Topics of Professional Nursing II, NRS 438

1. Topics of Professional Nursing II, NRS 438 • Dennis Ondrejka, Ph.D., RN, CNS • 303-577-0387, ext 209 • Emergencies 303-909-9011 cell • d.ondrejka@denverschoolofnursing.org

2. 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.

3. 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.

4. April 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 Course Assignments

5. 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.

6. The nurse as advocate • For care, • Presences, • Patient, • Family.

7. 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 healing • 3.Each person on the team plays a part

8. 12 Values Assumptions that guide the process of internal change are (2) • 4. Relationship is at the heart of all of this • 5.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.

9. 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 values • 8. We must understand and value of Relationship in patient care. • 9. A therapeutic relationship is essential for quality care • 10. Patient experiences improve measurably when staff own their own practice

10. 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.

11. 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 well • We cannot get out of this chaos unless we truly focus on the patient, but we are system driven

12. Traditional Drivers of HC • Systems driven • Risk Avoidance driven • Hierarchy driven • Power broker driven • Policy driven • Politically driven • Re-imbursement driven • Cost reduction driven

13. Disconnect page 2 • We understand human behavior as being non-rational most of the time, yet expect to solve these issues with rational interventions • We realize there is a critical need for the care provider to have a positive relationship to self and we tend to ignore it anyway

14. Transformational Change When we speak of “transforming” we are speaking of changing the conditions of what currently exists. Page 6

15. 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 vision • I2 is Infrastructure: The infrastructure must support the organizations overall vision (strategic, operational, tactical levels)

16. 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 leadership • E2 is Evidence: measure results of your actions and support inspiration.

17. 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

18. 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

19. RBC for the Clinician Colleagues Colleagues Patient & Family First Self “The CORE of the healing Environment is your Relationship to the Patient and Family” p. 29

20. 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)

21. The Caring and Healing Environment • Preparation to RBC requires crossing the threshold into the pt’s environment • It 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).

22. Development of RBC • It has been developing over 25 years • We have research • We have theorists • We have it tied to professionalism • It is now found in the science of Quantum Mechanics

23. Care Theories for This Course • Watson’s Caring-Healing Framework • Swanson’s Five Caring Processes • Leininger’s Caring Theory • Dingman’s Caring Model

24. Environment of Care • EC impacts how care is given • EC impacts how care is perceived • Research on Care Environments • Gerteis, 1993 • Ulrich, 1994 • Bilchick, 2002 • Malkin, 1992

25. 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

26. Practice Using Care Theories • Swanson (1993) • Maintaining Belief • Knowing • Being with • Doing for • Enabling/Informing

27. 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

28. 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.

29. Filters We Use to Interpret the Experiences of Others • ONE: Our personal and behavioral background of the care provider • TWO: Our own spiritual consciousness • THREE: Our beliefs about an individuals rights and responsibilities to exercise free will So How do these filters affect your patient care?

30. Complementary Therapies • http://www.csh.umn.edu/modules/index.html • http://www.cudfm.org/holistic/ • National Center for Complementary and Alternative Medicine (NCCAM) http://nccam.nih.gov/ • http://ods.od.nih.gov/Research/ProductQualityResources.aspx • 50% of public use it • $40 Billion spent on CAM today

31. 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

32. 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 clients • OJT does not normally meet the requirements of a professional occupation.

33. 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

34. 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? Cook Chef

35. Professional Practices Have a culture that supports professional activities: frameworks, CE, research Has a defined body of knowledge gained by formal education Is a discipline with peer review and a code of ethics Autonomy in practice with legislative and legal sanctions Is an organized system of practice-society recognized Technical Practices Are more likely to have more OJT than formal education. Are skill focused Have trade journals or technique trainings Do not focus on what advances the practice Develop through certifications Want less accountability Professional vs. Technicalfor all practice areas

36. 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. TechnicalThinking and Valuing

37. Professional Technical Professional vs. TechnicalNursing Competencies

38. 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

39. 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)

40. Imagine Minimal Change

41. Limited knowledge Information processing barriers Environmental barriers Motivational (internal) barriers Emotional barriers Perceptual barriers Intellectual barriers Cultural barriers (bias) KEY RESPONSES ARE: More people need to be stepping up to critical decisions with Shared Governance We 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 Professionals believe there are: Mind and Body Failures

42. 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

43. 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.

44. Conceptual Frameworks-Theory Allow You To Organize Your Thinking and Connect it to Principles • It helps to know what we believe and why • These are the the building blocks of our knowledge and beliefs • This allows us to move into new territory as if we have a map for the unknown • We have less surprises, and then react less stressed • It is an external support for our faulty thinking

45. Imagine Nursing as Random Practice—Not a Discipline • Inconsistent care • Patient confusion • Evidence based practices are not encouraged • There is confusion and constant conflict • No accountability

46. Metaparadigms • Broadest consensus of a discipline • Have general parameters & creates boundaries • Have a distinctive domain and cover all of it • Most theories include these components • Person (humans) • Environment (context) • Health (ideas of health) • Nursing (nursing as a discipline) • Caring • Quality

47. Propositions:Linkages & Relationships • Belief regarding person to their own health • Belief regarding person to environment • Belief regarding health to nursing practice • Belief regarding the connection of person, environment, health , and the practice of nursing • Beliefsabout caring, quality and practice

48. The Focus of One’s PracticeImpacts the practice and workplace • Client focused • Family focused • Person-environment focused • Nursing therapeutic focused • Humanistic focused • Spiritually focused • Process focused

49. Models Give you a Picture of How the Parts are Related

50. A Philosophy Has Your Key Values Presented for Others