Professional Nursing Practice:Health Care Systems, Health Policy & Evidence-Based PracticeNRS 101 Session 1

About Health Care Systems

• Methods of health care delivery and management

Types of Health Care Services

• Primary prevention– Focus on health promotion and illness

prevention– Healthy People updated every 10 years

• Childhood obesity/nutrition• Physical activity across lifespan• Dental/oral health• Tobacco use/smoking cessation• Health screening recommendations

Types of Health Care Services, continued

• Secondary prevention– Focus on early disease detection, treatment

– Prevent progression of disease

– Early detection provided through screening

• Tertiary prevention– Focus on restoring function, decreasing

disease-related complications of already established disease

– Includes rehabilitation and palliative care

Types of Healthcare Settings

• Primary care delivered in– Physician’s offices– Hospital-based clinics– Community health centers– Public health service organizations– Often the entry or gatekeeper for managed

care

Figure 44-1 Various health care settings.

Figure 44-1 (continued) Various health care settings.

Figure 44-1 (continued) Various health care settings.

Figure 44-1 (continued) Various health care settings.

Figure 44-1 (continued) Various health care settings.

Types of Healthcare Settings, continued

• Secondary care delivered in– Hospital– Outpatient surgical center– Specialist’s office

• Tertiary care delivered in– Hospital– Acute care facility– Rehabilitation center– Extended care facility

Factors Affecting Delivery of Health Care

• Changing demographics

• Advances in technology

• Health literacy– Lower health literacy:

• Elderly adults• Lower socioeconomic status• Lower education attainment

Frameworks for Providing Care

• Managed care

• Case management

• Client-focused care

Figure 44-2 Model of an integrated health care delivery system.

Nursing Care Delivery Systems

• Functional

• Team

• Primary

• Nurses must know – All types of health care settings– Requirements of agency

Nurses in Unique Position

• Many roles of nurses– Caregivers, teachers, advocates,

researchers – Create context for policy issues– Shape policy planning

• American Nurses Association (ANA) promotes health care reform agenda– Basic care for all citizens

Developing Health Policies

• Problem-solving framework

• Policy development affected by– Cost-benefit ratios– Client care issues– Equity of access

Figure 45-1 Why is health policy relevant to nurses?

Policy Development Process, continued

• Enacted by governmental entity– Through specific agency– Changes made in incremental fashion– Federal, state, local levels

• Health Care and Education Reconciliation Act of 2010

Accrediting Agencies

• Accreditation– Peer review process for measuring quality– Preparation requires self review– Standards of accrediting agency provide

structure

• The Joint Commission– Independent nonprofit organization– Sets standards for, accredits health care

organizations

Accrediting Agencies

• The Joint Commission– Mission to continuously improves safety,

quality of care– Three functional areas addressed

• Infection control• Patient’s rights• Patient treatment

– Focuses on organizations ability to provide safe effective care, actual provision of care

Accrediting Bodies, continued

• Nursing education program accreditation– Recognized by U.S. Secretary of Education– Commission on Collegiate Nursing Education

• CCNE baccalaureate and graduate programs

– National League for Nursing Accrediting Commission

• NLNAC clinical doctorate, master’s, baccalaureate, associate’s, diploma, practical

Professional Organizations

• Promote development of the profession

• ANA– Only full-service professional organization

• Represents nation’s RNs

– Advances nursing• Fosters high standards of nursing practice• Promotes rights of nurses in workplace• Projects positive, realistic view of nursing• Lobbies Congress, regulatory agencies

Professional Organizations

• National Student Nurses Association (NSNA)– Nonprofit organization for students– Fosters professional development of

nursing students

• Specialty practice organizations– Advocacy, education, connection– ANA has list on their website

Professional Organizations, continued

• Sigma Theta Tau International– Membership by invitation

• Baccalaureate and graduate nursing students• Nurse leaders exhibiting exceptional

achievements

• National League for Nursing (NLN)– Committed to delivering improved services– Champions high-quality nursing education– Promotes excellence in nursing education

Professional Organizations, continued

• American Association of Colleges of Nursing (AACN)– National voice for U.S. nursing education

programs• Baccalaureate and higher degree• Educational, research, governmental advocacy• Data collection• Publications

– Establishes quality standards

Types of Reimbursement

• United States only industrialized country without national policy

• Payment sources– Federal programs (public sources)

• Centers for Medicare & Medicaid Services (CMS)

• Supplemental Security Income (SSI)

– State Children’s Health Insurance Program (SCHIP)

Types of Reimbursement

• Payment sources– Private health insurance programs

• Through employer, professional organization• May extend to spouse/dependents/partner• Self-employment based expensive

– Types of private health insurance• Health maintenance organization (HMO)• Preferred provider organization (PPO)• Point of service (POS)• Consumer-driven health care plan (CDHP)

Types of Reimbursement, continued

• Medigap policy– Designed to supplement Medicare– Helps pay some uncovered costs

• Personal payments– Paid by client– Not covered by any type of insurance

Health Care Policies Affect Everyone

• Affect individuals, families number of levels– Almost daily basis– Determine what drugs approved– Services offered– Types of providers who may provide services– Eligibility for public health insurance

About Professional Behaviors

• Components of professionalism in nursing– Socialization of students– Always maintain client as focus

About Professional Behaviors, continued

• Knowledge

• Competence

• Appearance

• Teamwork

• Integrity

• Positive attitude

• Compassion

Figure 38-2 Nurses demonstrate compassion by recognizing each client’s needs and responding appropriately.

Unprofessional Behaviors

• Defined by nurse practice acts

• Specific unprofessional behaviors

• Abuses of power– Sexual advances– Improper use of authority– Intimidation

Work Ethic

• Attendance and punctuality

• Reliability and accountability

• Attitude and enthusiasm

• Appearance

Figure 38-4 It is essential for nurses to arrive at work on time.

About Evidence-Based Practice (EBP)

• Aim– To provide best possible care based on

best available research

• Institute of Medicine (IOM)– To Err is Human report– 10 strategies for improving health care

delivery system

• Sigma Theta Tau

Sigma Theta Tau International Honor Society of Nursing

• Evidence-based nursing is:

“an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.”

(Sigma Theta Tau, 2005)

Benefits of EBP

• Improves client care

• Credibility of nursing profession

• Accountability for nursing care

Barriers to EBP

• Lack of knowledge

• Negative attitudes

• Lack of institutional support

• Limited research findings applicable to nursing

• Lack of time

Barriers to EBP,continued

• Lack of access to information technology

• Problems accessing journals

• Lack of confidence in own ability to apply

• “We’ve always done it this way”

Nursing Research

• Goals of Nursing Research– Promote evidence-based nursing practice– Ensure the credibility of the nursing

profession– Provide accountability for nursing process– Document the cost effectiveness of

nursing care

Nursing Research, continued

• Definition of nursing research: “Systematic, objective process of analyzing

phenomena of importance to nursing”

• Definition of clinical nursing research: “Involv[es] clients or studies that have the

potential for affecting the care of clients, such as studies with animals or with so-called normal subjects.”

Sources of Nursing Knowledge

• Tradition

• Trial and error

• Scientific research– Most objective, reliable source

History of Nursing Research

• Florence Nightingale– Introduced importance of collecting data

• Growth of nursing research related to educational levels of nurses

• American Nurses Association (ANA)– Research is a standard of professional

performance

Scientific Research

• Scientific method– Empirical data– Obtained in unbiased manner– Researcher chooses population, sample,

setting

• Similarities to problem-solving approach

Purposes of Nursing Research

• Develop body of knowledge specific to nursing professions

• Basic research: generates new knowledge– Laboratory animals– Cannot be applied immediately

• Applied research: uses knowledge to solve immediate problems– Majority of nursing studies

Roles of Nurses in Research

• Educational level determines role

• Overall roles– Principal investigator– Member of research team– Identifier– Evaluator– User– Patient or client advocate– Subject or participant

Figure 43-1 Collecting data at the client’s bedside is an important component of research.

Research Priorities

• ANA Cabinet on Nursing Research

• Replication studies

• National Institute of Nursing Research

Ethical Considerations

• German concentration camps

• Tuskegee Study

Development of Ethical Codes

• Present based on Nuremberg Code– Researcher must inform subjects about study– Research must be for good of society– Research must be based on animal

experiments, if possible– Researcher must try to avoid injury to subjects– Researcher must be qualified to do research– Subjects/researcher can stop if problems occur

Development of Ethical Codes

• The Belmont Report

• Institutional Review Boards

• HIPAA

Development of Ethical Codes, continued

• The Belmont Report– Respect for persons– Beneficence– Justice

• Institutional Review Boards

• Health Insurance Portability and Accountability Act (HIPAA)

Research Guidelines

• ANA Guidelines

• Informed consent

• Pediatric research issues

Figure 43-2 It is important for clients to be fully informed before they participate in a research study.

Developing EBP

1. Develop question– PICO format

• Patient• Intervention of interest• Comparison intervention• Outcome

2. Find and review evidence– Agency for Healthcare Research and Quality– Cochrane Database of Systematic Reviews

Developing EBP, continued

3. Integrate information– Formulate clinical question– Search relevant databases– Critically judge quality of evidence– Develop plan– Evaluate the practice change

4. Share information– Dissemination done in variety of ways