Chapter 1

1. Chapter 1 Nursing Today

2. Historical Perspective Highlights • Nurses: • Respond to needs of patients • Actively participate in policy • Respond and adapt to challenges • Make clinical judgments and decisions about patients’ health care needs based on knowledge, experience, and standards of care • Nursing: • Care is provided according to standards of practice and a code of ethics.

3. Development of a Profession • Nursing has struggled with its definition, its image, and its role in the healthcare delivery system • Due in part to its history • Fact that it has both theoretical and practical aspects • Role of the nurse in the healthcare delivery system has probably never been more important than it is today.

4. Historical Influences on the Development of Nursing • Healthcare in ancient cultures • Historic perspectives and early images of nursing • Folk image • Religious image • Servant image

5. The Beginning of Change • Early providers of nursing care • Sisters of charity in France and the United States • Sisters of the holy cross in France and the United States • Catholic religious orders in Mexico and South America • Ursuline sisters in Canada • Deaconesses at Kaiserwerth, Germany and Pittsburgh, Pennsylvania • Nursing sisters in England and Ireland

6. The Nightingale Influence • Dramatically changed the form and direction of nursing • Set standards for nursing education and made significant recommendations for changes in how hospitals operated and how nursing was practiced • Many of her recommendations are valid today • Wrote Notes on Nursing

7. Florence Nightingale’s Basic Principles of Nursing Education • Trained teaching hospitals are associated with medical schools • Nurses reside in nurses’ houses • School matron is final authority in: • Curriculum • Living arrangements • All aspects of the school • Education includes theoretical material and practical experience • Teachers are paid for instruction • Records are kept on students

8. Florence Nightingale • First practicing epidemiologist • Organized first school of nursing • Improved sanitation in battlefield hospitals • Her practices remain a basic part of nursing today.

9. Civil War to the Beginning of the Twentieth Century • The growth of nursing in the United States: • Clara Barton founded the American Red Cross. • Dorothea Lynde Dix • Mother Bickerdyke • Harriet Tubman • Mary Mahoney • Isabel Hampton Robb • Lillian Wald and Mary Brewster: Henry Street Settlement

10. The Establishment of Early Schools • Nursing services provided by most hospitals during the 1860s were disorganized and inadequate. • In 1869 the American Medical Association established a committee to study the issue of training for nurses. • The New England Hospital for Women and Children is often credited with being the first hospital to establish a formal 1 year program to train nurses in 1872.

11. Characteristics of the Early Schools • Primarily apprenticeships • Long hours during which students provided much of the workforce of the hospital with little time left for study • Job description 1887

12. The Twentieth Century • Movement toward scientific, research-based practice and defined body of knowledge • 1901: Army Nurse Corps established • 1906: Mary Adelaide Nutting, first professor of nursing at Columbia University • 1908: Navy Nurse Corps established • 1920-1923: Study of nursing education • 1940s and 1950s: Associations emerged • 1970: Emergency Room Nurses Organization

13. Nursing Image • Struggle with image • Groups waging campaigns to: • Improve image • Attract individuals to profession • Critical issue because of nursing shortage • A positive image is needed to attract qualified individuals into the profession

14. The Twenty-First Century • Nursing code of ethics • Changes in curriculum • Nursing in multiple care settings • Advances in technology and informatics • End-of-life care

15. Influences on Nursing • Changes in society lead to changes in nursing: • Health care reform • Demographic changes • Medically underserved • Threat of bioterrorism • Rising health care costs • Nursing shortage

16. Nursing as a Profession • A profession has characteristics: • Requires an extended education • Requires a body of knowledge • Provides a specific service • Has autonomy • Incorporates a code of ethics

17. Scope and Standards of Practice • Nursing: Scope and Standards of Practice • 1960: Documentation began • Standards of Practice • Standards of Professional Performance • Goal • To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice

18. Standards of Practice • Nursing standards provide the guidelines for implementing and evaluating nursing care. • Six standards of practice: • Assessment • Diagnosis • Outcomes identification • Planning • Implementation • Evaluation

19. Standards of Professional Performance

20. Code of Ethics • A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care. • It is important for you to incorporate your own values and ethics into your practice. • Ask yourself: How do your ethics, values, and practice compare with established standards?

21. Quick Quiz! 1. Nursing is defined as a profession because nurses A. Perform specific skills. B. Practice autonomy. C. Utilize knowledge from the medical discipline. D. Charge a fee for services rendered.

22. Programs that Prepare Graduates for RN Licensure • Three major avenues to preparation for licensure as a registered nurse exist in the United States: • Diploma or hospital-based diploma • Associate degree • College-based baccalaureate degree • Master’s and doctoral prelicensure programs • Nontraditional prelicensure programs

23. Nursing Practice • Nurses practice in a variety of settings. • Nurses: • Protect, promote, and optimize our patients’ health • Prevent illness and injury • Alleviate suffering through the diagnosis and treatment of human responses • Advocate for the care of our patients

24. Nursing Practice • Nurse Practice Acts • Licensure and certification • Science and art of nursing practice • Benner’s stages of nursing proficiency: • Novice • Advanced beginner • Competent • Proficient • Expert

25. Professional Responsibilities • Nurses are responsible for obtaining and maintaining specific knowledge and skills. • In the past: • To provide care and comfort • Now: • To provide care and comfort and to emphasize health promotion and illness prevention

26. Professional Roles

27. Career Development • Nursing provides an opportunity for you to commit to lifelong learning and career development. {Fig 1-2 here}

28. Professional Nursing Organizations • National League for Nursing (NLN) • American Nurses Association (ANA) • International Council of Nursing (ICN) • National Student Nurses Association (NSNA) or Canadian Student Nurses Association (CSNA) • Other professional organizations focus on specific areas.

29. Quick Quiz! 2. The NLN and the ANA are professional organizations that deal with A. Nursing issues of concern. B. Political and professional issues affecting health care. C. Financial issues affecting health care. D. All of the above issues.

30. Forces for Change in Nursing Education • Incorporation of computer technology in nursing education • Computer technology in the classroom • Computers in the hospital environment • Distance learning options • Establishment of programs that provide for educational mobility • Increase in community-based practice experiences • Increase in emphasis on research • Education supporting evidence-based practice

31. Additional Nursing Trends • Genomics • Public perception of nursing • Impact of nursing on politics and health policy • Future trends

32. Chapter 2 The Health Care Delivery System

33. Challenges to Health Care • Reducing health care costs while maintaining high-quality care for patients • Improving access and coverage for more people • Encouraging healthy behaviors • Earlier hospital discharges result in more patients needing nursing homes or home care.

34. Emphasis on Population Wellness • Health Services Pyramid • Managing health instead of illness • Emphasis on wellness • Injury prevention programs {Fig 2-1 here}

35. National Priorities Partnership • National Priorities: • Patient and family engagement • Population health • Safety/eliminating errors as possible • Care coordination • Palliative care for advanced illnesses • Overuse/reducing waste

36. Institute of Medicine (IOM) • Nurses need to be transformed by: • Practicing to the full extent of their education and training • Achieving higher levels of education and training through an improved education system that provides seamless progression • Becoming full partners, with physicians and other providers, in redesigning the health care system • Improving data collection and the information infrastructure for effective workforce planning and policy making

37. Case Study • Amy Sue Reilly is a 15-year-old white female of Irish descent. She is a freshman at a Catholic high school. Although her parents are divorced, Amy Sue reports that her family (she has two brothers and lives with her mother) is very close, and that her parents work together to meet all their children’s needs. • Amy Sue has had asthma since she was 5 years old. She has been able to control her asthma by taking oral medications and by using inhalers when needed.

38. Health Care Regulation and Competition • Regulatory and competitive approaches • Professional standards review organizations (PSROs) • Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid • Utilization review committees (URs) • Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare

39. Health Care Regulation and Competition (cont’d) • Prospective payment system (PPS) • Diagnosis-related groups (DRGs) • Capitation • Resource utilization groups (RUGs) • Profitability • Managed care

40. Health Care Regulation and Competition (cont’d) • Patient Protection and Affordable Care Act • Access to health care for all • Reducing costs • Improving quality • Provisions include • Insurance industry reforms • Increased funding for community health centers • Increased primary care services • Improved coverage for children

41. Health Care Settings and Services

42. Health Care Accreditation/ Certification • Reasons: • To demonstrate quality and safety • To evaluate performance, identify problems, and develop solutions • Accreditation earned by the entire organization • Specific programs or services within an organization earn certifications. • The Joint Commission and others

43. Preventive and Primary Health Care

44. Secondary and Tertiary Care • Also called acute care • Focus: Diagnosis and treatment of disease • Disease management is the most common and expensive service of the health care delivery system. • 20% require 80% of health care spending. • Fastest growing age group of uninsured? • Postponement of care by uninsured

45. Secondary and Tertiary Care (cont’d) • Settings • Resource efficiency, word redesign • Discharge planning—nurses’ role

46. Restorative Care • Serves patients recovering from an acute or chronic illness/disability • Helps individuals regain maximal function and enhance quality of life • Promotes patient independence and self-care abilities • Requires multidisciplinary approach • Settings:

47. Restorative Care: Home Care • Provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation • Involves coordination of services • Focuses on patient and family independence • Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay sources

48. Restorative Care: Rehabilitation • Focus: To restore patients to their fullest physical, mental, social, vocational, and economic potential • Includes physical, occupational, and speech therapy, as well as social services • Occurs in many health care settings, both inpatient and outpatient

49. Restorative Care: Extended Care • Extended care facility • Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities • Skilled nursing facility (intermediate care) • Provides care for patients until they can return to their community or residential care location

50. Continuing Care • For people who are disabled, functionally dependent, or suffering a terminal disease • Available within institutional settings or in the home: