Professional

Caring & Ethics

Beth Torres, PhD, RN, CCRN

CJW Medical Center

Professional Caring &

Ethical Practice (20% = 30 questions)

• Advocacy / Moral Agency 3% (4 questions)

• Caring Practices 4% (6 questions)

• Collaboration 4% (6 questions)

• Systems Thinking 2% (3 questions)

– New PCCN: Informatics

• Response to Diversity 2% (3 questions)

• Clinical Inquiry 2% (3 questions)

• Facilitation of Learning 3% (4 questions)

The Synergy Model

• The core concept for the model of certified practice is the AACN Synergy Model for patient Care.

• The needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses.

• Synergy results when the needs and characteristics of a patient, clinical unit or system are matched with a nurse’s competencies

• Test questions cover application of the Synergy model, not its terminology

Assumptions of the

Synergy Model

• Patients are biological, psychological, social, and spiritual entities who present at a particular developmental stage. The whole patient (body, mind, and spirit) must be considered.

• The patient, family, and community all contribute to providing a context for the nurse-patient relationship.

• Patients can be described by a number of characteristics. All characteristics and connected and contribute to each other. Characteristics cannot be looked at in isolation.

• Similarly, nurses can be described on a number of dimensions. The interrelated dimensions paint a profile of the nurse.

Goal of Nursing in

Synergy Model • A goal of nursing is to restore a patient

to an optimal level of wellness as defined by the patient.

– Death can be an acceptable outcome, in which the goal of nursing care is to move the patient toward a peaceful death.

Patient Characteristics

• Each patient and family is unique, with a varying

capacity for health and vulnerability to illness.

• These characteristics span the health-illness

continuum.

• Patients / families bring a set of unique

characteristics to the care situation. They are:

Resource Availability ▪ Resiliency

Participation in Care ▪ Complexity

Participation in Decision Making ▪ Vulnerability

Predictability ▪ Stability

Nursing Characteristics

• Nursing care reflects on integration of knowledge, skills, experience, and attitudes needed to meet the needs of patients and families

• There are levels of expertise ranging from competent (1) to expert (5)

• Nurse characteristics are derived from patient needs. They include:

• Clinical Judgment

• Advocacy and Moral Agency

• Caring Practices

• Collaboration

• Systems Thinking

• Response to Diversity

• Facilitation of Learning

• Clinical Inquiry (Innovator / Evaluator)

Clinical Judgment

• Clinical reasoning which includes clinical decision making, critical thinking, and a global grasp of the situation, coupled with the skills required.

• Decision making: Information is assimilated, integrated, weighed and valued to arrive at the selection of a course of action from several alternatives.

• Critical thinking: Controlled purposeful, goal- directed reasoning, thinking based on evidence rather than conjecture.

Nursing

Process!

Moral Agency /Advocacy

• Working on another’s behalf and representing the concerns of the patient, family and community.

• Serving as a moral agent in identifying and helping to resolve ethical and clinical concerns.

• Advocacy: Respecting and supporting the basic values, rights, and beliefs of the critically ill patient

Source: AACN position statement

Role of the critical care nurse as patient advocate.

Caring Practices

• Nursing activities responsive to the uniqueness of the patient and the family

• Create a compassionate and therapeutic environment

• Goal of comfort and prevention of suffering

• Basic needs may be the same but the manner in which they are fulfilled depends on personal abilities, environment, and life experience.

Maslow’s

Hierarchy!

Recognizing that

Patients and Families

Come to Us in Crisis

• Crisis: An acute state of stress in which the person feels overwhelmed by stressors.

• Strategies: o Listen to the patient’s perception of the situation

o Encourage the patient to express feelings about the situation

o Help the patient to gain an understanding of the situation by discussing losses and positive outcomes

o Assist the patient in developing a viable solution

Recognizing that

Patients and Families

Have Fear/ Anxiety

• Anxiety: An acute state of stress in which the person feels overwhelmed by stressors.

• Strategies: o Listen to the patient’s perception of the situation

o Encourage the patient to express feelings about the situation

o Help the patient to gain an understanding of the situation by discussing losses and positive outcomes

o Assist the patient in developing a viable solution

Recognizing the Effect of

Powerlessness

• Perceived lack of control

• The patient’s perception that any action they take will not affect outcomes.

• Interventions: – Support the patient’s sense of control where

possible: time of bath, visitors, lights, etc.

– Assist them where they can perform activities independently

– Keep patient informed about plan of treatment

– Encourage involvement in decision making

– Increase control as condition improves

Assisting Patients &

Families at End of Life • Most Americans fear the process of dying more than death itself.

– Most would prefer to die at home

– A large percentage die in the hospital setting

• Many terminally ill patients report moderate to severe pain and discomfort during the last hours, often related to treatments / therapies such as:

– Wound care

– Suctioning

– Turning /positioning

• Patient’s desires regarding end of life care are often not known by the attending physician.

– Having an advance directive does not change the plan of care.

Assisting Patients &

Families at End of Life

• Encourage sharing concerns and fears

• Do not give false hope. Provide realistic projections by asking: – “Would I be surprised if this patient does not survive this ICU

stay?”

• As add more therapies, re-clarify patient and family wishes.

• Provide presence and compassion

• Encourage family presence

• Assure comfort measures and analgesia

Assisting Patients &

Families at End of Life What Do They Want?

• Frequent information about the patient ‘s condition

– Set up guidelines so that a family spokesperson can call for information

• Assurance

– To feel as if staff care about their loved one

– To know if they will be called if something happens

– To know they will get the best care

• Support

– To feel there is hope -- Even hope of a peaceful death

– Hope that the patient will be fully cared for

• Proximity

– To be able to see them frequently

– To be close by in a waiting room

• Comfort

– Families rank their need for comfort last

– Phones, refreshments, comfortable seating areas

Collaboration

• Working together in a way that promotes and

encourages each person’s contributions.

• Collaborative practice:

– Sharing in planning, decision-making, problem-

solving, goal- setting, and responsibility

– Coordinating

– Cooperating

– Communicating openly and respectfully

True Collaboration

• All team members master skilled communication

• Each team member embraces true collaboration as an ongoing process and invests in its development

– Team members know how unwillingness to collaborate will be addressed.

• Each team member acts with a high level of personal integrity

• Each team member demonstrates competence appropriate to his or her role and responsibilities

• Decision making authority of nurses is acknowledged and incorporated as the norm.

• Every team member contributes by giving power and respect to each person’s voice, integrating individual differences, resolving competing interests, and safeguarding the contribution of all team members .

AACN Standards for Establishing and Sustaining Healthy Work Environments

Systems Thinking

• Knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient / family.

• Helps patient / family navigate through the system.

• Anticipates their needs: • Includes care delivery models

• Outcome management

• Quality improvement

• Conflict resolution

• Managing change

Response to Diversity

• The sensitivity to recognize, appreciate and incorporate

differences into the provision of care.

• Culture: The learned, shared and transmitted values, beliefs,

and practices of a particular group that guide thinking,

actions, behaviors, interactions with others, emotional

reactions to daily living and one’s world view. – Culturally congruent care: Use of nursing interventions that

incorporate an individual’s cultural values, beliefs, and lifeways.

– Culturally inappropriate care and inattention to cultural differences may negatively affect health outcomes

– Individuals from different cultures and illegal immigrants often delay seeking medical attention because of language, cost, and cultural barriers.

Facilitation of Learning

• The ability to facilitate learning for patients/ families, nursing staff, other members of the healthcare team, and community.

• Adult learning principles: – Goal directed, less flexible

– Longer time to learn tasks

– Impatient in the pursuit of objectives

– Finds little use for isolated facts

– Strives for recognition and success

– Has multiple responsibilities, all of which compete for their time.

Adult Learners

• Experienced in the “school of life”

• Requires a more constant and ideal learning environment

• Usually comes to the learning situation on a voluntary basis

• Wishes to be involved in mutual planning of learning experiences

• Expects a climate of mutual respect, trust, and collaboration that supports learning

• Likes to participate in diagnosing needs for learning, formulating objectives, and evaluating learning.

Learning Issues for

Patients

• Physiologic instability

• Psychological factors (anxiety, pain, etc)

• Poor language or reading skills

• Sensory deficits (vision, hearing)

• Poor manual dexterity for psychomotor skills

• Attitudes and beliefs that conflict with teaching.

Clinical Inquiry

• The ongoing process of questioning and evaluating practice and providing informed practice.

• Creating practice changes through research utilization and experiential learning

• Primary goal of nursing research is to develop a specialized, scientifically based body of nursing knowledge to facilitate improvement in patient care

Research Ethics

• Protect the rights of research subjects

• Ensure the potential benefits of the study outweigh any potential risk to the subject

• Obtain informed consent from the subject

• Assure IRB review of the research

Nursing Responsibilities

in Research

• Identify problem areas and research questions for

investigation

• Assist in data collection

• Read and interpret research findings

• Assess the quality of the research and its applicability

to practice

• Apply research findings to change clinical practice

• Share research findings with peers

• Design and conduct research

During the Exam

• Read each question carefully

• Formulate your answer first

• Narrow down choices

• Spend about 1 minute per question

• Bookmark

• Trust your first instincts!