MPN BSN 3

Fundamentals in
Nursing 2
Midyear 2024
important to know
• the patient is the center of your practice.
• your patient includes individuals, families, population groups, and/or
communities.
• nursing is both an art and a science, nursing practice requires a blend of the most
current knowledge and practice standards with an insightful and compassionate
approach to patient care.
• your care will reflect the needs and values of society and professional standards
of care and performance, meet the needs of each patient, and integrate
evidence-based findings to provide the highest level of care
• nursing has a specific body of knowledge; however, it is essential that you
socialize within the profession and practice to fully understand and apply this
knowledge and develop professional expertise.
• clinical expertise takes time and commitment.
Standards in Nursing Practice: Nursing
Process
Standards of Professional Performance
Code of Ethics
• The code of ethics is the philosophical ideals of right and wrong that
define the principles you will use to provide care to your patients.
• It is important for you to also incorporate your own values and ethics
into your practice.
• Ethics is the study of conduct and character.
• It is concerned with determining what is good or valuable for individuals,
groups, and society at large.
• Acts that are ethical reflect a commitment to standards that individuals,
professions, and societies strive to meet.
Basic Terms in Health Ethics
• Autonomy refers to freedom from external control. In health care the
concept applies to provider respect for the autonomy of patients.
• It can also apply to institutional respect for the autonomy of
providers. A commitment to respect the autonomy of others is a
fundamental principle of ethical practice.
• Respect for patient autonomy refers to the commitment to include
patients in decisions about all aspects of care.
• It is a key feature of patient-centered care. In respecting patient
autonomy, you acknowledge and protect a patient's independence.
• Respect for autonomy is a relatively new concept and reflects a
movement away from paternalistic patient care in which the physician
made all decisions.
• Respect for provider autonomy refers to provider relationships to
institutions.
• What happens when a provider is asked to perform duties that conflict with a
religious or personal belief?
• Institutions have developed policies that accommodate respect for providers
by finding a way to reassign duties when this conflict occurs.
• Beneficence refers to taking positive actions to help others.
• The principle of beneficence is fundamental to the practice of nursing
and medicine.
• The agreement to act with beneficence implies that the best interests
of the patient remain more important than self-interest.
• It implies that nurses practice primarily as a service to others, even in the
details of daily work.
• Maleficence refers to harm or hurt.
• Nonmaleficence refers to the avoidance of harm or hurt. In health
care ethical practice involves not only the will to do good but the
equal commitment to do no harm.
• A health care professional tries to balance the risks and benefits of
care while striving at the same time to do the least harm possible.
• Decisions about the best course of action can be difficult and
uncertain precisely because nurses agree to avoid harm at the same
time as they commit to promoting benefit.
• Justice refers to fairness.
• The term is most often used in discussions about access to health
care resources, including the just distribution of scarce resources.
• Discussions about health insurance, hospital locations and services,
and even organ transplants generally refer to issues of justice.
• Does the principle of just distribution mean that health care resources should
be available to as many people as possible?
• Or is it more important to remain concerned about equality by ensuring that
all people receive resources equally?
• Especially as health care costs continue to rise, the issue of justice remains a
critical part of the discussion about health care reform and access to care.
• The term just culture refers to the promotion of open discussion
without fear of recrimination whenever mistakes, especially those
involving adverse events, occur or nearly occur.
• Blame is withheld at least at first so system issues and other elements
can be investigated for their contributions to the error.
• By fostering open discussion about errors, members of the health
care team become more richly informed participants, able to design
new systems that prevent harm.
• Fidelity refers to the agreement to keep promises.
• As a nurse you keep promises by following through on your actions
and interventions.
• Fidelity also refers to the unwillingness to abandon patients
regardless of the circumstances, even when personal beliefs differ as
they may when dealing with drug dealers, members of the gay
community, women who received an abortion, or prisoners.
Professional Nursing Code of Ethics
• A code of ethics is a set of guiding principles that all members of a
profession accept.
• It is a collective statement about the group's expectations and
standards of behavior.
Advocacy
• Advocacy refers to the support of a particular cause.
• As a nurse you advocate for the health, safety, and rights of patients,
including their right to privacy and their right to refuse treatment.
• Your special relationship with patients provides you with knowledge that is
specific to your role as a registered nurse and as such with the opportunity to
make a unique contribution to understanding a patient's point of view.
Responsibility

• The word responsibility refers to a willingness to respect one's

professional obligations and to follow through.
• An example is following an agency's policies and procedures.
• As a nurse you are responsible for your actions and the actions of
those to whom you delegate tasks.
• You agree to take responsibility to remain competent to practice so
you can follow through on your responsibilities reliably.
Accountability
• Accountability refers to the ability to answer for one's actions.
• You ensure that your professional actions are explainable to your
patients and your employer.
• Health care institutions also exercise accountability by monitoring
individual and institutional compliance with national standards
established by agencies.
Confidentiality
• Mandates confidentiality about and protection of patients' personal
health information.
• It defines the rights and privileges of patients for protection of
privacy.
• In practice you cannot share information about a patient's medical
condition or personal information to anyone not involved in the care
of the patient
• Anonymous is either the project does not collect identifying
information of individual persons (e.g., name, address, email address,
etc.), or the project cannot link individual responses with participants'
identities.
Values
• A value is a personal belief about the worth of a given idea, attitude,
custom, or object that sets standards that influence behavior.
• Inevitably you will work with patients and colleagues whose values differ
from yours.
• To negotiate differences of value, it is important to be clear about your
own values: what you value, why, and how you respect your own values
even as you try to respect those of others whose values differ from yours.
• The values that an individual holds reflect cultural and social influences,
and these values vary among people and develop over time.
• For example, in some cultures decisions about health care flow from group or family-
based discussion rather than independent decisions by one person. Such a practice
may challenge your commitment to respect patient autonomy.
• Your effort to resolve differing opinions and maintain your cultural
competence becomes the hallmark of your commitment to ethical practice.
Values Clarification
• Ethical dilemmas almost always occur in the presence of conflicting values.
• To resolve ethical dilemmas one needs to distinguish among value, fact,
and opinion.
• Sometimes people have such strong values that they consider them to be
facts, not just opinion. Sometimes people are so passionate about their
values that they become judgmental in a way that intensifies conflict.
• Clarifying values—your own, your patients', your co-workers'—is an
important and effective part of ethical discourse.
• In the process of values clarification, you learn to tolerate differences in a
way that often (although not always) becomes the key to the resolution of
ethical dilemmas.
Ethics and Philosophy
• Deontology defines actions as right or wrong on the basis of their “right-
making characteristics” such as fidelity to promises, truthfulness, and
justice.
• It specifically does not look at consequences of actions to determine right
or wrong. Instead, deontology examines a situation for the existence of
essential right or wrong.
• For example, if you try to make a decision about the ethics of a controversial medical
procedure, deontology guides you to focus on how the procedure ensures fidelity to
the patient, truthfulness, justice, and beneficence. You focus less on the
consequences (ethically speaking). If the medical procedure in the example is just,
respects autonomy, and provides good, it will be right, and it will be ethical according
to this philosophy. If it provides good, but only to a limited number of people, it
could be deemed unjust and therefore unethical
Utilitarianism
• A utilitarian system of ethics proposes that the value of something is determined
by its usefulness.
• This philosophy is also known as consequentialism because its main emphasis is
on the outcome or consequence of action.
• A third term associated with this philosophy is teleology, from the Greek word
telos, meaning “end,” or the study of ends or final causes. John Stuart Mill (1806-
1873), a British philosopher, first proposed its philosophical foundations.
• The greatest good for the greatest number of people is the guiding principle for
determining right action in this system.
• As with deontology, utilitarianism relies on the application of a certain principle
(i.e., measures of “good” and “greatest”) (Beauchamp and Childress, 2012). The
difference between utilitarianism and deontology is the focus on outcomes.
Utilitarianism measures the effect that an act will have; deontology looks to the
presence of principles regardless of outcome.
Feminist ethics
• Feminist ethics, it looks to the nature of relationships to guide
participants in making difficult decisions.
• For example, when deciding whether to perform a possibly futile
procedure on a dying patient, feminist ethics might guide us to look at
the patient's relationships with family and friends as a way to
determine the ethically right thing to do.
• How would the patient's ability to engage in relationships be affected?
• If the patient is a parent, how would the patient's relationship to the children
be affected by the intervention?
Ethics of care
The ethics of care and feminist ethics are closely related.
Both promote a philosophy that focuses on understanding
relationships, especially personal narratives.
An early proponent of the ethics of care, Nel Noddings, used the
term the one-caring to identify the individual who provides care and
the cared-for to refer to the patient. In adopting this language
Noddings hoped to emphasize the role of feelings.
Ethics of care strives to address issues beyond individual relationships
by raising ethical concerns about the structures within which
individual caring occurs—structures such as hospitals or universities
Professional Responsibilities and Roles
• Autonomy is an essential element of professional nursing that involves
the initiation of independent nursing interventions without medical
orders.
• Nursing profession regulates accountability through nursing audits and
standards of practice, you also need to develop a commitment to
personal professional accountability.
• For example, you independently implement coughing and deep-breathing exercises
for a patient who recently had surgery. As you continue to care for this patient, a
complication arises. You note that the patient has a fever and the surgical wound has
a yellow-green discharge. You collaborate with other health professionals to develop
the best treatment plan for this patient's surgical wound infection.
• With increased autonomy comes greater responsibility and
accountability.
• Accountability means that you are responsible professionally and legally
for the type and quality of nursing care provided.
• You must remain current and competent in nursing and scientific knowledge and
technical skills.
Caregiver
• As a caregiver you help patients maintain and regain health, manage
disease and symptoms, and attain a maximal level of function and
independence through the healing process.
• You provide healing through psychomotor and interpersonal skills. Healing
involves more than achieving improved physical well-being. You need to meet
all health care needs of a patient by providing measures to restore a patient's
emotional, spiritual, and social well-being.
• As a caregiver you help patients and families set realistic goals and
meet them.
Advocate
• As a patient advocate you protect your patient's human and legal
rights and provide assistance in asserting these rights if the need
arises.
• As an advocate you act on behalf of your patient and secure your
patient's health care rights.
• For example, you provide additional information to help a patient decide
whether or not to accept a treatment, or you find an interpreter to help
family members communicate their concerns.
• You sometimes need to defend patients' rights to make health care decisions
in a general way by speaking out against policies or actions that put patients
in danger or conflict with their rights (Wilson et al., 2013).
Educator
• As an educator you explain concepts and facts about health, describe the
reason for routine care activities, demonstrate procedures such as self-
care activities, reinforce learning or patient behavior, and evaluate the
patient's progress in learning.
• Some of your patient teaching is unplanned and informal.
• For example, during a casual conversation you respond to questions about the
reason for an intravenous infusion, a health issue such as smoking cessation, or
necessary lifestyle changes. Other teaching activities are planned and more formal
such as when you teach your patient how to self-administer insulin injections.
• Always use teaching methods that match your patient's capabilities and
needs and incorporate other resources such as the family in teaching plans
Communicator
• Your effectiveness as a communicator is central to the nurse-patient
relationship.
• It allows you to know your patients, including their strengths, weaknesses,
and needs.
• Communication is essential for all nursing roles and activities.
• You will routinely communicate with patients and families, other nurses and health
care professionals, resource people, and the community.
• Without clear communication it is impossible to advocate for your patients or to give
comfort and emotional support, give care effectively, make decisions with patients
and families, protect patients from threats to well-being, coordinate and manage
patient care, assist patients in rehabilitation, or provide patient education.
• Quality communication is a critical factor in meeting the needs of
individuals, families, and communities.
Manager
• Nurse managers need to establish an environment for
collaborative patient-centered care to provide safe, quality
care with positive patient outcomes.
• A manager coordinates the activities of members of the
nursing staff in delivering nursing care and has personnel,
policy, and budgetary responsibility for a specific nursing unit
or agency.
• A manager uses appropriate leadership styles to create a
nursing environment for patients and staff that reflects the
mission and values of the health care organization
Health Care Delivery System
• five levels of care for which health care
providers offer services:
• disease prevention;
• health promotion; and
• primary,
• secondary, and
• tertiary health care
• Primary Care (Health Promotion)
• Prenatal and well-baby care
• Nutrition counseling
• Family planning
• Exercise, yoga, and mediation classes
• Health promotion programs lower the overall costs of health
care by reducing the incidence of disease, minimizing
complications, and thus reducing the need to use more
expensive health care resources.
• Preventive care is more disease oriented and focused on
reducing and controlling risk factors for disease through
activities such as immunization and occupational health
programs.
• Preventive Care
• Blood pressure and cancer screenings
• Immunizations
• Mental health counseling and crisis prevention
• Community legislation (e.g., seat belts, air bags, bike helmets, no
texting while driving)
Secondary Acute Care
• Emergency care
• Acute medical-surgical care
• Radiological procedures for acute problems (e.g., x-rays, computed
tomography [CT] scans)
Tertiary Care
• Intensive care
• Subacute care
Restorative Care
• Cardiovascular and pulmonary rehabilitation
• Orthopedic rehabilitation
• Sports medicine
• Spinal cord injury programs
• Home care
Continuing Care
• Assisted living
• Psychiatric and older adult day care
Quality and Performance Improvement
• Quality improvement (QI) is an approach to the continuous
study and improvement of the processes of providing health
care services to meet the needs of patients and others and
inform health care policy.
• Performance improvement (PI) an organization analyzes and
evaluates current performance and uses the results to
develop focused improvement actions.
PDSA cycle
• PDSA cycle:
• Plan—Review available data to understand existing practice
conditions or problems to identify the need for change.
• Do—Select an intervention on the basis of the data reviewed and
implement the change.
• Study—Study (evaluate) the results of the change.
• Act—If the process change is successful with positive outcomes, act
on the practices by incorporating them into daily unit performance.
Evidence-based nursing practice
Example
• A nursing unit has an increase in the number of patient falls over the
last several months.
• QI data identifies the type of patients who fall, time of day of falls,
and possible precipitating factors (e.g., efforts to reach the
bathroom, multiple medications, or patient confusion). A thorough
analysis of QI data then leads clinicians to conduct a literature review
and implement the best evidence available to prevent patient falls
for the type of patients on the unit. Once the staff apply the evidence
in a fall prevention protocol, they implement the protocol (in this
case, focusing efforts on care approaches during evening hours) and
evaluate its results. Recurrent problems with falls lead staff to
conduct a research study specific to the problem.
Nursing Interventions to Promote Healthy
Psychosocial Responses
• Stress and adaptation
• Loss, grief, and dying-concept of death
• Post-mortem care
• Sexuality
• Spirituality