Reflective journal

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Module 4

Chapters 11, 18, 19:

Evidence-Based Practice, Ethical & Legal and Ethical Considerations

Evidence-Based Practice

Chapter 11

Evidence-Based Practice

  • The objective of integrating evidence-based practice (EBP) with nursing care is to empower the nurse to become a component consumer of research
  • What is evidence-based practice?
  • Integration of the best available evidence, combined with clinical expertise, enabling health practitioners of all varieties to address health care questions with an evaluative and qualitative approach

Evidence-Based Practice

  • Overall aim of EBP
  • To standardize practice by maximizing good practice, reducing costs, and improving quality of care
  • To integrate the best available research and clinical expertise in the context of patient characteristics, culture, and patient preferences and values
  • To use a problem-solving approach to nursing practice, involving conscientious use of current best evidence in making decisions about patient care

Evidence-Based Practice

  • Defining attributes
  • Three key features unique to evidence-based practice
  • Problem solving in its approach, which takes into account the clinical experience of the nurse
  • Combines researched evidence with knowledge and theory
  • Allows for patient values to be expressed and incorporated in treatment regimens

Putting Evidence-Based
Practice to Work

  • Five-step process forms the basis for the integration of clinical evidence and nursing practice
  • Step 1: Construct a relevant, answerable question from an identified clinical concern
  • Step 2: Search the literature for the best external evidence that addresses the clinical concern
  • Step 3: Critically appraising the evidence for validity and applicability
  • Step 4: Applying the evidence to your clinical concern
  • Step 5: Evaluate your performance

Getting Started

  • Step 1: Construct a relevant, answerable question from an identified clinical concern case
  • PICO
  • P- Patient Population, or Problem
  • I- Issue of Interest
  • C- Comparison of intervention
  • O- Outcome to be measured or achieved.

  • Example: Does handwashing among healthcare workers reduce hospital acquired infections?

Getting Started

  • Clinical question categories
  • Diagnosis
  • Therapy
  • Harm or etiology
  • Prognosis
  • Prevention
  • Qualitative

Getting Started

  • Search the literature for the best external evidence
  • Track down the evidence
  • MedLine
  • HealthStar
  • The Cochrane Library
  • National Guideline Clearinghouse
  • Agency for Healthcare Research and Quality (AHRQ)
  • CINAHL
  • PubMed

Evaluating the
Strength of a Study

  • Studies are assigned a level of evidence based the quality, validity, and applicability
  • Level 1 Evidence: represents the most valid reports addressing patient-oriented outcomes
  • A level 1 ranking also indicates that specific quality criteria were met based on the study type

Level of Evidence

  • Level 2 Evidence: addresses patient-oriented outcome and uses some method of scientific investigation
  • Level 2 evidence implies an association rather than reliable evidence (EXAMPLE: hormone replacement therapy was associated with reduced cardiovascular problems)
  • Level 3 Evidence: represents reports that
    are not based on scientific analysis of
    patient-oriented outcomes

Limitations of
Evidence-Based Practice

  • The evidence
  • Accessibility
  • The end user (nurse) may have inadequate access to clinical researched evidence and guidelines
  • Large volume of research to sift through
  • The research language
  • Complex data retrieval systems
  • The individual
  • Resistant to change

Limitations of
Evidence-Based Practice

  • The health care system
  • Systemic barriers such policies, procedures, and financial accountability
  • Physician idiosyncrasy vs. Disciplined inquiry
  • Cost/benefit issues
  • Bureaucratic structures

Limitations of
Evidence-Based Practice

  • Nursing
  • Split between education and service
    (lack of time)
  • Lack of consensus about nursing responsibilities
  • Lack of communication among nurses and researchers
  • Lack of skills in locating, reading, and appraising nursing research data
  • Lack of organizational support

Reference

  • Claywell, L. (2009). LPN to RN transitions (2nd ed.). St. Louis, MO: Mosby Elsevier.

Disclaimer: This Microsoft PowerPoint Presentation was created by and is owned by Mosby Elsevier. This PowerPoint was edited to fit the needs of MPI. All content is to be credited to Lora Claywell, the author and Mosby Elsevier, the publishing company.

Ethical and Legal Considerations

Chapter 18

Ethical and Legal Considerations

  • Nursing ethics
  • Autonomy
  • Veracity
  • Role fidelity
  • Beneficence
  • Nonmaleficence
  • Confidentiality
  • Justice

Ethics and Culture

  • Culturally competent nursing care is the integration of knowledge, attitudes, and skills
  • Culturally competent nursing care means that the nurse is able to work within the specific cultural context of an individual, family, or community

Ethical Dilemmas

  • Moral development refers to how an individual learns to handle moral dilemmas
  • An ethical dilemma exists when a conflict arises between health care professionals, patients, families, health care professionals, and health care organizations

Ethical Dilemmas

  • The Code of Ethics for Nurses provides a framework for ethical analysis and decision making, is nonnegotiable, and is applicable to all practice settings and a variety of nursing roles

Theories for Ethical
Decision Making

  • Virtue ethics
  • The ethic of care
  • Deontology
  • Utilitarianism

Theories for Ethical
Decision Making

  • Virtue ethics
  • Focused on one’s characteristics, traits, and virtues
  • Courage, integrity, honesty, justice, and temperament
  • The ethics of care
  • Emphasizes the caring aspect of the nurse-patient relationship
  • Intuition, preventing and avoiding harm, and fairness

Theories for Ethical
Decision Making

  • Deontology (Kantian ethics)
  • Duty-oriented theory for ethical decision making
  • Morality of an action should be based judged based on the motive and intent behind the action. The consequences (positive or negative) do not impact the morality of the action
  • Utilitarianism (consequentialism)
  • One’s actions must be judged by the consequences
  • Only actions that produce the greatest good should be performed

Ethical Decision Making

  • Eight-step model
  • Gathering relevant information
  • Stating the practical problem
  • Identifying the ethical issues and questions
  • Selecting the ethical principles and/or theoretical frameworks to be considered
  • Conducting an analysis and preparing a justification

Ethical Decision Making

  • Eight-step model
  • Considering one or more counterarguments
  • Exploring the options for action
  • Selecting, completing and evaluating the action
  • Bioethics committees
  • Multidisciplinary group that serves as a resource for staff, patients, and families in resolving ethical dilemmas
  • Promote, advocate and protect patient rights, moral care standards, and enhance patient care

Issues in Law

  • Sources of law
  • Common law
  • Court-made decisions, based on judicial decisions
  • Administrative law
  • Congress delegates agencies of duty to make decisions
  • Ex: Centers for Medicare Services (CMS)
  • Statutory law
  • Constitutional and federal laws that take precedence of state laws
  • Ex: the United States Constitution

Issues in Law

  • Legal principles
  • Justice
  • Confidentiality and the right to privacy
  • Patient rights
  • Informed consent
  • Assault and battery

Issues in Law

  • Malpractice
  • Medical malpractice is professional misconduct, failure to perform professional duties, or failure to meet the professional standards of care that results in harm to another
  • Professional negligence
  • Intentional torts
  • Negligent torts
  • Torts where strict liability is enforced

Issues in Law

  • Malpractice
  • Four elements must be present for a person to recover damages suffered as the result of a negligent act
  • Duty to Care: An obligation exists to conform to a recognized standard of care
  • Breach of duty: There must be a failure to adhere to an obligation and a deviation from a recognized standard of care
  • Injury: Actual damages have occurred
  • Causation: The injury was foreseeable, caused by a breach of duty, and the conduct was the cause of the injury

Issues in Law

  • Negligence
  • Three basic forms of negligence
  • Malfeasance: act of performing unlawful act
  • Misfeasance: improper performance of an act
  • Nonfeasance: failure to act where a duty exists

Common Negligent Acts

  • Failure to appropriately assess
  • Failure to monitor in timely manner
  • Failure to use appropriate equipment
  • Failure to document observations
  • Failure to notify physician
  • Failure to follow orders
  • Failure to follow 6 rights of medication administration

Patient’s Bill of Rights

  • Include but not limited to:
  • Ability to see their own health record
  • Ability to update their own health record
  • Choose how to receive their health information
  • Choose who can receive their health information
  • Privacy/ confidentiality of information r/t HIPAA
  • Statutes require the reporting of communicable diseases, certain psychiatric illnesses, and HIV

Potential Breach of Patient Confidentiality

  • Displaying information on computer screen
  • Discussing patient information in public
  • Not discarding patient health information (PHI) papers appropriately
  • Faxing to unauthorized persons
  • Texts, emails, phone calls, pages that are not secure

Question

A patient was just admitted to the labor and delivery unit. The nurse is assessing the patient and completing her comprehensive initial assessment. The nurse trusts that the patient is exercising which ethical principle when answering the nurse’s questions?

Role fidelity

Nonmaleficence

Autonomy

Veracity

Question

  • A critically ill patient tells the nurse that he does not want CPR performed if he were to go into cardiac arrest. Later the patient’s estranged sister tells the nurse that they must do everything they can to save her brother’s life if it comes to that. Which is the best resource for the nurse?

A. The Joint Commission

B. National Board of Nursing

C. The hospital’s bioethics committee

D. Medical director

Reference

  • Claywell, L. (2009). LPN to RN transitions (2nd ed.). St. Louis, MO: Mosby Elsevier.

Disclaimer: This Microsoft PowerPoint Presentation was created by and is owned by Mosby Elsevier. This PowerPoint was edited to fit the needs of MPI. All content is to be credited to Lora Claywell, the author and Mosby Elsevier, the publishing company.

Putting It All Together

Chapter 19

Putting It All Together

  • Use the nursing process to assist you in reflecting on your journey thus far
  • Assessment
  • Critical reflection
  • Making the diagnosis
  • Planning
  • Implementation
  • Evaluation

Reference

  • Claywell, L. (2009). LPN to RN transitions (2nd ed.). St. Louis, MO: Mosby Elsevier.

Disclaimer: This Microsoft PowerPoint Presentation was created by and is owned by Mosby Elsevier. This PowerPoint was edited to fit the needs of MPI. All content is to be credited to Lora Claywell, the author and Mosby Elsevier, the publishing company.