Current Issues and Trends in Practice

Current Issues and Trends in Practice

Current Issues and Trends in Practice Linda Heitman, Ph.D., APRN-CNS,BC Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obligated, at least for a spell, to identify ourselves as citizens of that other place. Susan Sontag Illness as Metaphor,

1978, p.3 Health Care Is Not As Safe As It Could Be 4% of hospitalized patients are harmed by care supposed to help Deaths per Year Medical Errors-98,000 Motor Vehicle Accidents-43,458 Breast Cancer-43,297

AIDS-16,000 Post-operative infections and other preventable complications-32,000 8% of hospitalized patients experience preventable outcomes from errors Examples of Errors Medications Surgery>wrong site Diagnostic inaccuracy>wrong treatment Transfusion error>blood type, wrong

patient Laboratory>incorrect labeling System failure>no double check Environment>failure to clean up spills Security>child abduction The Lewis Blackman Story video American Association of Colleges of Nursing

QSEN Quality and Safety Education for Nurses GOAL To prepare future nurses with: Knowledge Skills Attitudes necessary to continuously

deliver quality and safe patient care Phase I Competencies 1. Patient Centered Care 2. Teamwork & Collaboration 3. Evidenced-Based Practice 4. Quality Improvement 5. Informatics 6. Safety

Health Care Delivery in this Millennium Chronic Conditions (all ages) Acute , hospital-based care is a slice of life Use as a starting point to change trajectory of an illness (Strauss, 1970; Naylor, 2009) Person and family-centered care Focus on patients across settings

>care will be paid for across settings in bundled payments or episodes of care The Burden on Medicare Number of beneficiaries with 5 + chronic conditions increased from 30 % in 1997 to more than 50% in 2002 Thorpe & Howard,2008

AARP Pubic Policy Institute on Chronic Care Nearly 20% care recipients and 25% caregivers said transitions not well coordinated 15 % care recipients and 32% caregivers reported readmissions within 30 days of discharge 24% received conflicting information from 2 or more providers 23% reported medical errors, 61% which were major 16% endured unnecessary tests and 13% unnecessary hospitalizations

Quality and safety problems were more likely among caregivers who felt less capable IOM: Four areas where health care should be redesigned Care should be based on continuous health relationships Care should be customized based on patients needs and preferences Patients should be the source of control; and Knowledge should be shared and information should flow freely.

IOM, 2001 Important Elements of Quality Chronic Care Wagners Chronic Care Model Self-management support Community resources Organization of health care Interdisciplinary teams Decision support Clinical Information Systems AARP, 2008

Transitional Care Home to Hospital>providers operate in a vacuum Hospital to Home>research identifies problems >Pennsylvania found 40% of readmits related to medications: 6 out of 10 preventable Hospital to Nursing Home> critical information missing. Nursing Home to Hospital>Up to half of

patients were lacking medical history, care plans and treatment wishes resulting in Patient Reported Problems with Transitions Loss of mobility and/or independence Uncertain expectations for recovery and/or prognosis Pain Anxiety Not remembering their clinicians instructions

Feeling abandoned Many patients and caregivers felt the ball was dropped after discharge Promising Models Medical (Health) Homes Home Health Care with House Calls Transitional Care Services Accountable Care Organizations Bundling Payments for Care Pay for Performance Nurse-Managed Clinics

Integrated EHR Systems Alerts about abandoned test results or other findings that need to come to the attention of a provider Clinical decision support tools such as linkage to protocols related to patient problems A centralized mechanism for access from different locations and institutions Efficient use of storage space for patient data Instantaneous retrieval of information by several people at the same time Aggregation of data to assess quality

measures Suggested Research Target Populations Cost Implementation Comparative Effectiveness Research Patient and Caregiver Research Health Care Policy Use in Practice: What we know from Science

10-20 years to get scientific findings incorporated into practice Efforts by federal government and professional organizations >Synthesis of evidence, including research evidence >Formulation of guidelines

>Dissemination of guidelines Professional Accountability. Nothing but our BEST will do. Current Issues and Trends in Education Brenda P. Johnson, PhD, RN Population Shifts & Complexity of Care Aging/ Chronicity/Acuity of Illness

Outcome Driven Reimbursement /Quality and Safety .several of he CMS hospitalacquired conditions are highly nurse-sensitive (Stage III & IV pressure ulcers, nosocomial infections, and falls) 85% of new BSN graduates are employed in acute care Increasing the number of BSN graduates in acute care decreases patient mortality rate and improves quality of care (Aiken, 2003) Interprofessional & International

Trends Occupational Therapist required to have a masters degree for professional licensure O.T. assistant required to have an Associate Degree Physical Therapist required to have a masters or doctorate for professional licensure (>90% of 210 accredited programs offer the DPT degree; 75%

of 2008 graduates had the DPT) P.T. assistant required to have an Associate Degree Growing international trend for BSN AACN Vision for entry into practice 2/3 of nursing workforce to hold BSN or graduate degrees by 2010(currently 45%) BSN identified as providing soundest foundation in the sciences and arts for

addressing the complex health care needs in a system of higher acuity and older patients with co-morbid conditions as well as a base from which nurses move into graduate education and advanced nursing roles. National Advisory Council on Nurse Education & Practice Currently more than 230 accelerated/2cnd degree BSN programs in U.S. 600 Rn-to-BSN programs 161 RN-to-MSN programs in U.S

AACN Vision -masters level generalist Masters programs to prepare generalist practitioner recognized by the credential CNL with role emphasis on improving patient safety Evaluating patient outcomes Cohort risks Changing plan of care Interprofessional teamwork Currently more than 88 masters CNLprograms in

U.S AACN Vision for Advanced Practice By 2015 ALL population specific specializations CNS, NPs (FNP, GNP, ANP), midwives, and anesthetists will be at doctoral level and recognized by credential DNP

(AACN, 2004) Expected roles are : Direct-care practitioners Executives and directors of clinical programs and quality initiatives

Clinical faculty positions Currently more than 200 DNP programs in U.S. Enrollment in DNP/PhD Programs Past 5 years E Projections for develop ment of future DNP pro grams

AACN Consensus Model ( for APRN Education (January, 2010) APRN education programs will be transitioned by 2012 and State Boards of Nursing will have regulation that reflects the model by 2015 Certification exams will be revised by 20122013 to reflect new model. All APRN (CNS and NP) education programs must prepare graduates for one of the four APRN roles and at least one of six populations (neonatal, gender specific,

pediatrics, adult-gerontology, psych/mental health, or across the lifespan) Model can be accessed at Preparing for an Aging Population All current NP or CNS programs preparing individuals to provide care to the adult populations must provide full complement of competencies for the entire adult population (young adult, older adult, and frail elderly). Adult Health CNS

Acute and Critical Care CNS-Adult Adult NP Gerontology NP Adult Acute Care NP JAHF/AACN Initiative (2009, 2010) Given the complexity of care, growth of information and biomedical technology, an aging and increasingly

diverse population, and worsening disparities in care, the need for a DNP program to prepare clinicians to fill the growing societal need for expert clinicians is timely and necessary. The DNP is the natural evolution and needed expansion of existing clinical degrees in nursing: the basic BS and the site-specific MS. Columbia University School of Nursing The DNP is an outgrowth of the increasingly complex role that

advanced practice nurses must play today. They arent just taking care of individual patients or groups of patients, but working in a system that requires them to understand policy, economics, and quality and safety issues, all topics that warrant preparation at the doctoral level. Dr. Anne Belcher, Johns Hopkins School of Nursing AACN Vision for Academia & Research PhD and DNS/DNSc as required

preparation for academic and research positions Small percentage of those with DNP preparation may move into a full faculty role and will also need to complete a PhD program (much as would an MD moving into an academic/research role requiring a PhD). Transforming Nursing Education to Meet National Goals for Quality and Safety Quality and Safety Education for Nurses (QSEN)

adapted IOMs 6 competencies (patientcentered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics) for nursing. Knowledge, Skills, and Attitudes (KSAs) developed for pre-licensure nursing education. Sample educational strategies at Challenges and Opportunities Transforming nursing education to

fit with the new roles and a team approach to care. Educating students so that they can learn to adapt . Teaching about the health care system and the political, social, financial context within which care is delivered. Collaborating with clinical partners to teach students how systems report outcomes, analyze adverse

What knowledge, skills, and attributes do nurses and midwives require to take a central role in the design and delivery of services? What would you like to see nurses and midwives doing more of and/or doing differently in the future whether in peoples own homes, in the community, or in hospital? What might be preventing nurses and midwives from doing this now? How can these barriers be overcome?

What is the potential for/benefits of nurses and midwives leading and managing their own services, and what frameworks and support are needed to achieve this? Nurses and midwives are responsible for so much of what we have achieved over the last 10 years. They are experts who know best how the service can meet the needs of patients and their local communities. We must be bold in putting nursing in control and at the heart of our plans

for a world-class NHS. Gordon Brown, Prime Minister of Great Britain, March 10, 2009 Then and Now. No man, not even a doctor, ever gives any other definition of what a nurse should be than this devoted and obedient. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.

I think ones feelings waste themselves in words; they ought all to be distilled into actions which bring results. Florence Nightingale 1859

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