CNA adopts a new code, called Code of Ethics for Nursing Through more than two decades of development and refinement to the CNA code The Code provides guidance for ethical relationships, behaviours and . to protect the vulnerable patient” (Falcó-Pegueroles, Lluch-Canut, .. their clients' health-care needs. The College of Nurses of Ontario (CNO) is pleased to respond to the Health Professions Dispensing is central and most common to pharmacy practice; Therapeutic Nurse-Client Relationship (see Appendix M) take action when team members put clients at risk or are abusive of clients in any way. Therapeutic nurse-client relationships College of Nurses of Ontario Practice Standard: Professional Standards, Revised Examples of CNO's practice standards In most circumstances, the client is an individual but working with clients to identify care needs, and to establish, implement and continually evaluate.
This is accomplished through methodical collection of data and in-depth analysis of the data; yielding, thick, rich descriptions of the phenomenon of studies that has been clearly saturated.
Dependability was achieved as each participant reviewed his or her verbatim transcript along with confirmability as the results were confirmed or collaborated by others showing details of the methodology used. CNO participants were accessed through professional nursing leadership organizations and through purchased targeted contact lists. Email invitations were sent to future participants advising them of the general scope of the studies. Institutional Review Board IRB approval was received for both the initial study and the replicated study.
Inclusion criteria for the two studies included: CNOs within an acute setting, a hospital which has facilities and all personnel including medical staff appropriate to diagnose, treat and care for acute conditions, including injuries, located within the Southeastern and Northeastern United States. CNOs were identified as the highest ranking administrative registered nurse in the acute care organization, responsible for the practice of nursing throughout their healthcare system.
Exclusion criteria included anyone not meeting the inclusion criteria. Department directors, division directors, unit or service managers, supervisors, charge nurses and other senior nurses who have non-nursing, executive positions in hospitals were also excluded.
Both studies were explained to the participants prior to the interviews, in which all questions were answered in regards to the informed consent. All the participants who met the inclusion criteria and who agreed to participate in the study then signed the informed consent.
A naturalistic inquiry research approach was integrated through the direct experience of the CNOs. This model-included context, perspectives, experiences, underlying motivations and factors that influence decision making and opinions of CNOs. The types of hospitals represented included; corporate system, community, government, academic health center and rural facilities. The number of beds per hospital ranged from less than 50 to over These reviews led to identification through horizontalization and delimited meanings of the invariant qualities in which patterns and themes emerged.
From these patterns and themes, an integrated textural and structural description was completed per participant. Results After careful and studied consideration and analysis of the phenomenon being studied, two essential themes emerged in regards to meeting the needs of the RN at point of care and how this affects quality patient care outcomes. These two themes were advocating and conflicting. The CNOs were continuously advocating for the patient and many times this advocacy for the patient could be conflicting with the needs of the nurse.
Following are examples of the transcriptions obtained in these two studies. The Chief Nursing Officer, by virtue of the title, might be assumed to chiefly represent nursing. However, all CNOs interviewed in this study noted their primary goal and responsibility was to the patient. According to these CNOs, this may or may not coincide with the best interest and objectives of the nurses. This is the conflict that is one of the primary themes that emerged from these two studies.
As one CNO described this conflict: This at times caused the CNO to feel frustrated in bringing new ideas and processes to the workplace for concern this would cause discord among the RNs. As one CNO stated this conflicting dilemma: So, you got to keep the nurses happy … but there is also this extreme pressure to get the largest workforce in the hospital to perform well for everyone else.
Only one of the CNOs interviewed seemed less conflictive and was an advocate for the nurse as they identified this connection; that if the nurses are allowed to self-actualize, the patient will be the ultimate beneficiary.
In practice, evidence of meeting goals and objectives of the non-nursing leadership team took priority. For example, peer pressure among nurses was utilized to meet staffing needs.
However, they were generally not concerned if, e. Yet, assessments are being documented as always being completed, even though they are not always fully or even substantially completed.
SAFE HARBOR PEER REVIEW
They also feel they do not have adequate time to spend with each patient. This CNO expressed continuous conflict; such as revenue versus patient care and advocating for nurses without providing appropriate time for assessment and other interventions at point of care: The median is probably 3.
I will tell you that there are a lot of things I would like to improve in terms of having nurses spend more time at the bedside … if they had more time, they would probably do more things … for patients … but within a few days … they go home. However, most RNs at point of care feel they do not have the time to give the best care to their patients which contributes to an unhealthy work environment.
This CNO did not perceive the conflict, instead felt that nurses are adequately advocated for, stating: This CNO explained how advocating for nurses helped achieve good results for the patient: And that did give great outcomes for the hospital … when nursing has a voice at the table at the board level and at the senior executive level, you can do good things.
Discussion These two studies found are groundbreaking in the area of qualitative research on the lived experiences of CNOs.
There were no comparable studies prior to these. The majority of CNOs interviewed for these two studies were considered highly clinically competent early in their careers. The skills required later at the executive level were not the focus of their undergraduate and graduate level of education. The need for highly educated nurses to manage complex healthcare systems, build relationships with healthcare teams in order to collaborate and coordinate across all specialties and professions within the healthcare industry is paramount to achieve better patient outcomes.
This will be accomplished by reinventing the nursing curriculum to include all aspects of competency in leadership, health policy, systems, research, and evidence based practice [ 23 ]. Many schools of nursing keep adding more knowledge and information due to the expanding growth of research.
The timeline of nursing education remains the same and yet the content for students to learn is increased resulting in more student memorization, less retention of knowledge and ability to critically analyze within the clinical environment [ 23 ]. One school of nursing had implemented an active learning approach to leadership in which reflection and observation of leadership is promoted to provide a baseline for future leadership development after graduation [ 24 ].
The philosophy behind this approach is to promote leadership awareness as nurses are expected to have leadership skills within their practice. A quantitative comparative study examining transformational leadership among graduating baccalaureate nursing students BSN and practicing nurses showed that the BSN nursing students had significantly lower scores in transformational leadership components than the practicing nurses and the practicing nurses in leadership positions did not consider themselves better transformational leaders than the staff nurses [ 25 ].
Overall, the educational methods in preparing undergraduate and graduate nurses in academia for the present and future healthcare industry is not adequate to provide continuous success for the nurse and nurse leader [ 232425 ]. In nursing, the primary focus is always the patient.
At the undergraduate level of nursing studies all the skills, learning the disease entities, and being able to apply this knowledge safely at the bedside is the nucleus of nursing. Nursing work environments, turnover, retention, and interdisciplinary collaboration are not generally discussed with nursing students at a high level of understanding.
Therefore, new nurses are not fully aware of the discontent within the profession of nursing. In fact, most of the time novice nurses are quite surprised that these types of issues are commonplace in the hospital work environment [ 259 ]. Many times they are confused and resort to a comfort zone of focusing on their clinical abilities and patients. Some actually leave the profession [ 2 ]. For those that stay, often they are not sure if these conditions are isolated events, temporary, or being perceived incorrectly [ 226 ].
Eventually these methods of adjustment are not long lasting, especially if it affects patient care outcomes. Nurses, including CNOs, are all about the patient; this is their nature and to some their calling. If most of the time nurses feel they are unable to deliver the care needed for their patients, then the nurse may feel inadequate, unhappy, and unsure if they represent the caring nurse they have been taught to be [ 11 ].
The instinctual need to defend the care delivered to their patients is customary within the nursing culture. Most of these CNOs are very good to excellent leaders despite these obstacles within their environments. This takes persistence, intelligence, communication, and courage to be successful within these circumstances. In spite of their challenges, they continued to set themselves apart from their colleagues.
They were promoted without much mentoring or additional education. This additional education would have allowed them to be even more effective leaders by changing the healthcare system in a global aspect, rather than in fragments [ 1012 ]. If remediation will address the deficit sa remediation plan must be developed to address the deficit s.
If remediation will not address the deficit sthen the error cannot be considered a minor incident and the nurse must be reported to the nursing peer review committee or, in practice settings with no nursing peer review, to the Board.
If the determination is that the nurse could be remediated but the nurse does not complete the required remediation, then the nurse must be reported to a nursing peer review committee or the Board.
If such factors are found, a report must be made to the patient safety committee, or if the facility does not have a patient safety committee, to the chief nursing officer. If remediation will not address the deficit sthen the error cannot be considered a minor incident and must be reported to the nursing peer review committee or to the Board if there is not a nursing peer review in the practice setting.
Multiple Incidents [Board Rule In practice settings with nursing peer review, the nurse must be reported to the nursing peer review committee if a nurse commits five minor incidents within a month period.
In practice settings with no nursing peer review, the nurse who commits five minor incidents within a month period must be reported directly to the Board. A report must be prepared, monitored, and maintained for a minimum of 12 months that contains: The nursing peer review committee that receives a report must investigate and conduct incident-based nursing peer review in compliance with Texas Occupations Code Chapter Nursing Peer Review Law and Board Rule If there is no evidence of nursing practice violations, a nurse may be reported to either the BON or to a peer assistance program [Rule The BON will determine in such cases whether or not the nurse is eligible to take part in a peer assistance program.
The IBPR committee may need to re-convene for the sole purpose of determining whether or not external factors contributed to the incident s that lead to peer review. For purposes of exchange of information, the Peer Review committee reviewing the conduct is considered as established under the authority of both so that confidentiality requirements of peer review are enforceable against any nurse involved in the investigation or peer review proceeding.
Texas Board of Nursing - Practice - Nursing Practice Peer Review
The two entities may choose to have a contract with respect to which entity will conduct Peer Review of the nurse. When properly invoked, safe harbor protects a nurse from employer retaliation and from licensure sanction by the BON. Safe Harbor must be invoked prior to engaging in the conduct or assignment for which peer review is requested, and may be invoked at any time during the work period when the initial assignment changes.
The latter is an example of a situation where a prudent nurse would refuse to engage in the conduct requested.
There is now a separate form on the BON web page that can be used for this process. Invocation of Safe Harbor protections [ Rule At the time the nurse is requested to engage in the activity, notify the supervisor making the assignment in writing that the nurse is invoking Safe Harbor.
Additional supporting documents may still be supplied at a later date. All of these BON forms are optional and do not have to be utilized by the nurse making a written request for Safe Harbor. Patients are better off with the nurse than without the nurse in the vast majority of cases; however, Rule A request to falsify a patient record is an example of conduct that a nurse should refuse to engage in while awaiting a peer review committee determination, since there is no legal or factual basis that would support a nurse falsifying a patient record.
The BON urges each nurse to consider the duty to the patient s as the highest priority in make any determination to accept or refuse an assignment or requested conduct. The ability to invoke Safe Harbor protections and to have a nursing peer review committee evaluate the requested assignment are the same whether the nurse accepts or refuses the assignment.
Note that Rule A collaborative effort with patient safety as the focus will require the nurse and supervisor to set aside any personal animosity and to explore additional options that are safer for both the patient s and the nurse s.