Student Nurse Laura

Orem – "creative effort of one human being to help another human being."

Archive for the ‘Professional Practice’ Category

NIH Office of Extramural Research

Posted by Laura on April 14, 2015

Respect

Beneficence

Justice

The Belmont Report – Ethical Principles and Guidelines for the Protection of Human Subjects of Research by the National Commission drafted in 1979. These words are the foundation of the HHS (Health and Human Services) on human subjects in research.

find at:   http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html

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Reflective Journaling

Posted by Laura on February 19, 2015

 

I have to do reflective journaling with an online digital clinical program. After I complete the day’s activities, I need to write in my reflective journal. My instructor has access to this and wants us to include specific areas for improvement, what we learned and how we can apply it in our practice. She wants to know the moments of

      AHA!!   

LEARN is an acronym to help guide my journaling. I’ll be using these five steps: Look back, Elaborate and describe, Analyze the outcome, Revising my approach, and New approach.

L – Looking back

  • Recall the experience. Reflecting shortly after the experience will help.
  • Describe what transpired. Who was involved?

E – Elaborate and describing

  • What subjective and objective factors contributed to the experience?
  • What did I say or do? What were my actions? What bothered me? What didn’t feel right?

A – Analyze the outcome

  • Was this experience a positive or negative experience for me and why?
  • Did I make assumptions? Why did I intervene as I did? What other choices did I have? What happened as a result of my actions?
  • What internal and/or external factors influenced me?

R – Revising my approach

  • As a result, what will I continue to use in practice, what am I satisfied with, and could I have done differently?
  • Was there other choices? What do I need to do better? What do I know now, that I did not know before?

N – New approach

  • Try the revision out. Do I need to change my practice, gain more knowledge? What did I learn from this experience? What will I be able to do now that I could not do before? How will I find opportunities to include my new point of view into my clinical practice? How will I evaluate the success?

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Criteria of expected outcomes can be done SMART

Posted by Laura on February 17, 2015

S – Specific

M – Measurable

A – Achievable

R – Realistic

T – Time phased

Gina is to obtain clear lung fields by using her medication as prescribed. Her goal will be obtained when her lungs are not wheezing, but have normal lung sounds upon auscultation at end of shift

CDC. SMARTobjectives. Retrieved from: http://www.cdc.gov/healthyyouth/evaluation/pdf/SMARTcards.pdf

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Federally Funded CARE, Federally Funded AID

Posted by Laura on February 9, 2015

medicare medicaid

 

info retrieved from: Healthcare.gov

http://www.hhs.gov/answers/medicare-Medicaid/medicare-medicaid/difference-medicare-medicaid.html

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SBAR

Posted by Laura on January 22, 2015

The SBAR provides safe communication when passing off information from caregiver to caregiver.

Situation

Background

Assessment

Recommendation

This is a modified example my instructor gave on the SBAR:

  • Dr. Pangelinan, this is Flora Cruz, RN, I am calling from Borja Hospital about your patient Rai Perez.

  • Here’s the situation: Mr. Perez is having increasing dyspnea and is complaining of chest pain.

  • The supporting background information is that he had a total knee replacement two days ago. About two hours ago he began complaining of chest pain. His pulse is 120 and her blood pressure is 126/55. He is restless and short of breath.

  • My assessment of the situation is that he may be having a cardiac event or a pulmonary embolism.

  • I recommend that you see him immediately and that we start him on O2 stat. Do you agree?

Read more here @ Home with The Joint Commission, or

Why is SBAR communication so critical?

 

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12 Languages – How many do you know?

Posted by Laura on January 21, 2015

NANDA-Nursing Diagnoses, Definitions, and Classification

Nursing Interventions Classification System (NIC)

Clinical Care Classification System (CCC

Omaha System

Nursing Outcomes Classification (NOC)

Nursing Management Minimum Data Set (NMMDS)

Peri-Operative Nursing Data Set (PNDS)

SNOMED CT

Nursing Minimum Data Set (NMDS)

International Classification for Nursing Practice (ICNP®)

ABC Codes

Logical Observation Identifiers Names and Codes (LOINC®)

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Standardized Nursing Language

Posted by Laura on January 20, 2015

Standardized nursing language enables better communication among nurses and other health care providers. by increasing visibility of nursing interventions, standardized nursing language  improves patient care and enhances data collection to evaluate nursing care outcomes.

You can read a nice article on standardized nursing language on the ANA site here:  Standardized nursing language: What does it mean for nursing practice?

The ANA recognizes 12 languages. Two of them actually make up one of them. Where I work we use the Peri-Operative Nursing Data Set (PNDS). You can find the list here. This document has links to where you may find more information on each one.

Periperative Nursing Data Set

 

 

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Have you seen the latest Do Not Use List?

Posted by Laura on January 18, 2015

Find This and more facts by The Joint Commission here

The Joint Commission “Do Not Use” List

Official “Do Not Use” List Potential Problem Use Instead
U, u (unit) Mistaken for “0” (zero), the number “4” (four) or “cc” Write “unit”
IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit”
Q.D., QD, q.d., qd (daily)Q.O.D., QOD, q.o.d, qod(every other day) Mistaken for each otherPeriod after the Q mistaken for “I” and the “O” mistaken for “I Write “daily”Write “every other day”
Trailing zero (X.0 mg)*Lack of leading zero (.X mg) Decimal point is missed Write X mgWrite 0.X mg
MSMSO4 and MgSO4 Can mean morphine sulfate or magnesium sulfateConfused for one another Write “morphine sulfate”

Write “magnesium sulfate”

Find This and more facts by The Joint Commission here

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Have you ever been in a situation where you didn’t feel safe, if so what was your reaction?

Posted by Laura on January 16, 2015

What did you do?

What have you done differently since?

How do mandatory staffing ratios help you?

If a patient is done with surgery, and brought to our post-anesthesia care unit (PACU), and I see the nurses on the floor are not available to receive the patient, I will go over there and receive the patient. I will leave my duties with the new patients coming in for their procedure. There is no hesitation. I react immediately when a patient’s vital signs drop and their nurse is occupied by another patient. It is obvious at this time, if do not have adequate nursing on staff to be receiving patients from the operating room (OR).
It is our policy if there is no staffing/space for a patient, they are to hold them in OR until it is safe for the patient to be brought out. In this particular situation, I wouldn’t do anything different. In my earlier days starting in PACU, I would hesitate, thinking…does the other nurse want me there…do they know there is another patient…am I abandoning my patient in pre-op? I no longer have this doubt and know where the priorities lie. I am glad California’s Board of Registered Nursing (BRN) has the staffing ratios we use. I know I can handle my patient load. We always have two nurses on the floor, even if there is only one patient left who is stable and about to be discharged. I’ve never felt it was an unsafe environment.
In California, we have safe staffing ratios. Ten years ago these ratios were implemented. They are regulated by the California Department of Public Health, effective January 1, 2004 (CDPH). In a surgical center, as where I work, our PACU is required to have a ratio of one to two, nurse-to-patients ratio. I know in our facility we do 1:1 ½ for most. Children and compromised airways are one to one.

There's been some sort of mistake ...
What I did learn from researching was Title 22 of the California Code of Regulations states charge nurses, or nurses working in the position of administrator, supervisor or manager are not included in the nurse-to-patient ratio. Only when they are providing direct patient care are they counted. This would be when they are relieving a nurse for her lunch break – but the breaking nurse is no longer part of the ratio (nurseallianceca.org). I know I have worked on the floor when I have heard the charge nurse included as part of the ratio. I will bring this up to the administration if I am in this situation again – protecting my nursing right (ANA, #6).

References:

ANA. Nurses’ bill of rights. Retrieved from: http://nursingworld.org/MainMenuCategories/WorkplaceSafety/ Healthy-Work-Environment/Work-Environment/NursesBillofRights

California Department of Public Health. Nurse-to-patient staffing ratio regulations. Retrieved from: http://www.cdph.ca.gov/services/DPOPP/regs/Documents/R-37-01_Regulation_Text.pdf

Image from: http://www.wolfescape.com/Humour/MedSurg.htm

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Bill of Rights

Posted by Laura on January 15, 2015

The Nurses’ Bill of Rights enables a nurse to feel safe in their practice. The ANA endorses standards to apply this practice as a professional nurse. The Bill of Rights is not a legal document but can guide organizational policy development regarding contracts and work agreements. 

  1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care.
  2. Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice.
  3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses with Interpretive Statements.
  4. Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
  5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional responsibilities.
  6. Nurses have the right to a work environment that is safe for themselves and for their patients.
  7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.

   Not being supported, or considered troublemakers, creates poor working conditions. Kangasniemi, Stievano, and Pietila’s report  shows where many studies have been done on “nurses rights as part of professional ethics” (2013), but lacks in the area of supporting autonomy as a nurse, as stated in the Nurses’ Bill of Rights (ANA),  advocating for their patients as well as themselves by the American Nursing Association.
A nurse’s load can be hard due to short staffing, due to no days off or extended hours. These factors lead to nursing fatigue as well as patient errors. The American Association of Critical Nurses Standards (AACN) for Establishing and Sustaining Healthy Work Environments  Number four says, “Inappropriate staffing is one of the most harmful threats to patient safety and to the well-being of nurses” (AACN). A hospital study showing 13% of 335 medication errors resulting from nursing had an estimated monitoring and treatment cost of 450,260 dollars (Frith, Anderson, Fan, et al., pg 293). Medication errors due to over-stressed or overworked nurses can lead to an unsafe practice, surely not wanted by the facility or the healthcare practitioner.
Work environments need continual assessment and ongoing reflection on staffing needs. Today’s technology provides a safety net in medication errors. It gives on-hand patient information at the touch of a screen. Today’s workplaces have incentives and demands to automate and provide technology, making administrative functions quicker. Technology helps in decreasing errors and implementation of new practices. But, what is done for the direct patient care? I feel the registered nurse needs incentives, education, and ability to contribute to the development of new or improved practices. Through these areas, we can help ensure nursing rights and patient safety in a professional working environment.

References:

American Association of Critical Nursing. [AACN]. Healthy work environment standards. Retrieved from:   http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf

American Nursing Association, Nurses’ bill of rights. Retrieved from: http://nursingworld.org/MainMenuCategories/WorkplaceSafety/ Healthy-Work-Environment/Work-Environment/NursesBillofRights

Frith, K. H., Anderson, E., Fan, T., & Fong, E. A. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economic$, 30(5), 288-294.

Kangasniemi, M., Stievano, A., Pietilä, A. (2013). Nurses perceptions of their professional rights. Nursing Ethics 20(4), 259-26

Other Links:

The Nurses’ Bill of Rights at the ANA website

AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence.

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The Five Rights of Delegation

Posted by Laura on January 14, 2015

Right Task
One that is delegable for a specific patient.
Right Circumstancesperry 04
Appropriate patient setting, available resources, and other relevant factors
Right Person
Right person is delegating the right task to the right person to be performed on the right person.
Right Direction/Communication
Clear, concise description of the task, including its objective, limits, and expectations.
Right Supervision
Appropriate monitoring, evaluation, intervention, as needed, and feedback

https://www.ncsbn.org/

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Position Statements by The International Council of Nurses (ICN) 5 of 5 sets

Posted by Laura on January 13, 2015

Social Issues

  1. Armed conflict: Nursing’s perspective(2012)
  2. Child labour(2007)
  3. Cloning and human health(2007)
  4. Falsified/Counterfeit medicines(2010)
  5. Health information: protecting patient rights(2008)
  6. Informed patients(2008)
  7. Health care waste: role of nurses and nursing(2010)
  8. Nurses, climate change and health(2008)
  9. Nurse – industry relations(2006)
  10. Nurses and human rights(2011)
  11. Reducing environmental and lifestyle related health risks(2011)
  12. Rights of children(2008)
  13. Torture, death penalty and participation by nurses in executions(2012)
  14. Towards elimination of weapons of war and conflict(2012)
  15. Universal access to clean water(2008)

The International Council of Nurses. (2013). Retrieved from http://www.icn.ch/about-icn/about-icn/

 

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Position Statements by The International Council of Nurses (ICN) 4 of 5 sets

Posted by Laura on January 12, 2015

Health Care Systems

  1. Health human resources development (HHRD)(2007)
  2. Nurses and primary health care(2007)
  3. Nursing and development(2007)
  4. Participation of nurses in health services decision-making and policy development (2008)
  5. Patient safety(2012)
  6. Promoting the value and cost-effectiveness of nursing(2001)
  7. Publicly funded accessible health services(2012)

The International Council of Nurses. (2013). Retrieved from http://www.icn.ch/about-icn/about-icn/

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Position Statements by The International Council of Nurses (ICN) 3 of 5 sets

Posted by Laura on January 11, 2015

Socio Economic Welfare of Nurses

  1. Abuse and violence against nursing personnel(2006)
  2. Career development in nursing(2007)
  3. Ethical nurse recruitment(2007)
  4. Reducing the impact of HIV infection and AIDS on nursing and midwifery personnel (2008)
  5. Industrial action(2011)
  6. International trade agreements(2010)
  7. Nurse retention and migration(2007)
  8. Nurses and shift work(2007)
  9. Occupational health and safety for nurses(2006)
  10. Part-time employment(2007)
  11. Socio-economic welfare of nurses(2010)

The International Council of Nurses. (2013). Retrieved from http://www.icn.ch/about-icn/about-icn/

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Position Statements by The International Council of Nurses (ICN) 2 of 5 sets

Posted by Laura on January 10, 2015

Nursing Profession

  1. Assistive or support nursing personnel(2008)
  2. Continuing competence as a professional responsibility and public right(2006)
  3. Cultural and linguistic competence(2007)
  4. Nursing regulation(1985)
  5. Nursing research(2007)
  6. Protection of the title “Nurse”(2012)
  7. Scope of nursing practice(2003)

 

The International Council of Nurses. (2013). Retrieved from http://www.icn.ch/about-icn/about-icn/

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Position Statements by The International Council of Nurses (ICN) 1 of 5 sets

Posted by Laura on January 9, 2015

Nursing Roles in Health Care Services

  1. Antimicrobial resistance(2004)
  2. Breastfeeding(2004)
  3. Distribution and use of breast milk substitutes(2004)
  4. Elimination of female genital mutilation(2010)
  5. Elimination of substance abuse in young people(2008)
  6. Health services for migrants, refugees and displaced persons(2006)
  7. HIV infection and AIDS(2008)
  8. Management of nursing and health care services(2000)
  9. Mental health(2008)
  10. Nature and scope of practice of nurse-midwives(2007)
  11. Nurses and disaster preparedness(2006)
  12. Nurses’ role in providing care to dying patients and their families(2006)
  13. Nurses’ role in the care of detainees and prisoners(2011)
  14. Nurses’ role in prevention of cancer(2008)
  15. Nursing care of the older person(2006)
  16. Prevention of disability and the care of people with disabilities(2000)
  17. Reducing travel-related communicable disease transmission(2011)
  18. Tobacco use and health(2012)
  19. Women’s health(2012)

The International Council of Nurses. (2013). Retrieved from http://www.icn.ch/about-icn/about-icn/

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ANA Needs your help this week

Posted by Laura on January 8, 2015

Re-post from Tricia Hunter American Nurses Association\California

In December, ANA made significant progress in an effort to add nurse staffing and skill mix along with falls and falls with injury measures to Hospital Compare, CMS’s public reporting and pay for quality site.  This would be the first time that nursing measures would be included on a national public reporting site.  ANA is expecting significant opposition as this moves forward through the NQF and CMS’ Federal Register process.  We need a strong nursing presence during the upcoming NQF comment period.  Please help by submitting comments as noted below! 

ACTION REQUESTED:  Submit comments to NQF’s Measure Application Partnership (MAP) to Improve Patient Safety Outcomes and Transparent Reporting

The deadline for submitting comments is close of business on 1/13/15.

Comments should focus on supporting all four critical NQF-endorsed nursing-sensitive safety measures (nurse staffing, skill mix, falls, and falls with injury).

 

Process

To help support your submission, ANA has drafted the following text that can be personalized to your organization and members for submission.  Please note that there are report errors that need correction prior to the MAP Coordinating Committee meeting scheduled for 1/26-27. Thus, the need for detailed comments.  Please note that you can divide up your comments in the provided comment areas (e.g., General Comments) for each report if you reach the maximum character limits in any one topic area.  For example, you can simply note you are continuing comments in the additional topic areas if you reach the character limits in any one section.

 

  • Nurse Staffing and Skill Mix
    • Enter the following comments into this link for the MAP 2014-2015 Preliminary Recommendations (XLS)  – Measures Voting Results Excel Report at this link:  COMMENT on Recommendations through January 13, 6:00pm
      • The (Organization name) supports the Hospital Workgroup (WG) vote of “conditional support” of the NQF-endorsed measures nurse staffing and skill mix and requests MAP report corrections
      • The MAP report should be amended to accurately reflect the MAP Hospital WG vote that identified only one “condition”, NQF endorsement at the hospital-level reporting, be met
        • Majority of the workgroup (73% vote) for “conditional support” only related to one condition, NQF-endorsement for hospital-level reporting
        • Other conditions listed in the MAP report were not agreed upon by the Hospital Workgroup during voting majority, are incorrectly listed as conditions to be met and should be removed
    • Enter the following comments on the Draft Programmatic Deliverable Report (PDF) – Text Report by Programs at this link: COMMENT ON REPORTthrough January 13, 6:00pm
      • The (Organization name) supports the Hospital Workgroup vote of “conditional support” of the NQF-endorsed measures nurse staffing and skill mix
      • These are high impact safety measures
        • Two decades of research has provided evidence that better nurse staffing and skill mix is associated with lower patient harm rates (e.g., death, falls, infections, pressure ulcers etc.)
        • Wide variance in nurse staffing continues, particularly in medical surgical units
      • The MAP Hospital WG discussion should be reflected accurately by amending the MAP draft report
        • Parsimony and lack of importance of structural measures for inclusion were rejected by the Hospital WG as reasons to exclude these measures with the required majority vote
          • NQF MAP suggested vote and rationale of “Do Not Support” were rejected by the WG
          • MAP’s Measure Selection Criteria includes structural measures to achieve the right mix of high impact measures for accountability
      • The MAP report should also be amended to reflect the broad Hospital WG support for these measures
        • Members noted these measures are essential to improve patient safety and to inform consumers, purchasers and other stakeholders
        • Both co-chairs supported these measures as a floor of safety to transparently report
      • Data is low burden and is already collected by hospitals
  • Falls and Falls with Injury –
    • Enter the following comments into this link for the MAP 2014-2015 Preliminary Recommendations (XLS)  – Measures Voting Results Excel Report at this link:  COMMENT on Recommendations through January 13, 6:00pm
      • The (Organization name) supports the Hospital Workgroup (WG) vote of “conditional support” of the NQF-endorsed measures falls and falls with injury and requests MAP report corrections
      • The MAP report should be amended to reflect the Hospital WG vote accurately to reflect the following
          • The only condition identified by the MAP Hospital WG by the majority vote was NQF-endorsement for hospital-level reporting
          • CMS noted that CMS and AHRQ do not consider the measures as duplicative to any existing measure (no harmonization issue exists)
          • The Hospital WG did not identify under-reporting related to falls with injury
          • Under-reporting was not an agreed upon condition for the falls rate measure
    • Enter the following comments on the Draft Programmatic Deliverable Report (PDF) – Text Report by Programs at this link: COMMENT ON REPORTthrough January 13, 6:00pm
      • The (Organization name) supports the Hospital Workgroup (WG) vote of “conditional support” of the NQF-endorsed measures falls and falls with injury
      • The MAP report should be amended to reflect the broad Hospital WG majority support (73% vote for “conditional support”) for these measures
        • Both these safety outcome measures are critical to improving patient safety
        • They Fill a serious gap in falls measures on Hospital Compare that consumer, purchasers, ANA and other stakeholders have noted
        • Are superior to claims based measures because they are
          • Not subject to known coding issues (server under-reporting with claims driven metrics) and allow for timely reporting
          • Clinically enriched (e.g., clinical assessment data used)
          • Don’t have harmonization issues with other measures per CMS and AHRQ and fill a gap 

BACKGROUND:

  • NQF-convened MAP reviews measures submitted by CMS for prioritization for CMS’s public reporting and pay for quality programs as well as identifies high impact measure gap areas
  • MAP Hospital Workgroup voted “conditional support” for inclusion all four measures in the CMS Inpatient Quality Reporting Program (i.e., public reporting on Hospital Compare)
    • These are the First nursing sensitive measures from the NQF-endorsed Nursing-Sensitive Safety Set of 15 to be advanced by the MAP Hospital Workgroup for CMS’s Inpatient Quality Reporting (IQR) Program (Hospital Compare)
      • Comments are importance since the  MAP Coordinating Committee will review the Workgroup preliminary voting 1/26-27/15 in light of submitted comments to the MAP.

 

THANK YOU for your support of this important effort.

Honorable Tricia Hunter, RN, MN
1121 L Street Suite 508
Sacramento, CA 95814
916-447-0225
916-837-1620 Cell
858-225-0227 Personal Fax

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National Patient Safety Goals – 2015

Posted by Laura on January 7, 2015

Patient safety in practice is an essential component in nursing. The National Patient Safety Goals (NPSGs), established in 2002, ( a 2015 PowerPoint presentation available here) addresses specific areas of concern in our workplace. It is important to know who lead the safety initiatives,  who collects the data, and what the results have shown.  Untitled

    Last Wednesday we just had a meeting on our NPSGs. Our staff is small, so it is easy for our administration to go over lots of information to keep us updated. I believe by staying up to date with current data, and reflecting of events through the week – keeps us improving the quality of care and safety in our workplace. In our center, we work with the following Patient Safety Goals:

1. Improve the accuracy of patient identification
2. Improve the effectiveness of communication among caregivers
3. Improve the safety of using medicationscp 2
6. Reduce the harm associated with clinical alarm systems
7. Reduce the risk of health care – associated infections
9. Reduce the risk of patient harm resulting from falls
14. Prevent health care-associated pressure ulcers (decubitus ulcers).
15. The organization identifies safety risks inherent in its patient population
(The Joint Commission, 2015)

We also have the following Universal Protocol for preventing wrong site, wrong procedure, wrong person surgery

1. Conduct a pre-procedure verification process
2. Mark the procedure site
3. A time-out is performed before the procedure
(The Joint Commission, 2015)

The Joint Commission. (2015). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx

PS – if you wondered why the goals aren’t renumbered, its because: In order to track specific NPSG progress, the numbers remain the same, even if there is a removal from a previous goal which was reached.

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American Nursing Association

Posted by Laura on January 4, 2015

The American Nursing Association (ANA) is looking out for me as a Registered Nurse so I can keep working in a safe environment for my patients, as well as my peers. I almost feel as I take advantage of this organization. I am a member in good standing, but don’t participate in many of the activities done by this organization to secure the professionalism I have here in California. I could be more active, attend legislative events, and show support in getting policy changes as needed. On the ANA website right now, they are asking for support of the Nurse and Health Care Worker Protection Act of 2013. This act is “designed to decrease the potential for injury to health care personnel and patients while reducing work-related health care costs and improving the safety of patient care delivery” (hppts://www.nursingworld.org). I can easily relate to this need as in my practice I am often moving patients in their beds or from bed to bed.

The ANA states on their site there are 3.1 million registered nurses in the United States (http://www.nursingworld.org/). Current membership in the ANA is around 145,790 according to Union Facts.com. How less than 150 thousand individuals can keep my profession of 3.1 million safe and evolving with evidence-based standards, must be trying. I believe calling my local government representatives would the greatest additional strategy I can use to aid the nursing profession on matters the ANA has decided to take action on.

ANA congrats

 

 

 

 

 

 

 

American Nurses Association (n.d.) Re: Safe Patient Handling & Mobility. Retrieved from https://secure3.convio.net/ana/site/Advocacy?cmd=display&page=UserAction&id=423

American Nurses Association (n.d.) Re: About ANA. Retrieved from
http://www.nursingworld.org/functionalmenucategories/faqs

UnionFacts.com (n.d.) Re: American Nurses Association. Retrieved from http://www.unionfacts.com/union/American_Nurses_Association

Image Retrieved from http://www.nursingworld.org/

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just books

Posted by Laura on January 3, 2015

                                          cloud thoughtPerry blue

More booksbooks (Medium)

 

 

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