Evidence-Based Practice and Patient-Centered Care Study Guide, Exams of Nursing

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Role & Scope Exam 2 Study Guide (NUR 2868)

EVIDENCE BASED PRACTICE:

What is it?

EBP : the integration of individual clinical expertise, built from practice, with the best available clinical

evidence from systematic research applied to practice

How does research improve practice guidelines?

Research : A systematic investigation to determine the truth or falsity of a hypothesis, or to validate and

refine existing knowledge and generate new knowledge

What sources can help nurses use EBP?

 Agency for Healthcare Research and Quality (AHRQ) evidence-based practice: www.ahrq.gov/

 Centre for Evidence-Based Medicine (CEBM): www.cebm.net

 The Cochrane Collaboration: www.cochrane.org

 Cochrane Database of Systematic Reviews (CDSR):

 www.cochrane.org/cochrane-reviews/cochrane-database-systematic-reviews-numbers

 Centre for Evidence-Based Medicine Toronto: www.cebm.utoronto.ca

 Centre for Reviews and Dissemination (CRD): www.york.ac.uk/inst/crd

 Database of Abstracts of Reviews of Effects (DARE)

 Health Technology Assessment (HTA) Database

 NHS Economic Evaluation Database (EED)

 Guidelines International Network: www.g-i-n.net/

 International Council of Nurses: Closing the gap: From evidence to action:

www.icn.ch/images/stories/documents/publications/ind/indkit2012.pdf

 National Guideline Clearinghouse: www.guideline.gov

 National Institute for Health and Clinical Excellence: www.nice.org.uk

 National Institute of Clinical Studies: www.nhmrc.gov.au/nics/

 Primary Care Practice-Based Research Networks: pbrn.ahrq.gov

 Scottish Intercollegiate Guidelines Network (SIGN): www.sign.ac.uk/

Domain Intended use

.com Mainly for commercial entities, but unrestricted

.org Originally for organizations not clearly falling

within the other gTLDs, now unrestricted

.net Originally for network infrastructures, now

unrestricted

.edu Educational use, but now primarily for US third

level colleges and universities

.gov Governmental use, but now primarily for US

governmental entities and agencies

.mil Military use, but now primarily for US military only

What role does technology play in promoting EBP?

Who should use EBP? How can nurses get others involved in using it?

What is the function of the ANA? How can nurses utilize its web and literature contents?

Concerned with the quality of nursing practice in the daily health-care setting. Develops standards for

the profession.

The major purposes for the existence of the ANA, as stated in its bylaws, include improving the standards

of health and access to health-care services for everyone; improving and maintaining high standards for

nursing practice; and promoting the professional growth and development of all nurses, including

economic issues, working conditions, and independence of practice.

Why do some nurses resist using research or EBP?

Late Majority : skeptics who do not adopt something unless there is pressure. Feel safe when there is

limited uncertainty.

Laggards : most secure in holding on to the past. Most comfortable when an idea cannot fail.

How does the aging of the American population impact health care delivery?

PATIENT CENTERED CARE:

What is the significance of the report Crossing the Quality Chasm?

Identified 6 major aims in providing healthcare:

 Safe

 Effective

 Paitent-centered

 Timely

 Efficient

 Equitable

Moved care from discipline-centric foci to patient-centered foci

Reinforced the disparities that occur within health care, which, in turn, led to a focus on best practices

(and reinforced the need to be patient centered)

Addressed issues such as healing environments, evidence-based care and transparency, which led to a

more holistic environment that was built on evidence and that was transparent

What is patient centered care? How can nurses be sure patients’ needs are met?

How can the nurse assure that multidisciplinary needs are met for the patient?

Understand the effects of culture and language on the provision of patient centered care.

ADVOCACY:

Understand the premises of Patient Centered Care and the RN’s role in providing it.

How do nurses advocate for their patients?

What are the primary goals of the Affordable Care Act?

Legislation aimed at increasing access to uninsured Americans to quality, affordable care while reducing

costs of unnecessary services

Goals:

 Make affordable health insurance available to more people. The law provides consumers with

subsidies (“premium tax credits”) that lower costs for households with incomes between 100%

and 400% of the federal poverty level.

 Expand the Medicaid program to cover all adults with income below 138% of the federal poverty

level. (Not all states have expanded their Medicaid programs.)

 Support innovative medical care delivery methods designed to lower the costs of health care

generally.

What is the function of the Parish Nurse?

Parish nursing is viewed as a healing ministry, and parish nurses are attuned to spiritual issues raised by

health transitions and the healing nature of spiritual practice. They may assist people to remain in their

own homes, connect them with other health services for which they are eligible, or provide needed

health teaching and support. At times their role is simply to be present with them.

What is the nurses’ role in effecting changes in health policy?

Why should nurses contact legislators?

How can a nurse become involved in political advocacy?

What are the 3 legislative branches? What are their responsibilities?

Executive : at the federal level, the executive branch consists of the president, vice president, cabinet,

and various executive administrative bodies. Only the president and vice president are elected by the

people.

Judicial : the judicial branch is the court system. It is important to note the distinction between federal

court, state court, and local court; appeals and supreme courts are found at both levels. At the federal

level, there is the Supreme Court, federal courts of appeal, and district or circuit courts. At the state

level, there are supreme courts, appeals courts, and the lower courts.

Legislative : the primary function of the legislative branch of government is the formation of policy by

making laws. At the federal level, the legislative branch of government consists of the House of

Representatives and the Senate. Each state also has a legislative branch of government

What are the Nurse Practice Acts? Where are they found?

Nurse Practice Act : part of state law that establishes the scope of practice for professional nurses, as

well as educational levels and standards, professional conduct, and reasons for revocation of licensure.

Each state has its own Nurse Practice Act

Which organizations can help nurses gain more power in their practice?

The National League for Nursing (NLN) and the American Nurses Association (ANA) are the two major

national organizations that represent nursing in today's health-care system. The NLN is primarily

responsible for regulating the quality of the educational programs that prepare nurses for the practice of

nursing, whereas the ANA is more concerned with the quality of nursing practice in the daily health-care

setting

CLINICAL JUDGMENT AND DECISION MAKING:

Review the steps of the Nursing Process. How are they applied to Leadership, Management, & Clinical

Judgment? How is it similar to Critical Thinking?

“ADPIE”: assessment, diagnosis, planning, implementation and evaluation

What is the decision making process? How important is it to first identify the problem?

Anything previously tested is possible to appear again!

Review the various types of Leadership.

Review the principles of Delegation and Prioritization.

Review ethics, ethical behavior, and values.

Review Quality Improvement.

Review pharmacologic principles.

MODULE 4:

M o d u l e 0 4 - E v i d e n c e - B a s e d P r a c t i c e

What Is Evidence-Based Practice and Why Is It Important?

By this point in your program, you must have read dozens of nursing articles, based on research done by other professional nurses. Hopefully, you were able to find articles that interested you, and not just those required for your courses. Have you ever wondered about something that could be changed in nursing? Have you ever asked yourself what could be done differently in a given situation? Those questions are often the bases for research which leads to changes in practice. That is how Evidence Based Practice comes into being. Evidence-based practice (EBP) is an organized method for clinical decision making to provide the most effective care to patients. EBP uses current research findings that define best practices, clinical knowledge, proficiency and expertise, and values to optimize patient outcomes as well as their quality of life (Yoder-Wise, 2011). Research is typically defined as generation of new knowledge; EBP is a priority for all health care providers in order to ensure patient safety. EBP promotes the use of effective strategies to help patients be well. It also helps nurses prevent harm to their patients, to themselves, or to the global community. Florence Nightingale is considered the first person to use research in nursing to elevate it to the status of a profession (Catalano, 2009). Simple sanitary practices, such as hand washing, were promoted by Nightingale and became commonplace in modern society. The ANA Code of Ethics for Nurses directs that the nurse participates in advancement of the profession through contributions to practice, education, administration and knowledge development. Because of this, all nurses need to be aware of how to conduct and use research. The desire to achieve low-cost, high-quality and safe care generates the need for evidence-based practice (EBP). It has been said that there is a gap of approximately 17 years between new nursing research and clinical usage of that knowledge (Yoder-Wise, 2011). Many times, evidence which has been proven through research does not make it to the bedside in a timely fashion. Consider the method of

Foley insertion: To test the balloon or not? How about NG tube placement? Why are we still using the stethoscope to test placement when the research has proven that the pH method is best? The Institute of Medicine (IOM) has called for nurses to be educated in EBP. The IOM's recommendation is that all health care professionals be able to do the following:  Know where and how to find the best possible sources of evidence  Formulate clear clinical questions  Search for relevant answers to those questions from the best possible sources  Determine when and how to integrate those findings into practice (Yoder-Wise, 2011)

Research in Evidence-Based Practice

For research to be translated into practice, it needs to reach not just the nurse, but also nurse leaders, managers, and administrators in an institution, as well as policymakers who can provide the support necessary for the implementation of research results (Yoder-Wise, 2011). Clinical nurse specialists are a valuable asset to provide connections from research to practice. Nurses need to be aware of several critical steps in evidence reports when attempting to integrate EBP into their care. The first part of the report should include a structured summary statement of the problem, practice, or disease that describes what is in the evidence report. The second part should comprise a lengthy and detailed analysis of the published and unpublished data, including reviews of articles and reports, the populations included in the studies, and the nature of the nursing actions investigated. The third, and important, is the ranking of such evidence. After gathering that information, the nurse must now ask the following:

1. Is this the best available evidence? Look for sources that are peer-reviewed and no more than 5 years old.
2. Will the recommendations work for my practice given the client population and problems? If the study population is of the elderly and the nurse's primary work is with children, the information may not be applicable.
3. Do the recommendations fit well with the preferences, needs, and values of the clients I serve? If the values of the nurse's primary group vary greatly from those of the study group, it is likely the recommendations may not work well (Catalano, 2012).

How Can You Conduct and Use Research to Improve Nursing Care?

Several strategies can help nurses conduct and use research for the improvement of nursing care. Attending conferences and poster presentations in which clinical research findings and ideas for practice are presented is an excellent way to quickly view the findings and network with the researchers. Other strategies proposed include conducting research via textbooks and procedure manuals, connecting research use to a facility's goals, developing committees between colleges and hospitals, and inviting nurses to present during routine meetings and conferences. Technology makes the location of and the dissemination of the research possible and necessary. The goals of EBP include cost-effective practice based on the data produced by research, the dissemination of data, and the implementation of best practice interventions into the nurse's practice. EBP is problem based and within the scope of the practitioner's experience, and it is concerned with quality of service and care. It requires the utilization of collaboration and teamwork across the professional spectrum, and clinical recommendations evolving from this process present the nurse with sound decisions based on best evidence (Catalano, 2012). Associate Degree nurses (A.D.N.s) are expected to be able to demonstrate an awareness of the value of research by becoming knowledgeable consumers of current information and by helping identify problems within their scope of nursing practice that may warrant exploration. Are you ready to be that nurse? If not, why not start today by researching a nursing topic of interest to you?

MODULE 5:

M o d u l e 0 5 - C l i n i c a l J u d g m e nt a n d P a t i e n t - C e n t e r e d C a r e Nurses use examples of clinical judgment in everyday activities. How did you know which size IV catheter to insert in your patient last night? How, when you assessed that Stage IV pressure ulcer, did you determine that it was improving? You used knowledge of past experiences, remembered your lab and clinical instructor's lessons, assessed the current patients' situations; you used clinical judgment in both situations!

What Is Clinical Judgment?

The concept of clinical judgment basically refers to interpretations and inferences that influence actions in the clinical setting (Nielsen & Lasater, 2013). To use judgment, one needs to form an opinion (an inference, interpretation or discernment) and apply it to the current clinical picture. A lot of experience helps but even in first time situations, nurses can judge the scene and apply the correct decisions. How? A related term, clinical reasoning, is the thinking process by which a nurse reaches a clinical judgment. It is defined as a way of noticing, interpreting, and responding to the patient and how the patient responds to treatments and interactions (Nielsen & Lasater, 2013). The complexity of nursing judgment requires that the nurse recognize the unique status of the patient, including a deep understanding both of the clinical situation and of the nurse's contribution to the patient care situation. Every patient and each nurse are different, and will respond differently to given situations.

Two Approaches to Clinical Judgment in Nursing

There are two approaches to clinical judgment in nursing.

Standards-based Approach

A Standards-based approach puts the nurse and the needs of the patient outside the caregiving situation, rather than situating the specific patient issue in a context of care. Decision making from this perspective involves selection from options of mutually exclusive possibilities, implying that there is one right decision. This approach often involves use of maps, decision trees, and policy and procedure manuals. These guides provide clear-cut direction that may standardize approaches to patient care within an institution and may be important to general patient care quality.

Interpretivist Approach

The Interpretivist approach originates from the belief that life experiences are culturally bound, that individual patients will interpret these experiences on the basis of their culture, and that one set approach is often not right for all patients. Because nursing care is not linear, and in many situations there are many uncertainties, approaches that consider multiple factors in clinical reasoning are often more appropriate. There are often no clear-cut answers about what to do in nursing. The influence of an individual patient changes circumstances of care, so clinical judgments by nurses become very specific to a given patient care situation. Interpretivist approaches bring the nurse to the sphere of the patient centered care, and account for what the nurse personally contributes to the caring encounter, including previous experiences, values, and emotions (Nielsen & Lasater, 2013). Nurses also need to determine how to establish priorities for solving problems. The problem-solving process is a dynamic one. Nurses can certainly follow the above steps for solving some problems, but a team based and patient centered approach is more likely to be successful.

Three Attributes of Clinical Judgment

There are, according to Nielsen & Lasater, three attributes used to understand the concept of Clinical Judgment. They are:

1. Holistic view of the patient situation : This is a willingness to consider all factors involved in patient care, including certain characteristics of the patient (as well as the nurse).
2. Process orientation : This requires an understanding of the individual patient situation and a nurse's own personal background, experience, and values. Each is unique and brings different backgrounds to the caregiving situation. The nurse notices features of a situation based on these factors and intervenes. The nurse observes the patient response and comes to understand what the next steps should be.
3. Reasoning and interpretation : At least 3 types of reasoning are required, and they are analytic, intuitive, and narrative. In unfamiliar situations, the nurse tends to rely on analytic reasoning processes, consider the options, and come to a solution. The expert nurse may recognize a situation immediately and act intuitively and tacitly, but the novice nurse typically relies on analytic reasoning. Some nurses formulate their reasoning in narrative form, that is, they use tales of the patient's prior experience with illness to engage in interventions based on understanding of the patient's needs.

Problem Solving

Several models of problem solving exist. A traditional approach is outlined by Yoder Wise (2011) and requires the nurse to (1) know the facts, (2) separate the facts from interpretation, (3) be objective and descriptive, and (4) determine the scope of the problem. Does some of this look familiar? Perhaps the problem solving process and the nursing process have more in common than first believed! Look more closely:  Assess the problem: Collect and record data to provide the information needed.  Diagnose and Identify Outcomes: Clarify realistic outcomes and identify problems, risks, or issues.  Plan : Make certain that there is a realistic, attainable, measurable patient-centered goal.  Implementation (Interventions): Put the plan into action.  Evaluation : Where does the patient stand? Has the goal been achieved? Does it need revision? Another way to look at it is through critical thinking. If you add your critical thinking skills (reasoning gained outside of the clinical setting) and add it to your critical reasoning skills (gained inside the clinical setting), you'll have a complex thought process of problem solving and patient centered care (Alfaro- Levre, 2013). Add your past experiences, your intuition, your culture, your morals and ethics, and combine them with your patient's situation; you'll soon be thinking like a nurse! Clinical judgment, or thinking like a nurse, does require a lot of clinical knowledge and some layers of thinking (Nielsen & Lasater, 2013). As you may have guessed, clinical knowledge and experience provides the nurse with the background needed to recognize patterns and therefore differences when they occur in patients. As you, the nurse, become more experienced, clinical judgments will become more intuitive, and soon you'll be recognizing those patterns and grabbing on to the meaning of clinical situations as they present themselves. M o d u l e 0 5 - C l i n i c a l J u d g m e nt a n d P a t i e n t - C e n t e r e d C a r e

What Exactly Is Patient-Centered Care?

You've heard, and possibly have used, the phrase "patient-centered care" many times over the past year. But what is it, really? If care is truly patient-centered, shouldn't it be what the patient wants, whenever he wants it? One can define patient centered care as a focus on the patient and the individual's particular health care needs. That makes is sound simple, doesn't it? But the goal of patient centered care is not quite so simplistic; it requires the empowerment of patients to become more active in their plans of care. This means that providers must develop great communication skills and help the patient understand and advocate for himself. Care which was once directed by the physician must now be rendered with the patient rather than to the patient, with the emphasis of said care being on what is provided - not who controls the decision about the care (Yoder-Wise, 2011). According to the Agency for Healthcare Research and Quality (AHRQ), Health care has been evolving away from a "disease-centered model" and toward a patient-centered model (Stanton, 2002). In the past, the disease-centered model had doctors making almost all treatment decisions. Now, in a patient- centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals. When the Institute of Medicine (IOM) published Crossing the Quality Chasm in 2001, it established six aims for health care improvement, three of which was that patient care must be safe, effective, and patient-centered. That report went on to acknowledge things that nurses commonly value, such as the idea of a healing environment (think Florence Nightingale), individualized care, autonomy of the patient in making decisions, evidence-based decision making, and the need for transparency (Yoder-Wise, 2011). It also stated that all health care professionals should be educated to deliver patient centered care and provided the impetus for payment methods being based on quality outcomes. What better way to measure quality outcomes than by patient satisfaction? By establishing a connection with the patient and his or her family, we can help foster patient centered care. Understanding the culture and diversity of each individual client can help us develop plans of care which are truly client-focused. These plans of care should be based on sound use of the Nursing Process and utilize therapeutic communication skills, respect, and realization of patient preferences. Keeping an

awareness of the patient's individual life experiences, his responses to previous health care situations, and his age, gender, spirituality, etc., make the nurse more effective in promoting patient centered care. Still, sometimes the ideal of patient-centered care collides with the reality of cost effective treatment. Look at the example of short staffing: Don't you think the patient would like a one-on-one nurse at his bedside? Is that realistic? The trick, then, is to create the perception of care that is within the patient's ideal vision and the hospital's realm of reality. We'll be discussing communication further on in this course. You can begin thinking about ways your communication with your patient adds to or detracts from his optimal care experience! How can you, the bedside nurse, empower your patient?

MODULE 6:

M o d u l e 0 6 - A dv o c a c y When you hear about nurses needing to advocate for their patient, you probably think about protecting vulnerable populations. Certainly, nurses need to be able to speak for patients who may not be able to speak for themselves. We need to speak up when errors are about to be made or when situations are unsafe. We should make suggestions to provide better, more consistent care to our clients. Consider these issues of patient advocacy: Decisions regarding end of life care, protection of patient privacy, informed consent. What are the nurses' roles in these complex situations? How do their work places affect those roles? Keep in mind:

1. The nurse supports clients by ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care.
2. Nurses must act as advocates even when they disagree with clients' decisions.
3. Nurses must advocate for clients when the health care system is not acting in their best interests. Numbers 1 and 2, above reflect the Code of Ethics of the ANA and should be familiar concepts to you. Number 3, however, introduces several new concepts: Health Care Organizations, Health Care Economics, and Health Care Policy. Let's take a closer look at these concepts.

Healthcare Organizations

Healthcare organizations are groups of individuals brought together in a designated environment to achieve one of two goals: Provide illness care or provide wellness care. Nurses are a large part of staffing for both of those facilities, but found in greater numbers in the hospital, or restorative, settings. However, that idea is changing as nurses are taking more active roles and seeking to provide wellness-based care (Yoder-Wise, 2011). The United States' healthcare system is a dynamic thing, responding to rapid changes in the economic, social, and demographic environment at the federal, state, and local levels. Institutional providers may be the hospitals, long term care and skilled nursing facilities, and rehabilitation centers. Most hospitals are considered acute care facilities and provide short-term, episodic or emergency care, with stays lasting fewer than 30 days. These services are usually described as primary care (first-access care), secondary care (disease-restorative care), and tertiary care (rehabilitative or long-term care). These definitions may differ from what you've learned in primary, secondary, and tertiary care, and belong only to the realm of level of care hospitals provide (Yoder-Wise, 2011).

Healthcare Economics

There are three forms of health care organization ownership in the U.S. Public institutions : These provide health services to individuals under the support and/or direction of a government agency. These organizations answer to the sponsoring government agency. An example of this is the Veteran's Administration. Private non-profit (or not-for-profit) : Run by voluntary boards or trustees and provide care to both paying and non-paying patients, these facilities place any excess revenue over expenses back into the organization for maintenance and growth rather than returned as dividends to stock-holders (Yoder-Wise, 2011). These organizations are required to serve people regardless of their ability to pay. These organizations often serve primarily impoverished individuals, creating a great burden in uncompensated care. These facilities may be run by churches, industries, and special interest groups such as the Shriners.

For-profit organizations : These are proprietary or investor-owned organizations. These organizations operate with the purpose of earning a profit by providing healthcare services to individuals who can afford to pay. Owners may be individuals, partnerships, corporations, or multi-systems. Many receive additional funds through private and public sources to provide some services and research (Yoder-Wise, 2011). This funding helps them to treat patients who may be insured but are not for catastrophic services such as NICU care, or organ transplants, which can be hundreds of thousands of dollars. There are many examples of these for-profit organizations in the United States. Hospitals and skilled nursing centers are not the only healthcare facilities where nurses are found. Cost containment has given birth to an abundance of out-patient settings. Community health nurses are found in most rural communities and schools, typically funded by the local health departments. Parish nurses, funded by churches, serve as health educators, case managers, and advocates. Visiting nurse associations provide nursing services for families in need and are usually voluntary organizations. Historically, these organizations' purpose has been to control infectious diseases. Today, most of their work is aimed at education and prevention. Healthcare organizations commonly seek accreditation by either The American Osteopathic Association (AOA) or The Joint Commission (formally known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO). The Joint Commission accredits approximately 80% of acute care hospitals in the United States. Failure to comply with Joint Commission recommendations may be costly for a facility (Yoder-Wise, 2011). Organizations such as private or public insurers who provide healthcare insurance coverage are known as third-party payers. Established in 1965, Medicare is the U.S.'s largest health insurance program; it provides coverage to more than 40 million Americans (Yoder-Wise, 2011). Medicare is not just for senior citizens; it also covers disabled persons. An example of a private insurer is Blue Cross/Blue Shield. Third- party financing organizations have a major effect on our health care, as they identify which procedures, tests, services or medications will be covered.

Health Care Policy

The United States spends more per person on health care than any other developed country, yet in overall quality its care ranks last among the seven leading industrialized nations (Catalano, 2013). Many factors contribute to this; one pressing problem is the aging of the American population. Much of the time, though, the cost increase is due to so many patients being uninsured, or underinsured. The Health Care Reform Act, sometimes referred to as "Obama-care," is an attempt to insure more Americans who beforehand could not obtain adequate health insurance. Another goal is to prevent the powerful insurance companies from controlling individual patient care. The legislative powers have eliminated much of the original language and therefore, a "watered" down version now exists. Still, approximately 32 million Americans, previously uninsured, have enrolled. Positive changes , stemming from the Affordable Care Act include:  Ending the insurance companies' ability to drop coverage for someone when he or she gets sick.  Care for all children by eliminating the preexisting conditions restrictions found in most policies.  Access to high-risk pools for all uninsured, even adults with preexisting conditions.  Increasing the age to 26 years for young adults to be covered on their parents' plans.  Eliminating higher insurance premiums based on a person's gender or health status.  Expanding Medicare payment to health-care facilities that have a small number of Medicare clients. Negative changes include:  An anticipated gradual increase in premiums, up to 13%. However, most individuals and families will qualify for subsidies.

 A requirement that Americans buy health insurance or pay a penalty starting in 2014. The penalty will start out at 1 percent of income in 2014 and rise to 2.5 percent by 2016; however, the total amount will not exceed $2085 per year (Catalano, 2013). What does all of this mean for nurses? How will it make us better advocates for our patients? As stated above, 32 million more Americans will now be insured and able to access care. Nurses should be looking to expand their scope of practice and look to their own future employment. For the first time, all Americans can receive screening procedures such as prostate examinations, mammograms, annual physical examinations, and preventive care such as immunizations at no out-of-pocket costs. Advanced practice nurses need to be developing ways in which they can practice in a preventive, wellness model, rather than in our previous medical, disease-focused model. Consider this as well…if the changes being brought about by the Affordable Care Act are confusing to you, how then will our less educated clients feel about it? How will they maneuver through the process of enrollment and access care they now have? As advocates, nurses must ensure that clients are informed of their rights and have the correct information on which to base health care decisions. Nurses must be careful to assist clients with making health care decisions and not direct or control their decisions, especially if they're relying on their own personal feelings or opinions. Nurses continue to be the face of American health care. We need to recognize our authority and powerful influence in managing the changing health care system. We need to understand the healthcare systems and how our patients are affected by them. We need to be able to advocate for changes which will benefit all of our clients. M o d u l e 0 6 - A dv o c a c y Suppose you are working as a Registered Nurse in a major hospital which provides you with great health insurance coverage. Your daughter, however, is a 22-year-old full time college student who works part time. She makes less than $12,000 per year and cannot find health insurance coverage because she has asthma. The Affordable Care Act has helped thousands of families in just that situation; students are now able to stay on their parent's health insurance plans until age 25. Nurses were at the table while developing that stipulation!

The Nurse Practice Act

When thinking about nursing and the law, you probably (and rightly) recall the Nurse Practice Act. Each state has its own Nurse Practice Act, and it is every nurse's responsibility to become familiar with it. The State Board of Nursing will have links to the Practice Act; these Boards have the authority to issue and revoke a nursing license based upon compliance or violation of the Nurse Practice Acts. Standards of care are developed by the ANA and other professional organizations, and they direct the level of care given by nurses. Nurses should refuse to practice beyond the scope of their practice or outside of their area of competence.

How Laws Come into Being

But how did the Nurse Practice Act come into existence? How does any law become a law? The three branches of the United States government are the judicial, legislative, and executive branches. These 3 branches exist at the local, state, and federal levels.  Judicial branch: This is our court system, whose primary role is to interpret laws.  Legislative branch: This consists of our House of Representatives and Senate, whose roles are to represent the people in the forming of laws.  Executive branch: This is where we find the President, vice president, cabinet, and various executive administrative bodies (Governors, County Commissioners, Mayors). Their role is to enforce the laws. Laws may begin with any elected official, lobbyist, consumer group, advocate, public interest group, or governmental agency. Once a need is identified, any individual may contact a legislator to discuss concerns and possible solutions. If and when that legislator takes up the cause, he or she becomes a sponsor to a Bill. The bill is assigned a number (with the prefix HB for House Bill or SB for Senate Bill) and referred to a committee. The committee holds hearings (which are public and open for nurses to attend!) and a debate may be scheduled before a final vote of Yes, for passage of the bill, or No, for rejection or veto of the bill. Driving influences include funding (who will pay for the service?), public

demand (does it benefit everyone or a select few?) and program issues (does it interfere with or change any existing laws?) Most nurses avoid becoming involved in politics, or government issues, but they need to realize that their professional survival may depend upon it! Why? Because politics and health care laws are related to almost every aspect of life. Politics Influence:  Where (and when) children go to school  Quality of food and water  Medications, prescriptions, over the counter drugs  Where nurses work  What nurses do  Ability to organize professionally  Professional status through licensure and certification (Catalano, 2013).

How You Can Become Involved

How can you, a novice nurse, become more involved?

Become Active in a Professional Organization

The easiest way is to join and be active in a professional organization, such as the ANA, the NLN, or any other nursing organization. The ANA and most state chapters have legislative tool kits which offer suggestions for nurses to become politically involved. They maintain that the numbers of Registered Nurses in our country make us a powerful force. Our respect and ethics make us valuable assets to any elected official. They want us on their side!

Develop a Political Relationship with a Local Legislator

If you're interested in becoming more involved on a personal level, try to develop a political relationship with a legislator in your area. Letter writing, letters to the Editor of your local newspaper, emails, and telephone calls to the office are very successful methods of communicating with your elected official. For best results, schedule a meeting. They often have open office hours and, believe it or not, are always very willing to speak with their constituents. Do your research and find some common ground with him. They live in your legislative district. Do his children go to the same school as yours? Is anyone in his family a nurse? Getting to know your legislator is simple if you just relax and be yourself, and then you can discuss the important matter for which you came. First, identify specific goals that affect you, as a nurse. With what are you most concerned? Is it the level of responsibility in delegating that you have? Is it poor or unsafe staffing? Is it shorter hospital stays which send patients home too sick to care for themselves? Secondly, realize that your success in bringing about needed change depends on in-depth knowledge of the situation, as well as an understanding of the political process. You also need to be able to verbalize what is needed to solve the problem. Thirdly, you'll need to have something of value to offer the elected official, which fortunately, is easy. Your vote! That's what keeps him or her employed. And if you're speaking on behalf of a group of nurses, family members, or special interest group, that means even more votes. Make certain to tell him or her how many people will be positively affected by the change you seek. Politically involved nurses have the following credentials: They have self-confidence, motivation, creativity, a capacity to change, and persistence. In short, all nurses have the ability and skills to be more involved! Nurses are skilled patient advocates and are well qualified to advocate or lobby for health care legislation. It just takes a little time and motivation and any nurse can become a powerful change agent. Nurses in all areas of the country are saying, "Somebody's should do something about this problem." The reality of the situation is that the "somebody" is nurses themselves (Catalano, 2013, p. 403).