery, organizational effectiveness, and
nursing competency.
* The best answers and consequently the best
decisions come from informed, evidence-based
analysis of each situation.
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As the largest healthcare occupation, registered nurses held about 2.6
million jobs in 2014.
For registered nurses specifically, the Bureau of Labor Statistics
anticipates 19.4 percent employment growth and 526,800 brand
new jobs between 2012 and 2022.
This tremendous growth, when compounded by a low
unemployment rate,just 2.6 percent, and good job prospects,
helped registered nurse secure the No. 6 slot on the US News
Best Jobs list.
Nursinhttp://www.amnhealthcare.com/uploadedFiles/MainSite/C
ontent/Healthcare_Industry_Insights/Industry_Research/AMN%2
02012%20RN%20Survey.pdfg Employment
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Gender Role Changes in Nursing A new study from the Unite...
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Licensure in a Compact State,
by where registered nurses live
and work by Number
Percent
Live and work in same Compact State
791,444 96.0
Live in one Compact State and work in
another Compact State
13,537 1.6
Live in a Compact State and work in nonCompact State 19,681 2.4
Total
824,662 100.0
2016 National Patient
Safety Goals
http://www.jointcommission.org/standards_information/npsgs.aspx
Background
*The National Patient Safety Goals (NPSGs) were
established in 2002 to help accredited
organizations address specific areas of concern
in regards to patient safety
*The first set of NPSGs was effective January 1,
2003
*The Patient Safety Advisory Group advises The
Joint Commission on the development and
updating of NPSGs
The purpose of the National Patient Safety Goals
is to improve patient safety in a variety of
settings.
The goals focus on problems with health care
safety and ways in which they can be resolved.
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*Comprised of a panel of widely recognized patient
safety experts, including nurses, physicians,
pharmacists, risk managers, clinical engineers,
and other professionals with hands-on experience
in addressing patient safety issues in a wide
variety of healthcare settings
*Advises The Joint Commission how to address
emerging patient safety issues in NPSGs, Sentinel
Event Alerts, standards and survey processes,
performance measures, educational materials,
and Center for Transforming Healthcare projects
* Changes for 2016
A NPSG focusing on safe clinical alarm
management for hospitals and critical
access hospitals was introduced in 2014
with a phased implementation
*Phase one begins January 1, 2014
*Phase two begins January 1, 2016
* Began January 1, 2014
* Hospitals were required to:
* establish alarm safety as organizational priority
* identify the most important alarms to manage based on their
own internal situations
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* Begins January 1, 2016
* Hospitals will be expected to:
* develop and implement specific components of policies and
procedures
* educate staff in the organization about alarm system
management
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Patient safety goals are deleted when they
become a Joint Commission Standard of
Care.
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Improve the accuracy of patient identification.
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NPSG.01.01.01: Use at least two patient
identifiers when providing care, treatment
and services.
* For example, use the patient’s name and date of birth. This is
done to make sure that each patient gets the correct medicine
and treatment.
•Applies to:
Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Laboratory,
Nursing Care Center, Office-Based Surgery
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*NPSG.01.03.01:
Eliminate transfusion
errors related to patient misidentification.
Applies to: Ambulatory, Critical Access Hospital, Hospital,
Office-Based Surgery
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Improve the effectiveness of communication among
caregivers.
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*NPSG.02.03.01:
Report critical results of
tests and diagnostic procedures on a timely
basis.
* Get important test results to the right staff person
on time.
• Applies to:
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Critical Access Hospital, Hospital, Laboratory
Improve the safety of using medications.
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*NPSG.03.04.01:
Label all medications,
medication containers, and other solutions
on and off the sterile field in perioperative
and other procedural settings.
• Applies to:
Ambulatory, Critical Access Hospital, Hospital,
Office Based Surgery
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*NPSG.03.05.01:
Reduce the likelihood
of patient harm associated with the use of
anticoagulant therapy.
• Applies to:
Ambulatory, Critical Access Hospital,
Hospital, Nursing Care Center
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*NPSG.03.06.01:
Maintain and communicate
accurate patient medication information.
• Applies to:
Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Nursing Care Center,
Office-Based Surgery
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Reduce the harm associated with clinical alarm systems.
* Make improvements to ensure that alarms on medical
equipment are heard and responded to on time.
* Clinical Alarm Safety
NPSG.06.01.01: Improve the safety of clinical
alarm systems.
* Make improvements to ensure that alarms
on medical equipment are heard and
responded to on time
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Clinical Alarm Safety
• Applies to: Critical Access Hospital, Hospital
Reduce the risk of health careassociated infections.
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*NPSG.07.01.01:
Comply with either the
current Centers for Disease Control and
Prevention (CDC) hand hygiene guidelines or
the current World Health Organization (WHO)
hand hygiene guidelines.
• Applies to:
Ambulatory, Behavioral Health Care, Critical
Access Hospital, Home Care, Hospital, Laboratory, Nursing
Care Center, Office-Based Surgery
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*NPSG.07.03.01:
Implement evidencebased practices to prevent health careassociated infections due to multidrugresistant organisms in acute care hospitals.
• Applies to:
Critical Access Hospital, Hospital
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*NPSG.07.04.01:
Implement evidencebased practices to prevent central lineassociated bloodstream infections.
• Applies to:
Critical Access Hospital, Hospital, Nursing
Care Center
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*NPSG.07.05.01:
Implement evidencebased practices for preventing surgical
site infections.
• Applies to:
Ambulatory, Critical Access Hospital,
Hospital, Office-Based Surgery
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*NPSG.07.06.01:
Implement evidencebased practices to prevent indwelling
catheter-associated urinary tract
infections (CAUTI).
• Applies to:
Critical Access Hospital, Hospital
(Note: This NPSG is not applicable to pediatric populations.
Research resulting in evidence-based practices was
conducted with adults, and there is not consensus that
these practices apply to children.)
* Make sure that the correct surgery is done on
the correct patient and at the correct place on
the patient’s body.
* Mark the correct place on the patient’s body
where the surgery is to be done.
* Pause before the surgery to make sure that a
mistake is not being made.
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*UP.01.01.01:
Conduct a preprocedure
verification process.
• Applies to:
Ambulatory, Critical Access Hospital, Hospital,
Office-Based Surgery
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*UP.01.02.01:
• Applies to:
Mark the procedure site.
Ambulatory, Critical Access Hospital, Hospital,
Office-Based Surgery
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*UP.01.03.01:
A time-out is performed
before the procedure.
• Applies to:
Ambulatory, Critical Access Hospital, Hospital,
Office-Based Surgery
* In early 1999, The Joint Commission solicited input
from a wide variety of stakeholders (e.g., clinical
professionals, health care provider organizations,
state hospital associations, health care consumers)
and convened a Cardiovascular Conditions Clinical
Advisory Panel about the potential focus areas for
core measures for hospitals. In May 2001, the Joint
Commission announced four initial core
measurement areas for hospitals, which included
acute myocardial infarction (AMI) and heart failure
(HF).
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Accountability Measures (formerly Core
Measures) track a variety of evidence-based,
scientifically-researched standards of care which
have been shown to result in improved clinical
outcomes for patients. CMS (the Center for
Medicare & Medicaid Services) established the
Core Measures in 2000 and began publicly
reporting data relating to the Core Measures in
2003. Currently, we report on 22 Accountability
Measures.
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Accountability measures are quality measures that meet four criteria that
produce the greatest positive impact on patient outcomes when hospitals
demonstrate improvement on them.
The criteria for classifying accountability measures include:
Research: Strong scientific evidence exists demonstrating that compliance
with a given process of care improves health care outcomes (either directly or by
reducing the risk of adverse outcomes).
Proximity: The process being measured is closely connected to the outcome it
impacts; there are relatively few clinical processes that occur after the one that is
measured and before the improved outcome occurs.
Accuracy: The measure accurately assesses whether the evidence-based
process has actually been provided. That is, the measure should be capable of
judging whether the process has been delivered with sufficient effectiveness to
make improved outcomes likely. If it is not, then the measure is a poor measure
of quality, likely to be subject to workarounds that induce unproductive work
instead of work that directly improves quality of care.
Adverse Effects: The measure construct is designed to minimize or eliminate
unintended adverse effects.
These criteria are based on The Joint Commission’s experience implementing and
evaluating the outcomes of quality measures for more than a decade. The criteria
provide a more rational approach to the process of collecting and reporting
quality data.
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Acute Myocardial Infarction
Heart Failure
Pneumonia
Perinatal Care
Venous Thromboembolism (VTE)
Stroke
Immunizations
Hospital Outpatient Measures
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http://www.jointcommission.org/core_measure_set
s.aspx
* Critical pathways, also known as critical
paths, clinical pathways, or care paths, are
management plans that display goals for
patients and provide the sequence and timing
of actions necessary to achieve these goals
with optimal efficiency.
* More simply put, Clinical pathways (CPs) are
decision-making tools designed to improve the
quality of patient care processes and reduce
costs.
*
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thways+in+nursing&qpvt=critical+pathways+in+nu
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GRE
* A review of the literature suggest the use of
critical pathways reduces the cost of care and
the length of patient stay in hospital. They also
have a positive impact on outcomes, such as
increased quality of care and patient
satisfaction, improved continuity of
information, and patient education.
* (Renholm, et. al., Journal of Nursing
Administration)
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* The median number of adult critical pathways used by academic
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hospitals, community teaching hospitals, and community hospitals
was 25, 18, and 3, respectively. The most common pathways are
community-acquired pneumonia, total hip or knee replacement, and
stroke or transient ischemic attack. The percentage of hospitals with
pathways dedicating staff to manage them was 78% for academic
hospitals, 22% for community teaching hospitals, and 14% for
community hospitals (P = 0.02). Evaluation practices varied widely
among hospitals with pathways. Measures assessed included
monitoring length of stay (85%), total hospital costs (74%), in-hospital
mortality (62%), infectious complications (53%), readmission rates
(47%), functional status (18%), and adverse drug events (15%).
Conclusion. The use of critical pathways varies substantially among
hospitals participating in quality improvement consortia. Use was
highest in academic centers and lowest in community hospitals. Many
hospitals with pathways do not track important clinical outcomes as
part of their evaluation practices.
(Jonathan Darer, Effective Clinical Practice, American College of Physicians, Bethesda, MD).
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McCue, et. al conducted a retrospective analysis to
determine whether multidisciplinary CPs had improved core
measure scores. Comparative data to document secular
trends were obtained from 45 Maryland hospitals. There
were 6013 discharges with community-acquired pneumonia
(CAP), congestive heart failure (CHF), or acute myocardial
infarction (AMI) for the 3-year data collection period ending
in 9/30/05. The 72.5% of cases in which CPs were employed
to manage CAP, CHF, or AMI were significantly more likely to
meet the Appropriate Care Measure (ACM) standards than the
26% that did not (81% vs. 67.8%, p < .001). Scores for all 10
ACM components for CP-managed patients were better than
Maryland state averages. Improvements were stable over a 3year period of time.
(Journal of Healthcare Quality)
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* Hospital Value-Based Purchasing (VBP) is part of the
Centers for Medicare & Medicaid Services’ (CMS’)
long-standing effort to link Medicare’s payment
system to a value-based system to improve
healthcare quality, including the quality of care
provided in the inpatient hospital setting.
* The program attaches value-based purchasing to the
payment system that accounts for the largest share
of Medicare spending, affecting payment for
inpatient stays in over 3,500 hospitals across the
country.
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* The mission of QSEN is to address the challenge of
assuring that nurses have the knowledge, skills, and
attitudes (KSA) necessary to continuously improve
the quality and safety of the healthcare systems in
which they work. QSEN is a national movement that
guides nurses to redesign the ‘what and how’ they
deliver nursing care so that they can ensure highquality, safe care. Linda Cronenwett, PhD, RN,
FAAN, the founder of QSEN, often states that QSEN
helps nurses to identify and bridge the gaps
between what is and what should be and helps
nurses focus their work from the lens of quality and
safety.
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Latent Failure (the blunt end): Errors arising from
decisions that affect organizational policies,
procedures and allocation of resources. Also
included are management, organizational culture,
protocols/policies, transfer of knowledge
Active failure (the sharp end): Errors arising from
direct contact with the patient (i.e. memory
failures, attentional failures, competing demands,
fatigue).
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Organization: Safety is a priority. Teamwork, patient
involvement, transparency and accountability are key.
Individual (i.e. Nurse): Decrease dependence on memory
and vigilance.
Avoid Vigilance: checklists, well-designed alarms, rested
Avoid Memory: Standardizing and simplifying procedures
and tasks. Plan and problem-solve!
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Equipment (design, availability and maintenance)
Environment (staffing levels and skills, workload and shift patterns,
administrative and managerial support, physical space)
Processes: As the problem was developing, when were key factors
occurring?
Management/Organization: (financial resources and constraints,
organizational structure, policy standards and goals, safety culture and
priorities)
Regulation: (economic and regulatory situation, availability and use of
protocols, availability and accuracy of tests)
People/Teamwork: (knowledge and skills/training, competence,
physical and mental health, verbal and written communication,
supervision and assistance)
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Standardize/Simplify/Make Protocol
Automation/Computerize
Education/Training
Improve or Change Devices/Equipment
Communication
Other (Describe)
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