Professional Nursing Practice:
Health Care Systems, Health Policy & Evidence-Based
Practice
NRS 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
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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
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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
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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
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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
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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
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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
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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
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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 socalled 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
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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