Download - Lichtenstein_Nursing Personnel 2005
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Nursing and Nursing Personnel
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What is Nursing?
The diagnosis and treatment of human
responses to actual or potential healthproblems. Its aim is the care of the
patient
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What Qualities Does It Take to
Be a Good Nurse?
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Nursing deals with Biological,
Psychological, Social and
Environmental factors that shape
illness and human responses toillness.
It is HOLISTIC.
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General Focus of Nursing
To help people obtain, retain and
regaintheir health.
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Domains of Nursing and
Medicine Nursing
HealthMaintenance
Preventive
Caring
Medicine
CurativeDiagnostic
Prescriptive
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Nursings Relationship to
Medicine Legal Requirements
Nurse Practice Acts
Independent Actions Dependent Actions
Determining a Treatment PlanPhysicians Order
Nurse-Initiated Activities
Collaboration/Interdependence
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What Are the Functions Nurses
Perform?
How is what nurses do different
from what people in other
health occupations do?
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The Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
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What is the Training of an RN?
Diploma
Associate Degree (AA) Bachelors Degree (BSN)
Masters Degree (MSN)
Doctoral Degree (Ph.D.) LPNs (LVNs)
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0
10
20
30
40
50
60
70
80
90
100
1952 1960 1970 1980 1990 1994 1996
Percentineachprogram
Diploma
Associate
Bachelors
Admissions to Nursing School by
Type of DegreeThere has been a major shift in the types of nurses being trained.
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Demographic and Employment
Characteristics of Nurses
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Age
Race
Place of Employment
Undergoing big changes
Salaries
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39.5
42.4
45.4 45.1
37.9
30
35
40
45
50
1980 1990 2000 2010 2020
AgeinYea
rs
Average Age
Actual and Projected Average Age of
RN Workforce, 1980 - 2020
Buerhaus, Staiger, and Auerbach, JAMA, 2000
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Nursing Graduates are Aging
National Sample Survey of Registered Nurses, BHPr, HRSA, 2000
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Distribution of RNs by Age
Average age of working RNs increased from 37.4 to41.9 years between 1983 and 1998, an increase of 4.5 years
(versus U.S. workforce as a whole: increased < 2 years)
During same time, number of working nurses under 30
decreased by 40%, from 30.3% of RN workforce to 12.1%
By 2010, average age forecast to increase to 45.4 years,
an increase of 3.5 years
By 2010, more than 40% of RN workforce will beolder than 50
By 2020, RN workforce will be 20% below projected
requirements, given current trends
Buerhaus, Staiger, and Auerbach, JAMA, 2000
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0
1
2
3
4
5
6
7
8
1984 1988 1992 1996 2000
Males
Percentage of Male RNs, US, Selected Years
Source: National Sample Survey of Registered Nurses, USDHHS, BHPr, 2000
Percen
ta
ge
Note: Approx.
94% of Nursesare female
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0
0.5
1
1.5
2
2.53
3.5
4
4.55
1984 1988 1992 1996 2000
BlackAsian
Hispanic
American Indian
Percent of RNs by Race/Ethnicity, Selected Years
Note: Approx. 87% of
Nurses are White
Source: National Sample Survey of Registered Nurses, USDHHS, BHPr, 2000
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Percent of RNs by Race/Ethnicity, Comparison
of Armed Services with National RN Population
0%
3%
6%
9%12%
15%
18%
Army Nurse C orpsNa vy N urse C orps Air F orce Nurse
Corps
National RN
Population
Black H ispanic Asian American India
Source: Schmieding, 2000
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Geographic Distribution of
Nurses
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Registered Nurses Per
100,000 Population by Area
782
1075
885788
815 831
654 596
0
200
400
600
800
1000
1200
US New
England
Mid-
Atlantic
South
Atlantic
East S
Cent
East N
Central
Mountain Pacific
Nurses
per100,000
Geographic Region
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The Supply of Nursing Personnel
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Total Number of Licensed
Nurses (RNs)
19922,239,816
19962,558,874
20002,696,540
20032,311,970
Source: Bureau of Labor Statistics
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N b f N i S h l
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Number of Nursing School
Graduates by Type of Degree
Offered, 2001-2002
0
20,000
40,000
60,000
80,000
100,000
200
1
200
2
Total BA AA Di loma
Source: Health, United States, 2004, Table 106.
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The supply of nurses has
fluctuated widely over time
Periods of dramatic shortages of
nurses have been followed by
periods of oversupply
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There was a majornursing
shortage in the late 1980s, butduring the 90s nursing units
were being re-engineered and
many nurses were hit by layoffs.
Now there is talk about an
imminent nursing shortage!
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Projection of RN Shortage
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The Nursing Shortage is Already
Affecting Many Urban Hospitals
In many cities, hospitals have to close their
emergency rooms (regularly) because they
cannot accommodate any new patients,especially critically ill patients. Some of
this is due to bed shortagesbut part is
also due to insufficient staffing
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Restructuring Nursing Practice
Team Nursing
Primary Nursing
Case ManagementCritical Pathways
Clinical Practice Guidelines
Patient Centered (Focused) Care
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Team Nursing
Characteristics
RN as team leader
Team consists of RN, LPNs and aides
RN assesses, plans, and evaluates care
and delegates tasks according to the skill
needed to perform them
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Team Nursing
Advantages
Functional Nursing
Disadvantages
Team changes daily
RN accountable for continuity one shiftonly
Minimal of care for patient or team
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Primary Nursing
Characteristics
Every patient has a primary nurse that isaccountable for planning care for all threeshifts
Associate nurses carry out plan of care
when the primary nurse is not on duty
Usually implemented as an all-RN model
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Primary Nursing
AdvantagesImproved patient outcomes and communication
between health care team
Improved nurse satisfaction because of the
increased continuity of care and accountability
Disadvantages
ExpensiveNot cost-effective to have RNs doing non-
nursing tasks
Burn-out
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Case Management
Characteristics
Blends team and primary care
RN is case manager (often is a MSN orNP)
Tends to utilize critical pathways as the
basis for the care plan
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Case Management
Characteristics (contd)
CM is accountable 24 hours a day and
from admission to discharge- sometimes
for an entire floor of patients
RNs on all three shifts make sure the plan
is carried out
Utilizes the team approach with nurse
extenders
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Case Management
Disadvantages
Requires a lot of coordination across all
disciplines
Requires the organizational structure to
increase nursings accountability
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Critical Pathways
Characteristics (contd)Tend to be developed by nursing-- review of
literature, approval by medicine
Developed on a hospital-by-hospital basis
Case managers are notified of patients that vary
from the expected course of treatment and then
determine why the variance is occurring and,
with MD, make plans for corrective actionA patient version of the pathway is developed
and used for teaching
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Critical Pathways
Advantages
Improves clinical processes over time
Increases collaboration between nursing and
medicine
Reduces redundancy
Decreases unnecessary variations in care-
grassroots standardization
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Critical Pathways
Disadvantages
Variations in care across the country will still
occur
Issues
Physicians are not uniformly in favor, it decreases
their autonomy and increases their accountability
for their decisions
Criticized for being cookbook medicine and
nursing
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Clinical Practice Guidelines
Characteristics
Similar to pathways except usually focuses on a
condition or use of a technology not a DRGDifferent format -- narrative or algorithm
Developed by physician groups, HMOs and
government (AHRQ)
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Clinical Practice Guidelines
Advantages Care is developed according to scientific evidence
May eliminate small area variations for certain
conditions Provides a means to identify outlier care
Disadvantages
Often crystallizes the status quo rather than appropriatecare as determined by empirical evidence
Almost none consider costs or cost-effectiveness
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The New Way of OrganizingCare in Hospitals
Patient-Centered Care
or
Patient-Focused Care
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Patient-Centered Care Prompted by:
Shift to capitation and managed care
Escalating labor costs (This was done toeliminate the shortage of the early 90s!)
and recruitment difficulties.
Fragmentation caused by traditional task-centered, departmental-based, hospital
organization Nursing dissatisfaction
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Three Components of Patient-
Centered Care
Restructured Care Delivery
Interdisciplinary Team Management
Shared Values of Excellence in Patient Care
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Patient-Centered Care
Restructuring of how care will be delivered
A movement away from task-centered,
centralized care to patient-centered,decentralized care. (Cross-training)
Attempt to eliminate single-function, dead-
end jobs, and replace them with multi-skilled, Unlicensed Assistive Personnel
(UAPs)
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C t l M d l f PCC
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Conceptual Model of PCC
Associate tasks
Obtain history
Take vital signs
Accuchecks
Phlebotomy
ABGs
Reinforce education
Simple treatments
Documentation
Telemetry application
Personal care
C t l M d l f PCC
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Conceptual Model of PCC Unit Assistant tasks
Room set-up
Orient to room
Transport patient
Change linens
Clean rooms
Maintain supplies
Tray passingAmbulate patient
Patient safety
Reposition patient
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Conceptual Model of PCC
Unit Secretary tasksLocate MDs
Transcribe
PhonesIntercom
Direct visitors
Call lights
Charts
Admissions
Computer
N i Vi f PCC/PFC
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Nursings View of PCC/PFC
PROFIT-FOCUSED CARE A DANGER TO PATIENTS
using Unlicensed Assistive Personnel (UAPs)
to provide technical care which they are not
trained to do
WILL CAUSE MASSIVE LAYOFFS OF
RNs
RNs not comfortable with delegating and
yet, still legally liable
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Nursings Concerns
Unlicensed workers are doing proceduresthat only physicians and nurses are
qualified to perform
Personnel trained in basic first aid areperforming ER procedures such as stapling
head wounds
Techs are assessing patients, doing sterileprocedures and complex wound care, and
inserting catheters
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What Strategies Should We
Pursue to Eliminate the
Impending Nursing Shortage?
Should states set minimum nurse
staffing ratios?
Magnet Hospitals (Aiken et al)
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Magnet Hospitals (Aiken,et al)Provide better nursing practice environments
and have better patient outcomes
Higher nurse/patient ratios
More autonomy (control over practice
setting and freedom to make patient-caredecisions)
Better RN support services (effective
supervisors and chief nurse executive)
Better nurse-physician collaboration
Not-for-profit, teaching hospitals