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PARADIGMS AND METHODS FOR NURSING RESEARCH

A 
paradigm
 is a worldview, a general perspective on the complexities of the world. Paradigms for human inquiry are often characterized in terms of the ways in which they respond to basic philosophical questions, such as, What is the nature of reality? (ontologic) and What is the relationship between the inquirer and those being studied? (epistemologic).

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Disciplined inquiry in nursing has been conducted mainly within two broad paradigms, 
positivism
 and 
constructivism
. This section describes these two paradigms and outlines the research methods associated with them. In later chapters, we describe the 
transformative paradigm
 that involves 
critical theory research
 (
Chapter 21
), and a 
pragmatism paradigm
 that involves 
mixed methods research
 (
Chapter 26
).

The Positivist Paradigm

The paradigm that dominated nursing research for decades is known as 
positivism
 (also called 
logical positivism
). Positivism is rooted in 19th century thought, guided by such philosophers as Mill, Newton, and Locke. Positivism reflects a broader cultural phenomenon that, in the humanities, is referred to as 
modernism
, which emphasizes the rational and the scientific. paradigms and methods for nursing research.

As shown in 
Table 1.2
, a fundamental assumption of positivists is that there is a reality 
out there
 that can be studied and known (an 
assumption
 is a basic principle that is believed to be true without proof or verification). Adherents of positivism assume that nature is basically ordered and regular and that reality exists independent of human observation. In other words, the world is assumed not to be merely a creation of the human mind. The related assumption of 
determinism
 refers to the positivists’ belief that phenomena are not haphazard but rather have antecedent causes. If a person has a cerebrovascular accident, the researcher in a positivist tradition assumes that there must be one or more reasons that can be potentially identified. Within the positivist paradigm, much research activity is directed at understanding the underlying causes of phenomena.

TABLE 1.2: Major Assumptions of the Positivist and Constructivist Paradigms

TYPE OF QUESTION

POSITIVIST PARADIGM ASSUMPTION

CONSTRUCTIVIST PARADIGM ASSUMPTION

Ontologic
: What is the nature of reality?

Reality exists; there is a real world driven by real natural causes and subsequent effects paradigms and methods for nursing research

Reality is multiple and subjective, mentally constructed by individuals; simultaneous shaping, not cause and effect

Epistemologic
: How is the inquirer related to those being researched?

The inquirer is independent from those being researched; findings are not influenced by the researcher

The inquirer interacts with those being researched; findings are the creation of the interactive process

Axiologic
: What is the role of values in the inquiry?

Values and biases are to be held in check; objectivity is sought

Subjectivity and values are inevitable and desirable

Methodologic
: How is evidence best obtained?

Deductive processes → hypothesis testing

Inductive processes → hypothesis generation

Emphasis on discrete, specific concepts

Emphasis on entirety of some phenomenon, holistic

Focus on the objective and quantifiable

Focus on the subjective and nonquantifiable. paradigms and methods for nursing research.

Corroboration of researchers’ predictions

Emerging insight grounded in participants’ experiences

Outsider knowledge—researcher is external, separate

Insider knowledge—researcher is internal, part of process

Fixed, prespecified design

Flexible, emergent design

Controls over context

Context-bound, contextualized

Large, representative samples

Small, information-rich samples

Measured (quantitative) information

Narrative (unstructured) information

Statistical analysis

Qualitative analysis

Seeks generalizations. paradigms and methods for nursing research

Seeks in-depth understanding

Positivists value objectivity and attempt to hold personal beliefs and biases in check to avoid contaminating the phenomena under study. The positivists’ scientific approach involves using orderly, disciplined procedures with tight controls of the research situation to test hunches about the phenomena being studied.

Strict positivist thinking has been challenged, and few researchers adhere to the tenets of pure positivism. In the 
postpositivist paradigm
, there is still a belief in reality and a desire to understand it, but postpositivists recognize the impossibility of total objectivity. They do, however, see objectivity as a goal and strive to be as neutral as possible. Postpositivists also appreciate the impediments to knowing reality with certainty and therefore seek 
probabilistic
 evidence—that is, learning what the true state of a phenomenon 
probably
is, with a high degree of likelihood. This modified positivist position remains a dominant force in nursing research. For the sake of simplicity, we refer to it as positivism. paradigms and methods for nursing research.

The Constructivist Paradigm

The 
constructivist paradigm
 (often called the 
naturalistic paradigm
) began as a countermovement to positivism with writers such as Weber and Kant. Just as positivism reflects the cultural phenomenon of modernism that burgeoned after the industrial revolution, naturalism is an outgrowth of the cultural transformation called 
postmodernism
. paradigms and methods for nursing research. Postmodern thinking emphasizes the value of
deconstruction
—taking apart old ideas and structures—and 
reconstruction
—putting ideas and structures together in new ways. The constructivist paradigm represents a major alternative system for conducting disciplined research in nursing. 
Table 1.2
 compares the major assumptions of the positivist and constructivist paradigms.

For the naturalistic inquirer, reality is not a fixed entity but rather is a construction of the individuals participating in the research; reality exists within a context, and many constructions are possible. Naturalists thus take the position of relativism: If there are multiple interpretations of reality that exist in people’s minds, then there is no process by which the ultimate truth or falsity of the constructions can be determined. paradigms and methods for nursing research.

The constructivist paradigm assumes that knowledge is maximized when the distance between the inquirer and those under study is minimized. The voices and interpretations of study participants are crucial to understanding the phenomenon of interest, and subjective interactions are the primary way to access them. Findings from a constructivist inquiry are the product of the interaction between the inquirer and the participants.

Paradigms and Methods: Quantitative and Qualitative Research

Research methods
 are the techniques researchers use to structure a study and to gather and analyze information relevant to the research question. The two alternative paradigms correspond to different methods for developing evidence. A key methodologic distinction is between 
quantitative research
, which is most closely allied with positivism, and 
qualitative research
, which is associated with constructivist inquiry—although positivists sometimes undertake qualitative studies, and constructivist researchers sometimes collect quantitative information. This section provides an overview of the methods associated with the two paradigms. paradigms and methods for nursing research.

The Scientific Method and Quantitative Research

The traditional, positivist 
scientific method
 refers to a set of orderly, disciplined procedures used to acquire information. Quantitative researchers use deductive reasoning to generate predictions that are tested in the real world. They typically move in a systematic fashion from the definition of a problem and the selection of concepts on which to focus to the solution of the problem. By 
systematic
, we mean that the investigator progresses logically through a series of steps, according to a specified plan of action. paradigms and methods for nursing research.

Quantitative researchers use various control strategies. 
Control
 involves imposing conditions on the research situation so that biases are minimized and precision and validity are maximized. Control mechanisms are discussed at length in this book.

Quantitative researchers gather 
empirical evidence
—evidence that is rooted in objective reality and gathered through the senses. Empirical evidence, then, consists of observations gathered through sight, hearing, taste, touch, or smell. Observations of the presence or absence of skin inflammation, patients’ anxiety level, or infant birth weight are all examples of empirical observations. The requirement to use empirical evidence means that findings are grounded in reality rather than in researchers’ personal beliefs. paradigms and methods for nursing research.

Evidence for a study in the positivist paradigm is gathered according to an established plan, using structured methods to collect needed information. Usually (but not always) the information gathered is 
quantitative
—that is, numeric information that is obtained from a formal measurement and is analyzed statistically.

A traditional scientific study strives to go beyond the specifics of a research situation. For example, quantitative researchers are typically not as interested in understanding why a 
particular
 person has a stroke as in understanding what factors influence its occurrence in people generally. The degree to which research findings can be generalized to individuals other than those who participated in the study is called the study’s 
generalizability
.

The scientific method has enjoyed considerable stature as a method of inquiry and has been used productively by nurse researchers studying a range of nursing problems. This is not to say, however, that this approach can solve all nursing problems. One important limitation—common to both quantitative and qualitative research—is that research cannot be used to answer moral or ethical questions. Many persistent, intriguing questions about human beings fall into this area—questions such as whether euthanasia should be practiced or abortion should be legal.

The traditional research approach also must contend with problems of 
measurement
. To study a phenomenon, quantitative researchers attempt to measure it by attaching numeric values that express quantity. For example, if the phenomenon of interest is patient stress, researchers would want to assess if patients’ stress is high or low, or higher under certain conditions or for some people. Physiologic phenomena such as blood pressure and temperature can be measured with great accuracy and precision, but the same cannot be said of most psychological phenomena, such as stress or resilience. paradigms and methods for nursing research.

Another issue is that nursing research focuses on humans, who are inherently complex and diverse. Traditional quantitative methods typically concentrate on a relatively small portion of the human experience (e.g., weight gain, depression) in a single study paradigms and methods for nursing research. Complexities tend to be controlled and, if possible, eliminated, rather than studied directly, and this narrowness of focus can sometimes obscure insights. Finally, quantitative research within the positivist paradigm has been accused of an inflexibility of vision that does not capture the full breadth of human experience.

Constructivist Methods and Qualitative Research

Researchers in constructivist traditions emphasize the inherent complexity of humans, their ability to shape and create their own experiences, and the idea that truth is a composite of realities. Consequently, constructivist studies are heavily focused on understanding the human experience as it is lived, usually through the careful collection and analysis of 
qualitative
 materials that are narrative and subjective.

Researchers who reject the traditional scientific method believe that it is overly 
reductionist
—that is, it reduces human experience to the few concepts under investigation, and those concepts are defined in advance by the researcher rather than emerging from the experiences of those under study. Constructivist researchers tend to emphasize the dynamic, holistic, and individual aspects of human life and attempt to capture those aspects in their entirety, within the context of those who are experiencing them paradigms and methods for nursing research.

Flexible, evolving procedures are used to capitalize on findings that emerge in the course of the study. Constructivist inquiry usually takes place in the 
field
 (i.e., in naturalistic settings), often over an extended time period. In constructivist research, the collection of information and its analysis typically progress concurrently; as researchers sift through information, insights are gained, new questions emerge, and further evidence is sought to amplify or confirm the insights. Through an inductive process, researchers integrate information to develop a theory or description that helps illuminate the phenomenon under observation.

Constructivist studies yield rich, in-depth information that can elucidate varied dimensions of a complicated phenomenon. Findings from in-depth qualitative research are typically grounded in the real-life experiences of people with first-hand knowledge of a phenomenon. Nevertheless, the approach has several limitations. Human beings are used directly as the instrument through which information is gathered, and humans are extremely intelligent and sensitive—but fallible—tools. The subjectivity that enriches the analytic insights of skillful researchers can yield trivial and obvious “findings” among less competent ones.

Another potential limitation involves the subjectivity of constructivist inquiry, which sometimes raises concerns about the idiosyncratic nature of the conclusions. Would two constructivist researchers studying the same phenomenon in similar settings arrive at similar conclusions? paradigms and methods for nursing research The situation is further complicated by the fact that most constructivist studies involve a small group of participants. Thus, the generalizability of findings from constructivist inquiries is an issue of potential concern.

Multiple Paradigms and Nursing Research

Paradigms should be viewed as lenses that help to sharpen our focus on a phenomenon, not as blinders that limit intellectual curiosity. The emergence of alternative paradigms for studying nursing problems is, in our view, a healthy and desirable path that can maximize the breadth of evidence for practice. Although researchers’ worldview may be paradigmatic, knowledge itself is not. Nursing knowledge would be thin if there were not a rich array of methods available within the two paradigms—methods that are often complementary in their strengths and limitations. We believe that intellectual pluralism is advantageous.

We have emphasized differences between the two paradigms and associated methods so that distinctions would be easy to understand—although for many of the issues included in 
Table 1.2
, differences are more on a continuum than they are a dichotomy. paradigms and methods for nursing research. Subsequent chapters of this book elaborate further on differences in terminology, methods, and research products. It is equally important, however, to note that the two main paradigms have many features in common, only some of which are mentioned here:

Ultimate goals
. The ultimate aim of disciplined research, regardless of the underlying paradigm, is to gain understanding about phenomena. Both quantitative and qualitative researchers seek to capture the truth with regard to an aspect of the world in which they are interested, and both groups can make meaningful—and mutually beneficial—contributions to evidence for nursing practice.

External evidence
. Although the word 
empiricism
has come to be allied with the classic scientific method, researchers in both traditions gather and analyze evidence empirically, that is, through their senses. Neither qualitative nor quantitative researchers are armchair analysts, depending on their own beliefs and worldviews to generate knowledge. paradigms and methods for nursing research.

Reliance on human cooperation
. Because evidence for nursing research comes primarily from humans, human cooperation is essential. To understand people’s characteristics and experiences, researchers must persuade them to participate in the investigation 
and
 to speak and act candidly.

Ethical constraints
. Research with human beings is guided by ethical principles that sometimes interfere with research goals. As we discuss in 
Chapter 7
, ethical dilemmas often confront researchers, regardless of paradigms or methods.

Fallibility of disciplined research
. Virtually all studies have some limitations. Every research question can be addressed in many ways, and inevitably, there are trade-offs. The fallibility of any single study makes it important to understand and critique researchers’ methodologic decisions when evaluating evidence quality.

Thus, despite philosophic and methodologic differences, researchers using traditional scientific methods or constructivist methods share overall goals and face many similar challenges. The selection of an appropriate method depends on researchers’ personal philosophy and also on the research question paradigms and methods for nursing research. If a researcher asks, “What are the effects of cryotherapy on nausea and oral mucositis in patients undergoing chemotherapy?” the researcher needs to examine the effects through the careful measurement of patient outcomes. On the other hand, if a researcher asks, “What is the process by which parents learn to cope with the death of a child?” the researcher would be hard pressed to quantify such a process. Personal worldviews of researchers help to shape their questions. paradigms and methods for nursing research.

In reading about the alternative paradigms for nursing research, you likely were more attracted to one of the two paradigms. It is important, however, to learn about both approaches to disciplined inquiry and to recognize their respective strengths and limitations. In this textbook, we describe methods associated with both qualitative and quantitative research in an effort to assist you in becoming 
methodologically bilingual
. This is especially important because large numbers of nurse researchers are now undertaking 
mixed methods
 research that involves gathering and analyzing both qualitative and quantitative data (
Chapters 26
–
28
). paradigms and methods for nursing research.

THE PURPOSES OF NURSING RESEARCH

The general purpose of nursing research is to answer questions or solve problems of relevance to nursing. Specific purposes can be classified in various ways. We describe three such classifications—not because it is important for you to categorize a study as having one purpose or the other but rather because this will help us to illustrate the broad range of questions that have intrigued nurses and to further show differences between qualitative and quantitative inquiry.

Applied and Basic Research

Sometimes a distinction is made between basic and applied research. As traditionally defined, 
basic research
 is undertaken to enhance the base of knowledge or to formulate or refine a theory. For example, a researcher may perform an in-depth study to better understand normal grieving processes, without having 
explicit
 nursing applications in mind. Some types of basic research are called 
bench research
, which is usually performed in a laboratory and focuses on the molecular and cellular mechanisms that underlie disease.

Example of Basic Nursing Research:
 Kishi and a multidisciplinary team of researchers (2015) studied the effect of hypo-osmotic shock of epidermal cells on skin inflammation in a rat model, in an effort to understand the physiologic mechanism underlying aquagenic pruritus (disrupted skin barrier function) in the elderly.

Applied research
 seeks solutions to existing problems and tends to be of greater immediate utility for EBP. Basic research is appropriate for discovering general principles of human behavior and biophysiologic processes; applied research is designed to indicate how these principles can be used to solve problems in nursing practice. In nursing, the findings from applied research may pose questions for basic research, and the results of basic research often suggest clinical applications.

Example of Applied Nursing Research:
S. Martin and colleagues (2014) studied whether positive therapeutic suggestions given via headphones to children emerging from anesthesia after a tonsillectomy would help to lower the children’s pain. paradigms and methods for nursing research.

Research to Achieve Varying Levels of Explanation

Another way to classify research purposes concerns the extent to which studies provide explanatory information. Although specific study goals can range along an explanatory continuum, a fundamental distinction (relevant especially in quantitative research) is between studies whose primary intent is to 
describe
 phenomena, and those that are 
cause-probing
—that is, designed to illuminate the underlying causes of phenomena paradigms and methods for nursing research..

Within a descriptive/explanatory framework, the specific purposes of nursing research include identification, description, exploration, prediction/control, and explanation. For each purpose, various types of question are addressed—some more amenable to qualitative than to quantitative inquiry and vice versa.

Identification and Description

Qualitative researchers sometimes study phenomena about which little is known. In some cases, so little is known that the phenomenon has yet to be clearly identified or named or has been inadequately defined. The in-depth, probing nature of qualitative research is well suited to the task of answering such questions as, “What 
is
 this phenomenon?” and “What is its name?” (
Table 1.3
). In quantitative research, by contrast, researchers begin with a phenomenon that has been previously studied or defined—sometimes in a qualitative study. Thus, in quantitative research, identification typically precedes the inquiry. paradigms and methods for nursing research.

The Evidence-Based Practice Movement

The Cochrane Collaboration was an early contributor to the EBP movement. The collaboration was founded in the United Kingdom based on the work of British epidemiologist Archie Cochrane. Cochrane published an influential book in the 1970s that drew attention to the dearth of solid evidence about the effects of health care. He called for efforts to make research summaries of clinical trials available to health care providers. This eventually led to the development of the Cochrane Center in Oxford in 1993, and an international partnership called the Cochrane Collaboration, with centers established in locations throughout the world. Its aim is to help providers make good decisions about health care by preparing and disseminating systematic reviews of the effects of health care interventions. The Evidence-Based Practice Movement.

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At about the same time, a group from McMaster Medical School in Canada (including Dr. David Sackett) developed a clinical learning strategy they called 
evidence-based medicine
. The evidence-based medicine movement has shifted to a broader conception of using best evidence by all health care practitioners (not just physicians) in a multidisciplinary team. The Evidence-Based Practice Movement. EBP is considered a major shift for health care education and practice. In the EBP environment, a skillful clinician can no longer rely on a repository of memorized information but rather must be adept in accessing, evaluating, and using new evidence.

The EBP movement has advocates and critics. Supporters argue that EBP is a rational approach to providing the best possible care with the most cost-effective use of resources. Advocates also note that EBP provides a framework for self-directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion. Critics worry that the advantages of EBP are exaggerated and that individual clinical judgments and patient inputs are being devalued. They are also concerned that insufficient attention is being paid to the role of qualitative research. Although there is a need for close scrutiny of how the EBP journey unfolds, an EBP path is the one that health care professions will almost surely follow in the years ahead. The Evidence-Based Practice Movement.

TIP:
 A debate has emerged concerning whether the term “evidence-based practice” should be replaced with 
evidence-informed practice
 (EIP). Those who advocate for a different term have argued that the word “based” suggests a stance in which patient values and preferences are not sufficiently considered in EBP clinical decisions (e.g., Glasziou, 2005). Yet, as noted by Melnyk (2014), all current models of EBP incorporate clinicians’ expertise and patients’ preferences. She argued that “changing terms now … will only create confusion at a critical time where progress is being made in accelerating EBP” (p. 348). We concur and we use EBP throughout this book.

Knowledge Translation

Research utilization and EBP involve activities that can be undertaken at the level of individual nurses or at a higher organizational level (e.g., by nurse administrators), as we describe later in this chapter. In the early part of this century, a related movement emerged that mainly concerns system-level efforts to bridge the gap between knowledge generation and use. 
Knowledge translation (KT)
 is a term that is often associated with efforts to enhance systematic change in clinical practice.

It appears that the term was coined by the Canadian Institutes of Health Research (CIHR) in 2000. CIHR defined KT as “the exchange, synthesis, and ethically-sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system” (CIHR, 2004, p. 4) The Evidence-Based Practice Movement.

Several other definitions of KT have been proposed. For example, the World Health Organization (WHO) (2005) adapted the CIHR’s definition and defined KT as “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health The Evidence-Based Practice Movement.” Institutional projects aimed at KT often use methods and models that are similar to institutional EBP projects.

TIP:
 
Translation science
 (or 
implementation science
) has emerged as a discipline devoted to developing methods to promote knowledge translation. In nursing, the need for translational research was an important impetus for the development of the Doctor of Nursing Practice degree. Several journals have emerged that are devoted to this field (e.g., the journal 
Implementation Science
).

EVIDENCE-BASED PRACTICE IN NURSING

Before describing procedures relating to EBP in nursing, we briefly discuss some important issues, including the nature of “evidence” and challenges to pursuing EBP, and resources available to address some of those challenges.

Types of Evidence and Evidence Hierarchies

There is no consensus about the definition of 
evidence
 nor about what constitutes usable evidence for EBP, but most commentators agree that findings from rigorous research are paramount. Debate continues, however, about what constitutes 
rigorous
 research and what qualifies as 
best
 evidence.

At the outset of the EBP movement, there was a strong bias toward reliance on information from studies called 
randomized controlled trials
 (RCTs). This bias stemmed from the fact that the Cochrane Collaboration initially focused on the effectiveness of therapies rather on other types of health care questions. RCTs are, in fact, very well suited for drawing conclusions about the effects of health care interventions (
Chapter 9
). The bias in ranking sources of evidence in terms of questions about effective treatments led to some resistance to EBP by nurses who felt that evidence from qualitative and non-RCT studies would be ignored.

Positions about the contribution of various types of evidence are less rigid than previously. Nevertheless, many published 
evidence hierarchies
 rank evidence sources according to the strength of the evidence they provide, and in most cases, RCTs are near the top of these hierarchies. We offer a modified evidence hierarchy that looks similar to others, but ours illustrates that the ranking of evidence-producing strategies depends on the type of question being asked.

Figure 2.1
 shows that 
systematic reviews
 are at the pinnacle of the hierarchy (Level I), regardless of the type of question, because the strongest evidence comes from careful syntheses of multiple studies. The next highest level (Level II) depends on the nature of inquiry. For Therapy questions regarding the efficacy of an intervention (What works best for improving health outcomes?), individual RCTs constitute Level II evidence (systematic reviews of multiple RCTs are Level I). Going down the “rungs” of the evidence hierarchy for Therapy questions results in less reliable evidence—for example, Level III evidence comes from a type of study called quasi-experimental. In-depth qualitative studies are near the bottom, in terms of evidence regarding intervention effectiveness. (Terms in 
Figure 2.1
will be discussed in later chapters.) The Evidence-Based Practice Movement.

Evidence hierarchy: levels of evidence.

For a Prognosis question, by contrast, Level II evidence comes from a single prospective cohort study, and Level III is from a type of study called case control (Level I evidence is from a systematic review of cohort studies). Thus, contrary to what is often implied in discussions of evidence hierarchies, there really are multiple hierarchies. If one is interested in best evidence for questions about Meaning, an RCT would be a poor source of evidence, for example. We have tried to portray the notion of multiple hierarchies in 
Figure 2.1
, with information on the right indicating the type of 
individual study
 that would offer the best evidence (Level II) for different questions. In all cases, appropriate systematic reviews are at the pinnacle. Information about different hierarchies for different types of cause-probing questions is addressed in 
Chapter 9
.

Of course, 
within
any level in an evidence hierarchy, evidence quality can vary considerably. For example, an individual RCT could be well designed, yielding strong Level II evidence for Therapy questions, or it could be so flawed that the evidence would be weak. The Evidence-Based Practice Movement.

Thus, in nursing, 
best evidence
 refers to research findings that are methodologically appropriate, rigorous, and clinically relevant for answering persistent questions—questions not only about the efficacy, safety, and cost-effectiveness of nursing interventions but also about the reliability of nursing assessment tests, the causes and consequences of health problems, and the meaning and nature of patients’ experiences. Confidence in the evidence is enhanced when the research methods are compelling, when there have been multiple confirmatory studies, and when the evidence has been carefully evaluated and synthesized.

Of course, there continue to be clinical practice questions for which there is relatively little research evidence. In such situations, nursing practice must rely on other sources—for example, pathophysiologic data, chart review, quality improvement data, and clinical expertise. As Sackett and colleagues (2000) have noted, one benefit of the EBP movement is that a new research agenda can emerge when clinical questions arise for which there is no satisfactory evidence.

Evidence-Based Practice Challenges

Nurses have completed many studies about the use of research in practice, including research on barriers to EBP. Studies on EBP barriers, conducted in several countries, have yielded similar results about constraints on clinical nurses. Most barriers fall into one of three categories: (1) quality and nature of the research, (2) characteristics of nurses, and (3) organizational factors. The Evidence-Based Practice Movement.

With regard to the research, one problem is the limited availability of high-quality research evidence for some practice areas. There remains an ongoing need for research that directly addresses pressing clinical problems, for replication of studies in a range of settings, and for greater collaboration between researchers and clinicians. Another issue is that nurse researchers need to improve their ability to communicate evidence, and the clinical implications of evidence, to practicing nurses.

Nurses’ attitudes and education are also potential barriers to EBP. Studies have found that some nurses do not value or know much about research, and others simply resist change. Fortunately, many nurses do value research and want to be involved in research-related activities. Nevertheless, many nurses do not know how to access research evidence and do not possess the skills to critically evaluate research findings—and even those who do may not know how to effectively incorporate research evidence into clinical decision making. Among nurses in non-English-speaking countries, another impediment is that most research evidence is reported in English The Evidence-Based Practice Movement.

Finally, many of the challenges to using research in practice are organizational. “Unit culture” can undermine research use, and administrative and other organizational barriers also play a major role. Although many organizations support the idea of EBP in theory, they do not always provide the necessary supports in terms of staff release time and availability of resources. Nurses’ time constraints are a crucial deterrent to the use of evidence at the bedside. Strong leadership in health care organizations is essential to making evidence-based practice happen.

RESOURCES FOR EVIDENCE-BASED PRACTICE IN NURSING

The translation of research evidence into nursing practice is an ongoing challenge, but resources to support EBP are increasingly available. We urge you to explore other ideas with your health information librarian because the list of resources is growing as we write.

Preappraised Evidence

Research evidence comes in various forms, the most basic of which is in individual studies. 
Primary studies
 published in professional journals are not preappraised for quality or use in practice. 
Chapter 5
discusses how to access primary studies for a literature review.

Preprocessed (preappraised) evidence is evidence that has been selected from primary studies and evaluated for use by clinicians. DiCenso and colleagues (2005) have described a hierarchy of preprocessed evidence. On the first rung above primary studies are synopses of single studies, followed by systematic reviews, and then synopses of systematic reviews. Clinical practice guidelines are at the top of the hierarchy. At each successive step in the hierarchy, the ease in applying the evidence to clinical practice increases. We describe several types of preappraised evidence sources in this section. The Evidence-Based Practice Movement.

Overview of Philosophy

Within any discipline, both scholars and students should be aware of the philosophical orientations that are the basis for developing theory and advancing knowledge (Dahnke & Dreher, 2011; DiBartolo, 1998; Northrup et al., 2004; Risjord, 2010). Rather than a focus on solving problems or answering questions related to that discipline (which are tasks of the discipline’s science), the philosophy of a discipline studies the concepts that structure the thought processes of that discipline with the intent of recognizing and revealing foundations and presuppositions (Blackburn, 2008; Cronin & Rawlings-Anderson, 2004). Overview of Philosophy.

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Philosophy has been defined as “a study of problems that are ultimate, abstract, and general. These problems are concerned with the nature of existence, knowledge, morality, reason, and human purpose” (Teichman & Evans, 1999, p. 1). Philosophy tries to discover knowledge and truth and attempts to identify what is valuable and important.

Modern philosophy is usually traced to Rene Descartes, Francis Bacon, Baruch Spinoza, and Immanuel Kant (ca. 1600–1800). Descartes (1596–1650) and Spinoza (1632–1677) were early rationalists. Rationalists believe that reason is superior to experience as a source of knowledge. Rationalists attempt to determine the nature of the world and reality by deduction and stress the importance of mathematical procedures.

Bacon (1561–1626) was an early empiricist. Like rationalists, he supported experimentation and scientific methods for solving problems. Overview of Philosophy.

The work of Kant (1724–1804) set the foundation for many later developments in philosophy. Kant believed that knowledge is relative and that the mind plays an active role in knowing. Other philosophers have also influenced nursing and the advance of nursing science. Several are discussed later in the chapter.

Although there is some variation, traditionally, the branches of philosophy include metaphysics (ontology and cosmology), epistemology, logic, esthetics, and ethics or axiology. Political philosophy and philosophy of science are added by some authors (Rutty, 1998; Teichman & Evans, 1999). 
Table 1-2
 summarizes the major branches of philosophy.

Table 1-2: Branches of Philosophy

Branch

Pursuit

Metaphysics

Study of the fundamental nature of reality and existence—general theory of reality

Ontology

Study of theory of being (what is or what exists)

Cosmology

Study of the physical universe

Epistemology

Study of knowledge (ways of knowing, nature of truth, and relationship between knowledge and belief) Overview of Philosophy

Logic

Study of principles and methods of reasoning (inference and argument)

Ethics (axiology)

Study of nature of values; right and wrong (moral philosophy)

Esthetics

Study of appreciation of the arts or things beautiful

Philosophy of science

Study of science and scientific practice

Political philosophy

Study of citizen and state

Sources: Blackburn (2008); Teichman & Evans (1999).

Science and Philosophical Schools of Thought

The concept of science as understood in the 21st century is relatively new. In the period of modern science, three philosophies of science (paradigms or worldviews) dominate: rationalism, empiricism, and human science/phenomenology. Rationalism and empiricism are often termed 
received view
 and human science/phenomenology and related worldviews (i.e., historicism) are considered 
perceived view
(Hickman, 2011; Meleis, 2012). These two worldviews dominated theoretical discussion in nursing through the 1990s. More recently, attention has focused on another dominant worldview: “postmodernism” (Meleis, 2012; Reed, 1995).

Received View (Empiricism, Positivism, Logical Positivism)

Empiricism
 has its roots in the writings of Francis Bacon, John Locke, and David Hume, who valued observation, perception by senses, and experience as sources of knowledge (Gortner & Schultz, 1988; Powers & Knapp, 2011). Empiricism is founded on the belief that what is experienced is what exists, and its knowledge base requires that these experiences be verified through scientific methodology (Dahnke & Dreher, 2011; Gustafsson, 2002). This knowledge is then passed on to others in the discipline and subsequently built on. The term 
received view
 or 
received knowledge
 denotes that individuals learn by being told or receiving knowledge.

Empiricism holds that truth corresponds to observable, reduction, verification, control, and bias-free science. It emphasizes mathematic formulas to explain phenomena and prefers simple dichotomies and classification of concepts. Additionally, everything can be reduced to a scientific formula with little room for interpretation (DiBartolo, 1998; Gortner & Schultz, 1988; Risjord, 2010).

Empiricism focuses on understanding the parts of the whole in an attempt to understand the whole. It strives to explain nature through testing of hypotheses and development of theories. Theories are made to describe, explain, and predict phenomena in nature and to provide understanding of relationships between phenomena. Concepts must be operationalized in the form of propositional statements, thereby making measurement possible. Instrumentation, reliability, and validity are stressed in empirical research methodologies. Once measurement is determined, it is possible to test theories through experimentation or observation, which results in verification or falsification (Cull-Wilby & Pepin, 1987; Suppe & Jacox, 1985). Overview of Philosophy.

Positivism
 is often equated with empiricism. Like empiricism, positivism supports mechanistic, reductionist principles, where the complex can be best understood in terms of its basic components. 
Logical positivism
was the dominant empirical philosophy of science between the 1880s and 1950s. Logical positivists recognized only the logical and empirical bases of science and stressed that there is no room for metaphysics, understanding, or meaning within the realm of science (Polifroni & Welch, 1999; Risjord, 2010). Logical positivism maintained that science is value free, independent of the scientist, and obtained using objective methods. The goal of science is to explain, predict, and control. Theories are either true or false, subject to empirical observation, and capable of being reduced to existing scientific theories (Rutty, 1998). Overview of Philosophy.

Contemporary Empiricism/Postpositivism

Positivism came under criticism in the 1960s when positivistic logic was deemed faulty (Rutty, 1998). An overreliance on strictly controlled experimentation in artificial settings produced results that indicated that much significant knowledge or information was missed. In recent years, scholars have determined that the positivist view of science is outdated and misleading in that it contributes to overfragmentation in knowledge and theory development (DiBartolo, 1998). It has been observed that positivistic analysis of theories is fundamentally defective due to insistence on analyzing the logically ideal, which results in findings that have little to do with reality. It was maintained that the context of discovery was artificial and that theories and explanations can be understood only within their discovery contexts (Suppe & Jacox, 1985). Also, scientific inquiry is inherently value laden, as even choosing what to investigate and/or what techniques to employ will reflect the values of the researcher.

The current generation of postpositivists accept the subjective nature of inquiry but still support rigor and objective study through quantitative research methods. Indeed, it has been observed that modern empiricists or postpositivists are concerned

with explanation and prediction of complex phenomena, recognizing contextual variables (Powers & Knapp, 2011; Reed, 2008).

Nursing and Empiricism

As an emerging discipline, nursing has followed established disciplines (e.g., physiology) and the medical model in stressing logical positivism. Early nurse scientists embraced the importance of objectivity, control, fact, and measurement of smaller and smaller parts. Based on this influence, acceptable methods for knowledge generation in nursing have stressed traditional, orthodox, and preferably experimental methods. Overview of Philosophy.

Although positivism continues to heavily influence nursing science, that viewpoint has been challenged in recent years (Risjord, 2010). Consequently, postpositivism has become one of the most accepted contemporary worldviews in nursing.

Perceived View (Human Science, Phenomenology, Constructivism, Historicism)

In the late 1960s and early 1970s, several philosophers, including Kuhn, Feyerbend, and Toulmin, challenged the positivist view by arguing that the influence of history on science should be emphasized (Dahnke & Dreher, 2011). The perceived view of science, which may also be referred to as the interpretive view, includes phenomenology, constructivism, and historicism. The interpretive view recognizes that the perceptions of both the subject being studied and the researcher tend to de-emphasize reliance on strict control and experimentation in laboratory settings (Monti & Tingen, 1999).

The perceived view of science centers on descriptions that are derived from collectively lived experiences, interrelatedness, human interpretation, and learned reality, as opposed to artificially invented (i.e., laboratory-based) reality (Rutty, 1998). It is argued that the pursuit of knowledge and truth is naturally historical, contextual, and value laden. Thus, there is no single truth. Rather, knowledge is deemed true if it withstands practical tests of utility and reason (DiBartolo, 1998).

Phenomenology
 is the study of phenomena and emphasizes the appearance of things as opposed to the things themselves. In phenomenology, 
understanding
 is the goal of science, with the objective of recognizing the connection between one’s experience, values, and perspective. It maintains that each individual’s experience is unique, and there are many interpretations of reality. Inquiry begins with individuals and their experiences with phenomena. Perceptions, feelings, values, and the meanings that have come to be attached to things and events are the focus.

For social scientists, the 
constructivist
 approaches of the perceived view focus on understanding the actions of, and meaning to, individuals. What exists depends on what individuals perceive to exist. Knowledge is subjective and created by individuals. Thus, research methodology entails the investigation of the individual’s world (Wainwright, 1997). There is an emphasis on subjectivity, multiple truths, trends and patterns, discovery, description, and understanding.

Feminism and critical social theory may also be considered to be perceived view. These philosophical schools of thought recognize the influence of gender, culture, society, and shared history as being essential components of science (Riegel et al., 1992). Critical social theorists contend that reality is dynamic and shaped by social, political, cultural, economic, ethnic, and gender values (Streubert & Carpenter, 2011). Critical social theory and feminist theories will be described in more detail in 
Chapter 13
.

Nursing and Phenomenology/Constructivism/Historicism

Because they examine phenomena within context, phenomenology, as well as other perceived views of philosophy, are conducive to discovery and knowledge development inherent to nursing. Phenomenology is open, variable, and relativistic and based on human experience and personal interpretations. As such, it is an important, guiding paradigm for nursing practice theory and education (DiBartolo, 1998).

In nursing science, the dichotomy of philosophic thought between the received, empirical view of science and the perceived, interpretative view of science has persisted. This may have resulted, in part, because nursing draws heavily both from natural sciences (physiology, biology) and social sciences (psychology, sociology). Overview of Philosophy.

Postmodernism (Poststructuralism, Postcolonialism)

Postmodernism began in Europe in the 1960s as a social movement centered on a philosophy that rejects the notion of a single “truth.” Although it recognizes the value of science and scientific methods, postmodernism allows for multiple meanings of reality and multiple ways of knowing and interpreting reality (Hood, 2010; Reed, 1995). In postmodernism, knowledge is viewed as uncertain, contextual, and relative. Knowledge development moves from emphasis on identifying a truth or fact in research to discovering practical significance and relevance of research findings (Reed, 1995).

Similar or related constructs and worldviews found in the nursing literature include “deconstruction,” “postcolonialism,” and at times, feminist philosophies. In nursing, the postcolonial worldview can be connected to both feminism and critical theory, particularly when considering nursing’s historical reliance on medicine (Holmes, Roy, & Perron, 2008; Mackay, 2009; Racine, 2009).

Postmodernism has loosened the notions of what counts as knowledge development that have persisted among supporters of qualitative and quantitative research methods. Rather than focusing on a single research methodology, postmodernism promotes use of multiple methods for development of scientific understanding and incorporation of different ways to improve understanding of human nature (Hood, 2010; Meleis, 2012; Reed, 1995). Increasingly, in postmodernism, there is a consensus that synthesis of both research methods can be used at different times to serve different purposes (Hood, 2010; Meleis, 2012; Risjord, Dunbar, & Moloney, 2002) Overview of Philosophy.

Criticisms of postmodernism have been made and frequently relate to the perceived reluctance to address error in research. Taken to the extreme as Paley (2005) pointed out, when there is absence of strict control over methodology and interpretation of research, “nobody can ever be wrong about anything” (p. 107). Chinn and Kramer (2011) echoed the concerns by acknowledging that knowledge development should never be “sloppy.” Indeed, although application of various methods in research is legitimate and may be advantageous, research must still be carried out carefully and rigorously.

Nursing and Postmodernism

Postmodernism has been described as a dominant scientific theoretical paradigm in nursing in the late 20th century (Meleis, 2012). As the discipline matures, there has been recognition of the pluralistic nature of nursing and an enhanced understanding that the goal of research is to provide an integrative basis for nursing care (Walker & Avant, 2011).

In terms of scientific methodology, the attention is increasingly on combining multiple methods within a single research project (Chinn & Kramer, 2011). Postmodernism has helped dislodged the authority of a single research paradigm in nursing science by emphasizing the blending or integration of qualitative and quantitative research into a holistic, dynamic model to improve nursing practice. 
Table 1-3
 compares the dominant philosophical views of science in nursing.

Table 1-3: Comparison of the Received, Perceived, and Postmodern Views of Science

Received View of Science—Hard Sciences

Perceived View of Science—Soft Sciences

Postmodernism, Poststructuralism, and Postcolonialism

Empiricism/positivism/logical positivism

Historicism/phenomenology

Macroanalysis

Reality/truth/facts considered acontextual (objective)

Reality/truth/facts considered in context (subjective)

Contextual meaning; narration

Deductive

Inductive

Overview of Philosophy

Contextual, political, and structural analysis

Reality/truth/facts considered ahistorical

Reality/truth/facts considered with regard to history

Reality/truth/facts considered with regard to history

Prediction and control

Description and understanding

Metanarrative analysis

One truth

Multiple truths

Different views

Validation and replication

Trends and patterns

Uncovering opposing views

Reductionism

Constructivism/holism

Macrorelationship; microstructures

Quantitative research methods

Qualitative research methods

Methodologic pluralism

Sources: Meleis (2012); Moody (1990).

Nursing Philosophy, Nursing Science, and Philosophy of Science in Nursing

The terms 
nursing philosophy
, 
nursing science
, and 
philosophy of science in nursing
 are sometimes used interchangeably. The differences, however, in the general meaning of these concepts are important to recognize.

Nursing Philosophy

Nursing philosophy has been described as “a statement of foundational and universal assumptions, beliefs and principles about the nature of knowledge and thought (epistemology) and about the nature of the entities represented in the metaparadigm (i.e., nursing practice and human health processes [ontology])” (Reed, 1995, p. 76). Nursing philosophy, then, refers to the belief system or worldview of the profession and provides perspectives for practice, scholarship, and research (Gortner, 1990). Overview of Philosophy.

No single dominant philosophy has prevailed in the discipline of nursing. Many nursing scholars and nursing theorists have written extensively in an attempt to identify the overriding belief system, but to date, none has been universally successful. Most would agree then that nursing is increasingly recognized as a “multiparadigm discipline” (Powers & Knapp, 2011, p. 129), in which using multiple perspectives or worldviews in a “unified” way is valuable and even necessary for knowledge development (Giuliano, Tyer-Viola, & Lopez, 2005).

Nursing Science

Barrett (2002) defined nursing science as “the substantive, discipline-specific knowledge that focuses on the human-universe-health process articulated in the nursing frameworks and theories” (p. 57). To develop and apply the discipline-specific knowledge, nursing science recognizes the relationships of human responses in health and illness and addresses biologic, behavioral, social, and cultural domains. The goal of nursing science is to represent the nature of nursing—to understand it, to explain it, and to use it for the benefit of humankind. It is nursing science that gives direction to the future generation of substantive nursing knowledge, and it is nursing science that provides the knowledge for all aspects of nursing (Barrett, 2002; Holzemer, 2007).

Philosophy of Science in Nursing

Philosophy of science in nursing helps to establish the meaning of science through an understanding and examination of nursing concepts, theories, laws, and aims as they relate to nursing practice. It seeks to understand truth; to describe nursing; to examine prediction and causality; to critically relate theories, models, and scientific systems; and to explore determinism and free will (Nyatanga, 2005; Polifroni & Welch, 1999).

Knowledge Development and Nursing Science

Development of nursing knowledge reflects the interface between nursing science and research. The ultimate purpose of knowledge development is to improve nursing practice. Approaches to knowledge development have three facets: ontology, epistemology, and methodology. Ontology refers to the study of being: what is or what exists. Epistemology refers to the study of knowledge or ways of knowing. Methodology is the means of acquiring knowledge (Powers & Knapp, 2011). The following sections discuss nursing epistemology and issues related to methods of acquiring knowledge.

Epistemology

Epistemology
 is the study of the theory of knowledge. Epistemologic questions include: What do we know? What is the extent of our knowledge? How do we decide whether we know? and What are the criteria of knowledge? (Schultz & Meleis, 1988).

According to Streubert and Carpenter (2011), it is important to understand the way in which nursing knowledge develops to provide a context in which to judge the appropriateness of nursing knowledge and methods that nurses use to develop that knowledge. This in turn will refocus methods for gaining knowledge as well as establishing the legitimacy or quality of the knowledge gained. Overview of Philosophy.

Use the “Translational Research Graphic Organizer Template” to compare three types of translational research with traditional (qualitative or quantitative) research. Make sure to include methodology, goals, and data collection in your organizer.

You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.

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Translational Research Graphic Organizer Template

 

 

Observations (Similarities/Differences)

Methodology

 

 

Translational Research Graphic Organizer

 

 

 

 

 

Goals

 

 

 

 

 

 

 

 

Data Collection

 

 

 

 

 

 

 

Translational Research Graphic Organizer

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

Introduction

In the Prospectus, Proposal, and Direct Practice Improvement Project there are
10 key or strategic points
that need to be
clear, simple, correct, and aligned
to ensure the project is
doable, valuable, and credible
. These points, which provide a guide or vision for the project, are present in almost any research. They are defined within “The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project” (10 Strategic Points) document.

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The ten strategic points are developed in table format.

The 10 Strategic Points

The 10 strategic points emerge from researching literature on a topic that is based on, or aligned with, the defined need in the literature as well as the learner’s personal passion, future career purpose, and degree area. The 10 Strategic Points document
includes
the following 10 key or strategic points that define the project focus and approach: The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project.

Topic (10%)
– Provides a broad project topic area/title.

Literature Review (15%)
– Lists primary points for four sections in the Literature Review:

Background of the problem/gap and the need for the project based on citations from the literature.

Theoretical foundations (models and theories to be foundation for project).

Review of literature topics with key theme for each one.

Summary.

Problem Statement (10%)
– Describes the problem to address through the project based on defined needs or gaps in practice from the literature.

Sample and Location (10%)
– Identifies sample, needed sample size, and location.

Clinical/PICOT Questions (10%)
– Provides clinical/PICOT questions to collect data to address the problem statement. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project.

Variables (5%)
– Identifies and describes independent and dependent variables.

Methodology and Design

(10%)
– Describes the selected methodology and specific project design to address problem statement and clinical questions

Purpose Statement (10%)
– Provides one sentence statement of purpose including the problem statement, methodology, design, population sample, and location.

Data Collection (10%)
– Describes primary instruments to answer clinical questions.

Data Analysis

(10%)
– Describes the specific data analysis approaches to be used to address clinical/PICOT questions.

The Process for Defining the 10 Strategic Points

The order of the 10 strategic points listed above reflects the order in which the learner completes the work product. The first five strategic points focus primarily on defining the focus for the project based on a clearly defined need or gap from the literature as well as the learner’s passion, purpose, and specialty area focus. First, learners identify a broad topic area to investigate for their Direct Practice Improvement (DPI) Project based on a clearly defined need or gap from the literature or practice problem, and one in which they are interested based on personal passion, future career purpose, and degree being pursued. Second, learners complete a review of the literature to define the need or gap to be addressed, the theories and models that will provide a foundation for the project, related topics that are needed to demonstrate the learner’s expertise in the field, and to define the key strategic points behind the learner’s proposed research. Third, the learners develop a clear, simple, one-sentence problem statement that defines the problem or gap that will be addressed by the DPI project. Fourth, learners identify potential population samples for which they would have access in order to collect the data for the project, considering the fact the quantitative study sample sizes need to be much larger than those for qualitative studies. Fifth, learners develop the clinical/PICOT question(s) that will define the data needed to address the problem statement. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project.

Based on the first five strategic points above, learners next define the key aspects of the project methodology through the last five strategic points. The sixth point describes the independent and dependent variables. Seventh, learners determine if the project will be a qualitative, quantitative or mixed methodology. Due to the nature of the DPI project requirements, most projects will be utilizing a quantitative method because learners are not creating new research in a qualitative study. Qualitative projects often do not facilitate the intervention needed to demonstrate direct practice improvement. Please note that if you choose a qualitative project, you are still responsible for ensuring practice improvement is demonstrated through your work. Additionally, learners must be able to perform both qualitative and quantitative data analysis. A qualitative project with numbers or descriptive statistics does not mean it is mixed method study. Qualitative data can be displayed using tables, charts, graphs and descriptive statistics. Following are samples for a quantitative project and a qualitative project. A mixed method project, which includes quantitative and qualitative methods, takes much more time and many more resources to complete and
is not recommended
unless learners have a significant amount of extra time and resources to complete it. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project.

For the eighth strategic point, learners develop a purpose statement by integrating the problem statement, methodology, design, sample, and location. Ninth, learners identify the data they will need to collect to address the clinical questions or hypotheses and how they will collect the data (e.g., interviews, focus groups, observations, tested and validated instruments or surveys, databases, public media, etc.). Tenth and last, learners identify the appropriate data analysis, based on their project design, which will be used to answer the clinical questions and address the problem statement.

Criteria for Evaluating the 10 Strategic Points: Clear, Simple, Correct, and Aligned

When developing a project, it is important to define the 10 strategic points so they are
simple
,
clear
, and
correct
in order to ensure that anyone who reviews them will easily understand them. It is important to
align
all of the 10 strategic points to ensure it will be possible to conduct and complete the project. The problem statement must come out of the literature or practice problem. The clinical questions must collect the data needed to answer the problem statement. The methodology and design must be appropriate for the problem statement and PICOT questions. The data collection and data analysis must provide the information to answer the PICOT questions.

Developing the 10 Strategic Points document as a two- or three-page document can help ensure clarity, simplicity, correctness, and alignment of each of these 10 key or strategic points in the prospectus, proposal, and Direct Practice Improvement Project. Developing these 10 strategic points in this format also provides an easy-to-use use template to ensure the 10 strategic points will always be worded the same throughout the prospectus, proposal, and Direct Practice Improvement Project. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project.

Value of the 10 Strategic Points Document

The 10 Strategic Points document can be used for communicating and aligning key stakeholders for the Direct Practice Improvement Project. This document can be used to obtain agreement between the learner and the chair regarding the initial focus and approach for the project. The document can be used to review the proposed project with the people or organizations from whom learners need to gain permission to conduct their research, a critical step required before learners can develop their proposal. The document also proves useful for communicating the Direct Practice Improvement Project focus when attracting a Content Expert, as well as for reviewing the proposal with the Direct Practice Improvement Project committee and the AQR reviewers. Learners may choose to consult methodologists, statisticians, and editors in the process of developing the final manuscript.

Examples of the 10 Strategic Points Document

It is important that the 10 strategic points are clear, concise, doable, and aligned throughout the prospectus, proposal, and Direct Practice Improvement Project. Provided below is an example of a completed 10 Strategic Points document for a quantitative project. A blank 10 Strategic Points Table template is provided following the example for learners to use when developing their own 10 Strategic Point documents.

Example: 10 Strategic Points Document for a Quantitative Project

The 10 Strategic Points

Comments or Feedback

Broad Topic Area

1.     
Broad Topic Area:

Hint: What would I title my project?

Literature Review

2.     
Literature Review:

List primary points for four sections in the Literature Review: Background of the problem/gap; theoretical foundations (models and theories to be foundation for study); review of literature topics with key theme for each one; and summary.

a.     
Background of the Problem/Gap:

·         Rural ambulatory clinics have had to reorganize their management structures to enhance reimbursement.

·         Access to appropriate health services for rural Americans needs to be improved in areas where specialists are not available (Schoenberg, 2012).

·         Telehealth nursing services can be provided through rural health clinics to support specialty clinics (Schoenberg, 2012).

·         Approximately 200 telemedicine networks have been established nationwide. (American Telemedicine Association, 2017)

b.     
Theoretical Foundations (models and theories to be foundation for study):

·         The Greenhalgh’s Dissemination of Innovations model (Greenhalgh, Robert, Bate, Macfarlane, & Kyriakidau, 2005) can be used to implement rural telehealth services for rural Americans.

·         The D&M Information System Success model (DeLone &McLean, 2003) is a framework to conceptualize and operationalize information system success. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

·         Path constitution theory combines two contrasting perspectives on technology, path dependence, and path creation (Singh, Mathiassen, & Mishra, 2015).

c.      
Review of Literature Topics With Key Organizing Concepts or Topics for Each One

Rural Telehealth Services:

·         Rural telehealth can improve care in burn patients (McWilliams, Hendricks, Twigg, Wood, & Giles, 2016); smoking cessation (Carlson, Lounsberry, Maciejewski, Wright, Collacutt, & Taenzer, 2011), psychotherapy (Gonzales & Brossart, 2015);  cancer education (Doorenbos et al., 2011); diabetes (Holloway, Coon, Kersten, & Clemins, 2011).

Population Specific Telehealth Services:

·         Community based telehealth: Home-based telehealth can enhance older adults’ access to care and facilitate patient-provider collaboration which may in turn improve patient self-management (Hsieh, Tsai, Chic, & Lin, 2015).

·         Chronically ill: Disease management needs of chronically ill patients include prescription refills, medication and symptom management, lab results, and patient education (Vinson, McCallum, Thornlow, & Champagne, 2011).

·         Rural Native American telehealth:  Telehealth can improve health disparities in Native American communities (Kruse, Bouffard, Dougherty, & Parro, 2016).

·         Diabetes education and management:  Telehealth education improves glycemic control (Barker, Mallow, Theeke, & Schwertfeger, 2016).

·         Mental health emergencies can be managed effectively through telehealth services (Saurman et al., 2011).

Settings:

·         Rural health clinic/hospital (Carlson et al., 2011); Doorenbos et al., 2011; Gonzales & Brossart, 2015; Holloway et al., 2011). The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

·         Home-based (Demiris et al., 2103).

·         Community center (Demiris et al., 2103).

·         Library (Demiris et al., 2103).

·         Smart phone, computer-based (Forchuk et al., 2016).

Certifications:

·         National Committee for Quality Assurance (n.d). Disease Management Accreditation. Retrieved from http://www.ncqa.org/programs/accreditation/disease-management-dm

·         American Association of Critical Care Nurses (n.d.). CCRN-E: Certification for Tele-ICU Nurses. Retrieved from https://www.aacn.org/certification?tab=First-Time%20Certification

·         Acute stroke ready designation (Slivinski, Johes, Whitehead, & Hooper, 2017).

Network Systems
:

·         American Telemedicine Association: approximately 200 telemedicine networks have been established nationwide (Frederick, 2013).

·         Tablet PC Enabled Body Sensor System: real-time continuous collection of physiological parameters (Panicker, Kumar, 2016).

d.     
Summary

·         Gap/Problem: There is a need to implement evidence-based methods of improving health outcomes of rural residents through the use of telehealth.

·         Prior studies: Prior studies show that telehealth improves patient outcomes in diverse settings, including rural areas.

·         Quantitative application: Sources of data exist to collect numerical data on the rate of follow-up with primary care provider in rural areas.

·         Significance: Improving rate of follow-up with primary care provider will improve health outcomes of rural residents.

Problem Statement

3.     
Problem Statement:

Describe the variables/groups to study, in one sentence.

 

A well-written problem statement begins with the big picture of the issue (
macro)
and works to the small, narrower, and more specific problem (
micro
). It clearly communicates the significance, magnitude, and importance of the problem and transitions into the Purpose of the Project with a declarative statement such as: “It is not known if and to what degree/extent…” or “It is not known how/why and….”

Other examples are:

·         While the literature indicates ____________, it is not known in _________ (organization/community) if __________.

·         It is not known how or to what extent ________________.

While the literature indicates that telehealth is an important emerging technology for rural patient access, it is unknown if the implementation of telehealth impacts the rate of patient follow up for patients living in a rural area.

Clinical/

PICOT Questions

4.     
Clinical/PICOT Questions:

Provide PICOT question to guide the implementation and data collection of findings of the project:

(P)
Among adult patients in a rural care setting,
(I)
how does implementation of a telehealth program
(C)
compare to traditional commute-for-care (
O)
impact rate of follow-up with the primary care provider (
T)
over a period of four weeks.

Sample

5.     
Sample (and Location):

Identify sample, needed sample size, and location (study phenomena with small numbers and variables/groups with large numbers).

a.       Location: Arizona

b.      Population: Two neighboring rural towns equal distance from the nearest primary care provider.

c.       Sample: 40 participants include a power analysis if appropriate.

Define Variables

6.     
Define Variables:

a.      
Independent Variable:
Telehealth program.

b.     
Dependent Variable:
Follow-up rate with primary care provider. The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

Methodology  and Design

7.     
Methodology and Design:

Name the selected methodology and specific design to address the problem statement and clinical questions:

This project will use a quantitative methodology with a quasi-experimental design.

Purpose Statement

8.     
Purpose Statement:

Provide one sentence statement of purpose including the problem statement, sample, methodology, and design:

Creswell (2003) provided some sample templates for developing purpose statements aligned with the different project methods as follows:

The purpose of this
quantitative
___________ (correlational, descriptive, etc.) project is to ____________ (compare or see to what degree a relationship exists) between/among ______________________ (independent variable) to ___________________ (dependent variable) for ________________ (participants) at ___________________ (project site/geographical location). The ________ (independent variable) will be defined/measured as/by _______ (provide a general definition). The
                                 
 (dependent variable) will be defined/measured as/by ______ (provide a general definition).

 

 

Data Collection Approach

9.     
Data Collection Approach:

Describe primary instruments that will be used to answer clinical question.

Data Analysis Approach

10. 
Data Analysis Approach:

Descriptive statistics will describe the sample characteristics and variable results. An independent t-tests will test for difference between the two groups of 40 participants (telehealth and commute-for-care) follow-up with primary physician. A priori analysis will be used to justify the sample size.

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

 

 

10 Strategic Points Table

(Use this table to complete the 10 Strategic Points document for your project.)

10 Strategic Points

Comments/Feedback

Broad Topic Area

Literature Review

Problem Statement

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

Clinical/PICO Questions

Sample

Define Variables

Methodology  and Design

Purpose Statement

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

 

 

Data Collection Approach

Data Analysis Approach

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Week Two Assignment Instructions DNP 820

Please read the instructions thoroughly there are strict requirements

I need at least 10 different articles/literature reviews added to the ones in the 815 attachment. I have also included the chart to be filled out All within 5 years and pertinent to the subject.

Tutor MUST have a good command of the English language

The Rubric must be followed,

and all the requirements met DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

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This is a thorough professor, and she has strict requirements

I have attached the PICOT and the first 10 points (DNP 815) assignment. This is a continuation of that assignment. Please read the attachments

The following needs to be addressed:

Please note the followings: The introduction and the literature review are complete and thorough. The problem statement is written clearly PICOT is clear and very good Sample: 

·
How will you determine the sample size? 

·
What are the inclusion/exclusion criteria of the subjects? Methodology: Why is the selected methodology is appropriate? Please justify! 

·
Data collection approach needs to be clear. How will you collect your data? What is needed here is to describe the process of collecting data form signing the informed consent until completing the measuring.

·
Data analysis-What test will you use to answer your research question? 

Clinical/PICOT Questions:  

“In adult patients with CVC

at a Clear Lake Regional Medical Center, does interventional staff education about hub hygiene provided to RN’s who access the CVC impact CLABSI rates compared to standard care over a one-month period?” DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

P: Patients with Central Venous Catheters

I: Staff re-education related to Hygiene of the hub

C: Other hospitals

O: Reduce probability of CLABSIs

T: Two months

“In Patients > 65 years of age with central line catheters at a Clear Lake Regional Medical Center, how does staff training of key personnel and reinforcement of central line catheter hub hygiene after its insertion, along with the apt cleansing of the insertion site, before every approach compared with other area hospitals, reduce the incidence of CLABSIs (Central Line Associated Blood-stream Infections) over a one-month period?”

P: Patients > 65 years of age with a Central line

I: Staff training and reinforcement of Central Catheter, Hub Hygiene 

C: Other area hospitals 

O: Reduce probability of CLABSIs

“In adult patients, with

define CVC (CVC), does interventional staff education about hub hygiene provided to RN’s who access the CVC impact CLABSI rates compared to pre and post-intervention assessments 

1. I used central Missouri as an example, replace with a description of your site. 

2. While you might be interested in CLASBI rates as a primary variable, there are other patient outcomes that would also be important to consider DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

3. Ensure you can find validity and reliability measures on CLASBI rates if you cannot, we need to determine another question to help

4. How are your two comparison groups different, as they are currently stated the groups seem very much the same, could you state, standard care instead of pre and post intervention assessments? 

5. One month is the longest time you can use for a prospective project

Please note the following regarding the instructors grading

IMPORTANT INFORMATION ABOUT MY GRADING STYLE

As you prepare for written papers and manuscripts I’d like to give you some details about my grading style. I provide significant feedback on your papers, this is because I believe you should be working towards improving your writing so that at the end of this program you are able to successfully write your DPI project. In order to write well, you need feedback and you need to review that feedback and make progress on the next written work. To that end I always grade accordingly. This means that if I provide feedback one an item (for example APA format of your reference page) I expect that this will be improved on the next written submission. Otherwise I will deduct additional points. In addition, some other criteria to get down pat now. References should always DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

1.

Be current, no older than 5 years that means 5 years from your proposed graduation date (2014-2019). Otherwise you will have to redo everything in DNP 955.

2.

Be primary sources. You can no longer cite Young declared literary war in 1956 (as cited by Brown 2006). You must cite Young 1956. That means go find that paper and read it and make sure that you agree with what Brown said. What if you don’t agree due to some very valid points? Then the literary war is not what occurred, but instead you have concerns regarding point ____, ____, and ____.

3.

You may no longer cite textbooks, they are 1) secondary sources and 2) not current enough, and please use peer reviewed manuscripts.

One more item that is not a reference. You may not use direct quotes any longer. There is no need. This may be difficult at first, but you are moving towards a different type of writing. This is manuscript writing (scientific writing). Scientific writing is terse, clear, and concise. No frilly words. In order to avoid the use of direct quotes you will synthesize the literature. There is a great resource for synthesizing the literature under Resources – Add-ons. These are also some other great writing resources there.

Details:

In the prospectus, proposal, and scholarly project there are 10 strategic points that need to be clear, simple, correct, and aligned to ensure the research is doable, valuable, and credible. The 10 strategic points emerge from researching literature on a topic that is based on or aligned with the learner’s personal passion, future career purpose, and degree area. These 10 points provide a guiding vision for DPI Project. In this assignment, you will continue the work begun in DNP-815, working on your draft of a document addressing the 10 key strategic points that define your intended research focus and approach. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project.

General Requirements:

Use the following information to ensure successful completion of the assignment:

Locate      the “The 10 Strategic Points for the      Prospectus, Proposal, and Direct Practice Improvement Project” that      you completed in DNP-815.

Doctoral      learners are required to use APA style for their writing assignments. The      APA Style Guide is located in the      Student Success Center. An abstract is not required.

This      assignment uses a rubric. Please Review the rubric prior to the beginning to become familiar with the      expectations for successful completion.

You      are required to submit this assignment to Turnitin. Please refer to the      directions in the Student Success Center.

Directions:

Use the “The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project” resource to draft statements for each of the 10 points for your intended research study.

You worked on this last in DNP 815. Pick up from where you left off
(if you transferred in and did not complete this, you will have to begin fresh).
Please include a copy of your last instructor feedback when you submit this assignment. You can either copy and paste the instructor feedback into your current paper (as an appendix and clearly marked); or upload two separate papers. I expect significant improvement from your last submission.

Please review the 10 Strategic Points document for additional instructions and an example. Add references to this document,
I suggest 5-10 at this point.
You need to realize that your literature review chapter will need at least 50+ articles by the time you get to DNP 955, so work on expanding your literature search each week, to include more and more to this paper as you move through each course. If you cannot locate 50+ articles you can ask your faculty for assistance or chose a different topic. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

 

For the methodology and design sections. Methodology should cover the broad methods you plan to use (qualitative, quantitative, or mixed methods). The design portion will then go into more detail and discuss the design (i.e. correlational, cross-sectional, pre/posttest, etc.). Describe each and explain why your chosen methodology and design are appropriate to your topic and project questions. You may NOT use qualitative, GCU leadership does not support a qualitative methodology.

Intervention. You must have an intervention that you implement. Since you cannot evaluate a project that has already been implemented, please write up a description of your intervention and what your role will be in implementing this intervention. This is not a section listed on your 10 Strategic Points document as of yet, so add it after the methodology and design sections. Describe step by step what the intervention consists of, how it is evidence based, how you will implement, and your role in implementation.

Data collection should go step by step (extremely over-detailed) on how you will collect the data. Tell me about all instruments, surveys, and/or questions you will ask of participants. One MUST be a valid and reliable tool.

Data Analysis. Tell me the specific statistics you will use. Start with descriptive statistics, which ones will you use, why (cite current primary sources). Then tell me how you will compare your data (which statistic), what your p value will be before you start your data collection.

Apply Rubrics

 

 

1

Unsatisfactory

0.00%

2

Does Not Meet Expectations

74.00%

3

Approaching Meeting Expectations

87.00%

4

Meets Expectations

100.00%

100.0 %Content

 

10.0 %Topic: Provides a broad project topic area/title.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

15.0 %Literature Review: Lists primary points for four sections in the Literature Review: (a) Background of the problem/gap and the need for the project based on citations from the literature; (b) Theoretical foundations (models and theories to be foundation for study); (c) Review of literature topics with key concept (??) for each one; (d) Summary.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Problem Statement: Describes the problem to address through the project based on defined gaps or needs from the literature.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Sample and Location: Identifies sample, needed sample size, and location.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Clinical/PICOT Questions: Provides clinical/PICOT questions to all of the collected data needed to address the problem statement.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

5.0 %Variables

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Methodology and Design: Describes the selected methodology and specific research design to address problem statement and clinical/PICOT questions.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Purpose Statement: Provides one sentence statement of purpose including the problem statement, methodology, design, population sample, and location.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Data Collection: Describes primary instruments and sources of data to answer research questions. Reliability and Validity of the instruments are addressed.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

10.0 %Data Analysis: Describes the specific data analysis approaches to be used to address clinical/PICOT questions. The statistical test(s) that will be used must be identified and must be appropriate for the level of data and the clinical/PICOT question.

Item is not present.

Not all components are present. Large gaps are present in the components that leave the reader with significant questions.

Component is present and adequate. Small gaps are present that leave the reader with questions.

Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions.

 

The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project

Introduction

In the Prospectus, Proposal, and Direct Practice Improvement Project there are
10 key or strategic points
that need to be
clear, simple, correct, and aligned
to ensure the project is
doable, valuable, and credible
. These points, which provide a guide or vision for the project, are present in almost any research. They are defined within “The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project” (10 Strategic Points) document.

The ten strategic points are developed in table format.

The 10 Strategic Points

The 10 strategic points emerge from researching literature on a topic that is based on, or aligned with, the defined need in the literature as well as the learner’s personal passion, future career purpose, and degree area. The 10 Strategic Points document
includes
the following 10 key or strategic points that define the project focus and approach:

Topic (10%)
– Provides a broad project topic area/title.

Literature Review (15%)
– Lists primary points for four sections in the Literature Review:

Background of the problem/gap and the need for the project based on citations from the literature.

Theoretical foundations (models and theories to be foundation for project).

Review of literature topics with key theme for each one.

Summary.

Problem Statement (10%)
– Describes the problem to address through the project based on defined needs or gaps in practice from the literature.

Sample and Location (10%)
– Identifies sample, needed sample size, and location.

Clinical/PICOT Questions (10%)
– Provides clinical/PICOT questions to collect data to address the problem statement.

Variables (5%)
– Identifies and describes independent and dependent variables.

Methodology and Design

(10%)
– Describes the selected methodology and specific project design to address problem statement and clinical questions

Purpose Statement (10%)
– Provides one sentence statement of purpose including the problem statement, methodology, design, population sample, and location.

Data Collection (10%)
– Describes primary instruments to answer clinical questions.

Data Analysis

(10%)
– Describes the specific data analysis approaches to be used to address clinical/PICOT questions.

The Process for Defining the 10 Strategic Points

The order of the 10 strategic points listed above reflects the order in which the learner completes the work product. The first five strategic points focus primarily on defining the focus for the project based on a clearly defined need or gap from the literature as well as the learner’s passion, purpose, and specialty area focus. First, learners identify a broad topic area to investigate for their Direct Practice Improvement (DPI) Project based on a clearly defined need or gap from the literature or practice problem, and one in which they are interested based on personal passion, future career purpose, and degree being pursued. Second, learners complete a review of the literature to define the need or gap to be addressed, the theories and models that will provide a foundation for the project, related topics that are needed to demonstrate the learner’s expertise in the field, and to define the key strategic points behind the learner’s proposed research. Third, the learners develop a clear, simple, one-sentence problem statement that defines the problem or gap that will be addressed by the DPI project. Fourth, learners identify potential population samples for which they would have access in order to collect the data for the project, considering the fact the quantitative study sample sizes need to be much larger than those for qualitative studies. Fifth, learners develop the clinical/PICOT question(s) that will define the data needed to address the problem statement.

Based on the first five strategic points above, learners next define the key aspects of the project methodology through the last five strategic points. The sixth point describes the independent and dependent variables. Seventh, learners determine if the project will be a qualitative, quantitative or mixed methodology. Due to the nature of the DPI project requirements, most projects will be utilizing a quantitative method because learners are not creating new research in a qualitative study. Qualitative projects often do not facilitate the intervention needed to demonstrate direct practice improvement. Please note that if you choose a qualitative project, you are still responsible for ensuring practice improvement is demonstrated through your work. Additionally, learners must be able to perform both qualitative and quantitative data analysis. A qualitative project with numbers or descriptive statistics does not mean it is mixed method study. Qualitative data can be displayed using tables, charts, graphs and descriptive statistics. Following are samples for a quantitative project and a qualitative project. A mixed method project, which includes quantitative and qualitative methods, takes much more time and many more resources to complete and
is not recommended
unless learners have a significant amount of extra time and resources to complete it.

For the eighth strategic point, learners develop a purpose statement by integrating the problem statement, methodology, design, sample, and location. Ninth, learners identify the data they will need to collect to address the clinical questions or hypotheses and how they will collect the data (e.g., interviews, focus groups, observations, tested and validated instruments or surveys, databases, public media, etc.). Tenth and last, learners identify the appropriate data analysis, based on their project design, which will be used to answer the clinical questions and address the problem statement.

Criteria for Evaluating the 10 Strategic Points: Clear, Simple, Correct, and Aligned

When developing a project, it is important to define the 10 strategic points so they are
simple
,
clear
, and
correct
in order to ensure that anyone who reviews them will easily understand them. It is important to
align
all of the 10 strategic points to ensure it will be possible to conduct and complete the project. The problem statement must come out of the literature or practice problem. The clinical questions must collect the data needed to answer the problem statement. The methodology and design must be appropriate for the problem statement and PICOT questions. The data collection and data analysis must provide the information to answer the PICOT questions.

Developing the 10 Strategic Points document as a two- or three-page document can help ensure clarity, simplicity, correctness, and alignment of each of these 10 key or strategic points in the prospectus, proposal, and Direct Practice Improvement Project. Developing these 10 strategic points in this format also provides an easy-to-use use template to ensure the 10 strategic points will always be worded the same throughout the prospectus, proposal, and Direct Practice Improvement Project. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project.

Value of the 10 Strategic Points Document

The 10 Strategic Points document can be used for communicating and aligning key stakeholders for the Direct Practice Improvement Project. This document can be used to obtain agreement between the learner and the chair regarding the initial focus and approach for the project. The document can be used to review the proposed project with the people or organizations from whom learners need to gain permission to conduct their research, a critical step required before learners can develop their proposal. The document also proves useful for communicating the Direct Practice Improvement Project focus when attracting a Content Expert, as well as for reviewing the proposal with the Direct Practice Improvement Project committee and the AQR reviewers. Learners may choose to consult methodologists, statisticians, and editors in the process of developing the final manuscript. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project.

Examples of the 10 Strategic Points Document

It is important that the 10 strategic points are clear, concise, doable, and aligned throughout the prospectus, proposal, and Direct Practice Improvement Project. Provided below is an example of a completed 10 Strategic Points document for a quantitative project. A blank 10 Strategic Points Table template is provided following the example for learners to use when developing their own 10 Strategic Point documents.

Example: 10 Strategic Points Document for a Quantitative Project

The 10 Strategic Points

Comments or Feedback

Broad Topic Area

1.     
Broad Topic Area:

Hint: What would I title my project?

Literature Review

2.     
Literature Review:

List primary points for four sections in the Literature Review: Background of the problem/gap; theoretical foundations (models and theories to be foundation for study); review of literature topics with key theme for each one; and summary.

a.     
Background of the Problem/Gap:

·         Rural ambulatory clinics have had to reorganize their management structures to enhance reimbursement.

·         Access to appropriate health services for rural Americans needs to be improved in areas where specialists are not available (Schoenberg, 2012).

·         Telehealth nursing services can be provided through rural health clinics to support specialty clinics (Schoenberg, 2012).

·         Approximately 200 telemedicine networks have been established nationwide. (American Telemedicine Association, 2017)

b.     
Theoretical Foundations (models and theories to be foundation for study):

·         The Greenhalgh’s Dissemination of Innovations model (Greenhalgh, Robert, Bate, Macfarlane, & Kyriakidau, 2005) can be used to implement rural telehealth services for rural Americans.

·         The D&M Information System Success model (DeLone &McLean, 2003) is a framework to conceptualize and operationalize information system success.

·         Path constitution theory combines two contrasting perspectives on technology, path dependence, and path creation (Singh, Mathiassen, & Mishra, 2015).

c.      
Review of Literature Topics With Key Organizing Concepts or Topics for Each One

Rural Telehealth Services:

·         Rural telehealth can improve care in burn patients (McWilliams, Hendricks, Twigg, Wood, & Giles, 2016); smoking cessation (Carlson, Lounsberry, Maciejewski, Wright, Collacutt, & Taenzer, 2011), psychotherapy (Gonzales & Brossart, 2015);  cancer education (Doorenbos et al., 2011); diabetes (Holloway, Coon, Kersten, & Clemins, 2011).

Population Specific Telehealth Services:

·         Community based telehealth: Home-based telehealth can enhance older adults’ access to care and facilitate patient-provider collaboration which may in turn improve patient self-management (Hsieh, Tsai, Chic, & Lin, 2015).

·         Chronically ill: Disease management needs of chronically ill patients include prescription refills, medication and symptom management, lab results, and patient education (Vinson, McCallum, Thornlow, & Champagne, 2011).

·         Rural Native American telehealth:  Telehealth can improve health disparities in Native American communities (Kruse, Bouffard, Dougherty, & Parro, 2016).

·         Diabetes education and management:  Telehealth education improves glycemic control (Barker, Mallow, Theeke, & Schwertfeger, 2016).

·         Mental health emergencies can be managed effectively through telehealth services (Saurman et al., 2011).

Settings:

·         Rural health clinic/hospital (Carlson et al., 2011); Doorenbos et al., 2011; Gonzales & Brossart, 2015; Holloway et al., 2011).

·         Home-based (Demiris et al., 2103).

·         Community center (Demiris et al., 2103).

·         Library (Demiris et al., 2103).

·         Smart phone, computer-based (Forchuk et al., 2016).

Certifications:

·         National Committee for Quality Assurance (n.d). Disease Management Accreditation. Retrieved from http://www.ncqa.org/programs/accreditation/disease-management-dm

·         American Association of Critical Care Nurses (n.d.). CCRN-E: Certification for Tele-ICU Nurses. Retrieved from https://www.aacn.org/certification?tab=First-Time%20Certification

·         Acute stroke ready designation (Slivinski, Johes, Whitehead, & Hooper, 2017).

Network Systems
:

·         American Telemedicine Association: approximately 200 telemedicine networks have been established nationwide (Frederick, 2013).

·         Tablet PC Enabled Body Sensor System: real-time continuous collection of physiological parameters (Panicker, Kumar, 2016).

d.     
Summary

·         Gap/Problem: There is a need to implement evidence-based methods of improving health outcomes of rural residents through the use of telehealth.

·         Prior studies: Prior studies show that telehealth improves patient outcomes in diverse settings, including rural areas. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

·         Quantitative application: Sources of data exist to collect numerical data on the rate of follow-up with primary care provider in rural areas.

·         Significance: Improving rate of follow-up with primary care provider will improve health outcomes of rural residents.

DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Problem Statement

3.     
Problem Statement:

Describe the variables/groups to study, in one sentence.

 

A well-written problem statement begins with the big picture of the issue (
macro)
and works to the small, narrower, and more specific problem (
micro
). It clearly communicates the significance, magnitude, and importance of the problem and transitions into the Purpose of the Project with a declarative statement such as: “It is not known if and to what degree/extent…” or “It is not known how/why and….”

Other examples are:

·         While the literature indicates ____________, it is not known in _________ (organization/community) if __________.

·         It is not known how or to what extent ________________.

While the literature indicates that telehealth is an important emerging technology for rural patient access, it is unknown if the implementation of telehealth impacts the rate of patient follow up for patients living in a rural area. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Clinical/

PICOT Questions

4.     
Clinical/PICOT Questions:

Provide PICOT question to guide the implementation and data collection of findings of the project:

(P)
Among adult patients in a rural care setting,
(I)
how does implementation of a telehealth program
(C)
compare to traditional commute-for-care (
O)
impact rate of follow-up with the primary care provider (
T)
over a period of four weeks.

Sample

5.     
Sample (and Location):

Identify sample, needed sample size, and location (study phenomena with small numbers and variables/groups with large numbers).

a.       Location: Arizona

b.      Population: Two neighboring rural towns equal distance from the nearest primary care provider.

c.       Sample: 40 participants include a power analysis if appropriate. DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Define Variables

6.     
Define Variables:

a.      
Independent Variable:
Telehealth program.

b.     
Dependent Variable:
Follow-up rate with primary care provider.

Methodology  and Design

7.     
Methodology and Design:

Name the selected methodology and specific design to address the problem statement and clinical questions:

This project will use a quantitative methodology with a quasi-experimental design.

Purpose Statement

8.     
Purpose Statement:

Provide one sentence statement of purpose including the problem statement, sample, methodology, and design:

Creswell (2003) provided some sample templates for developing purpose statements aligned with the different project methods as follows:

The purpose of this
quantitative
___________ (correlational, descriptive, etc.) project is to ____________ (compare or see to what degree a relationship exists) between/among ______________________ (independent variable) to ___________________ (dependent variable) for ________________ (participants) at ___________________ (project site/geographical location). The ________ (independent variable) will be defined/measured as/by _______ (provide a general definition). The
                                 
 (dependent variable) will be defined/measured as/by ______ (provide a general definition).

 

 

Data Collection Approach

9.     
Data Collection Approach:

Describe primary instruments that will be used to answer clinical question.

Data Analysis Approach

10. 
Data Analysis Approach:

Descriptive statistics will describe the sample characteristics and variable results. An independent t-tests will test for difference between the two groups of 40 participants (telehealth and commute-for-care) follow-up with primary physician. A priori analysis will be used to justify the sample size.

 

 

10 Strategic Points Table

(Use this table to complete the 10 Strategic Points document for your project.)

10 Strategic Points

Comments/Feedback

Broad Topic Area

Literature Review

DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Problem Statement

Clinical/PICO Questions

Sample

Define Variables

Methodology  and Design

Purpose Statement

 

 

Data Collection Approach

Data Analysis Approach

 

DNP 820 – 10 Strategic Points For The Prospectus, Proposal, And Direct Practice Improvement Project

Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Week 8: Cognitive Behavioral Therapy for Groups

CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems. CBT is the first order of business and treatment of choice for most patients who need internal resources and coping skills enhanced.

—Dr. Sharon M. Freeman Clevenger,
Psychotherapy for the Advanced Practice Psychiatric Nurse

Although designed for therapy with individuals, cognitive behavioral therapy (CBT) has also proven effective in group settings. With its many benefits, including cost-effectiveness and efficiency, this therapeutic approach allows the psychiatric mental health nurse practitioner to effectively treat a greater number of clients in a relatively short length of time. With the widespread use of CBT with groups, it is important for you to understand how to use this therapeutic approach in clinical settings. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays .

This week, as you explore CBT for groups, you compare CBT in group and family settings. You also develop diagnoses for clients receiving group psychotherapy and consider legal and ethical implications of counseling these clients.

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

Learning Resources

Note:
To access this week’s required library resources, please click on the link to the Course Readings List, found in the
Course Materials
section of your Syllabus.

Required Readings

Yalom, I. D., & Leszcz, M. (2005).
The theory and practice of group psychotherapy
(5th ed.). New York, NY: Basic Books.

Chapter 11, “In the Beginning” (pp. 309–344)

Yalom, I. D., & Leszcz, M. (2005).
The theory and practice of group psychotherapy
(5th ed.). New York, NY: Basic Books.

Chapter 12, “The Advanced Group” (pp. 345–390)

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays .

Note:
You will access this text from the Walden Library databases.

Bjornsson, A. S., Bidwell, L. C., Brosse, A. L., Carey, G., Hauser, M., Mackiewicz Seghete, K. L., … Craighead, W. E. (2011). Cognitive-behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: A randomized controlled trial.
Depression and Anxiety, 28
(11), 1034–1042. doi:10.1002/da.20877

Note:
You will access this text from the Walden Library databases.

Safak, Y., Karadere, M. E., Ozdel, K., Ozcan, T., Türkçapar, M. H., Kuru, E., & Yücens, B. (2014). The effectiveness of cognitive behavioral group psychotherapy for obsessive-compulsive disorder.
Turkish Journal of Psychiatry, 25
(4), 225–233. Retrieved from http://www.turkpsikiyatri.com/

Note:
You will access this text from the Walden Library databases.

Document: Group Therapy Progress Note

 

Discussion: Cognitive Behavioral Therapy: Group Settings Versus Family Settings

As you might recall from Week 5, there are significant differences in the applications of cognitive behavior therapy (CBT) for families and individuals. The same is true for CBT in group settings and CBT in family settings. In your role, it is essential to understand these differences to appropriately apply this therapeutic approach across multiple settings. For this Discussion, as you compare the use of CBT in group settings and family settings, consider challenges of using this approach with your own groups. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays .

Learning Objectives

Students will:

Compare the use of cognitive behavioral therapy for groups to cognitive behavioral therapy for families

Analyze challenges of using cognitive behavioral therapy for groups

Recommend effective strategies in cognitive behavioral therapy for groups

To prepare:

Reflect on your practicum experiences with CBT in group and family settings.

Note:
For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the
Post to Discussion Question link
and then select
Create Thread
to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking Submit! Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays 

By Day 3

Post
an explanation of how the use of CBT in groups compares to its use in family settings. Provide specific examples from your own practicum experiences. Then, explain at least two challenges counselors might encounter when using CBT in the group setting. Support your response with specific examples from this week’s media.

Read
a selection of your colleagues’ responses.

By Day 6

Respond
to at least
two
of your colleagues by recommending strategies to overcome the challenges your colleagues have identified. Support your recommendation with evidence-based literature and/or your own experiences with clients.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 8 Discussion Rubric

 

Post by Day 3 and Respond by Day 6

To participate in this Discussion:

Week 8 Discussion

 

Assignment 1: Practicum – Week 8 Journal Entry

Learning Objectives

Students will:

Develop effective documentation skills for group therapy sessions *

Develop diagnoses for clients receiving group psychotherapy *

Evaluate the efficacy of cognitive behavioral therapy for groups *

Analyze legal and ethical implications of counseling clients with psychiatric disorders *

Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

*
 The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.

Select two clients you observed or counseled this week during a group therapy session. 
Note:
 The two clients you select must have attended the same group session.

Then, in your Practicum Journal, address the following:

Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session.

Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.

Using the DSM-5, explain and justify your diagnosis for each client.

Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Explain any legal and/or ethical implications related to counseling each client.

Support your approach with evidence-based literature.

By Day 7 of Week 10

Submit
 your Assignment.

Assignment 2: Board Vitals

This week you will be responding to twenty Board Vitals questions that cover a broad review of your Nurse Practitioner program courses up to this point.

These review questions will provide practice that is critical in your preparation for the national certification exam that’s required to certify you to practice as a nurse practitioner. These customized test questions are designed to help you prepare for your Nurse Practitioner certification exam. It is in your best interest to take your time, do your best, and answer each question to the best of your ability.
Cognitive Behavioral Therapy: Group Settings Versus Family Settings
– Week 8 Discussion Sample Essays

You can access Board Vitals through the link sent to you in email or by following the link below:

https://www.boardvitals.com/

 

By Day 7

Complete the Board Vitals questions.

Making Connections

Now that you have:

Explored cognitive behavioral therapy (CBT) for groups and compared CBT in group and family settings

Developed diagnoses for clients receiving group psychotherapy and considered legal and ethical implications of counseling these clients

Next week, you will:

Explore psychotherapeutic approaches to group therapy for addiction

Develop diagnoses for clients receiving psychotherapy for addiction and consider legal and ethical implications of counseling these clients Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

 

Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays Individual vs. Family CBT

Cognitive behavioral therapy is short-term psychotherapy that emphasizes the need for attitude change in order to maintain and promote behavior modification (Nichols, 2014). Cognitive behavior therapy (CBT) has been found to be effective in a broad range of disorders. CBT can be done as an individual treatment or in a family setting. Individual CBT has a broadly defined framework with an emphasis on harm-reduction, especially with clients that have anxiety and substance abuse (Wheeler, 2014).

Cognitive-behavioral therapy for families is also brief and is solution-focused. Family CBT is focused on supporting members to act and think in a more adaptive manner, along with learning to make better decisions to create a friendlier, calmer family environment (Nichols, 2014). An example from practicum is a male (T.M) that participates in individual CBT once a week and family CBT once a week. T.M is struggling with alcoholism.

He originally presented for individual CBT because he had been “told by his wife” that he had a problem with alcohol. He reported that he drank “a few vodka drinks” three times a week but none for six weeks. Individual CBT therapy is a collaborative process between the therapist and client that takes schemas and physiology into consideration when deciding the plan of care (Wheeler, 2014). We worked with him using open-ended questions to assist with obtaining cognitive and situational information.  He would become angry easily and it was a felt that he was not being truthful about his alcohol use. Each time he was questioned about it, the story would change. He attended two individual sessions and it was then recommended he begin family CBT with his significant other (S.M) because “things were not going well at home.”

With family CBT, cognitions, emotions, and behaviors are seen as having a mutual influence on one another (Nichols, 2014). The first session was stressful, to say the least. T.M began talking about his alcohol use. S.M interrupted and said, “what about that one-time last month at the hotel. You were seeing things.” He became defensive, raised his voice, and said, “I was drugged. It had nothing to do with drinking.” She then looked down and was tearful. When he left the room to use the bathroom, S.M questioned if he could be tested for alcohol. This led the therapist to believe that T.M’s last use was not six weeks ago.

T.M’s automatic thoughts were that his alcoholism was not a problem in the marriage or in life. One of the core principles in using CBT for SUDs is that the substance of abuse serves as a reinforcement of behavior (McHugh et al., 2010). Over time, the positive and negative reinforcing agents become associated with daily activities. CBT tries to decrease these effects by improving the events associated with abstinence or by developing skills to assist with reduction (McHugh et al., 2010).

It was noticed that when T.M was alone, his stories would change. But when his wife was in the room, he would look at her while he spoke to ensure what he was saying was accurate. The therapist informed the client that it would be appropriate to continue individual therapy and family CBT once a week with the recommendation of joining the ready for change group. The CBT model for substance use states that, when a person is trying to maintain sobriety or reduce substance use, they are likely to have a relapse (Morin et al., 2017). Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Ready for change meetings was recommended because like this week’s media showed, clients may relate to others that are going through similar situations. Getting T.M to realize that his alcohol use is a problem, is the primary goal currently. This example was shared because it shows the difficulties that may be encountered with psychotherapy and that both individual and family may be needed to ensure that goals are met. Some challenges that counselors face when using CBT in the family setting are wondering if the structure of the session and if the proper techniques were effective (Ringle et al., 2015). Evaluating and consulting with peers may also assist with meeting client and family goals.

References

McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. 
The Psychiatric clinics of North America
, 
33
(3), 511-25. doi:
10.1016/j.psc.2010.04.012

Morin, J., Harris, M., & Conrod, P.  (2017, October 05). A Review of CBT Treatments for Substance Use Disorders. 
Oxford Handbooks Online.
 Ed.  Retrieved from
http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199935291.001.0001/oxfordhb-9780199935291-e-57.

Nichols, M. (2014).
The essentials of family therapy
(6th ed.). Boston, MA: Pearson. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Patterson, T. (2014). A Cognitive-Behavioral Systems Approach to Family Therapy. 
Journal of Family Psychotherapy
, 
25
(2), 132–144.
https://doi-org.ezp.waldenulibrary.org/10.1080/08975353.2014.910023

Ringle, V. A., Read, K. L., Edmunds, J. M., Brodman, D. M., Kendall, P. C., Barg, F., & Beidas, R. S. (2015). Barriers to and Facilitators in the Implementation of Cognitive-Behavioral Therapy for Youth Anxiety in the Community. 
Psychiatric services (Washington, D.C.)
, 
66
(9), 938-45. doi:
10.1176/appi.ps.201400134

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to

guide for evidence-based practice. New York, NY: Springer.

 

Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays POST 2

Cognitive Behavioral Therapy is one of the most effective psychotherapy approaches, whether it be used in group, family, or individual treatment. It is important to understand the purpose of it what its process consists off. It can be used to treat different mental health conditions, ranging from addiction to more severe illnesses. Its approach is to work with the patient into strategizing ways to change unhealthy thoughts and behaviors. Throughout the process, the patient not only learns solving skills, but also to re-evaluate and learn how to understand other’s perspectives, skill that helps build their confidence.

Some believe group therapy is more effective than individual therapy, as established by Kellett, Clarke, and Matthews (2007, p. 211). It has been established that CBT in general can be effective, but based on the Johnson Family Session video, it leads me to believe that either group/family or individual would be effective depending on the condition that is being treated. It is clear from the video that the girl who had been sexually assaulted at the fraternity does not believe talking or sharing her experience, even if it is with other girls who went through the same experience, will help in any way. She still has some internal issues that need to be addressed individually in order to make progress and get her to a place where she can participate in group/family therapy with an awareness that it will help her and purpose to it. Another important aspect of having a client be committed to the treatment is that research has showed “Poor compliance can adversely affect the remaining group members who may become worried or insecure” (Söchting, Lau, Ogrodniczuk, 2018, p. 185).

An example during practicum that supports my belief is the case of a terminally ill patient who had been recommended comfort care through hospice. She was ready to do so, understood and accepted her prognosis, but her daughters and husband were in denial. Every time they participated in a family session the patient held back on her wishes and verbalized whatever their wishes were as if they were her own. When treated as an individual client, she would express her concerns of not being able to “disappoint and abandon my family”. She had suffered all her life from anxiety, insecurities, severe depression, and low self-esteem. Those were issues that should have been addressed individually before she could fully engage in a family session in a healthy and productive way, if she would’ve had the time. CBT would have still been the choice of treatment for individual therapy for this client, as evidenced by Driessen et al. who stated it “is the psychotherapy method with the best evidence-base in the treatment of depression” (2017, p. 654). Not being fully engaged in the program, or believing the treatment will not help, or having other issues that need to be addressed on an individual basis, are all challenges presented in a family setting when relying on CBT.

References

Kellett, S., Clarke, S., & Matthews, L. (2007). Delivering Group Psychoeducational CBT in

Primary Care: Comparing Outcomes with Individual CBT and Individual

Psychodynamic-Interpersonal Psychotherapy.
British Journal of Clinical Psychology,

           46(2).

Söchting, I., Lau, M., & Ogrodniczuk, J. (2018). Predicting Compliance in Group CBT Using the

Group Therapy Questionnaire.
International Journal of Group Psychotherapy, 68(2).

Driessen,E., Van, H. L., Peen, J., Don, F. J., Twisk, J. W. R., Cuijpers, P., & Dekker, J. J. M.

(2017). Cognitive-Behavioral Versus Psychodynamic Therapy for Major Depression:

Secondary Outcomes of a Randomized Clinical Trial. Journal of Consulting Clinical

Psychology, 85)7).

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Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays POST 3

Week 8 discussion

Cognitive Behavioral Therapy: Group Settings Versus Family Settings

Cognitive behavioral therapy (CBT) is an effective treatment for a broad range of psychiatric disorders and problems (Naik et al. 2013). CBT can be offered as an individual treatment, in a family setting or used in a group setting. Group cognitive behavioral therapy (GCBT) may be a more efficient form of delivering CBT in areas of the mental health system where providing adequate amounts of treatment for patients is challenging (Naik et al. 2013). To be able to recommend the use of GCBT in mental health settings, more work needs to be undertaken to establish patients’ perceptions of such treatment and whether it is effective in reducing symptoms (e.g., anxiety, depression, distress) in actual practice settings. In a study done to show the effectiveness of group CBT, it was assumed that CBT efficacy varies widely depending on the disorder presented. CBT is highly effective in the treatment of adult unipolar depression, adolescent unipolar depression, bulimia nervosa, childhood depressive and anxiety disorders, generalized anxiety disorder, panic disorder with or without agoraphobia, post-traumatic stress disorder, schizophrenia, and social phobia (Naik et al. 2013). Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Group cognitive behavioral therapy has also been shown to be more cost-effective because Group treatment has been presented as a more cost-effective method of treating a large number of children and adolescents especially in children or adolescent with anxiety disorders, depression, bulimia nervosa to mention but a few. Group CBT result in reduced medical and nonmedical costs, thereby contributing to a societal cost offset, but in a family setting, there is the scarcity of properly trained therapists and high costs (Hedman et al.2010). However, CBT is not readily available in healthcare settings. Therefore, it is essential to develop and evaluate methods of therapy that are more time- and cost-efficient. Because health care resources are limited, there has been an increasing demand for cost-effective treatments that reduce the societal costs of sick leave and health care consumption (Hedman et al.2010). Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

References:

Hedman, E., Ljótsson, B., Andersson, E., Rück, C., Andersson, G., & Lindefors, N. (2010).

Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a

psychiatric setting: an open trial. Cognitive Behaviour Therapy, 39(4), 239–250.

https://doi-org.ezp.waldenulibrary.org/10.1080/16506073.2010.496460

Naik, A., O’Brien, A., Gaskin, C., Munro, I., & Bloomer, M. (2013). The Acceptability and

Efficacy of a Group Cognitive Behavioural Therapy Programme in a Community Mental

Health Setting. Community Mental Health Journal, 49(3), 368–372. https://doi-

org.ezp.waldenulibrary.org/10.1007/s10597-012-9484-3

 

Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays POST 4

Week 8 Discussion

Cognitive behavioral therapy (CBT) is an evidence-based practice for therapy. CBT can be used in individual, group, or family therapy. The use of CBT in the family setting grew from the Thibaut and Kelley’s theory of social exchange (Nichols, 2014). The theory of social exchange states that people will endeavor to increase rewards and decrease sacrifice in a relationship. Thibaut and Kelly express that this behavior has the goal of maintaining homeostasis in the relationship which they call behavior exchange theory(Nichols, 2014). CBT postulates that one person’s behavior affects how another person will react to them. CBT use in group therapy has a similar premise the difference between group CBT and family CBT is schemas (Wheeler, 2014). Schemas are a persons core beliefs, and these underlying beliefs shape the way a person responds even if it is unconsciously done. One challenge in the group setting is group members may attempt to bring the family schemas they possess into the group(Wheeler, 2014). Another challenge in the group setting with CBT is keeping group members focused on the here and now; even if the factors leading to the behavior was in the past (Wheeler, 2014). I have seen this in my practicum experience in the group therapy the therapist has to work hard on keeping members in the here and now and reinforcing the goal of change. In the family therapy sessions, I have seen more struggles over how to blend two family schemas into one where everyone can be happy. Creating new schemas is generally especially difficult for the families I have seen because they have autistic children which changes how families must react to behaviors. Bjornsson, Bidwell, and Brosse at el report that CBT in the group may be less effective because the concentration on restructuring activities, prevents the formation of group dynamics that is crucial in group therapy (2011). Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

 

References

Bjornsson, A. S., Bidwell, C., Brosse, A. L., Carey, G., Hauser, M., Mackiewicz, K. L., … Craighead, W. E. (2011). Cognitive-Behavioral Group Therapy Versus Group Psychotherapy For Social Anxiety Disorder Among College Students: A Randomized Controlled Trial.
Depression and Anxiety
,
28
(11), 1034-1042. http://dx.doi.org/10.1002/da.20877

Nichols, M. (2014).
The essential of family therapy
(6th ed.). Boston, MA: Pearson.

Wheeler, K. (2014).
Psychotherapy for the Advanced Practice Psychiatric Nurse
(2nd ed.). New York, NY: Springer Publishing Company. Cognitive Behavioral Therapy: Group Settings Versus Family Settings – Week 8 Discussion Sample Essays

Assessing the Abdomen

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

Note:
 By 
Day 1
 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. 
Remember that not all comprehensive SOAP data are included in every patient case
.

Case 1
: Abdominal Pain

A 12-year-old female complains of malaise with abdominal pain pointing to the right lower quadrant. The patient has been vomiting and feeling nauseated for several days. The abdominal pain has been insidious and now is more pronounced. Both parents are with the child and are concerned because she has not been eating and has had a fever for the past 3 evenings.

Case
 
2
: Gastrointestinal Pain

A 50-year-old male complains of burning pain starting at the abdomen and rising to the middle of his chest. He describes the pain as a gnawing feeling that begins after meals, especially when lying down.

Case 3
: Nausea and Vomiting

A 20-year-old female complains of nausea and has vomited three times over the past 48 hours. The patient also experienced a low-grade fever this morning. She states that she recently ate shellfish at a new restaurant with two friends who are suffering from similar symptoms.

To prepare:

With regard to the case study you were assigned:

·        Review this week’s Learning Resources, and consider the insights they provide about the case study.

·        Consider what history would be necessary to collect from the patient in the case study you were assigned.

·        Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

·        Identify 
at least five
 possible conditions that may be considered in a differential diagnosis for the patient.

Note:
 Before you submit your initial post, replace the subject line (“Week 7 Discussion”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

Post A 1 page paper APA format

1.      a description of the health history you would need to collect from the patient in the case study to which you were assigned. (
case 2)

2.      Explain which physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3.      List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

 

Important note
(Remember to focus on the appropriate body systems for the clinical scenarios instead of focusing on the whole body system- Usually a complete physical exam is done during an annual wellness visit. This is not a wellness exam .

2. Your diagnosis for the clinical scenario must have a rationale and reasoning as to why

Remember to link the diagnosis to patients symptoms and clinical exam findings along with the rationale)

 

 

Course Readings

 

·        Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). 
Seidel’s guide to physical examination
 (8th ed.). St. Louis, MO: Elsevier Mosby.

o   Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.

o   Chapter 17, “Abdomen” (pp. 370-415)

In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.

·        Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). 
Advanced health assessment and clinical diagnosis in primary care 
(5th ed.). St. Louis, MO: Elsevier Mosby.

o   Chapter 3, “Abdominal Pain” (pp. 11-32)

This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.

o   Chapter 10, “Constipation” (pp. 110-117)

The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

o   Chapter 12, “Diarrhea” (pp. 133-147)

In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.

o   Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)

This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.

·        Sullivan, D. D. (2012). 
Guide to clinical documentation
 (2nd ed.). Philadelphia, PA: F. A. Davis.

o   Chapter 7, “Admitting a Patient to the Hospital” (pp. 143–188)

Note:
 Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.

·        Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). 
Adult examination checklist: Guide for abdominal assessment
. In 
Mosby’s guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to 
Seidel’s guide to physical examination
 (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

·        Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). 
Physical exam summary: Abdomen
. In 
Mosby’s guide to physical examination 
(7th ed.). St. Louis, MO: Elsevier Mosby.

This Abdomen Physical Exam Summary was published as a companion to 
Seidel’s guide to physical examination
 (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

·        Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis. 
Nephrology Nursing Journal
,
 38
(2), 173–186.

Retrieved from the Walden Library databases.

This article explains various types of abdominal pain. The authors detail the etiologies, symptoms, and treatment for the abdominal pain described.

·        Mills, A. M., & Chen, E. H. (2011). Abdominal pain in special populations. 
Emergency Medicine Reports
,
 32
(7), 81–91.

Retrieved from the Walden Library databases.

The authors of this article explore the characteristics and diagnoses associated with abdominal pain in patients with special conditions. The article also provides recommendations for emergency department staff when encountering abdominal pain.

·        University of Virginia. (n.d.). 
Introduction to radiology: An online interactive tutorial
. Retrieved from
http://www.med-ed.virginia.edu/courses/rad/index.html

This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.

NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

Post 
a description of the interview and communication techniques you would use with your selected patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient

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NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Building a Comprehensive Health History

Gaining the most information as possible from any patient is ideal.  This allows the advanced practice nurse (APN) to evaluate and gain a better understanding of the patient holistically which fosters a more unobstructed view of their health status to the healthcare professional.  To gain the best knowledge and the most substantial amount of information from the patient, it is essential for the APN to know and utilize communication skills and techniques that are most conducive for the retrieval of patient information.  The purpose of this discussion is to explain how I would conduct an interview to obtain a comprehensive health history for a 76-year-old African-American male with disabilities living in an urban setting. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

Impact of Age and Disability on Obtaining Health History

When assessing an individual of advanced age, it is important to remain cognizant that there could be barriers in communication from sensory loss.  Because sensory loss is common in elderly individuals, it is essential for the APN to assess each elderly patient in an individualized way rather than overgeneralizing by assuming that they all have sensory loss or deficits.  According to the text of Ball et al. (2015), physiologic age and chronological age are not always parallel nor do age-related changes occur at the same rate in all individuals.  With this knowledge, it is crucial that the APN assess and monitor each elderly patient in an individualized manner so that communication techniques that are patient-specific can be used.  Regardless of age, it is always important to guard against everything that that is said during a patient interview.  According to Ball et al. (2015), the provider is the one in power and the patient is the vulnerable one. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History. Because of this, the patient is often seeking meaning in everything that is said by the APN during the interview which could cause the patient to misinterpret something during the meeting that was intended to be innocuous.

Greeting the Patient

When greeting the patient for the first time, I would first introduce myself while warmly shaking the patient’s hand.  I would then ask my patient how he would like for me to address him.  If individuals are accompanying the patient during the interview, I would likewise introduce myself to those individuals and inquire about their level of involvement with the patient and ensure with the patient that I have permission to speak openly about his health while in the presence of those accompanying him.  I would seat myself comfortably in front of the patient and away from the door.  I would also maintain appropriate eye contact throughout the interview and take notes sparingly to prevent the patient from feeling that I am not focused on the conversation.

Identifying Health Risks

When conducting a comprehensive health history interview, it is essential to consider the patient’s age, gender, ethnicity, and lifestyle to determine what the patient might be at risk for.  For example, according to the article authored by Cordner et al. (2017), African-American males have higher mortality rates than Hispanic and white men due to heightened risk for diabetes, cancer, and heart disease.  According to Dolezsar, McGrath, Herzig, and Miller (2014) 42% of African-American individuals have a diagnosis of hypertension whereas only 28% of Caucasians have a diagnosis of hypertension.  With consideration of this knowledge, it would be prudent for the APN to specifically ask questions that pertain to these risk factors. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

Communication

During the interview process, I would construct questions so that the answers will yield robust information.  The use of open-ended questions is the ideal method of information retrieval.  Asking the patient, the following question, “What made you come in today?” will likely elicit a broad response.   Additionally, I would try to avoid the use of medical jargon that may confuse the patient or make him feel insecure about his health status.  Disabilities of the patient may impede communication.  Communication techniques should be tailored to overcome communication barriers resulting from disabilities.  Decreased hearing, decreased vision, depression, and neurological impairments are common culprits that can deter the ease of communication or prevent the patient from providing a reliable history (Ball et al., 2015).  If this is the case, other resources can be used to obtain the history.  Other methods of retrieving pertinent patient history include patient records, close family members, and other healthcare professionals that are involved in the patient’s care.

Risk Assessment Instrument

Because falls are a common occurrence in the elderly population I would use a fall risk assessment tool on this patient.  It is that estimated falls create 35 million disabilities worldwide each year (Palumbo, Palmerini, Bandinelli, & Chiari, 2015).  Risk factors for falls include one or more falls in the past year, history of stroke, dementia, Parkinson’s Disease, sensory loss, visual impairments, and the use of an assistive walking device (Ball et al., 2015).  Due to the patient’s age and knowing that he has disabilities, it is reasonable to assume that he is at a high risk for falls. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History.  If the patient is identified as being a fall risk, then interventions can be set in place to help prevent them.

Targeted Questions

 

After I have introduced myself to the patient and established the best method of overcoming any communication barriers, I will ask the following questions to gain insight about the patient:

What brought you here today?

Explain how you feel about your current health status.

What medical problems do you have now?

What medical problems have you had in the past?

What medications do you currently take?

Describe your level of physical activity.

Do you have any concerns about your health status?

 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015).
Seidel’s guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby.

Cordner A, Wilkie A, Wade T, Hudgens E, Birch R, Gallagher J. Gender and Racial/Ethnic Disparities: Cumulative Screening of Health Risk Indicators in 20-50 Year Olds in the United States. 
Journal Of Health Disparities Research & Practice
[serial online]. March 2017;10(1):126-142. Available from: Academic Search Complete, Ipswich, MA. Accessed August 25, 2018. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

 

Dolezsar, C. M., McGrath, J. J., Herzig, A. M., & Miller, S. B. (2014). Perceived racial discrimination and hypertension: A comprehensive systematic review. 
Health Psychology
, 
33
(1), 20-34. doi:10.1037/a0033718

 

Palumbo, P., Palmerini, L., Bandinelli, S., & Chiari, L. (2015). Fall Risk Assessment Tools for Elderly Living in the Community: Can We Do Better?. 
Plos ONE
, 
10
(12), 1-13. doi:10.1371/journal.pone.0146247

Week 1 Discussion Nurs- 6512-Main Post

Building a Health History

Introduction

A provider who can build a rapport and earn the trust of a patient will meet less resistance when gathering information for health history.  It is essential to look at the whole person, considering factors that could influence the patient’s overall health such as occupation, culture, ethnicity, and socioeconomic status (Ball, Dains, Flynn, Solomon, & Stewart,2015).  The purpose of this discussion is to identify techniques in building a health history for Adolescent Hispanic/Latino boy living in a middle-class suburb.

Patient Scenario

The adolescent patient in this scenario is also Hispanic. First of all, I will find out if he understands English enough to answer my questions during the exam. If he does not, I will arrange for an interpreter. Additionally, I need to be culturally competent. I can do this by being first recognizing that cultural diversity exists, be sensitive to the patient’s heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background (Ball, et al.,2015) NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

Communication Techniques

An adolescent is a time of life from puberty to maturity. This is the most vulnerable time in a person’s life. Most of them are usually not easy to open up to any conversation. Getting information from them can be quite challenging. It is also essential to provide them with privacy. I will do my best to get the chief concern for seeking care from the parent. If possible, I will request the patient to step out of the room to investigate further. I will begin the conversation with day to day activities in the patient’s life.  I have to remember to respect him and gain his trust. If I am faced with silence, I have to recognize that as well. I will gauge if this silence is out of anger, shame, or just the unwillingness to share. My primary focus will be to find out the details about his concerns and show genuine interest and curiosity.  I will use language that is understandable. I will avoid confrontation. I will listen to what the patient is saying. Once I figure out the chief concern, I can go on to discuss other sensitive issues such as sex, drug, or alcohol use (Ball, Dains, Flynn, Solomon, Stewart, 2015).

Risk Assessment Tool

Knowing the fact that adolescents go for risky behaviors, it will be important to assess him for the same.  I would use the HEEADSSS screening tool for adolescent issues for this. Here I can find out more about his home environment, education, employment, eating pattern, his activities, ambitions. I can also find out about any drug use, his sexuality, or if he has any suicidal thoughts and if he is safe from injury and violence (Ball, Dains, Flynn, Solomon, Stewart, 2015).

Asking appropriate questions and avoiding stereotypes is essential to providing care that is tailored to the individual patient (Ball, Dains, Flynn, Solomon, & Stewart,2015).   Questions should be open-ended and asked in a manner that is easily understood. Some of the questions I would ask him are as follows: 1. What brought you to be seen today? 2. How are things at home?  3. Tell me about your friends. 4. Do you play any type of computer or video games? If so What kind? 5. What are you good at doing?

Thus, I will ask such open-ended questions which will allow my patient to talk about areas that are troubling him if any. NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

Conclusion

A successful interview develops the patient-provider relationship and builds trust. Providing quality individualized care requires an Advanced Practice Nurse to understand not only the disease process but as well as other factors like the culture that will influence the patients’ health, medical care, and healing process.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Cuellar, N. G., Brennan, A. M., Vito, K., & Siantz, M. L. (2008). Cultural Competence in the Undergraduate Nursing Curriculum.
Journal of Professional Nursing,

24
(3), 143-149. doi:10.1016/j.profnurs.2008.01.004

Flores, G. (2005). The Impact of Medical Interpreter Services on the Quality of Health Care:  A Systematic Review. Medical Care Research and Review, 62(3), 255-299. doi:10.1177/1077558705275416

Kuo, D. Z., O’connor, K. G., Flores, G., & Minkovitz, C. S. (2007). Pediatricians’ Use of

Language Services for Families with Limited English Proficiency. Pediatrics, 119(4). doi:10.1542/peds.2006-1508 NURS 6512 week 1: Advanced Health Assessment and Diagnostic Reasoning
 Building a Comprehensive Health History

NURS 6512 FINAL & MIDTERM EXAMS

NURS 6512 FINAL EXAM: WALDEN UNIVERSITY

1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: –

2. In older adults, overflow fecal incontinence is commonly due to:

3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment?

4. Auscultation of borborygmi is associated with:

5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? –

BUY A PLAGIARISM-FREE PAPER HERE

6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: –

7. The major function of the large intestine is: –

8. Which structure is located in the hypogastric region of the abdomen? –

9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): – NURS 6512 FINAL & MIDTERM EXAMS

10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: –

11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: – 12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: – 13. The perception of pain: –

14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: –

15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured?

16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? –

17. Visible intestinal peristalsis may indicate: –

18. Infants born weighing less than 1500g are at higher risk for:

19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? –

20. One of the most important aspects to consider in the orthopedic screening examination is: –

21. The sequence of the physical examination should be individualized to:

22. As you greet the patient, which examination technique is first implemented? –

23. Which of the following is most likely to enhance examiner reliability?

24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? –

25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?

26. Skeletal changes in older adults are the result of: –

27. A positive straight leg raise test usually indicates: –

28. What technique is performed at every infant examination during the first year of life to detect hipdislocation? –

29. Expected normal findings during inspection of spinal alignment include-

30. Temporalis and masseter muscles are evaluated by:-

31. When palpating joints, crepitus may be caused when: –

32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: –

33. Light skin and thin body habitus are risk factors for: –

34. Risk factors for sports-related injuries include: –

35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: –

36. Ligaments are stronger than bone until: –

37. The family history for a patient with joint pain should include information about siblings with: –

38. The Thomas test is used to detect: –

39. A goniometer is used to assess: –

40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ­­­­­­­­­­­­­­­­________ test. –

41. You note that a child has a positive Gower Sign. You know that this indicates generalized:  –

42. The dowager hump is: –

43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention?–

44. A common finding in markedly obese and pregnant women is: –

45. A 45-year-old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression?A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? –

46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? –

47. Testing of cranial nerve ­­­­________ is not routinely performed unless a problem is suspected. – I

48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? –

49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? –

50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? –

51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? –

52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – –

52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: – –

53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? –

54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? –

55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: –

56. Motor maturation proceeds in an orderly progression from: –

57. The thalamus is the major integration center for perception of: –

58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. –

59. Normal changes of the aging brain include: – –

60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: —

61. The area of body surface innervated by a particular spinal nerve is called a: – –

62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requires further evaluation? – –

63. The finger-to-nose test allows assessment of: – –

64. You ask the patient to follow a series of short commands to assess: – –

65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: –

66. When is the mental status portion of the neurologic system examination performed? –

67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: —

68. The autonomic nervous system coordinates which of the following? –

69. The major function of the sympathetic nervous system is to: – –

70. The parasympathetic nervous system maintains the day-to-day function of: –

71. Cerebrospinal fluid serves as a: – –

72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: —

73. Which type of hallucination is most commonly associated with alcohol withdrawal? – –

74. On a scale of 0 to 4+, which deep tendon reflex score is appropriate for a finding of clonus in a patient? –

75. Which statement is true regarding mental status changes in older adults? – –

76. A characteristic related to syphilis or diabetic neuropathy is testicular: —

77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: – –

78. What risk factor is associated with cervical cancer? – –

79. A 23 year old female presents with severe right lower quadrant tenderness. All of the following should be considered in the differential except: – –

80. What is the initial diagnostic radiology test that should be ordered if you suspect a ruptured ovarian cyst? – –

81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. The differential diagnosis should include all except: –

82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremicbreasts bilaterally. You should advise the patient to: – –

83. A normal vas deferens should feel: – –

84. In a woman complaining of a breast lump, it is most important to ask about: – –

85. The finding of a painless indurated lesion on the glans penis is most consistent with: – –

86. Thrombosed hemorrhoids are: – –

87. Pregnancy-related cervical changes include: –

88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: – –

89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: –

90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: – –

91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – –

92. Sexual differentiation in the fetus has occurred by ­­­_______weeks gestation. – –

93. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: —

94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: —

95. A therapeutic technique for dealing with grieving individuals is to: –

96. The examination of the newborn should begin with: – –

97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – –

98. In crying infants, it is often difficult to: – –

99. Which of the following statements accurately reflects the sensitivity and specificity of laboratory tests? –-

100. Which medical condition would exclude one from sports participation? – –

101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: – –

102. Which of the following are examined with the patient in a reclining 45 degree position? –-

103. Functional assessment is most important during the examination of a(n): —

104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: – –

105. An ophthalmoscopic eye examination involves: – –

106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: –

107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: –

108. Which of the following is true regarding the relationship between the examiner and the patient? –

109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? –

110. One of the most important aspects to consider in the orthopedic screening examination is: –

111. As you greet the patient, which examination technique is first implemented? –

112. Which portion of the physical examination is best done with the patient standing? –

113. Which patient position facilitates inspection of the chest and shoulders? –

114. The least reliable indicator of newborn distress is: –

115. Proprioception should be assessed while the patient is: –

116. Part of the screening orthopedic component of the examination includes evaluating the person while: –

NURS 6512 
Week 6 Midterm Exam: Advanced Health Assessment: Walden University

 

1. Before performing an abdominal examination, the examiner should:

2. During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially, you should:

3. Which of the following is the most accurate reflection of an individual’s food intake?

4. Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the:

5. A fixed image of any group that rejects its potential for originality or individuality is known as a:

6. Peritonitis produces bowel sounds that are

7. Brittle nails are typical findings in:

8. Which of the following is an expected change in the assessment of the thyroid during pregnancy?

9. You are planning to palpate the abdomen of your patient. Which part of the examiner’s hand is best for palpating vibration?

10. A 5-year-old child presents with nasal congestion and a headache to assess for sinus tenderness you should palpate over the:

11. During physical examination of a 30-year-old Chinese man you notice a slight asymmetry of his face. the cranial nerve examination is normal. Your best action is to

12. Unusual white areas on the skin may be due to

13. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for:

14. Mrs. Webb is a 38-year old patient who has been changing her lifestyle to eat in a healthy way and lose weight: during your health promotion education regarding her nutritional status, you explain the function of dietary protein as:

15. Mr. Akins is a 78-y/o patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply.

16. The most superior part of the stomach is the

17. Mrs. Grace is a 58-year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia?

18. A 51-y/o woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to:

19. Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for:

20. Which technique is most likely to result in the patients understanding of questions?

21. Mr. Williams, age 25, has recovered recently from an upper and lower respiratory infection. He describes a long-standing nasal dripping. He is seeking treatment for a mild hearing loss that has not gone away. Information concerning his chronic postnasal drip should be documented within which section of the history?

22. Nasal symptoms that imply an allergic response include:

23. Mr. Franklin is speaking with you the health care provider, about his respiratory problem. Mr. Franklin says, “I’ve had this cough for 3 days and it’s getting worse.” You reply, “Tell me more about your cough.” Mr. Franklin states, “I wish I could tell you more, that’s why I am here! You tell me what’s wrong.” Which caregiver response would be the most appropriate for enhancing communication?

24. When taking a history, you should:

25. Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

26. Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to:

27. Which question would be considered a leading question?

28. Mr. Black is a 44y/o patient who presents to the clinic with complaints of neck pain that he thinks is from his job involving computer data entry.  As the examiner, you are checking the range of motion in his neck and note the greatest degree of cervical mobility is at?

29. The term denoting the caregiver’s need to do no harm to the patient is:

30. A tool used to screen adolescents for alcoholism is the:

31. Under normal circumstances, how much water is lost daily by the body?

32. You have just completed a skin assessment on Mr. Baker. During your assessment, you have transilluminated a skin lesion. During the physical examination, you know that skin lesions are transilluminated to distinguish:

33. Mr. Mills is a 55/y/o patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of activities of daily living is part of a(n):

34. Sweat glands, hair, and nails are all formed from?

35. A brief statement of the reason the patient is seeking health care is called the?

36. Which part of the information contained in the patient’s record may be used in court?

37. Which cranial nerves innervate the face?

38. In counseling a client regarding nutrition education, you explain that linoleic acid, a major fatty acid, is thought to be essential for?

39. When are open-ended questions generally most useful?

40. Knowledge of the culture or cultures represented by the patient should be used to?

41. Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process?

42. A guideline for history taking is for caregivers to?

43. Which type of speculum should be used to examine a patient’s tympanic membrane?

44. You are palpating a patient’s thyroid and find that its broadest dimension measures 4cm. the right lobe is 25% larger than the left. These data would indicate?

45. Mr. L. presents to the clinic with severe groin pain and a history of kidney stones. Mr. L.’s son tells you that, for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response?

46. Before performing an abdominal examination, the examiner should?

47. You are examining a pregnant patient and have noted a vascular lesion. When you blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a?

48. As you explain your patient’s condition to her husband, you notice that he is leaning toward you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate response to this behavior is to?

49. When palpating the abdomen, you should note whether the liver is enlarged in the?

50. Expected normal percussion tones include?

51. Mr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with the complaint of new abdominal pain. You ate concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to?

52. Fluorescing lesions are best distinguished using a(n)?

53. Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet?

54. Underestimation of blood pressure will occur if the blood pressure cuff’s width covers?

55. Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a 4’3cm, rough, elevated area of psoriasis. This is an example of a?

56. Penicillin is considered a?

57. Small, minute bruises are called?

58. After thorough inspection of the abdomen, the next assessment step is?

59. When you are questioning a patient regarding alcohol intake, she tells you that she is only a social drinker. Which initial response is appropriate?

60. Regardless of the origin, discharge is described by noting?

61. Recommended carbohydrate content of total dietary intake (% total calories) is?

62. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure?

63. Auscultation should be carried out last, except when examining the?

64. Mr. Kevin Marks is a new health care provider. What is the best method to develop cultural competence?

65. Which of the following is an “ABCD” characteristic of malignant melanoma?

66. Tracheal tug suggests the presence of a(n)?

67. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course?

68. The review of systems is a component of the:

69. Cherry angiomas are a common finding in:

70. Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted:

71. To correctly document absent bowel sounds, one must listen continuously for:

72. The adult recommended dietary fat intake should be ____g/day.

73. Mr. Jones is a 45-year-old patient who presents for a physical examination. On examination, you note costochondral beading, enlarged skull, and bowed legs and diagnose him with rickets. A deficiency of which fat-soluble micronutrient can result in rickets?

74. A flat, nonplapable lesion is described as a macule if the diameter is:

75. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight.  In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient?

76. Which of the following organs is part of the alimentary tract?

77. Mr. Sanchez is a 45-year-old gentleman who has presented to the office for a physical examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator?

78. To approximate vocal frequencies, which tuning fork should be used to assess hearing?

79. During percussion, a dull tone is expected to be heard over:

80. The attitudes of the health care professional:

81. When recording physical findings, which data are recorded first for all systems?

82. Spasmodic muscular contractions of the head, face, or neck are called:

83. Which of the following occurs when firm pressure is used to apply the stethoscope’s bell end-piece to the skin?

84. Differential diagnoses belong in the:

85. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish:

86. Mr. Walter’s, a 32-year-old patient, tells you that his ears are “stopped up.” An objective assessment of this complaint is achieved by using the:

87. Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well-baby visit. As the health care provider, you teach her that newborns are more vulnerable to hypothermia due to:

88. Tympanic thermometers measure body temperature when a probe is placed:

89. A serous membrane that lines the abdominal cavity and forms a protective cover for many abdominal structures is the:

90. White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are:

91. When assessing abdominal pain in a college-age woman, one must include:

92. Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:

93. The infant should be placed in which position to have his or her height or length measured?

94. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic. Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem?

95. Which of the following is the most vital nutrient?

96. What finding is unique to the documentation of a physical examination of an infant?

97. Mrs. G. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the:

98. Mr. D. complains of a headache. During the history he mentions his use of alcohol and illicit drugs. This information would most likely belong in the:

99. You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient:

100. When communicating with older children and teenagers, you should be sensitive to their:

101
. 
Periods of silence during the interview can serve important purposes, such as:

NURS 6512 
Week 6 Midterm Exam: Advanced Health Assessment: Walden University

 

Which of the following is an expected change in the assessment NURS 6512 FINAL & MIDTERM EXAMS

of the thyroid during pregnancy?

 

When recording physical finding, which data are recorded first for all systems?

 

In counseling a Client regarding education .,you explain that Linoleic acid, a major fatty acid, is thought to be essential for:

Peritonitis produces bowel sounds that are:

 

Sweat glands, hair, and nails are all formed:

 

The adult recommended dietary fat intake

 

Recommended carbohydrate content of total dietary intake (% total calories) is

____ %.

 

Which of the formats would be used for a  (POMR)

 

Question 141 out of 1 pointsMr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with the complaint of new abdominal pain. You are concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to:

 

Question 151 out of 1 pointsYour patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:

 

Question 161 out of 1 pointsWhen examining the skull of a 4-month-old baby, you should normally find:

 

Question 171 out of 1 pointsMs. G. is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G.’s _____ history. NURS 6512 FINAL & MIDTERM EXAMS

 

To perform the Rinne test, place the tuning fork on the:

 

Question 71 out of 1 pointsWhen are open-ended questions generally most useful?

Question 80 out of 1 pointsThe review of systems is a component of the:

 

Fluorescing lesions are best distinguished using a(n):

 

Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish:

 

Mr. Franklin is speaking with you, the health care provider, about his respiratory problem. Mr. Franklin says, “I’ve had this cough for 3 days, and it’s getting worse.” You reply, “Tell me more about your cough.” Mr. Franklin states, “I wish I could tell you more. That’s why I’m here. You tell me what’s wrong!” Which caregiver response would be most appropriate for enhancing communication?

 

The term denoting the caregiver’s need to do no harm to the patient is:

 

Underestimation of blood pressure will occur if the blood pressure cuff’s width covers:

 

Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet?

 

The most superior part of the stomach is the:

 

When recording physical findings, which data are recorded first for all systems?

 

Kevin Marks is a new health care provider. What is the best method to develop cultural competence?

 

Which cranial nerves innervate the face?

 

When communicating with older children and teenagers, you should be sensitive to their:

 

Before performing an abdominal examination, the examiner should:

 

The infant should be placed in which position to have his or her height or length measured?

 

Regardless of the origin, discharge is described by noting:

 

Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process?

 

To correctly document absent bowel sounds, one must listen continuouslyfor:

 

The position on a clock, topographic notations, and anatomic landmarks:

 

Bulging of an amber tympanic membrane without mobility is most often associated with:

 

Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic. Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem? NURS 6512 FINAL & MIDTERM EXAMS

 

A flat, nonpalpable lesion is described as a macule if the diameter is:

 

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):

 

Which type of speculum should be used to examine a patient’s tympanic membrane?

 

During physical examination of a 30-year-old Chinese man, you notice slight asymmetry of his face. The cranial nerve examination is normal. Your best action is to:

 

Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a 4′ 3-cm, rough, elevated area of psoriasis. This is an example of a:

 

Knowledge of the culture or cultures represented by the patient should be used to:

 

A tool used to screen adolescents for alcoholism is the:

 

Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to:

 

To approximate vocal frequencies, which tuning fork should be used to assess hearing?

 

During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially, you should:

 

Nuchal rigidity is most commonly associated with:

Question 221 out of 1 pointsA serous membrane that lines the abdominal cavity and forms a protectivecover for many abdominal structures is the:

 

Question 261 out of 1 pointsWhen assessing abdominal pain in a college-age woman, one must include:

 

Question 281 out of 1 pointsA fixed image of any group that rejects its potential for originality or individuality is known as a(n):

 

Question 301 out of 1 pointsMr. Walters, a 32-year-old patient, tells you that his ears are “stopped up.” An objective assessment of this complaint is achieved by using the:

 

Question 311 out of 1 pointsMs. Davis is a 27-year-old patient with a BMI of 33. Based on her BMI, yourdiagnosis would be:

 

Question 321 out of 1 pointsTracheal tug suggests the presence of a(n):

 

Question 331 out of 1 pointsMr. Black is a 44-year-old patient who presents to the clinic with complaints of neck pain that he thinks is from his job involving computer data entry. As the examiner, you are checking the range of motion in his neck and note the greatest degree of cervical mobility is at:

 

Question 341 out of 1 pointsThe most common form of birth trauma of the scalp is:

 

Which question would be considered a leading question?

 

A brief statement of the reason the patient is seeking health care is called the:

 

Expected hair distribution changes in older adults include:

 

Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck region at the base of the tongue. This is most likely a: NURS 6512 FINAL & MIDTERM EXAMS

 

When hearing is evaluated, which cranial nerve is being tested?

Which of the following is the most accurate reflection of an individual’s food intake.

 

Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the:

 

Brittle nails are typical findings in:

 

You are planning the palpate the abdomen of your patient. Which part of the examiner’s hand is best for palpating vibrations?

 

A 5 year old child presents with nasal congestion and a headache. To assess for sinus tenderness you should palpate over the :

 

Unusual white areas on the skin may be due to:

 

You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector clockwise, then counterclock wise to compensate for:

 

Mrs. Webb is a 38 year old patient who has been changing her lifestyle to eat in a health way and lose weight. During your health promotion education regarding her nutritional status, you explain the function of dietary protein as:

 

Mr. Atkins is a 78 year old patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply.

Mrs. Grace is a 58year old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia?

 

A 51 year old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to:

 

Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for:

 

Which technique is most likely to result in the patient’s  understanding of questions?

 

MR WILLIAMS, AGE 25 HAS RECOVERED RECENTLY FROM AN UPPER AND LOWER RESPIRATORY INFECTION. HE DESCRIBES A LONG-STANDING NASAL DRIPPING. HE IS SEEKING TREATMENT FOR A MILD HEARING LOSS THAT HAS NOT GONE AWAY. INFORMATION CONCERNING HIS CHRONIC POSTNASAL DRIP SHOULD BE DOCOUMENTED WITHING WHICH SECTION OF HIS HISTORY?

 

NASAL SYMPTOMS THAT IMPLY AN ALLERGIC RESPONSE INCLUDE:

WHEN TAKING A HISTORY, YOU SHOULD:

 

Under normal circumstances, how much water is lost daily by the body?

 

You have just completed a skin assessment on Mr. Baker. During your assessment, you have transiluminated a skin lesion. During the physical examination, you know the skin lesions are transiluminated to distinguish:

 

Mr. Mills is a 55 year old patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of daily living (ADLs) is part of a(n):

 

Which part of the information contained in the patient’s record may be used in court? NURS 6512 FINAL & MIDTERM EXAMS

 

A guideline of history taking is for caregivers to:

 

You are palpating a patient’s thyroid and find that its broadest dimension measure 4cm. The right lobe is 25% larger than the left. These data would indicate:

 

Mr. L presents to the clinic with severe groin pain and a history of kidney stones. Mr. L’s son tells you that , for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response?

 

You are examining a pregnant patient and have noted a vascular lesion. When you blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a:

 

As you explain you patient’s condition to her husband, you notice that he is leaning toward you and pointedly blinking his eyes. Knowing that he is from England, you most appropriate response to this behavior is to:

 

When palpating the abdomen, you should note whether the liver is enlarged in the:

 

Expected normal percussion tones include:

 

Penicillin is considered a:

 

Small, minute bruises are called:

 

When you are questioning a patient regarding alcohol intake, she tells you that she is only a social drinker, which initial response is appropriate?

 

Tuning forks with a frequency of 20 to 100 Hz are most commonly used to measure:

 

Auscultation should be carried out last, except when examining the:

 

Which of the following is an ABCD characteristic of malignant melanoma?

Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least like to be associated with this condition early in its course?

 

Cherry angiomas are a common finding in:

 

Mr. Donalds is a 45 year old roofer. Your inspection to determine color variations of the skin is best conducted:

92.

Mr. Jones is a 45 year old patient who presents for a physical examination. On examination, you note costochondral beading, enlarged skull, and bowed legs and diagnose him with rickets. A deficiency of which fat-soluble micronutrient can result in rickets?

 

Which of the following organs is part of the alimentary tract?

 

Mr. Sanchez is a 45 year old gentleman who has presented to the office for a physical examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator?

93.

To approximate vocal frequencies, which tuning fork should be used to assess hearing?

 

The attitude of the health care professional:

 

When recording physical findings, which data are recorded first for all systems?

 

Spasmodic muscular contraction of the head, face, or neck are called:

 

Which of the following occurs when firm pressure is used to apply the stethoscope’s ball end piece to the skin? NURS 6512 FINAL & MIDTERM EXAMS

 

Differential diagnosis belong in the:

 

Pigmented, raised, watery lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish:

 

Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well baby visit. As a health care provider, you teach her newborns are more vulnerable to hypothermia due to:

 

Tympanic thermometers measure body temperature when a probe is placed:

 

White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are:

 

Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:

Which of the following is the most vital nutrient?

 

What finding is unique to the documentation of a physical examination of an infant?

 

Mrs. G reports and increase in her alcohol intake over the past 5 years. To screen her for problem drinking, would use the:

 

Mrs. D complains of a headache. During the history, he mentions his use of alcohol and illicit drugs. The information would most likely belong in the:

 

You are completing a general physical examination of Mr. Rock, a 39 year old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient: NURS 6512 FINAL & MIDTERM EXAMS