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⮚ “Avoiding Socialization Pitfalls” (Utley-Smith)
2nd degree students seeking ABSN have expectations based on their training and experience in another
field that are not met
o "Returning-to-school syndrome" (Dr. Shane) - a framework to describe why/when this mismatch
occurs
a) Honeymoon – excitement, positive outlook – hours to months
b) Conflict – academic difficulties negative emotions, inadequate, helpless – 2nd semester
c) Reintegration – rejection of new culture, hostility towards faculty – end of 2nd semester
Duration depends on person's resilience, feelings, interpretation of faculty or peers 
 Biculturalism - culmination of reintegration - student successfully integrates new
culture of nursing – by end of 4th semester
 Maladaptation - faculty must identify it and provide guidance
 False acceptance: pretend to care/value ABSN program just to finish it
 Chronic hostility: does not drop, fights for their original professional identity
Applications and Implications - nursing educators anticipate challenges faced by students and mentor
them; better socialization into nursing  resulting positive student outcomes
⮚ “Transitions: A Central Concept” (Schumacher and Meleis)
Change in a fundamental life pattern
o Developmental: change in life cycle  parenthood, pregnancy + postpartum, adolescence, etc.
▪ typically focused on the individual
o Situational: education or profession (scope of practice or setting)
▪ Family: widowhood, elderly to nursing home
▪ Immigration
▪ Near death
▪ Moving out of an abusive
▪ Homelessness
experience
relationship
o Health-illness: chronic illness, injury, post-operative, recovery
▪ levels of care the course of an illness
Acute condition ≠ transition
▪ mechanical ventilation process of recovery from
critical illness
▪ tube feeding  process of rehabilitation to oral nutrition
▪ Hospital  outpatient/rehab  home
 continuity of care +  costs
o Organizational: within the environment
▪ leadership, new policies, staffing patterns
 intraorganizational structure
o Universal Properties of Transitions
a) Processes that occur over time and involves development from one state to another
b) Nature of change
 Individuals - personality, identity, abilities, relationships
 Organizations – function, dynamics
o Transition Conditions Model (Chick and Meleis)
Personal and environmental factors affecting transition
▪ Meaning – subjective appraisal of an anticipated or experienced transition and evaluating
its likely effect
 can be neutral, positive, or negative.
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o
o
 Essential for understanding the experience of transition and consequences on health
▪ Expectations – subjective; influences transition experience
 knowing what might happen = stress alleviated
 or unrealistic expectations (influenced by past experiences)
▪ Level of Knowledge/Skill – relevant to a transition
 May influence health condition; can be insufficient to meet needs of new transition
 New parents have to learn to care of premature infant or chronically ill child;
need to learn new skills to accommodate that transition.
 Caring for a loved one who recently transitioned from the hospital to
continuous care
 Transition to a new profession necessitates new knowledge and skill
▪ Environment – available resources or facilities
 Preceptors serve as mentors providing support and guidance for a smooth transition
▪ Level of Planning – influences success of a transition
 involves extensive planning in the case of a catastrophic event where optimal
preparation for each phase is achieved
 Accomplished by continuous evaluation and assessment, recognizing issues that may
arise, identifying key individuals to provide support
▪ Emotional and Physical Well-Being – often anxiety, depression, insecurity, frustration
 Can result in fear of the unknown + unwillingness to take risks
 If physical discomfort accompanies a transition, it may interfere with the adjustment
 Bodily unpredictability: distress
 Bodily predictability: energy, and normal operation facilitate transition
(3) Indicators of Healthy Transitions - emphasize the process versus the identification of factors
that indicate a positive outcome; relevant across all types of transition
a) Subjective well-being: effective coping and managing one's emotions, sense of dignity,
integrity, quality of life; there is also growth, liberation, self-esteem, empowerment
b) Role mastery: achievement of skilled role performance; comfort with the behavior
required; competence, decision-making, and psychomotor skills, self-confidence
c) Well-being of relationships: move forward despite disputes, ability to integrate, meaningful
interactions; appreciation of closeness with family
(3) Nursing Therapeutics
Measures applicable to therapeutic intervention during transitions
▪ Readiness –comprehensive understanding of the client, create to for identifying patterns
 Incudes each condition
▪ Preparation - education to develop new skills, organize, assume responsibilities
 Orientation for new nurses, Transitional Treatment Program, Project Adventure
▪ Role supplementation – first time parents, patients recovering from MI, family caregivers
Transition Model (Brooten)  costs +  quality of care for discharged patients
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⮚ Guiding People Through Change (Bridge)
Change occurs to someone
Transition – slow internal process
Transition ≠ change
o Three Stages
1) Ending, Losing, and Letting Go – resistance and emotional upheaval;
 Fear, denial, anger, sadness, frustration
 Acknowledge their feelings, empathize,
2) The Neutral Zone– bridge between the old and new where people are feeling confused,
uncertain, and impatient as they are still holding on to the past

People can experience low morale/productivity, resentment towards the change
initiative, anxiety about their role, skepticism about change initiative BUT this stage
can yield great creativity, innovations, and renewal (good time to encourage new
ways of thinking/working)
 Remind clients that they are still making progress even if it feels like nothing much is
going on, remind them of their goals, and let them know it is okay to feel lost or
unsettled
 Give constant feedback and set small goals, enabling the person to have a positive
perception on the change effort; boost morale and help lessen their workload (help
prioritize or bring in extra resources)
3) The New Beginning – time of acceptance and energy, people have begun to embrace the
change initiative, building skills they need to work successfully in the new way

▪
People experience high energy, openness to learning, and renew commitment to
their group or role
 Important to help client sustain success by having them link their personal goal to
long-term objectives and highlighting success stories that occurred during the change
People can advance through the stages at different speeds, do not force them into rushing
through it. You are there to guide them and help throughout the process
⮚ Cohen: The Image of Nursing
o There are many images of nursing that have developed over time such as being female only, being
the angel of mercy, and sexual stereotype as seen in works of fiction
o Although nurses have been consistently ranked top 10 in the most trusted profession (5 years
which including being #1), the image of a nurse does not reflect that
o The goal is to redefine the image of nursing in a more professional away and eliminate certain
stereotypes (i.e. being female dominant) and can be accomplished by
▪ Take themselves seriously and dress professionally (i.e. no more cartoon-themed scrubs)
▪ Value nursing and project that image daily
▪ Recognize the value of what they do
▪ Believe in themselves/colleagues
▪ Defining unacceptable behavior in the workplace and holding people accountable for their
actions
▪ Defining the appearance of nursing staff in written guidelines
▪ Posting/advertising accomplishments of nurses
▪ Having staff contribute health articles to community newspaper
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▪
▪
o
Listening to patient's and caregiver's perception of nursing
Teaching/mentoring staff how to validate what they do with documentation and active
committee involvement
The goal is to change the image of nursing to the general public because as nurses there many
factors to consider that create our image (i.e. how we behave, how we dress, how we uphold
ourselves)
Chapter 1
 ACA: What is it? Why is it important?
o Affordable Care Act – also known as "health care reform" and are laws that provide the incremental
but progressive change in the way American can access and pay for their health care.
o Made up of two laws:
▪ The Patient Protection and Affordable Care Act
▪ The Health Care and Education Affordability Reconciliation Act
 Know generally what type of people make up nursing and where they practice
o Predominantly female, but male population in nursing has increased by 50% since 2000; most men
work in the hospital setting (overrepresented in the nurse anesthetists as well)
o We've noticed younger and younger people taking on nursing such as the average graduate age from
BSN programs being 28 years old
o Racial/ethnic minorities make up about 18% of the RN population, with largest disparity seen with
hispanics/latinos
o 91% of nurses younger than 50 are employed in nursing
o 8% of nurses are men
o ~63% in hospitals; ~10.5% in ambulatory care (clinics, outpatient centers, medical offices, SNFS); ~8%
public and community health, home health 6.4%, extended care facilities 5.3%, etc.
 Know how to qualify for the NCLEX
o Graduating from an accredited nursing school and there are three ways:
▪ 1) graduating from a 4-year BSN program at a college or university
▪ 2) 2-year ADN program at community college or technical school
▪
3) receiving a diploma in nursing through a hospital-based program that typically takes 3 years
(includes prereqs that can be taken at another school)
 How did nursing begin?
o Homes and in the community – only been in hospitals for 150 years
▪ Direct pt care main area for nurses
 Roles of Nurses
o Advanced practice registered nurse( APRN) – educational and clinical requirements basic/BSN
▪ Nurse practitioner (NP) – can perform physical exams, take medical histories, diagnose and
treat common acute and chronic illnesses and injuries, order/interpret lab results and x-rays,
legally write prescriptions independently without physician involvement (some states)
▪ Clinical nurse specialist (CNS) – handle a wide range of physical and mental health problems,
perform physical assessments, make diagnoses, develop quality control methods, and work in
consultation, research, education, and administration
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▪
o
o
Certified nurse-midwife (CNM) – provide well-woman care and attend or assist in childbirth in
various settings such as hospitals, birthing centers, private practice, and homes; over half
identify reproductive care as their main responsibility
▪ Certified registered nurse anesthetist (CRNA) – administer anesthetics and can collaborate with
physician anesthesiologists or independently and are found in ORs, OB delivery rooms, office of
dentists, ambulatory surgical facilities
Nurse researchers
Nurse entrepreneurs – self-employed- identify a need and create a service to meet it
▪ Nurse consultants – hospitals, nursing homes, schools
▪ Can start nurse-based practices and carry their own caseload of pt's with physical or emotional
needs, sometimes involved in educational workshops or seminars, or create merchandise,
own/operate health equipment agencies, home health agencies
▪ Advantages: autonomy (since you don’t deal with too many people) and scope of practice
▪ Disadvantages: losing financial investment if business is bad/slow, certain amount of pressure
created from trying to make ends meet and worrying about your business taking off
 Know about telehealth: Upsides? Downsides?
o Telehealth is the delivery of health care services and related health care activities through
telecommunication technologies; has bedside computers, interactive audio/video linkages, real-time
transmission of pt's diagnostic and clinical data, telephone triage, remote monitoring
▪ COVID…
▪ Upsides: the ability to skip meeting in person and having a client be in the comfort of their
home or bed, ability to expand services to underserved populations, reduces sense of
professional isolation experienced by those who work in those areas and may assist in
attracting/retaining health care professionals in remote areas
▪ Downsides: keeping up with the advancement of technology, competency with telehealth
technology, removal of emotional/personal experience of meeting with provider in person;
people in lower income areas might not have access to telehealth, numerous legal and
regulatory issues (e.g. ethical issue of pt being in a different state from the provider, and not
being to “practice” or consult with pt), companies not getting reimbursed properly for visits
 Employment outlook in nursing
o 15% increase in outlook; and as aging nurses retire, more positions open
o Employment opportunities will continue to grow as technology advances, patient needs increase, and
the shift of focus to primary care
o Hospital opportunities will continue to grow slowly, but hospital-based growth will occur rapidly in
outpatient facilities such as same-day surgery centers, rehab programs, and outpatient cancer
centers
o Large growth in home health due to the expansion of elderly population's needs and the preference
for/cost effectiveness of home care; assisted living/nursing home care will experience growth as well
due to the larger number of elderly people (80-90 year olds) requiring long-term care
o Salaries are the highest in employment services and general medical and surgical hospitals
o Salaries are lowest at nursing care facilities
o California has the highest nursing salaries in the U.S. and most vigorous nursing union
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o
o
o
CRNAs (nurse anesthetists) average the highest salary compared to other advanced nursing positions
"wage compression" = most of wage growth for nurses occurs early in their career and tapers off as
they near the top of salary scale due to leaving patient care for additional education or other nursing
careers outside the profession (flattening of salaries for experienced nurses)
In general, the employment outlook is looking very good/positive
Chapter 3
● Difference between occupation and profession (personal identification) (Table 3.1)
○ The distinction between the two is not always clear. The term occupation is often used
interchangeably with the term profession, but their definitions differ.
○ Collins English Dictionary (2015) defines occupation as “a person’s regular work or profession; job
or principal activity.”
○ Huber’s (2000) definition of profession is used to make the distinction between an occupation
and a profession: “a calling, vocation, or form of employment that provides a needed service to
society and possesses characteristics of expertise, autonomy, long academic preparation,
commitment, and responsibility”
○ Professional Preparation
■ A profession is different from an occupation in at least two major ways—preparation and
commitment. Professional preparation, typically taking place in a college or university,
requires instruction in the specialized body of knowledge and techniques of the
profession.
○ Professional Commitment
■ Professionals are usually highly committed to their work, deriving much of their personal
identification from it, and consider it an integral part of their lives; some people even
refer to their profession as their “calling.”
o what consistently appears in all models of professional attributes: service/altruism, specialized
knowledge, and autonomy/ethics.
●
●
●
pg. 6
4 areas of professional preparation
○ this preparation is what differentiates a profession from an occupation
■ instruction: this being within the specialized body of knowledge and techniques of the
profession (i.e. nursing school)
■ orientation: to beliefs, values, and attitudes expected of the members of the profession
■ commitment: transcends expectations of material reward
■ professional identity: it is less common to change careers in a profession vs. in an
occupation
4 domains of interprofessionality
1. Values/ethics for interprofessional practice
2. Roles/responsibilities
3. Interprofessional communication
4. Teams and teamwork
Kelly’s 8 criteria of a profession
1. The services provided are vital to humanity and the welfare of society.
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2. There is a special body of knowledge that is continually
enlarged through research. (in nursing, it is evidencebased.)
3. The services involve intellectual activities; individual
responsibility (accountability) is a strong feature.
4. Practitioners are educated in institutions of higher
learning.
5. Practitioners are relatively independent and control
their own policies and activities (autonomy).
6. Practitioners are motivated by service (altruism) and
consider their work an important component of their
lives.
7. There is a code of ethics to guide the decisions and
conduct of practitioners.
8. There is an organization (association) that encourages
and supports high standards of practice.
●
Miller’s wheel of professionalism
○ Each of the eight spokes represents other behaviors deemed necessary in maintaining or
increasing nurses’ professionalism. They are competence and continuing education; adherence to
the code of ethics; participation in the primary and referent professional organization (i.e. ANA)
and state constituent member association; publication and communication; orientation toward
community services; theory and research development and utilization; and self-regulation and
autonomy.
●
Roles of Professional Nursing Organizations
○ Promoting quality patient care
○ Developing standards of practice and codes of ethics
○ Research using EBP
■ Causes of errors, preventative strategies, issues
that affect ability to deliver patient care safely
 Lobbying for legislation and regulations
American Nurses Association (ANA)
The authority for nursing practice is based on a contract with society
that acknowledges professional rights and responsibilities, as well as
mechanisms for public accountability.
 primary professional organization for nursing
● defines nursing as "the protection, promotion, and optimization
of health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment of
human response, and advocacy in the care of individuals, families, communities, and populations
● What are nursing standards?
There are three major documents that guide all nurses in their professional commitments.
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○
○
○
Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010b) - serves as a
framework for understanding professional nursing’s relationship with society and nursing’s
obligation to those who receive professional nursing care. (obligation to the patients)
Nursing: Scope and Standards of Practice, second edition (ANA, 2010a) - outlines the
expectations of the professional role within which all RNs must practice and delineates the
standards of care and associated competencies for professional nursing. (expectations of the
professional role). Helps to improve health and wellbeing of patients
Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) - is generally considered a
tool that guides a group toward professional self-definition and provides evidence of professional
legitimacy. It is a written, public document that reminds practitioners and the public they serve
of the specific responsibilities and obligations accepted by the profession’s practitioners.
(strengthen and guide decision making)
●
3 components of collegiality
○ The promotion of a supportive and healthy work environment; cooperation and recognition of
interdependence among members of the nursing association (essence)
○ Cooperation (support) between nurses and students - sharing with, assisting and counseling
other nurses and nursing students
○ Recognition of interdependence among members of the nursing profession; sharing knowledge
with colleagues and students, mentoring, being able to serve as a role model, publishing in peerreviewed literature, supporting peer assistance programs for impaired nurses (collegial
behaviors)
●
5 barriers to professionalism
○ Varying Levels of Education for Entry into Practice - e.g. ADN, BSN, MSN. We are the only
profession allowed to work below a BS
○ Gender Issues - no gender balance in nursing, difficult for nursing to increase its status in society
as its seen as predominantly female and society’s perception/view on nursing; persistent
devaluing of women’s work in our society
○ Historical Influences - religious orders and military in nursing which can be good/bad
○ External Conflicts - tensions between nursing and medicine (e.g. NPs fighting for years to be
independent and not have to work “under” a physician)
○ Internal Conflicts - educational differences, various organizations that can create division (e.g.
union vs. non-union)
Chapter 6
● Understand the following terms: malpractice, negligence, assault, battery, informed consent,
confidentiality (& HIPAA ), licensure by endorsement, nurse licensure compact, standard of care
o Malpractice (aka professional negligence)= when a professional, such as a nurse or physician, fails
to act as a reasonably prudent professional would have acted in the same situation; does not
have to be intentional and can be done in two ways: by commission (doing something that
should not have been done) and by omission (failing to do things that should have been done)
▪ Malpractice is also negligence applied to the acts of a professional
▪ Civil, not criminal
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▪
▪
pg. 9
central question in any charge of malpractice: was the prevailing standard of care met?
Two requirements: the defendant (nurse) has the specialized knowledge and skills AND
causes the plaintiff’s (patient) injury through the practice of that specialized knowledge
and skill
o
Negligence = failure to act as a reasonably prudent person would have acted in the same
circumstances; it is a central issue in malpractice
▪ four elements needed to be proven
● 1) nurse has assumed the duty of care/responsibility for that pt
● 2) nurse has breached the duty of care by failing to meet standards of care
● 3) the failure of the nurse to meet the standard of care was the proximate cause
of the injury
● 4) the injury is proven
o
Assault = a threat or an attempt to make bodily contact with another person without the
person's consent; assault precedes battery, causing the person to fear that battery may occur
after
o
Battery = assault being carried out, which is the impermissible, unprivileged touching of one
person by another
o
Informed consent = full, knowing authorization by the patient for care, treatment, and
procedures and must include information about the risks, benefits, side effects, costs, and
alternatives UNLESS there is a life threatening-emergency
▪ Three conditions: 1) consent is given voluntarily, 2) must be given by an individual with
the decision-making capacity, and 3) patient must be given enough information about
the procedure/treatment/process
o
Confidentiality = protection of private information gathered about a patient during the provision
of health care services (think HIPAA); certain exceptions to confidentiality: can discuss pt
information with other providers directly involved in pt’s care, QA activities, disclosure to public
health authorities, or third-party payers (e.g. releasing pt information to insurance companies for
proper billing)
▪ HIPAA (Health Insurance Portability and Accountability Act) = governs protection of
patients' medical records, patient’s rights, and limitations, and was designed to reinforce
the protection of patient information as it is transmitted electronically
● was enacted to maintain confidentiality about a patient’s health information.
o
Licensure by endorsement = system where RNs or LVNs/LPNs can, submit proof of licensure in
another state and paying a licensure fee, receive licensure from the new state without sitting for
a licensing exam
▪ requirements: proof of licensure in another state, pay a licensure fee
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o
Nurse licensure compact = agreement in which some states, authorized by legislation, will honor
licenses issued to RNs by other states involved in the compact; this allows an RN to have a license
(in state of residency) yet practice in other compact member states without an additional license
in the state of employment. Helps improve mobility of nurses
▪ *remember*: you fall under the nursing practice act in the state you are practicing in, not
where you reside
▪ *remember*: a nurse who is licensed in a compact state and changes permanent
residence may still practice under license from former state of residence for up to 90
days.
o
Standard of care = guideline stating what the reasonably prudent nurse, under similar
circumstances, would have done
●
Know GENERALLY about the American legal system
o Purpose of law in the U.S. is found in the U.S. Constitution which does the following: ensure
order, protect the individual person, resolve disputes, and promote the general welfare
o All law in the United States flows from the Constitution
o Constitution established a government divided into three separate, but equal branches
▪ Executive branch = administers and implements law and includes the Office of the
President
▪ Legislative branch = creates law and includes Congress and other agencies that set law
▪ Judicial branch = interprets law and includes Supreme Court and federal court system
●
What is civil law vs. criminal law, vs. administrative law (and they qualify as civil vs. criminal)
o Administrative law = results when the legislative branch of a government delegates authority to
governmental agencies to create laws that meet the intent of statute (statutory laws);
administrative cases occur when a person violates regulations/rules established by administrative
law (ex. Nurse practicing without a valid license or beyond the scope of practice)
●
pg. 10
o
Civil law = recognizes/enforces the rights of individuals in disputes over legal rights or duties of
individuals in relation to one another; the party (person(s)) deemed responsible for the harm
caused are required to pay compensation to the affected/injured party (person(s)) (think Judge
Judy or The People's Court). the party judged responsible for harm may be required to pay
compensation to the injured party. In contrast...
o
Criminal law = public concerns regarding an individual's unlawful behavior that threatens society
such as murder, robbery, kidnapping, or domestic violence; the criminal court both defines what
is considered a crime and the appropriate punishment in doing so, within limits set by legislative
bodies and Constitution
What is the role of the state board of nursing? (HINT: it’s administrative/limited)
o Responsible for enforcing the nursing practice acts in the various states; publicizes rules and
regulations that expand the law; regulatory body that oversees the Nursing Practice Act
o Regulate nursing to protect the public from harm by unprepared or incompetent practitioners
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o
Limited: It can adopt rules that clarify general provisions of the nursing practice act, but it does
not have authority to enlarge the law (e.g. We cannot write an Rx for narcotics in California, but
in Florida they are allowed to)
●
What is the Nurse Practice Act and what is their scope/responsibility?
o Defines the practice of professional nursing (what the nurses can/cannot do)
o Sets the minimum educational qualifications and other requirements for licensure
o Determines the legal titles and abbreviations nurses may use
o Provides for disciplinary action of licensees for certain nurses (i.e. probation, license revocation,
suspension)
o The nursing practice act of the state in which nurses practice is statutory law affecting nursing
practice within the bounds of that state (ex. An RN working in California falls under the nursing
practice act of California despite having a home address in Texas)
●
What is the NCSBN and what is their role?
o National Council of State Boards of Nursing establish a comprehensive/model or document
(NCSBN's Model Nursing Practice ACT) to guide individual states' development and revisions of
their nursing practice act
▪ Standard toward which states may strive and a reflection of the current and changing
regulatory and health care system environments
▪ NCSBN and ANA (American Nurses Association) have fostered development of more
consistent standards across state lines, and provided increased protection for the public
●
What are 3 ways the state boards of nursing have power?
o Executive = authority to administer the nursing practice act
o Legislative = ability to adopt rules necessary the implement the act (rules are different from laws
where laws are made by the state's legislative body)
o Judicial = authority to deny, suspend, or revoke a license or to discipline a licensee or to deny an
application for licensure
●
Know GENERALLY about the NCLEX-RN exam
o Following completion of nursing education from a state-approved school of nursing, a person
may sit for the NCLEX-RN (National Council Licensure Examination for Registered Nurses)
o It is an adaptive test in which level of difficulty varies based on whether you answered the
previous question correctly; minimum number of questions is 75, and maximum number is 265,
and you have 6 hours to complete it
o Test stopping at 75 questions does not indicate whether or not you passed/failed; it indicates
that you either clearly passed with the minimum number of questions or clearly failed
o Updated regularly and tests critical thinking and nursing competence in all phases of the nursing
process
●
What is the role of delegation and how is it done properly?
o Role of delegation is giving someone authority to act for another; LPNs/LVNs cannot have the
authority to delegate (since they are not state licensed)
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o
o
▪ Example: RN asking a CNA to take vitals for charting
Done properly when the RN determines that the delegated person (delegatee) is competent,
safe, and legally liable to perform the delegated act and does so in a safe manner
▪ The professional nurse remains legally liable for the delegated act UNLESS the delegatee
is also a licensed professional whose scope includes the assigned act
● Example: The CNA taking the vitals for the RN can only take them and report the
vitals to the RN, the CNA cannot interpret the data (only the RN can), and the
CNA cannot reassign the responsibility to someone else
o HOWEVER, if the delegatee is also an RN, then he/she is also responsible
for carrying out the act (taking vitals in this example), and acting on them
accordingly
Five rights to ensure it is done properly
▪ Right Task (e.g. taking vitals, assisting a patient with getting up to use
commode/restroom)
▪ Right Circumstances (consider pt’s health activity, is the task complex?)
▪ Right Person (can the nurse verify that the person is competent enough to do the task?)
▪ Right Directive/Communication (did the nurse explain directions clearly?)
▪ Right Supervision/Education (can the nurse provide supervision and evaluate the
performance of the task?)
All are violated if a RN tasks meds administration to a UAP
●
What is the Patient Self Determination act of 1991? What are legal issues with it?
o Encourages patients to consider which life-prolonging treatment options they desire and to
document their preferences in case they should later become incapable of the decision-making
process (i.e. advance directive, Do Not Resuscitate order, POLST for [Physician's Orders for Life
Sustaining Treatment])
o Must:
▪ 1.provide written information to all adult patients about their rights under state law.
▪ 2.ensure institutional compliance with state laws on advance directives.
▪ 3.provide for education of staff and the community on advance directives.
▪ 4.document in the medical record whether the patient has an advance directive.
o Issues
▪ In some cases, even though pt's had advance directives in place, the directives were not
guiding end-of-life care as legislators and advocators expected
▪ Some advance directives were/are not specific enough or did not cover pertinent clinical
issues?
▪ Sometimes family members want to go against patient's wish on the advance directive in
hopes of keeping them alive despite being critically ill (added from experience, not from
the book)
●
What are ways RN’s can protect themselves from legal action?
o Practice in a safe setting = working in a place that has policies/procedures/personnel practices
that promote quality and safety and risk management (identifying/eliminating potential safety
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o
o
o
o
concerns); appropriate staffing ratio and personnel for pt's of all acuity levels; equipment in
working order; and facility provides comprehensive orientation to new employees
Communicate with other health professionals, patients, and families = ask others for clarity or a
second opinion on things such as patient assessment or medications, make sure to appropriately
document interventions, medications given, assessment findings on the electronic health record
so other providers can be on the same page regarding the patient's condition/status
Meet the standard of care = be technically competent, keeping up to date with health care
innovations, being aware of peer expectations, and participating as an equal on the health care
team
Carry/understand professional liability insurance
Promote positive interpersonal relationships = prevention of legal actions by giving personalized,
concerned care, including the patient and family in planning and implanting care, and promote
relationships that communicate caring and passion
Chapter 11
● Understand the following terms: subjective data, objective data
o Subjective Data: what you record from the patient talking about their illness and conditions such
as symptoms, theirs or their’s family needs, feels, or perception of a problem, what the patient
describes they are feeling
o Objective Data: measurable signs like vital signs, lab results, observable patient’s behavior,etc.
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Attributes of a Well-Cultivated Critical Thinker
o Raise questions and problems and formulates them clearly and precisely
o Gather and always assess relevant information
o Arrives at conclusions and solutions that are well reasoned and test them against relevant
standards
o Being Open-Minded, recognizes alternative ways of seeing problems and has the ability to assess
assumptions, implications and consequences
o Communicates effectively with others as solutions to complex problem are formulated
●
What is the nursing process? Know the steps and how to apply them
o Universal, intellectual standard and we can address/solve problems. Method of critical thinking
to solving pt’s problems in a professional practice. Conceptual framework that enables the
practicing nurse to think systematically and process information about the patient. It also
combines the “art of nursing” (creativity) with the systems theory.
▪ Assessment: gathering information or data about the individual, family or community
● Types of data (subjective, objective, spiritual, physiologic, psychologic, etc)
● methods of collecting data (patient, family members, database)
▪ Diagnosis: identifies the problems the patient is experiencing as a result of the disease
process due to human response to illness, injury or threat. Follows NANDA guidelines for
writing diagnosis code
● prioritization: relative danger to patient (life-threatening vs overall general
health); potential to cause harm or injury; related to overall health of patient
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N138 MIDTERM STUDY GUIDE
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Planning: creating and writing goals from the diagnosis using Bloom's taxonomy and
domains of learning (cognitive, psychomotor, affective)
● Cognitive: focus on knowledge and intellectual skills
● Psychomotor: deals with physical movement (e.g. pt being able to walk by ____)
● Affective: emotions, feelings, values and attitude of patient (e.g. pregnant
woman willingness to feed her newborn child)
● Goals (objectives): are statements of what is to be accomplished and are derived
from the diagnoses.
o Goals usually begins with the words, “the patient will” or “the patients
will be able to”
o Use SMART model for general direction
● Outcome Criteria: define the terms under which the goal is met, partially met or
unmet; have to consider pt’s culture as well
Implementation: occurs when nursing orders are actually carried out
● Nurse is constantly assessing the patient when carrying out the planned
interventions, noting responses to interventions and modifying the care plan.
● Documentation is extremely important: “if it wasn’t documented, then it wasn’t
observed/it didn’t happen”
Evaluation: nurse examines the patient’s progress in relation to the goals and outcome
criteria to determine whether a problem is resolved, is in the process of being resolved or
unresolved.
● may reveal data, diagnosis, goals and nursing interventions
● may indicate a need for change in care plan
● Example: evaluation revealing that things were not prioritized correctly, nursing
interventions weren’t used properly, or our goal(s) were not appropriate
●
What is the difference between a nursing diagnosis and medical diagnosis?
o Nursing Diagnosis: A clinical judgment about the client, family, or community and their response
to an actual or potential health problem;
o Medical Diagnosis: The identification of a disease condition based on specific evaluation of signs
and symptoms
●
Nursing Interventions
o Independent Nursing Intervention: nurse interventions that doesn’t require any supervision or
direction by others within their scope of practice (e.g. teaching, patient positioning)
o Dependent Nursing Intervention: requires instruction, written prescription, or supervision of
another healthcare professional with prescription authority (e.g. administering medication,
inserting an IV or Foley catheter)
o Interdependent Nursing Intervention (collaborative): therapies that require the combined
knowledge, skills, and expertise of multiple health care providers; when you plan care for patient,
review necessary interventions and determine if other health care disciplines are necessary
(rehab, pharmacy, social work)
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N138 MIDTERM STUDY GUIDE
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Protocols (comes into play with interdependent nursing interventions): define under
what conditions and circumstances a nurse is allowed to treat the patient as well as what
treatments are permissible (e.g. insulin administration and using 2 RNs to confirm)
Interventions to Reduce Health Disparities
 Assess his or her own biases and prejudices and work to eliminate them.
 Ensure availability of culturally appropriate educational resources.
 Identify cultural and health care practices that are important to cultural and ethnic identity.
 Ensure the same standards of care are followed for all patients regardless of ethnicity or culture.
 Create health promotion materials that can be disseminated to everyone in a multicultural community.
pg. 15